Stillbirths: An Overlooked Consequence of the COVID-19 Pandemic
Photo: Reuters/Callaghan O'Hare
The day Sarmila Shrestha felt her baby was not moving, Nepal had just gone into lockdown. She was nine months pregnant and when she visited the hospital they told her she had to take a test for COVID-19 before she could be admitted.
“We were so confused about what to do next,” she said. When she was finally permitted to enter, the overwhelmed staff did not pay attention to her concerns and there were constant delays. Shrestha went into labor but her baby was stillborn.
“I was heartbroken,” she said. “My baby could have been alive if the service was done on time.”
Stillbirth – which is the loss of a baby before or during delivery, after the 20th week of pregnancy – has been on the rise around the world during the coronavirus pandemic.
In London, one hospital noticed that stillbirths almost quadrupled during the city’s spring lockdown. According to the Office for National Statistics in the United Kingdom, the national average rate for stillbirths is 3.8 per thousand. St George’s Hospital typically has a rate of almost half that, but between February and June, it increased from 2.38 to 9.31 per thousand, a recent study showed. In July alone, the rate was 14.2 per thousand, a sixfold increase from normal.
Similar data was reported in other UK hospitals, while a study in Italy found stillbirths tripled there in the spring. A large study in Nepal found that stillbirths had increased from 14 per thousand to 21; the most significant increase came during the first month of lockdown. The same trend has been reported around the world, from India to Iran, Pakistan to Peru, and Bangladesh to Brazil.
Stillbirths can occur due to complications with a pregnancy or delivery, or because of issues with the mother’s health. Initially, some doctors thought the increase in stillbirths must have been caused by coronavirus infections. But it became apparent that this was not the case. At St George’s Hospital none of the women who had stillbirths tested positive and doctors have said there is no evidence that suggests COVID-19 infection increases the chances of a stillbirth. So doctors searched for other causes.
When Not to ‘Stay at Home’
During the early days of the pandemic, it was difficult to know the many consequences of lockdown. By the end of March, the message in the UK, as in many countries, had been “stay at home”. There was regular news of overwhelmed staff and hospitals overrun by coronavirus patients. Shortages of personal protective equipment (PPE) have been well documented all across the globe. In New York, nurses resorted to wearing plastic bin bags.
Dr. Asma Khalil, a professor of obstetrics and maternal-foetal medicine and co-author of the London hospital study, found that by April very few pregnant women were coming in. “We had empty clinics,” she said.
Women, it seemed, thought they should not, or could not, come in for their antenatal care appointments. The switch to remote appointments and the lack of clarity from governments about whether antenatal care was an essential visit caused confusion. Combined with nervousness about the virus itself, many hesitated.
“If the baby’s not moving, if you have reduced fetal movements, that’s usually an alert to come to the hospital to have a check-up to make sure the baby’s ok,” said Khalil. “If you delay that for another day, maybe it’s too late.”
Healthcare has changed during the pandemic. In the UK, 89 percent of women had remote antenatal appointments during the pandemic, according to a survey by BJOG: An International Journal of Obstetrics and Gynaecology. In India, hospitalizations in general halved (PDF) and in Nepal births in hospitals also declined by 50 percent.
Monitoring a fetus’s health during pregnancy involves many processes that have to be done in person with a doctor or midwife. Despite some countries making an effort to provide pregnant women with blood pressure testing kits at home, they are unable, for example, to listen for the fetal heartbeat or take uterus measurements themselves.
“Although the virtual route can be very good, it’s not the same. It may well be that a caregiver can see something in an interaction with a woman, or a woman will open up about worries or concerns in a face-to-face interaction,” said Mary Renfrew, professor of Mother and Infant Health at the University of Dundee in Scotland. “Continuity of care makes a difference to stillbirths. If continuity of care is disrupted then that in itself will have an impact.”
In many countries, there were additional impediments preventing women from getting care. In India, many patients use public transport for emergency visits but during the lockdown, as in Nepal and Uganda too, all public transport stopped, often including taxis, meaning many women could not get to their appointments. For a while, Uganda even banned the use of private cars during the lockdown.
In Iran and Peru, some hospitals were so overwhelmed that maternity units were closed, deemed non-essential, to make room for COVID care, local midwives told Al Jazeera. Many other hospitals are short-staffed and, as people get ill, staff have been moved from maternity wards in order to care for COVID patients.
“A pregnancy, the birth of a child, doesn’t stop for a pandemic,” said Margarita Perez Silva from the College of Obstetricians of Peru. In Peru and Iran, midwives have reported that maternal deaths have been on the rise this year.
To complicate matters, some women and healthcare staff are mistaking symptoms of pregnancy complications for signs of COVID-19. Franka Cadée, president of the International Confederation of Midwives, said, “If women have a headache or don’t feel well, they could well think ‘oh dear I have COVID,’ when actually they could have high blood pressure”, which can be a symptom of pregnancy complications. With so much focus on the coronavirus, pregnant women and healthcare professionals may misunderstand the symptoms. And if a woman decides to self-isolate on the basis of this misunderstanding, it may be an unnecessary risk for the baby.
