Protecting Women’s, Pregnant Persons’ and Infants’ Health during the COVID-19 Pandemic
Emergencies such as natural disasters, pandemic diseases, and person-made disasters disrupt daily life for everyone, but pregnant persons and infants are particularly affected due to unique health concerns that may not be adequately addressed in disasters and public health crises. Unfortunately, disaster preparedness plans often do not fully consider or prioritize women’s reproductive health needs including access to essential services such as contraception and abortion services, or the health and well-being of pregnant and postpartum persons and their infants/children (Callaghan et al., 2007).
Women often experience increased stress levels, physical exertion, and caretaking responsibilities during disasters (CDC, n.d.-a). The effects of these burdens are especially salient for those who are pregnant and even more so for those who are also low-income and/or who face class and/or race discrimination. Pregnancy during a disaster is often associated with adverse birth outcomes including pregnancy loss, preterm birth, intrauterine growth restriction, and decreased birth weight (Callaghan et al., 2007; Zotti et al., 2015). With respect to the coronavirus (COVID-2019), there are insufficient data to know whether pregnant persons affected by COVID-19 are at increased risk of adverse health outcomes and if individuals with COVID-19 can pass the virus through the placenta to the fetus via vertical transmission (Weigel, 2020). Regardless of this lack of data, it is essential that pregnant persons protect themselves from COVID-19 in the same ways as non-pregnant persons: avoiding people who are sick, maintaining social distance from those one encounters outside the household, and washing hands frequently using soap and water or alcohol-based hand sanitizer.
It is especially important to make special accommodations for homeless and incarcerated pregnant persons; these individuals are particularly vulnerable, and in the case of COVID-19, are at increased risk because of the difficulty of practicing safe practices such as handwashing and social distancing.UIC Center of Excellence in Maternal and Child Health|
In order to ensure a healthy pregnancy and delivery, pregnant persons affected by disasters need to be assured of a continuation of prenatal care. Where possible, telehealth approaches for routine prenatal care should be implemented. However, this approach is not yet universally available and is more challenging for both medically and socially high-risk women for whom in-person visits may be particularly important. With respect to Medicaid (which pays for almost 50% of US births) payment for prenatal care delivered through telehealth mechanisms, new guidance (last updated March 18, 2020) from the Centers for Medicare and Medicaid Services (CMS) has been issued during the COVID-19 pandemic: “States have broad flexibility to cover telehealth through Medicaid, including the methods of communication to use (such as telephonic, video technology commonly available on smart phones and other devices). No federal approval is needed for state Medicaid programs to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services.” (CMS, 2020; Cuello, 2020).
More challenging during the COVID-19 pandemic is providing women with adequate support during labor and delivery, particularly with non-relatives. Allowing doulas to provide support during labor and delivery is an issue of concern and will take education and advocacy. CDC guidance on prevention of COVID-19 during labor and delivery mentions support persons of spouse or partner, but not doulas (CDC, 2020-a). In Chicago, BirthGuide Chicago is providing information on labor and delivery policies including whether doulas are permitted.
Mothers of infants face the additional difficulty of disrupted feeding practices during disasters and emergencies. For those who formula-feed, disasters may mean a lack of access to clean water, making it difficult to safely wash hands and infant feeding items (CDC, n.d.-b). If the disaster causes a loss of electricity, breastfeeding mothers cannot use breast pump equipment or safely refrigerate expressed milk (CDC, n.d.-c). According to the CDC, “In limited studies on women with COVID-19 and another coronavirus infection, Severe Acute Respiratory Syndrome (SARS-CoV), the virus has not been detected in breast milk; however, we do not know whether mothers with COVID-19 can transmit the virus via breast milk.” CDC suggests that a person with COVID-19 or who is suspected of having COVID-19, actively avoid transmitting the virus to the infant by washing their hands before touching the infant and wearing a face mask, if possible, while breastfeeding. If expressing breast milk with a manual or electric breast pump, hands should be washed before touching any pump or bottle parts and the breast pump cleaned properly after each use. CDC suggests that the breastfeeding person should consider having someone who is not sick, feed the expressed breast milk to the infant (CDC, 2020-b).
