Coronavirus COVID-19 | Evidence Based Birth® Resource Page

A SPECIAL MESSAGE FROM DR. REBECCA DEKKER

Founder and CEO of Evidence Based Birth®

Hi Everyone,

It’s Rebecca, here. I know this is an uncertain time and many are feeling a range of emotions. Our goal remains the same: to provide you with friendly, accessible, evidence based information so that you can make informed decisions

During a global pandemic, our goal is more important than ever.

At Evidence Based Birth®, we are continually monitoring the situation and our research team is examining the best available resources. We will keep this page updated with relevant information for both pregnant parents and birth professionals.

Wishing you calm and a sense of peace,

Rebecca

VIRTUAL DOULA SUPPORT FOR BIRTHING FAMILIES DURING COVID-19

Evidence Based Birth® has created a Virtual Doula Directory, populated by our Professional Members and Instructors. We know that birthing during a pandemic can be fraught with uncertainty, confusion, and even anxiety. We believe now, more than ever, birthing families will benefit from the support of a doula. Knowing many hospitals are restricting visitor access, the birth world has responded by increased virtual support options. We have collected some of the best of the best options for you!
Virtual Doula FAQs
What is a Virtual Doula?

A Virtual Doula provides education, comforting affirmations, and reassuring support throughout pregnancy, birth and the postpartum transition. You will be supported in a similar way as a traditional in-person doula, except services will be conducted virtually.

What does it look like to be supported by a Virtual Doula?

Virtual Doulas will likely meet for your prenatal consultations via video chat, and will still be available to answer any questions via phone, text, or email. For your birth, a virtual doula will likely use a video meeting platform and provide you with comfort measures and laboring techniques that you previously rehearsed and discussed. How virtual doula support is conducted varies from doula to doula – be sure to ask in your interview what the doula’s support package looks like!

Why would I hire a Virtual Doula?

Navigating birth during this unprecedented pandemic, having a virtual doula on your team for support is a great option for when a doula is not able to attend your birth in person.

What kinds of interview questions should I ask?

You should ask the same interview questions you would ask during a normal doula interview – including, and especially, what the virtual doula’s backup options are.

VIRTUAL CHILDBIRTH EDUCATION FOR BIRTHING FAMILIES DURING COVID-19

Evidence Based Birth® has moved its pioneering Childbirth Class completely online, taught by our Evidence Based Birth® Instructors. The best way to get enrolled in our completely online Childbirth Class is to click on the button below!

The Evidence on COVID-19

Webinar Replay | Monday, March 23rd 2020

COVID-19 Research Update

Webinar Replay | Monday, April 20th 2020

Evidence on Masks

Wearing masks seems to have become politicized. In some places everyone is wearing masks, and in other places wearing a mask is frowned upon. What is the latest research on face coverings and whether or not they are effective at preventing the spread of SARS-CoV-2?

A study was published June 11 in The Proceedings of the National Academy of Sciences (Zhang et al. 2020). The researchers looked at different strategies for reducing viral transmission and determined that wearing a facemask may be the key factor in preventing the spread of the virus.

They analyzed the disease trends and mitigation measures in three epicenters: Wuhan China, Italy, and New York City, from January 23 to May 9. The analysis found that the difference with and without mandated face covering largely determined the shape of the trends at these epicenters. When face covering was mandated, there was a significant reduction in the number of infections (by over 78,000 in Italy from April 6 to May 9 and over 66,000 in New York City from April 17 to May 9). Social distancing without mandated face covering was not an effective strategy to reduce the number of infections at the epicenters.

The researchers concluded that wearing face masks in public is the single most effective way to prevent SARS-CoV-2 transmission, especially when it takes place alongside social distancing, quarantine, extensive testing, and contact tracing. This is because airborne transmission is the dominant route for the spread of COVID-19.

The U.S. Centers for Disease Control has sew and no sew instructions on how to make cloth face coverings here.

The Royal College of Obstetricians & Gynecologists updated their guidance on COVID-19 infection and pregnancy on June 19, 2020. You can access the full text here. A page with Q&A’s relating to this guidance was updated June 26, 2020 and is available here.