In Uganda, some women have been denied entry to overwhelmed hospitals because their shortness of breath was suspected to be COVID, according to Dr. Peter Waiswa, an associate professor at Makerere University School of Public Health, in the capital Kampala. Shortness of breath, however, is usual during pregnancy. A similar issue occurred during the 2014 Ebola outbreak; doctors in Sierra Leone mistook pregnant women’s bleeding for Ebola symptoms and turned them away.
'A Perfect Storm’
The hesitation to go in for appointments, an inability to travel to the hospital, and the complications caused by closures and a lack of staff, amounts to what Renfrew describes as “a perfect storm for women.”
Stress can be harmful to pregnancy and women are coping with a lot. In addition to fear of infection, the pandemic has brought about widespread economic worries which have hit women hardest. According to the United Nations, women make up 70 percent of the world’s health workers and first responders and women tend to work in sectors which have been worst hit by the pandemic. There is also the stress of being in lockdown.
Less privacy at home means that women may not be able to open up about issues on the phone or on the family computer while other family members are around. As a result, matters that would normally be discussed in the privacy of a doctor’s office could go unnoticed.
Additionally, there has been a rise in incidents of domestic abuse during the pandemic, and, as Cadée points out, “domestic violence often originates in pregnancy”. According to the World Health Organization (PDF), between 13 and 50 percent of women experienced domestic violence for the first time during pregnancy and, according to another study, pregnant women who experience domestic violence are 37 percent more likely to experience complications that result in hospitalization, such as hypertension, premature rupture of membranes and anemia.
For many higher-income countries in the northern hemisphere, the rise in stillbirths during the first wave of COVID-19 in spring prompted an effort to ensure antenatal care and encourage women to attend appointments in person. The authors of the study in London have said that the stillbirth rate has gone down since the summer. It seems that wealthier countries had the opportunity to react to the warning signs in spring. But the same cannot be said of low and middle-income countries which face more challenges in containing the virus and spreading awareness to healthcare staff and pregnant women. Data is difficult to come by, but Cadée has spoken with midwives in the 142 countries where the ICM has a membership. She said, “The stories were nearly all similar.” Stillbirths are rising and women are unable to get the proper care.
In some cases, staff exhaustion is causing the maltreatment of pregnant women. Healthcare workers may be insensitive or not communicate clearly and there have even been reports of some women getting cesarean sections without being properly informed beforehand. Due to social distancing regulations, many have to go to appointments, as well as give birth, without the support of their partner; this can increase the chance of unclear communication between the mother and healthcare staff.
Fear of hospitals, and possible infection, still linger in many countries. In Nepal, the lockdown was lifted in August but the trend continued.
“The critical factor, we think, is the fear factor,” said Ashish KC, a perinatal epidemiologist at Uppsala University and author of the Nepal study. He compared it with the lingering distrust of healthcare facilities seen in the aftermath of West Africa’s Ebola epidemic and said it could be a long time before women feel safe returning to hospitals. The continuing public transport disruption has also broadened an already stark social divide, as only wealthier women had the means to reach the hospitals.
A Baby Boom – At the Worst Possible Time
In April, the United Nations Population Fund predicted that 47 million women would lose access to contraception because of the pandemic. This, they modeled, could lead to seven million unwanted pregnancies. These could not come at a worse time.
Many joked early in the pandemic about a baby boom, but for many of the poorest women around the world the boom will be involuntary, brought about by the confinement of lockdown and an inability to access family planning. This boom, of babies conceived early in the pandemic, is putting pressure on maternity services now as COVID cases rise and lockdowns tighten. And with it, the risk of stillbirths also grows.
“There likely will be a coronavirus baby boom,” Renfrew said. “It could put immense pressure on the maternity service right at the peak of winter flu season. We could start seeing it, January onwards. It causes the maternity services a lot of concern.”
So far, none of the companies producing coronavirus vaccines tested their vaccine on pregnant women during trials, meaning they have no data on this specific demographic. Countries are taking different approaches as to whether to recommend pregnant women take the vaccine; many will therefore be hesitant. Meanwhile, midwives worry that maternity staff will be low on the priority list of healthcare workers to get the vaccine – in the same way that they were low on this list to get PPE during the first wave of the virus in March.
As COVID cases increase, with new strains of the virus emerging and lockdowns tightening, it could mean more anxiety and complications for pregnant women who are already stressed due to the pandemic.
For the maternal health staff helping them, the complications in pregnancies conceived earlier this year, will be seen for months to come.
“Staff are already exhausted,” said Renfrew in Scotland, “and they’ve got a long time to go before there is real light on their horizon.”