Background

COVID-19, first documented in Wuhan, China at the end of 2019 [1], has rapidly spread across the globe, infecting tens of millions of individuals [2]. While sex-disaggregated data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mortalities suggest it poses more severe health outcomes for men than women [3], there are concerns that the disease could disproportionately burden women in a social and economic sense. Furthermore, it is a particularly salient question whether pregnant women are more susceptible to infection with SARS-CoV-2 or have more severe disease outcomes. Outside of direct infection, the impact of the pandemic and pandemic-control policies on healthcare infrastructure, societies, and the global economy may also affect maternal health. Pregnant women and new mothers are a unique population, with particular mental and physical healthcare needs who are also particularly vulnerable to issues such as domestic violence. Finally, the impact of the COVID-19 pandemic is likely to be context-specific, and differ depending on a variety of country-specific factors. A global pandemic is likely to only reveal its consequences after significant time passes, and literature published before or immediately after policies are implemented may not capture all relevant outcomes. The goal of this sco** review is to synthesize the current literature on both the direct consequences of contracting COVID-19 during pregnancy and the indirect consequences of the pandemic for pregnant individuals and mothers, taking into account the myriad ways in which containment and prevention measures have disrupted daily life.

Methods

This sco** review followed the framework outlined by Arksey and O’Malley [4], in order to map the existing literature on the direct and indirect impacts of COVID-19 on maternal health, incorporating the following 5 stages:

Identify research question

How has the COVID-19 pandemic directly and indirectly impacted maternal health globally?

Identify relevant types of evidence

Literature published in English from January 1st, 2020 to September 11, 2020 was included in the search. The search strategy involved the algorithm used by the Maternal Health Task Force’s Buzz, a biweekly e-newsletter presenting current research relevant to maternal health. Hand searches were conducted in PubMed using MeSH terms (see Additional file 1), along with broader searches of “COVID” and “corona” followed by the terms: “pregnant”, “maternal”, “women”, “reproductive”, “economic”, “social”, “indirect”, “direct.” Google Scholar was also searched using these terms to capture grey literature, such as news articles and working papers that have not yet completed the peer review process. This sco** review aimed to capture rapidly evolving evidence in a timely manner, including issues not yet addressed in well-funded, epidemiological studies. The snowball method of consulting sources’ bibliographies was used for certain articles to supplement referenced evidence. The search strategy as outlined above was not registered with PROSPERO.

Study selection

Literature was included if published during the time frame outlined above and primarily assessed the direct or indirect effects of the COVID-19 pandemic on maternal health. Search terms utilized did not directly address neonatal health, but publications on topics relevant to both populations (transmission, breastfeeding, maternity care practices) were also included if returned by the search terms. Case reports, case series, qualitative studies, systematic and sco** reviews, and meta-analyses were included. As some publications included were systematic or sco** reviews or meta-analyses, there was some duplication in data on which publications were based. The article containing the more complete description of the data was used for data charting. Sources were excluded if they consisted only of recommendations for future research. Predictive research was excluded if it consisted only of speculation referencing past epidemics but included if based on quantitative methods. News articles, reports, and other grey literature were included if they contained quantifiable evidence (case reports, survey results, qualitative analyses).After reading full texts and synthesizing relevant evidence, literature was organized thematically. Themes were discussed and decided upon by all four authors. Themes that reflected potential impacts of COVID-19, but for which no quantitative evidence existed were excluded from the review. Of 200 peer-reviewed articles, 129 were excluded; 7 did not pertain to maternal health or COVID-19, 3 were responses to articles, and 199 were commentaries, editorials, or practice guidelines which did not contain relevant evidence. Of 196 articles from the grey literature, 172 articles were excluded; 124 did not pertain to maternal health or COVID-19, and 48 did not contain objective information. See Fig. 1 for a visual representation of inclusion and exclusion.

Fig. 1
figure 1

Flowchart of literature selection

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Chart the data

71 peer-reviewed articles and 24 publications from the grey literature were included from the original search. Two peer-reviewed articles that contradicted earlier findings that were published after September 11, 2020 were added. Publications included represented a wide range of methodologies including case reports, case series, observational studies, letters to the editor, and news articles. The authors developed a rubric of major themes that arose in the literature and recorded standard information including location, sampling method, and size of sample, and key findings of each study (see Table 1). An adaptive thematic analysis [5] was applied using the following steps. The authors identified themes in the literature by a reading and discussing each article included. Articles were then coded independently by two authors. All four authors discussed each code and grouped codes into final themes.

Table 1 Studies included in the sco** review
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Collate, summarize, and report results

Narrative descriptions of the evidence were written for each theme that the authors determined in the above stages. All authors reviewed descriptions for clarity and relevance and some themes were combined post hoc to improve readability and avoid redundancy.

Main text

Direct effects on pregnancy

During pregnancy, people undergo significant physiologic and immunologic alterations to support and protect the develo** fetus. These changes can increase the risk of infection with respiratory viruses for pregnant individuals and their fetuses. Thus, pregnant individuals and their children may be at heightened risk for infection with SARS-CoV-2 [2].