They changed their advice on face masks to reflect national guidance from NHS England, which says that face masks and coverings should be worn by all NHS hospital staff and visitors. Specifically, all pregnant people and any visitors are advised to wear face coverings at prenatal appointments. In addition, they specified that babies should not be advised to wear face masks because of the risk of suffocation.

To take the U.S. for example, there have been 125,803 deaths from COVID-19 in the U.S. as of June 28. The U.S. is projected to reach nearly 180,000 deaths from COVID-19 by October 1, 2020. That number falls to about 146,000 if at least 95% of people wear masks in public. So, they are estimating that more than half of the predicted deaths between now and October 1st could be avoided if 95% of people wore masks in public.

Official Evidence Based Birth® Research Updates on COVID-19

Research Update for Tuesday, September 8 + Detailed Q&A!

 This week we share findings from a “living systematic review” that will be updated with new evidence on a regular basis, new recommendations from the MBRRACE-UK: Saving Lives Improving Mothers’ Care rapid report (*trigger warning: maternal mortality and racial disparities*), findings from another living systematic review on transmission of SARS-CoV-2 through breast milk and breastfeeding, and links to more interesting research that has come out over the last few weeks.

Today’s questions (answered in a Q&A section at the bottom of this email) include:

  • Are any COVID-19 vaccine clinical trials including pregnant or postpartum volunteers?

And a few updated FAQs from previous research updates:

  • I was trying to conceive, but now I am so concerned about COVID-19 and pregnancy. How do I weigh the potential risks of infection during pregnancy versus the risks of delaying trying to conceive at my advanced maternal age? 
  • I was wondering if there is any research on the incidence of spontaneous abortions in pregnancy? 
  • What precautions should be made once home with a newborn? Should family members remain 6 feet from baby, wear masks, etc.? 

To ask a question for consideration for future newsletters, submit your question here.

 Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.

Research Update for August 3, 2020

Numbers Update from Johns Hopkins University

As of 10 AM EDT on September 7, 2020, there are about 27 million confirmed and probable cases of COVID-19 around the world. The highest number of cases is still in the U.S. (over 6.2 million), followed by Brazil, India, Russia, Peru, Colombia, South Africa, and Mexico.

A “living systematic review” that will be updated with new evidence on a regular basis

  • Note from EBB:We are very excited about this new research that was published in the BMJ on September 1! Since the start of the pandemic, there has been a steep increase in review articles on COVID-19 in pregnancy. These reviews vary in quality, and even the most rigorous systematic reviews are quickly outdated. Now, this research collaborative (called the PregCOV-19 Living Systematic Review Consortium) has coordinated with the World Health Organization (WHO), the Cochrane Centre, and other key groups to conduct a first-rate systematic review in a framework that allows them to quickly update the findings as new data emerge. Going forward, this living systematic review will inform living practice guidelines on COVID-19 and pregnancy.  
  • The goal of the systematic review and meta-analysis by Allotey et al. (2020) was to determine the risk factors and pregnancy/birth outcomes among pregnant and recently pregnant people with suspected or confirmed COVID-19.
  • The authors conducted an extensive literature search of major databases, and even searched preprint servers, website repositories of COVID-19 studies, guidelines, social media, and reference lists of published and unpublished studies—with no language restrictions. They were trying to find every single cohort study on COVID-19 and pregnancy from December 1, 2019 to June 26, 2020. The authors were careful to exclude studies with duplicate data; they reached out to the authors of the primary studies when there was any uncertainty about duplicates.
  • The research team coordinated their efforts with a patient and public advisory group in London. Members of the public attended virtual meetings so that they could be involved in the conduct, interpretation, and reporting of the systematic review.
  • Altogether, the researchers identified 77 studies to include (over 13,000 pregnant and recently pregnant people with COVID-19 and over 83,000 non-pregnant women of reproductive age with COVID-19). Of the 77 studies, 26 were from the United States (U.S.), 24 from China, seven from Italy, six from Spain, three each from the United Kingdom (U.K.) and France, and one each from Belgium, Brazil, Denmark, Israel, Japan, Mexico, the Netherlands, and Portugal.
  • Findings: Overall, about 1 in 10 pregnant or recently pregnant people who were admitted to the hospital for any reason (i.e. illness, childbirth) were diagnosed as having suspected or confirmed COVID-19. Note that these findings only apply to pregnant people admitted to a hospital at some point during pregnancy or postpartum. Also, hospitals used different screening strategies, with some testing only people with symptoms and others testing everyone upon admission (universal testing).
  • The most common clinical signs/symptoms of COVID-19 in pregnancy were fever (40%) and cough (39%). Pregnant and recently pregnant people with COVID-19 were less likely to report symptoms of fever and myalgia (muscle pain) compared to non-pregnant women of the same age.
  • Compared to non-pregnant women of the same age, pregnant people and recently pregnant people were more likely to be admitted to an intensive care unit and receive invasive ventilation.
  • Severe COVID-19 was diagnosed in about 13% of pregnant and recently pregnant people with suspected or confirmed COVID-19 (out of more than 13,000 people). Sadly, 73 mothers with confirmed COVID-19 died (from any cause).
  • They did not find any differences in the risk of stillbirth or newborn death with COVID-19. Very few studies reported outcomes by trimester, so they were not able to assess the rate of miscarriage.
  • Risk factors that were significantly linked to severe COVID-19 in pregnancy included maternal age 35 years and older, body mass index (BMI) 30 and above, chronic high blood pressure, and pre-existing diabetes.
  • Pregnant and recently pregnant people were at increased risk of preterm birth; however, many of the preterm births were iatrogenic (caused by medical intervention in the pregnancy). The overall rate of spontaneous preterm birth in pregnant people with COVID-19 was not high (6%, similar to the pre-pandemic rate).
  • About 25% of newborns born to mothers with COVID-19 were admitted to the neonatal unit (significantly more than newborns born to mothers without COVID-19).
  • You can read the WHO’s news coverage of this research study here.

