There is no doubt the past year has been a major learning curve for clinicians to deal with the effects of a global pandemic, and COVID-19 in particular. Obstetricians, medical teams and midwives have also had to learn how to care for pregnant and postnatal women during this time, to keep them safe. During the past year, as understanding has developed, guidance has been altered to match the evidence as it has arisen. Clinical practice has not always reflected the guidance, as it takes time to filter down.
The latest MBRRACE rapid review of maternal deaths relating to the COVID-19 infection is salutary reading as always. The review covers the stories of 17 women who died during the period of the beginning of June 2020 to the end of March 2021. 10 of the women died directly from COVID-19 infection or associated complications while another 7 died from other causes, including 4 who had also tested positive for the infection.
It is always a shock to read that, in this day and age, women still die related to pregnancy. It is even more sad to realise that, as this report highlights, that improvements to care for 15 of these women may have saved their lives. The three conclusions the MBBRACE team came to are:
- The pandemic instructions led to fear among women to get help resulting in not contacting midwives or medical help late or not at all. They point out the need to ensure women feel safe about attending face to face, but also to recognise remote conversations are not always appropriate. Clear messages should be given to women of what actions to take should their condition deteriorate at home.
- We should all be aware of not being “COVID-centric” and that pregnancy related complications are more common and significant. Many of the cases indicated that the infection was being viewed in isolation from the woman being pregnant rather than taking a holistic view. This often led to delay to include obstetricians in the care. Some cases resulted in slow decision making around birth, and lack of observation in the postnatal period. They add “Think sepsis, not just COVID-19” and ensure regular antenatal care to prevent the risk of complications from hypertensive disorders should be maintained.
- There should be no difference in the care pregnant and non-pregnant women with COVID-19 receive. They highlight the delay of involving the multidisciplinary team and a reluctance to give treatment due to the pregnancy.
It is also significant to note in this group that 9 of the 10 women who died were from black or brown communities. The appropriate use of interpreting services is raised to communicate with families as well as the women themselves. Along with the current concerns of black and brown women receiving inequitable care to those from white communities, this report adds more fuel to the fire.
The report also points out how some women were impacted by lockdown of mental health services with women’s care slipping through the gaps. They noted how the use of telephone rather than face to face consultation may have missed important cues, and the need to listen carefully to family members and take seriously previous mental health symptoms is vital. Women at risk of domestic abuse were also let down with lack of appropriate safeguarding to provide a place of safety. The report highlights concern at the reduction of face to face visits by community based midwives in the postnatal period and the lack of health visiting services.
A strong message is given in the report that COVID-19 is a serious condition for pregnant women and there should be a joined-up multidisciplinary approach to care with at least daily review from senior Obstetricians. At all times considering the emotional care for the woman and families is vital, facilitating visits between women and their partners as a priority when women are critically ill and for the woman to see her baby prior to death.
Women and birthing people in the final trimester should be encouraged to continue to socially distance, as the main risks are in that time period. But this should not be at the detriment to provision of continued appropriate antenatal and mental health care.
The final point to remember in this and other reports about COVID-19 are the long-term impact on families. It was noted that:
Overall, three quarters of the women who died were multiparous; the 17 women who died had 30 existing children, thus a total of 38 motherless children remain.
It is a salutary reminder that, if we are not getting care right in our services, there are much wider, long-term implications than a number in a load of statistics.
Dr Jenny Hall