In general, pregnant individuals with COVID-19 do not seem to display more severe disease symptoms than non-pregnant individuals. Most cases among pregnant people are asymptomatic or mildly symptomatic [6]. For symptomatic cases, the most common clinical presentations included fever, cough, and dyspnea [17, 18]. Additionally, the non-medical impact of the COVID-19 pandemic is already apparent in this vulnerable population. While short and medium-term consequences of these impacts are emerging, the long-term consequences are currently unknown and will require careful research to be elucidated.

To date, studies of the effects of the COVID-19 pandemic have, perhaps understandably, given time constraints and availability of data, lacked rigorous methods. To adequately assess these effects, we require research that carefully controls for pre-COVID-19 levels of the different outcomes of interest (e.g. depressive symptoms, C-Section) and population characteristics (e.g. comorbidity, socio-economic status) to more validly assess time trends. While reducing the frequency of prenatal visits in high income countries (HIC) may not necessarily be associated with worse birth outcomes, reducing the basic antenatal care in low- and middle-income countries (LMIC) is likely to impact maternal and neonatal health [110, 111]. Continued surveillance and reporting are critical to ascertain whether maternal mortality and morbidity have increased during the pandemic and which populations were affected most severely.

The Covid-19 pandemic has created a multitude of questions regarding the optimal policies to reduce the spread of SARS-Cov-2 while minimizing the unintended detrimental consequences to family wellbeing and gender equity. Salient among these are: in what circumstances should schools and daycares resume care and in what format? Which models of antenatal and delivery care produce optimal outcomes? Which economic relief policies protect gender equity in the workplace and family wellbeing? Heterogeneous and inconsistent application of policies and models for healthcare and childcare delivery both within and across countries, while potentially not ideal for pandemic response, provide a near-natural experiment that helps to explore these questions.

At the same time, policies impacting pregnant and parenting people have been implemented with little evidence. Several of these policies have the potential to significantly harm pregnant individuals’ health and undermine their rights. Most concerning are those that limit emotional support during labor and delivery, mandate early infant separation, and shorten postpartum stays. While the clinical rationale behind high C-section rates among pregnant individuals diagnosed with Covid-19 are unclear, these rates are alarming given that no evidence exists that C-section delivery lowers risk of transmission of SARS-CoV-2 or improves maternal health [81, 112].

These concerns lead us to provide several clear policy recommendations we believe either have sufficient evidence to merit implementation or must be pursued because of ethical and human rights considerations. The first two pertain to healthcare policy. Given the evidence on the paucity of severe outcomes from SARS-CoV-2 infection in newborns, we urge the CDC to align with the WHO’s strong recommendation to keep the mother/infant dyad together even if the mother has a confirmed infection of SARS-CoV-2. Precautions, of course, are warranted, but our opinion is that the overwhelming evidence behind the benefits of early bonding and breastfeeding outweigh the risk of infection in the newborn.

Second, whenever possible, healthcare organizations should consider the mental health impacts of any policies implemented to reduce risk of transmission. Early and convincing evidence currently exists that maternal mental health issues have increased during the pandemic. Policies that limit or eliminate the ability to give birth with a support person present or that are likely to increase distress, potentially exacerbating underlying mental health issues, should be avoided. With many healthcare organizations shortening postpartum hospital stays or providing postpartum visits through telemedicine, there is also the risk that screening for postpartum depression or other mental health issues will be forgotten or glossed over. Healthcare providers should be vigilant of the increased mental health needs of their pregnant and parenting patients.

Finally, daycare and school closures are causing incredible stress and destabilization to caregivers, especially women, who often bear the brunt of childcare duties. These closures along with other workplace related consequences of the pandemic pose a serious threat to gender equity in the workforce. Without serious mitigation through policy, this threat is potentially far-reaching. We strongly recommend that governments prioritize the resumption of schooling under safe conditions and childcare when easing shelter in place or other pandemic-related restrictions. Failure to do so is likely to worsen any short-term losses in women’s employment given women’s disproportionate burden of childcare, and to put vulnerable single-mother and low income households at risk of poverty and food insecurity.

Conclusion

While rigorous studies have not yet been conducted, early evidence from this sco** review shows that many of the social and economic consequences of the COVID-19 crisis likely affect women more than men. The low risk of mother to child transmission in-utero or via breast milk is well documented. It seems that pregnancy may constitute a particularly vulnerable period for COVID-19, but this requires further confirmation through well designed and implemented research. An increased risk of distress and psychiatric problems during pregnancy and postnatally during the pandemic is likely, but also in this case high-quality evidence is lacking. Likewise, a rise in the prevalence of domestic violence is plausible and supported by several studies, but we need more representative data. Studies of maternal morbidity and mortality are also lacking. Rigorous epidemiological studies must document the health impact of infection with SARS-CoV-2 during pregnancy as well as the changes in health care service and accessibility and their impact on maternal health. This review, however, provides good evidence that mothers with children are more likely to suffer job and income losses during the pandemic than men and women without children. Single mothers in particular are likely to suffer from food insecurity. These socioeconomic consequences for women are similar across many high- and low-income countries.