The MBRRACE-UK: Saving Lives Improving Mothers’ Care rapid report (**Trigger warning: Maternal mortality and racial disparities**)

  • MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom) issued a report on maternal deaths in the UK tied to COVID-19 (Knight et al. 2020). The goal of the report was to describe lessons learned from reviewing the care of mothers who died from COVID-19 as well as those who died from mental health-related causes or domestic violence between March and May 2020.
  • The UK has conducted “Confidential Enquiries into Maternal Deaths” since 1952, four years after the start of the National Health Service in the UK (Freedman & Lucas, 2015). The objective of these reports has always been to reduce maternal mortality and morbidity by identifying the causes of maternal deaths and—most importantly—identifying any substandard treatment that could be changed in order to improve care and save lives. The UK’s Confidential Enquiry Reports are considered a gold standard in quality improvement of maternity care.
  • In response to the pandemic, the MBRRACE-UK team instituted rapid notification of maternal deaths linked to COVID-19. Rapid reviews were conducted on every death to a mother with confirmed or suspected COVID-19 who died during pregnancy or up to one year after pregnancy. Maternal deaths from mental-health related causes or domestic violence were also reviewed, since they may have been linked to lockdown measures in response to the pandemic.
  • Importantly, there is no evidence of an increase in maternal deaths from COVID-19. There are about 70 maternal deaths every year in the UK, and these deaths from COVID-19 may not affect the overall 3-year maternal death rate.
  • A total of 10 women died with COVID-19 in the UK between March 1, 2020 and May 31. Seven (88%) of the women who died were from black and minority ethnic groups. Nine died up to 6 weeks after pregnancy and one died between 6 weeks and one year after the end of pregnancy. Seven of these women died from causes directly related to severe COVID-19 disease (six from cardio-respiratory complications and one from complications relating to a blood clot in the brain). Another woman’s exact cause of death could not be determined, but the reviewers thought it was related to her COVID-19 infection. Everyone who died from COVID-19 developed symptoms in the third trimester and died after giving birth. Two women with COVID-19 died from causes unrelated to their infection.
  • There were four maternal deaths from suicide (two during pregnancy, one up to six weeks after pregnancy, and one between six weeks and one year after the end of pregnancy). Two women died from domestic violence between six weeks and one year after the end of pregnancy.
  • The reviewers felt that improvements in care could have been made for most of the mothers who died, and improvements may have prevented an estimated 33% of maternal deaths related to COVID-19.
  • Key recommendations from the report include:
  • All pregnant and post-partum people with COVID-19 should receive multidisciplinary team care and obstetric-led daily review.
  • Pregnant and post-partum people with COVID-19 should be considered for antiviral and other therapies as part of routine care, and they should not be excluded from clinical trials unless there is a clear contraindication.
  • Pregnant and post-partum people with COVID-19 should be given specific advice (using an interpreter, if necessary) about the risk of symptoms getting worse and when to seek urgent medical care.
  • Communicate clearly with partners and families (using an interpreter, as necessary) and prioritize visits of severely ill pregnant and post-partum people with COVID-19 and their loved ones.
  • Mothers with mental health concerns must be appropriately assessed, included face-to-face if necessary, and a mental health expert should be involved in triage and clinical review. Referral with mental health concerns more than one time should be considered a “red flag” and prompt clinical review. Remove the mother to a place of safety when necessary, even during public health measures such as lockdown.
  • Pregnant and post-partum people of color with COVID-19 should be advised to seek medical advice without delay for health concerns. Clinicians should have a lower threshold to review and admit people of color with COVID-19.
  • All pregnant people admitted with confirmed or suspected COVID-19 should receive prophylactic low-molecular-weight heparin (LMWH, a class of anticoagulant medications), unless birth is expected within 12 hours. The appropriate dosing regimen of LMWH for people with severe COVID-19 should be discussed in a multidisciplinary review.
  • Signs of critical health failure (decompensation) include an increase in oxygen requirements or FiO2 > 40%, a respiratory rate >30/min, reduction in urine output, or drowsiness, even if oxygen saturations are normal. If any of these signs develop, escalate critical care urgently. Critical care support can be provided in a variety of settings (do not wait for a bed in the critical care unit).

