Maternal care and pandemics: how do we lower risks?

Maternal care during a pandemic: how do we stop putting mothers and babies at risk?

On March 19, 2020, the Australian government took the unprecedented step of closing Australia’s borders in a bid to prevent the spread of the yet unknown SARS-CoV-2 virus.

What followed was a period of movement and physical restrictions, which triggered in some people fear, loneliness and stress and has been associated with a modest negative change in overall population mental health.

While the true effects of lockdowns on our mental health are yet to emerge, experts in the maternal health space are concerned that the blunt-force public health measures invoked at the time disregarded the specific needs of pregnant women and new mothers.

“Our response to COVID highlighted that we still treat pregnancy in a medicalised way, and that we’re very quick to undervalue the social and emotional aspects of this time,” says University of New England researcher and maternal clinical psychologist Lucy Frankham.

She has recently released a study on the impacts of COVID-19 related distress on antenatal depression in Australia.

Her research found that in many cases, “mitigation efforts were at odds with usual best practice. The way routine care was delivered changed, many appointments were modified (e.g. changed to telehealth or less regular), visitors and support people were minimised or restricted altogether, and antenatal education was cancelled”. 

Frankham, whose patients are still dealing with the ramifications of birth and pregnancy trauma from 2020 and 2021, says that decreasing support for mothers at a time when it was most needed,  ran contrary to scientific evidence, which shows it is a vital buffer for perinatal mental health issues — and results in healthier, more well-adjusted infants.

“We know that women who are stressed and depressed in pregnancy are more likely to have depression postnatally,” she says. “Maternal stress also significantly impacts the developing foetus and infants when they are born — during pregnancy things change at the cellular level.”

It is a time when infants’ stress response system is developing, paving the way to how they will deal with stress down the track, Frankham says.  We know from previous incidences of exceptional circumstances that maternal hardships can have life-long consequences for their children.

“We know that women who are stressed and depressed in pregnancy are more likely to have depression postnatally.”

Lucy Frankham

One example is the 2014 study by Canadian researchers, which found specific markers on the DNA of children whose mothers were pregnant or became pregnant soon after the 1998 ice storm that resulted in power outages across eastern Ontario and southern Quebec, forcing Quebec residents to live through severe cold without electricity and heat for up to six weeks.

After following and testing more than 150 families after the storm in various ways (by issuing questionnaires and taking blood samples from some of the children 13 years after the event) the researchers found a correlation between the degree of DNA methylation (an epigenetic modification associated with gene regulation) and the degree of objective hardship the mothers experienced during the ice storm.

In other words, the events of the disaster had left markings on the children’s DNA, negatively impacting BMI and obesity, insulin secretion and their immune system.

Much of the research into the experiences of pregnant women during the pandemic has found frustration at confusing or limited guidelines from healthcare providers; the rigid nature of hospital policies, such as forcing women to choose between their planned support person (such as a doula or midwife) or their partner; limited postpartum help for breastfeeding; and reduced access to peer support in the antenatal period.

“It is an incredibly vulnerable time.”

Professor Deborah Lupton

For Professor Deborah Lupton, who works at UNSW’s Centre for Social Research in Health, the measures taken by various governments around Australia were appropriate, especially as the risk of COVID was still unknown.

“I totally understand the struggles people would have had having babies during this period,” she says. “It is an incredibly vulnerable time.” She points out that the strict lockdowns and border closures were initially brought in to protect vulnerable people — such as pregnant women, who are immuno-compromised — before we had a vaccine.

“I understand how difficult it has been for people, but it would have been much worse if they [pregnant women] or their child had died from COVID,” Lupton says. Recent studies show that pregnant women with COVID are four times as likely to be admitted to intensive care than uninfected women, with 2% of those infected needing mechanical ventilation to help them breathe. Pregnant women with COVID are also more likely to die, as well as develop pneumonia.

It is, as Lupton puts it, “just a crap situation all round”.

Reduced maternity care and support is linked to substance use, developing mental illness and adverse birth outcomes; and children whose mothers have had postnatal depression are more likely to have problems with physical health such as asthma and respiratory problems, neurodevelopmental issues, as well as behavioural and emotional concerns.

“We’ve seen that one in 10 people will have long COVID. Imagine those mothers looking after kids struggling with this long-term.”

Professor Deborah Lupton

But women and infants who have been diagnosed with COVID are also more likely to die and lead difficult lives. “We’ve seen that one in 10 people will have long COVID,” Lupton says. “Imagine those mothers looking after kids struggling with this long-term.”

So what have we learnt?

“Aspects of the measures were definitely an overreach — the amount of police that stopped and fined people swimming in the ocean, or others drinking and sitting alone on benches in parks,” Lupton says. “This over-rigorous and ridiculous implementation of rules needs to be looked at.”

Mark Davis, an Associate Professor at Monash University and an expert in public health, pandemics and influenza, agrees. “There’s a lot of discussion about proportionality now. A lot of people are saying, ‘was what we were required to do out of proportion with what needed to be done’?” he asks. 

“The scale of social, psychological and economic difficulties on different people really needs to be considered.”

Frankham believes that the social safety net for vulnerable populations really needs to be placed at the forefront of any future pandemic planning and messaging.

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“Simply screening better for antenatal depression will help; we have protocols in place already, and we really dropped the ball,” she says.  Continuity of care, already proven to have strong evidence in terms of health outcomes for women and babies (such as having the same nurse visiting at home) should also be implemented.

“In a pandemic, ensuring as many women as possible are receiving midwife group practice or some sort of continuous care is so important,” Frankham says. “Some of these women during COVID would talk to the same person during their pregnancy and it was so effective.”

The government should also put more funding into homebirth, she says, pointing to an increased number of women seeking that option during the pandemic as hospitals tightened regulations. Currently, only about 14 hospitals offer home birthing nationally, which Franham says is “grossly underfunded by Medicare”.

“In a pandemic, ensuring as many women as possible are receiving midwife group practice or some sort of continuous care is so important.”

Lucy Frankham

Professor Catherine Bennett, head of Deakin University’s Epidemiology Department, says we are still discovering the full impact of healthcare disruptions during the pandemic.

“Some impacts are the result of precautionary practices; and some would have occurred in the wake of uncontrolled community transmission in the pre-vaccine phase,” she says. “We just heard this week that a drop in swimming skills might be contributing to higher than usual swimming-related deaths this summer!”

Perhaps most tellingly, it will be the nature of the next pandemic that will help inform the response.

“We don’t know what the biological characteristics will be of the next pandemic, how dangerous it’s going to be, which people will be most impacted,” Davis points out. “There is a lot of talk now of what to do if the pandemic turns worse, or if other infectious diseases become problematic or we don’t have vaccines that work. How do we scale, triage, be more specific about the response?”

“It’s a horrible puzzle and an issue that has no answers,” he says.

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