As natural and manmade disasters become more frequent (e.g., flooding, hurricanes, tornadoes, spread of new viruses such as Zika and COVID-19) in the US (and across the globe), it is important to acknowledge that preparedness plans to support the needs of women, infants and children during disasters and emergencies are underdeveloped (American College of Obstetricians and Gynecologists, 2010; reaffirmed 2016 and 2018). Currently, most disaster preparedness centers on individuals and families developing their own emergency plans to access the services and supplies they need rather than ensuring that emergency services will be available to all to meet their needs. Moving forward, in order to foster optimal outcomes during disasters and emergencies, the responsibility for preparedness and action in the face of disasters must be shared between individuals, institutions, and local, state, and federal governments, and action to meet the needs of pregnant persons and infants should be specifically addressed. Surveillance systems that can immediately begin to track the experiences of pregnant women must be on the ready and retrospective systems such as Pregnancy Risk Assessment Monitoring Systems should include questions about exposure.
The reality is that public health infrastructure including the Maternal and Child Health Block Grant /Title V and our vital statistics systems need to be fully supported in non-disaster times to ensure a robust response when disaster strikes.UIC Center of Excellence in Maternal and Child Health|
Arden Handler, DrPH, is the interim director of the division of community health sciences at the UIC School of Public Health and the director of the UIC Center of Excellence in Maternal and Child Health. Her research focuses on the exploration of factors that increase inequities in adverse pregnancy outcomes and examination of the ways in which the health care delivery system, particularly prenatal care, perinatal care, postpartum care, and preconception/interconception/well-woman health care can ameliorate these inequities. She has conducted a number of evaluation projects focused on reducing racial/ethnic disparities in adverse pregnancy outcomes and has conducted a number of studies on women’s access, satisfaction, and utilization of prenatal care. She recently completed implementation of the Kellogg funded Well-Woman Project, is currently the evaluator for the Illinois Breast and Cervical Cancer Screening Program, and is working on a number of research projects related to postpartum care and contraception, including testing the feasibility of incorporating use of a reproductive life planning tool at the Well-Baby Visit. She is a former member of the US Secretary’s Advisory Committee on Infant Mortality.
Anna Dubnicka is a Master of Public Health in Maternal and Child Health Epidemiology student at the UIC School of Public Health.
The UIC Center of Excellence in Maternal and Child Health, formerly the Maternal and Child Health Program, is one of only 13 Centers of Excellence nationwide, funded by U.S. Department of Health and Human Services. The Center trains students to support and promote the health and well-being of women, children, and families. The Center emphasizes multi-level approaches to understanding the complex factors that affect population health and health disparities. An essential ingredient is the partnerships established with public and private agencies serving the maternal and child health population and the communities in which maternal and child health problems are prevalent. The Center is committed to scientific rigor, evidence-based public health practice and the principles of participatory and collaborative research and practice.
American College of Obstetricians and Gynecologists. (2010; reaffirmed 2018). Preparing for Disasters: Perspectives on Women (Committee Opinion No. 457).
Callaghan, W.M., Rasmussen, S.A., Jamieson, D.J., Ventura, S.J., Farr, S.L., … & Posner, S.F. (2007). Health concerns of women and infants in times of natural disasters: Lessons learned from Hurricane Katrina. Maternal and Child Health Journal, 11, 307-311. DOI: 10.1007/s10995-007-0177-4.
Centers for Disease Control and Prevention. (n.d.-a). Reproductive health in emergency preparedness and response.
Centers for Disease Control and Prevention. (n.d.-b). Safety messages for pregnant, postpartum, and breastfeeding women during disasters.
Centers for Disease Control and Prevention. (n.d.-c). Disaster planning: Infant and child feeding.
Centers for Disease Control and Prevention. (2020-a). Inpatient obstetric healthcare guidance.
Centers for Disease Control and Prevention. (2020-b). Pregnancy & breastfeeding: Information about Coronavirus Disease 2019.
Centers for Medicare & Medicaid Services. (2020). COVID-19 frequently asked questions for State Medicaid and Children’s Health Insurance Program Agencies [PDF].
Cuello, L. Overview on Using Medicaid to Respond to COVID-19. National Health Law Program. March, 18, 2020.
Weigel, G. (2020). Novel coronavirus “COVID-19”: Special considerations for pregnant women.
Zotti, M.E., Williams, A.M., Robertson, M., Horney, J., & Hsia, J. (2013). Post-disaster reproductive health outcomes. Maternal and Child Health Journal, 17(5), 783–796.