Another living systematic review: transmission of SARS-CoV-2 through breast milk and breastfeeding 

  • The objective of this review was to assess all of the available evidence relating to the possible transmission of the virus through breast milk and breastfeeding (Centeno-Tablante et al. 2020).
  • The WHO currently recommends exclusive breastfeeding for at least the first six months and continued breastfeeding until at least two years of age while taking necessary precautions for infection prevention in infants born to mothers with confirmed or suspected COVID-19. This living review will be updated regularly with new evidence. Its findings will inform future WHO guidelines on breastfeeding with COVID-19, as well as various national guidelines.
  • Altogether the review included 340 studies. Of these, 37 studies included data on breast milk samples that were tested for the virus and 303 studies described lactating people or infants but did not include data on breast milk samples tested.
  • The 37 studies with analyzed breast milk samples were case reports (28 studies) and case series (9 studies). The studies were from China (21), Italy (6), Germany (2), Turkey (2), Australia (1), Belgium (1), Canada (1), Jordan (1), Singapore (1), and the Repblic of Korea (1). A total of 77 breastfeeding/chestfeeding infants whose mothers were diagnosed with COVID-19 and able to provide a breastmilk sample for testing were included in these 37 studies.
  • Nineteen of the 77 children had confirmed COVID-19 (14 newborns and five older infants). Of these 19 positive infants, 10 were reported to be exclusively breastfed from someone with COVID-19, five were partially breastfed, two were fed with formula, and two did not report how the infant was fed.
  • Nine of the 68 breast milk samples from mothers with COVID-19 were positive (they had detectable levels of SARS-CoV-2 RNA). Six infants were exposed to positive breast milk samples; four of these infants tested positive for COVID-19 and two were negative.
  • The authors concluded that there is currently no evidence of SARS-CoV-2 transmission through breast milk. They say it is important to note that even though viral RNA has been detected in breast milk samples, there have been no attempts to culture the virus, so we do not know if viral particles in breast milk can be infectious when ingested by infants. The review authors did not recommend any changes to the current WHO guidelines on breastfeeding with COVID-19.

Links to additional interesting research that has come out over the last few weeks:

Q & A Section

Question: Are any COVID-19 vaccine clinical trials including pregnant or postpartum volunteers?  

Answer: It doesn’t appear that any vaccine trials are open to pregnant or lactating individuals at this time. On September 3, the WHO released a document with details about 34 candidate COVID-19 vaccines in clinical evaluation. For each vaccine developer/manufacturer, you can see whether they are in Phase 1, Phase 1/2, Phase 2, or Phase 3 clinical trials. I followed the links to each of the Phase 3 trials and they consistently mention pregnancy and lactation in their participant exclusion criteria. Some of them even specify that volunteers should have no intention of becoming pregnant during the study and should be using a reliable form of contraception. At least one trial asked volunteers to abstain from all activities that could result in pregnancy for at least 28 days prior to the first dose.  

