This scoping review synthesized the literature related to maternal health and COVID-19. Literature published through September 11 was included in the review. It was divided into the following categories: direct effects on pregnancy, intrauterine transmission, labor and delivery, breastfeeding and infant contact, prenatal care, mental health, and healthcare infrastructure.
Direct Effects on Pregnancy
When examining the direct effects on pregnancy, most cases were asymptomatic or mildly symptomatic with the common clinical presentations of fever, cough, and dyspnea. Further, adverse outcomes were noted as infrequent. Most cases of COVID-19 among pregnant women did not progress to severe disease, and ICU admission involving mechanical ventilation was seldom required. Preterm delivery was the most commonly experienced adverse outcome. Women who developed severe COVID-19 did have a low risk of a preeclampsia-like syndrome.
The literature on vertical transmission of SARS-CoV-2 is rather speculative therefore additional evidence is required to confirm mechanisms of transmission. Studies thus far do not support intrauterine infection with COVID-19. Only few cases of vertical transmission have been observed as there can be placental infection and the vertical transmission is illustrated by COVID-19 antibodies in neonatal blood. According to the review, risk of vertical transmission is very low ( <1%). Further research is needed to identify the plausibility of mother-child transmission.
Labor and Delivery
The review also provided the literature on C-section rates related to COVID-19. Infected pregnant women experienced a significant increase in operative delivery. Delivery by C-section occurred in 91% of infected women. Perhaps this was due to more aggressive measures being taken to ensure the safety of mother and child during the pandemic.
Breastfeeding and Infant Contact
It is unclear whether COVID-19 passes through breastmilk. The published evidence on this topic consisted of case reports and case series of postpartum infected women. Of milk samples collected from 37 women, the majority had tested negative. The only evidence was that of one positive sample among 8 breastfeeding women. Given this information, transmission of the virus through breastmilk is unlikely.
Non-essential health services were postponed as a result of the pandemic. This led to reductions in the obtention of antenatal and postnatal care. In high income countries, an online survey of 4,451 pregnant women found that nearly a third reported elevated levels of stress and this was largely due to changes in prenatal appointments.
In low-to-middle-income countries (LMIC), a modelling study on the indirect effects of the pandemic found that there was a reduction in antenatal care by at least 18%, and possibly up to 51.9%, and a similar reduction in postnatal care.
COVID-19 has significantly impacted mental health of pregnant women and those post-partum. Women who feared vertical transmission experienced feelings of anxiety and depression. Social distancing and isolation/quarantine measures greatly exacerbated these feelings. Unpredictability of COVID-19, along with deprivation of familial and social support led to an increase in perinatal distress. A global survey of pregnant and postpartum women found that 40% of women screened positive for post-traumatic stress disorder (PTSD) and over 70% of women reported clinically significant depression or anxiety.
The pandemic took a toll on LMICs. Many maternal and newborn healthcare providers worldwide were untrained in COVID-19 from their health facility. According to the scoping review, 53% of providers in LMICS and 31% in HICs did not feel knowledgeable in how to care for a COVID-19 maternity patient and 90% of participants reported higher stress levels. This caused quality of care issues as well as provider shortages. Many modelling studies indicated grim outcomes for LMICs and the weak healthcare infrastructure in these countries led to rapid spread of the virus. Brazil, for example, had limited resources available for antenatal care and with the pandemic, those resources were even more scarce. This led to an increased risk of maternal mortality resulting from COVID-19. These and other shortcomings of healthcare systems in LMICs led to poorer physical and mental health of pregnant and postpartum people.
This scoping review illustrated many important points regarding maternal health and COVID-19. It is important to note that majority of the studies in the review were either case reports, case series, or cross-sectional. Therefore, more rigorous studies are needed to firmly identify the health impact of COVID-19 on pregnant women.