24 August 2020

Pandemic pregnancies: missed checkups, home births, free births

Clinical O&G Women

COVID-19 restrictions are causing distress, confusion and disruption to antenatal care.

Disruption to antenatal care out of fear of exposure to SARS-CoV-2 is putting pregnant women and their babies at increased risk of other harms and even death, experts say.

Professor of Midwifery Hannah Dahlen AM, who is leading a nationwide survey on the experiences of pregnant women, told The Medical Republic that women were missing check-ups and choosing to give birth at home, according to early data.

In the three weeks since the “Birth in the time of COVID-19” survey opened there have been more than 3,500 responses from women in all states and territories, including more than 300 Aboriginal women.

“We’ve had a huge response, from all models of care,” said Professor Dahlen, of Western Sydney University. “Things we’re looking at include objective and subjective measures of stress in response to the pandemic, what their support systems are like, and how that moderates stress.”

She said the levels of sustained stress from the pandemic exceeded that experienced in most living people’s lifetimes.

“There is more and more evidence that significant stress during your pregnancy affects the unborn child, and those impacts go on into adulthood,” she said.

“This is not just ‘Oh, women are having a hard time’. This is about potentially reshaping the future of society.”

A common theme arising from the surveys is confusion over the mixed approaches to telehealth or face-to-face care among providers, Professor Dahlen said.

“There is absolutely no consistency anywhere, and this is causing enormous distress to women because they talk online and find out that in this hospital they’re doing something different to that hospital, this model of care is different to that model of care.

“I’ve been talking to women in Melbourne, due to give birth next couple of weeks, who have been seen physically twice.

“They’ve had everything else done virtually and it’s to the point where they’re actually purchasing blood pressure machines and just telling the midwife over the phone what the reading is.”

Other women reported having a blood test to check fasting glucose, but not having a glucose tolerance test at all, Professor Dahlen added.

“Some women said ‘the first or second time I had a baby, I was told I had to have all these tests and it was critical that I keep my appointments because my baby could die. Now suddenly COVID has struck and everyone is saying it’s actually not that important.’”

The team plans to follow up six months after women give birth, Professor Dahlen said.

“We’re getting concerned that women are perhaps putting off immunisation to avoid having to take their baby out.”

In a statement on its website, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) says it is difficult to give definitive advice for pregnant women and their families because information for one area might not be generalisable.

It advises seeking prompt treatment for concerns about a pregnancy. “Routine antenatal investigations, ultrasounds, maternal and fetal assessments should continue as before”, allowing for “modifications”.

It says changes to the delivery of care may include: replacing face-to-face consultations with telehealth; reducing, postponing and/or increasing the interval between antenatal visits; and restricting hospital visitors to partners only.

RANZCOG did not respond by time of writing as to whether it was concerned that women may be missing important pregnancy checks due to the pandemic.

While figures can’t be provided until the survey is published, Professor Dahlen said “a reasonable number” of women were choosing to give birth at home instead of hospital because they could only have one support person under the COVID-19 restrictions.

“The number one concern they have is not being able to have the support people present at the birth. And that is driving women to make other choices such as home birth, which is fine if you’re a low-risk woman and can access a midwife, but the midwives are overbooked: some home-birth services have seen a 30% increase in [demand].

“If women can’t access midwives, our concern is that more will choose to free birth – with no health professional present.”

Restrictions on support people during check-ups have also seen women receive confronting news alone, Professor Dahlen said.

“There’s a lot of distress coming from women who are not allowed to take anyone else into the ultrasound, and there’s been some very distressing reports of finding their baby has died and having no one there to share it with, which is just shattering.”

In mid-August, midwife and Associate Professor Jane Warland raised concern that discouraging face-to-face antenatal visits might result in high-risk pregnancies being missed.

Professor Warland, of the University of South Australia, referred to a four-fold increase in stillbirths at St George’s University Hospital in London during the COVID-19 pandemic, which was not accounted for by COVID-19 infections in mother or baby.

Professor Dahlen said there were also reports of women delaying seeking help because of COVID-19.

“A big thing that’s happening and we’ve discovered in the interviews with midwives, is women are not telling people they’re having reduced movements of the baby. They don’t want to come in, to expose themselves to the risk of COVID-19.

“The message from us health providers needs to be ‘we are open for business and will do everything we can to make you safe, but if you have any concerns please do not delay getting help.’”

GP and past RACGP Chair of the Sexual Health Medicine Network Dr Lara Roeske stressed that general practices had implemented a range of infection prevention and control measures for patient and staff safety.

“It is essential that patients keep up their antenatal checks and appointments during pregnancy.

“Women should always be given the option of shared care when this is available and in the current environment shared care arrangements may be a more attractive option for many. We have long maintained that general practice plays a central role in the provision of maternity care and we must adapt how we help our patients during the pandemic.”

The RACGP recently added translations in Arabic, Simplified Chinese, Traditional Chinese, Hindi and Vietnamese to the Expert Advice Matters website, following GP concerns that culturally and linguistically diverse (CALD) patients were not seeking out health services during the pandemic.

Dr Roeske said these patients faced barriers to accessing healthcare, including language and health literacy issues, prior to the pandemic.

“It would not surprise me to learn that a higher-than-usual percentage of pregnant women, including those from diverse backgrounds, are avoiding or delaying necessary visits to the GP and other health services. For the sake of the mother and her child, we must do all we can to stop this happening,” she said.

Professor Dahlen said she held particular concern for pregnant CALD women, and reduced access to support services and translators.

“For example if their partner is their main interpreter but has to stay at home and look after the kids, and they don’t want an interpreter in the room when they give birth but there’s virtually no English, you’ve got women going through their entire birth experience with nobody there who can tell them what’s going on.

“What I worry about, and we are going to look at in the six-month follow up, is the wave of birth trauma that is going to be cascading into the future because of the emotional and psychological impact of some of these things.”

Take the online survey here.