There has been a great deal of discussion in the research about the ethics of including pregnant people in COVID-19 vaccine trials (Farrell et al. 2020; Dashraath et al. 2020; Health et al. 2020).  Some researchers argue that pregnant people should be able to make autonomous, informed decisions about participating in clinical trials. Especially, they say, given the recent data showing that pregnant people are more likely to be admitted to an intensive care unit and receive invasive ventilation compared to non-pregnant women of reproductive age. Others argue that the risks of pregnant people taking part in experimental trials of drugs or vaccines are too high when non-drug alternatives exist (e.g., prolonged social distancing). However, there are also risks to consider from social distancing for an extended period of time (e.g., domestic violence, social isolation, mental health consequences, economic loss, etc.)

In a publication in The Lancet on September 5, the authors called for pregnant people to be included in phase 3 trial protocols of adenovirus-vectored vaccines and also protein-based vaccines for COVID-19 (Dashraath et al. 2020). It remains to be seen whether or not this will actually happen, and, if it does, whether a meaningful number of pregnant people will volunteer once invited.

A few updated FAQs from previous research updates:

Question: I was trying to conceive, but now I am so concerned about COVID-19 and pregnancy. How do I weigh the potential risks of infection during pregnancy versus the risks of delaying trying to conceive at my advanced maternal age?  

Answer: This is a deeply personal choice, but we can share a few factors you might consider when deciding whether or not to delay trying to conceive because of the pandemic. First, pregnant people are not any more likely to become infected with this virus compared to non-pregnant adults, and few develop severe illness. The majority of infected pregnant people will only experience mild or moderate cold/flu symptoms. There is no evidence of an increased rate of maternal death from COVID-19. There is also no evidence to suggest an increased risk of miscarriage with COVID-19. Some babies born to infected parents have tested positive soon after birth, but illness is often mild.

Question:  I was wondering if there is any research on the incidence of spontaneous abortions in pregnancy? 

Answer: So far, there is no evidence to suggest an increased risk of miscarriage if you are in early pregnancy and become infected with SARS-CoV-2. 

Case reports on fetal outcomes with maternal COVID-19 refer mostly to pregnant people who were infected in the third trimester, close to the time of birth. There have been several case reports of mothers with COVID-19 who experienced miscarriages or stillbirths related to their infection, but since these are individual reports (not from a larger study), researchers have not been able to determine if there is an increased risk of these outcomes with COVID-19, or if these are very rare events.

Question: What precautions should be made once home with a newborn? Should family members remain 6 feet from baby, wear masks, etc.?   

Answer: COVID-19 disease in infants is rare, but children under the age of one appear to be at higher risk of developing severe illness from infection compared to older children and healthy adults. A study of more than 2,100 children with suspected or confirmed COVID-19 in China showed that about 1 in 10 infants developed severe or critical illness (Dong et al. 2020).  

The U.S. Centers for Disease Control (CDC) has a page with info on how to protect vulnerable members of the household from COVID-19, but they do not include infants among those at higher risk for severe illness. The people at the greatest risk of severe illness from infection are older adults (65 and older) and people of any age who have serious underlying medical conditions.  

Grandparents or other visitors from outside of the household who fit that description are at increased risk and need to be protected just as the newborn needs to be protected. In fact, if your family just recently gave birth in the hospital, then the members of your household (who stayed in the hospital) may pose a greater risk to vulnerable visitors than the visitors pose to you and the new baby for the first two weeks after discharge.

So, depending on your individual risk perception, you could decide to consider your newborn a vulnerable member of the household and take the additional precautions outlined by the CDC. If you decide to bring the baby into contact with people from outside of the household (grandparents, for example), then you can consider taking precautions such as using face masks (not for children under age two) and keeping physical distance. [Side note: Many parents tell us they are navigating this situation by trying to do socially distanced visits outdoors.]

