Has Covid 19 changed maternal care forever?
News of multiple, effective vaccines for Covid 19 has been welcomed across the globe. The conversation is transitioning to ‘when’ rather than ‘if’ we will ever return to our pre-pandemic lifestyles. The effects of the Covid 19 pandemic on society will be the subject of study for many years to come. However the policies implemented to tackle the virus may prove to have the most revolutionary impact on lasting change.
On the 12 March, 2020 the Irish government began a process of shutting all schools, colleges, childcare facilities and cultural institutions. By the end of March Ireland had put in place stringent restrictions on how its citizens went about their daily lives. Although the government certainly would not have considered it at the time the introduction of movement restrictions and remote working policies have resulted in a whole new field of study on maternal care.
While the data regarding lockdowns’ impact on maternal care is still in its infancy, so to speak, initial studies are proving very interesting. Research has already been carried out in Ireland, Denmark and the Netherlands with similar studies currently commencing in Canada and Australia.
Danish Findings
Following implementation of lockdown restrictions in Denmark in March 2020 research has shown the rate of extremely premature birth (below 28 weeks) decreased during the Covid-19 lockdown. The average number of extremely premature births for the period 12th March to 14th April from 2015 to 2019 was 11.4. However for the same period in 2020 there was just 1 instance.
There is a drop from 0.27% of births being extremely premature to 0.02% — in effect a 93% reduction.
Irish Research
The study in Ireland focused on instances of Extremely Low Birth Weight (ELBW) and Very Low Birth Weight (VLBW). I interviewed Professor Roy Phillip, a senior neonatologist in University Maternity Hospital Limerick, who carried out the research in Ireland. Professor Phillip said he realized he needed to investigate when he saw first hand how low the instances of babies born with ELBW and VLBW were throughout March and April this year. University Maternity Hospital Limerick is an excellent case study as it is the only maternity facility for a population of over 450,000 from the counties of Limerick, Clare, North Tipperary and nearby areas. Professor Philips went on to say following his research he believes lockdown restrictions have influenced the health and well-being of pregnant women and the unborn fetus. The data from March — June 2020 has yielded some striking insights.
The data indicates a dramatic decrease in the number of ELBW and VLBW babies born in the Limerick hospital when compared with the average for the same four months of the year in the preceding 4 years.
Professor Philips acknowledges that it is still very early days to make any conclusive recommendations but should subsequent studies yield similar results it could be transformative.
When we factor in multiple criteria such as the rate of late fetal loss, moderate low birth weights (1500–2000g) and ELBW / VLBW an overall trend emerges.
As we can see there are significant drops in 2020 across all criteria.
In light of all this I asked Professor Philips the obvious question — How exactly did lockdown have such a dramatic impact so quickly? Understandably he was keen to stress there are no guarantees at the moment and extensive further research is required. However there are some factors that he is cautiously confident had some influence. Factors such as reduced exposure to infections and passive smoke, better nutrition and less exposure to environmental pollution may have had a significant impact. He placed the greatest emphasis however on reduced stress levels. Even though expectant mothers were still working from home they were not exposed to all the external stresses that go with having to attend the workplace every day. They were getting more sleep, had better partner support and were not having to commute long journeys each day.
Beyond Europe
Looking at this evidence it might feel like we are on the verge of a global revolution in maternal care practices. However thus far we have only looked at countries with robust health care systems which still provided substantial antenatal care throughout COVID-19 restrictions. There is emerging evidence that lockdown has had a detrimental effect on maternal health in more impoverished countries. A severe lockdown was implemented in Nepal from the 21st March, 2020 which included a large curtailing of healthcare services. The data indicates serious negative impacts across multiple criteria in maternal care.
Moreover there is a complete reversal of the trends seen in Denmark when we look at the impact lockdown had in Nepal. We tragically see a 207% increase in neonatal deaths and a 50% increase in stillbirths.
This is partially attributed to the impact lockdown measures had on peoples inability to actually get to hospitals quickly.
Therefore it is crucial that should further study confirm lockdown restrictions do significantly impact maternal care then governments must carefully consider socio-economic criteria when forming policies.
Ireland's duty of care
In Ireland we have a robust social and medical support system and can therefore look at extensive policy change around these findings. The responsibility for improving maternal wellbeing may not actually rest of with the Dept. of Health ultimately but with the Dept. of Social Protection. Looking at the factors listed by Professor Phillip expanding maternity benefit so that it commences at much earlier in the gestation period rather than the recommended 2 weeks before due date is crucial. Maternity leave starting from around 28 weeks may have significant positive impacts on the wellbeing of both mother and baby.
Another option would be exploring remote working from around the 28 week mark to best encapsulate the main benefits highlighted by the lockdown restrictions. Employers could be supported in this by something similar to the Employee Wage Subsidy Scheme now in place due to COVID-19. We must do more to support pregnant women and with the trial run already completed all that is required is swift policy change in state maternity care practices. Extensive further study is obviously required and we will need to study the data from countries that did not utilise lockdown measures when it becomes available to do a more robust study.
A little might just go a long way……
It is ironic that a global health crisis and the methods for fighting it might have unintentionally resulted in better healthcare for some. The data to support this is only now becoming available but should a trend develop governments will not be able to ignore the significance of those findings. 2020 has been a difficult year by any measure, but it may have shone a very bright light on a matter which is one of the most important to all of us — improving the health and well-being of mothers and children. It is remarkable that we may have accidentally discovered a real tool for tackling what can be a hugely distressful experience and it is medication free. We may just need to give women and developing babies a bit more time to look after themselves — not asking much really is it?
