COVID-19 hit the NHS like a tornado. A&E and intensive care were totally transformed. Elective surgery paused. Clinics went virtual. Maternity services were equally and perhaps uniquely disrupted, writes guest blogger Dr Anita Banerjee FHEA, FRCP* Obstetric Physician, Diabetologist and Endocrinologist based at London’s St Thomas’ Hospital.
‘Shutting up shop’ is simply not an option when babies are on their way. But knowing how to organise ‘the shop’ was less clear cut. The data explosion and advice that emanated from China and then Italy – the two epicentres of COVID-19 before it made its way to these shores – was certainly helpful but, faced with a novel virus moving at lightning speed, there were still more unknowns than knowns.
The two immediate questions faced by the UK maternity services were: how will the virus impact pregnant women and how best to respond. Fortunately there were two immediate responses.
First, a rapid review of the maternal deaths during COVID-19 was commissioned to really understand causes and figure out what maternity services can do, and do now.
It is well known that the BAME communities do face health inequalities that can impact their maternity care. It is also known that members of these communities are more likely to present with multi-morbidities when pregnant that can lead to complications and will require complex packages of care.
The rapid review led by Professor Marian Knight has revealed that of the women who died in the first wave of COVID-19, 88% were from the BAME population. Hypertension, diabetes (type one, type two and gestational diabetes) and a raised BMI (body mass index) were common to these women. This underlines the need for clearer communication and better education in this area.
A second lesson is the need to temper the advice to stay at home and self-isolate as well as ensure that the hospital environment is seen as a safe and welcoming space. Three women who featured in the study stayed at home a little bit longer than they should have and were reluctant to come into hospital, which meant by the time they were admitted, they were beyond help and unfortunately died. The mantra needs to be that if you’re not feeling well, are short of breath, or have a persistent cough, you must come in and be assessed.
The study also highlighted the need to safeguard mental health alongside the physical. Four women in the study actually committed suicide. We need to have an open discussion on how we assess women and how we talk to women. And, on a related note, lockdown has caused a spike in domestic violence and pregnant women are more vulnerable to domestic violence. It’s really important we have these conversations openly and transparently too so we help every single pregnant woman.
The second immediate response was led by Oxford University-based Professor Marian Knight, who set up the UK Observational Surveillance Study to look at pregnancies. This work has taken in every single pregnant woman that got COVID-19 between March and May. The paper was published in September.
Among this study’s key findings has been that of the first 427 pregnant women in the UK that got COVID-19, and were admitted into hospital, over half of them fall into the BAME (black, Asian and minority ethnic) population.
Actionable guidance for mothers and care providers
The profession has responded admirably to the coronavirus. There is a plethora of guidance being produced at pace. The Royal College of Obstetrics and Gynaecology and the Royal College of Midwifery have combined forces. The official guidance on COVID-19, infection and pregnancy, has gone through 11 iterations in the past six months meaning that we are learning something new and of significance at least every couple of weeks. This heightened transparency will only serve us well in the face of this unfolding challenge and longer term too.
For expectant mothers it’s important to know the determinants of health, including whether something is a modifiable genetic factor or constitutional factor. We all – whatever our background and ethnicity – bring risk factors to a pregnancy. Social and community networks make a difference as do multifactorial considerations including our social, economic, cultural and environmental standing. As health care providers we need to understand, communicate and listen carefully to ensure that every single expectant mother in this country has the best outcome.
Perspective is also important. Expectant mothers face the same risks as someone who is not pregnant of the same age up until the third trimester. Should the mother contract COVID-19 at this point she is more likely to decompensate which can result in a hospital stay and even a preterm delivery. This is where social distancing and the shielding in the third trimester is ever so important.
To paint pregnant women as helpless victims in the face of COVID-19 is wide of the mark. Many are playing a vital role in combating COVID-19. Many have joined the medical trials happening across the country and they deserve our gratitude. We know that steroids are safe in pregnancy. And we do know dexamethasone works for COVID-19. So being involved in these trials is really important and valuable.
Today’s focus on COVID-19 is understandable. It must not obscure the fact women will still have other medical and obstetric problems. So if the baby is not kicking, if the mother still experiences symptoms that are not right, she must come into hospital.
And finally everyone – whether medical professional or expectant mother or member of wider society – please look after your mental health.
*Dr Anita Banerjee FHEA, FRCP is an Obstetric Physician, Diabetologist and Endocrinologist based at London’s St Thomas’ Hospital. This blog is an edited version of a longer presentation made in a webinar titled COVID-19, pregnancy and separating fact from fiction first broadcast on 30 September and organised by BAME Birthing With Colour.
BAME Birthing With Colour is an initiative that highlights maternity issues facing the BAME communities. The programme is led by Helen Knower, Director of Midwifery, Lewisham and Greenwich NHS Trust and organised by UK registered charity The Brun Bear Foundation.
Proceeds from BAME Birthing With Colour’s event programme support projects that resonate with its core mission and values. This ranges from a bursary scheme to the funding of wellbeing wallets for expectant mothers. The organising committee work on an entirely pro bono basis.
The organisers are staging A one day virtual conference highlighting maternity issues facing the BAME communities on Saturday 07 November 09.00 – 17.00 GMT. To learn more as well as register please visit www.bamematernity.com