The Royal College of Obstetricians and Gynecologists (RCOG) advises that family members who live in the household with the newborn take regular hygiene precautions, such as careful hand washing and keeping anyone with symptoms of illness away from the baby, if possible. Large family gatherings to celebrate the baby’s arrival are not recommended.  

The American Academy of Pediatrics (AAP) recommends special care for newborns born to parents who have confirmed or suspected COVID-19. 

This concludes the research update for September 8, 2020. I hope you found it helpful! Our next research update will come out on October 5.

References

  • Allotey, J., Stallings, E., Bonet, M., et al. (2020). Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis BMJ,370, m3320. Click here. Free full text!
  • Centeno‐Tablante, E., Medina‐Rivera, M., Finkelstein, J.L., et al. (2020), Transmission of SARS‐CoV‐2 through breast milk and breastfeeding: a living systematic review. Ann. N.Y. Acad. Sci. Click here. Free full text!
  • Dashraath, P., Nielsen-Saines, K., Madhi, S. A., et al. (2020). COVID-19 vaccines and neglected pregnancy. The Lancet, 396(10252), E22. Click here. Free full text!
  • Farrell, R., Michie, M., & Pope, R. (2020). Pregnant Women in Trials of Covid-19: A Critical Time to Consider Ethical Frameworks of Inclusion in Clinical Trials. Ethics & human research, 42(4), 17–23. Click here. Free full text!
  • Heath, P. T., Le Doare, K., Khalil, A. (2020). Inclusion of pregnant women in COVID-19 vaccine development. Lancet Infect Dis., 20(9), 1007-1008. Click here.
  • Knight, M., Bunch, K., Cairns, A., et al. on behalf of MBRRACE-UK (2020). Saving Lives, Improving Mothers’ Care Rapid Report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK March – May 2020 Oxford: National Perinatal Epidemiology Unit, University of Oxford 2020. Click here. Free full text!
Research Update for Monday, August 3 + Detailed Q&A!

 

 This week we share updated guidance from the American Academy of Pediatrics (AAP), guidelines on infants born to mothers with COVID-19 from 17 countries, a paper reflecting on equity in maternity care during the pandemic, the first report of prolonged viral shedding of SARS-CoV-2 in a pregnant person, the most well documented case report of vertical transmission, a Canadian Medical Association News Brief on gaps in early pregnancy care due to COVID-19 fears, and links to more interesting research that has come out over the last few weeks.

 Today’s questions (answered in a Q&A section at the bottom of this email) include:

  • I was wondering if there is any research on the incidence of spontaneous abortions in pregnancy?
  • What precautions should pregnant teachers take if/when we return to the classroom?
  • What does the research say about wearing a mask while pregnant? Does wearing a mask pose any risks to mother or baby?

To ask a question for consideration for future newsletters, submit your question here

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.

Numbers Update from Johns Hopkins University

As of 10 AM EDT on August 3, 2020, there are about 18 million confirmed cases of COVID-19 around the world. The highest number of cases is still in the U.S. (over 4.6 million), followed by Brazil, India, Russia, South Africa, Mexico, Peru, Chile, Iran, and Colombia.

Updated guidance from the American Academy of Pediatrics (AAP)

  • On July 22, the AAP updated their guidance on the management of infants born to mothers with suspected or confirmed COVID-19 (AAP, 2020).
  • Earlier AAP guidance that came out in April and May said, “While difficult, the safest course of action from the perspective of minimizing the likelihood of the infant becoming infected is to separate mother and infant, at least temporarily.” Now, the AAP no longer recommends physical separation of the infant in a room separate from the infected birthing parent. They say that no published report has identified an infant who has died during the initial birth hospitalization as a direct result of infection with SARS-CoV-2. In addition, the National Perinatal COVID-19 Registry (with over 1,500 mother-infant pairs) has found that infants who separate from their infected mothers have a similar risk of testing positive as those who room-in with infection prevention measures in place. Data show that about 2% to 5% of infants test positive in the first 24 to 96 hours after birth if their birthing parent had COVID-19. Of course, if the birthing parent is very ill, they might not be able to care for their infant. In these situations, infants can be cared for by non-infected caregivers in the mothers’ room or temporarily separated as needed.
  • The current recommendations from the AAP are that infected birthing parents and their newborns may room-in according to usual center practice; mothers should wear a mask and perform hand-hygiene when proving hands-on care for their newborns; using an isolette (with properly latched doors) may help to protect the newborn from respiratory droplets; hospital staff should wear appropriate personal protective equipment (PPE); and everyone (including non-infected family members) should wear a mask and perform careful hand hygiene when providing hands-on care to the infant.
  • Delayed cord clamping should continue per usual practice, but infected mothers are advised to wear a mask while holding their baby.
  • The AAP strongly supports breastfeeding/chestfeeding. Infected parents should wear a mask and perform careful hand hygiene before nursing the baby or expressing breast milk.
  • Note from EBB: At the beginning of the pandemic, recommendations to separate parents from their infants prompted me to create a sample informed refusal of newborn separation document. We will that document with these latest recommendations, and you can download it here at our COVID-19 resource page. Unfortunately, while the AAP and the CDC no longer recommend separate rooms for newborns and infected parents, individual birth facilities may not be following the latest guidance.

 Guidelines on infants born to mothers with COVID-19 from 17 countries 

  • A review examined 20 guidelines and recommendations on caring for infants born to mothers with COVID-19 from 17 countries: Australia, Brazil, Canada, China, France, India, Italy, Japan, Saudi Arabia, Singapore, South Africa, South Korea, Spain, Sweden, Switzerland, the UK and the USA (Yeo et al. 2020). The review was published July 27, 2020 and included guidelines published before May 25, 2020.
  • They determined that the guidelines were based on expert opinion with very little evidence to support each recommendation. Ideally, guidelines should be informed by high quality evidence, but this has not been possible with the rapidly evolving pandemic. Most did not provide guidance on vaginal versus Cesarean birth with COVID-19 or caring for infants with symptoms of COVID-19. They did not find any that provided recommendations on caring for potentially infected infants after hospital discharge.
  • 13 of the guidelines encouraged keeping infants together with their infected birthing parents (rooming-in), while 6 recommended separation after birth until the mother tested negative. At the beginning of the pandemic, China, Singapore and South Korea isolated infants from their infected mothers for up to 14 days as a safety precaution.
  • The majority of guidelines encouraged breastfeeding or feeding with expressed breast milk, but two countries (Singapore and South Korea) did not recommend any breastfeeding or the use of breast milk. China recommended pasteurizing expressed breast milk before feeding it to the baby.
  • They concluded that global COVID-19 guidelines (published through May 25) were variable and low quality. Instead of centering on expert opinion, they said guidelines should emphasize the extent of uncertainty in the available evidence, and countries and organizations should participate in international efforts to find new evidence to fill the gaps.

Paper reflecting on equity in maternity care during the pandemic

  • A recent article published in Health Equity discusses the many ways that the pandemic has amplified pre-existing disparities and inequities in health care (Niles et al. 2020). The pandemic seems to be shining a light on all of the gaps and failures in health care.
  • The authors argue that institutional policies can uphold the rights of birthing people and simultaneously decrease COVID-19 transmission and protect health care workers. They are not mutually exclusive.
  • As we discussed above in regards to newborn care, there has been a lack of standardization in guidelines and recommendations that have come out in response to the pandemic. Niles et al. points out that clinical protocols and institutional policy that are not evidence-based most acutely harms historically disadvantaged people. For example, policies that prohibit labor support companions disproportionately impact Black and indigenous parents who experience consistently higher rates of mistreatment and abandonment during maternity care. Denying laboring people the presence of a labor support companion also places them at increased risk of poor birth outcomes, including a higher rate of Cesareans and instrumental vaginal births, longer labors, increased need for pain medication, and more negative feelings about their childbirth experience. Marginalized groups are already at increased risk of poor birth outcomes, so losing access to the benefits of continuous labor support especially harms them.
  • The authors caution that shortsighted policies in the name of safety do more harm than good. Instead, we must comprehensively examine the system level inequities that the pandemic has shed light on, and create compassionate systems of respectful “patient-centered care” to truly protect all birthing families.

The first report of prolonged viral shedding of SARS-CoV-2 in a pregnant person

  • For most people with COVID-19 in the general population, viral RNA from the SARS-CoV-2 virus can be detected on a swab by RT-PCR test for about 3 weeks after acute infection. After that, the virus becomes nondetectable for most patients and they test negative. There have been a few reports of prolonged viral shedding in the general population, where people with COVID-19 continue to shed virus and test positive for up to 83 days after their symptoms resolve. Prolonged viral shedding has been found to be more common in male patients, those with other medical conditions, and those with severe cases of COVID-19.
  • In the first case report of its kind, Molina et al. (2020) described a pregnant woman in Washington State who continued to test positive for 120 days from her initial positive test result. The 27 year-old previously healthy first-time mother developed symptoms of COVID-19 at 28 weeks of pregnancy and tested positive. Her symptoms were considered “mild” and included chest pain, cough, and shortness of breath on exertion. She did not have a fever. They sent her home and advised her to quarantine. After 3 days, her symptoms went away.
  • At about 37 weeks of pregnancy, the mother requested an antibody test and she had detectable immunoglobulin (Ig) G antibodies to the virus.
  • Just after 38 weeks of pregnancy, the mother’s water broke on its own and she went into early labor. The hospital tested her on admission (they had a universal testing policy) and she tested positive despite not having experienced any symptoms of COVID-19 since her initial infection at 28 weeks. The hospital treated her according to their guidelines for managing patients with SARS-CoV-2 infection.
  • The mother had her labor sped up with medication and gave birth vaginally with vacuum-use. The infant was healthy, roomed-in with the mother, and tested negative for the virus at 24 hours and 48 hours of life. Cord blood, placental samples, newborn meconium samples, and breast milk all tested negative. The cord blood was positive for IgG antibodies to the virus. They continued to test the mother after birth, and she finally tested negative for SARS-CoV-2 by RT-PCR test 50 days after giving birth and 120 days from her first positive test result.
  • The authors think pregnancy might result in physiologic immune changes that affect the clinical course of COVID-19, so that it takes longer for the body to clear the virus. The RT-PCR test does not distinguish infective from inactive virus, so prolonged viral shedding could be occurring with inactive virus. Researchers think that the virus becomes less infective within 8 to 9 days after the initial acute infection.
  • Tests can identify IgM antibodies against SARS-CoV-2 between 2 and 4 weeks after infection and IgG antibodies after about week 5. So, the authors think there may be a role for antibody testing with pregnant people who test positive but do not have symptoms. A positive SARS-CoV-2 IgG test result would be evidence of an infection that occurred many weeks ago rather than an active asymptomatic infection. 

The most well documented case report of vertical transmission

  • On July 14, doctors from France published a very well documented case of transplacental (through the placenta) transmission of SARS-CoV-2 infection (Vivanti et al. 2020). Other cases have been described, but in these reports it is not clear whether the infections were passed through the placenta, through the cervix, or through environmental exposures during or immediately following the birth.
  • A newborn congenital infection is an infection that was passed to the fetus during pregnancy or the baby during birth. To be considered a “proven” congenital SARS-CoV-2 infection, the virus must be detected in the amniotic fluid collected before the rupture of membranes or in the newborn’s blood drawn right after birth. In this case, the virus was detected in both.
  • A first-time mother with a previously uncomplicated pregnancy developed COVID-19 at 35 weeks, and came to the hospital with fever and severe cough. SARS-CoV-2 virus was detected in her blood, and in nasopharyngeal and vaginal swabs. She received a Cesarean under general anesthesia for abnormal fetal heart race tracings indicating fetal distress. Clear amniotic fluid was collected prior to rupture of membranes and tested positive. The placental samples also tested positive. The mother recovered in good condition 6 days after the birth.
  • The baby was in good condition but developed neurological symptoms on day 3. The baby’s blood and lung fluid, as well as nasopharyngeal swabs and rectal swabs (taken on days 1, 3, and 18 of life) all tested positive for SARS-CoV-2. The baby gradually recovered and was discharged after 18 days. A 2-month follow-up showed improved neurological findings.
  • The authors concluded that they reported “a proven case of transplacental transmission of SARS-CoV-2 from a pregnant woman affected by COVID-19 during late pregnancy to her offspring”.
  • Note from EBB: This case report provides stronger evidence that mother-to-baby transmission through the placenta can occur, but the clinical significance of this is still unclear. Most placental samples studied so far have tested negative. And, as we mentioned above, less than 5% of infants born to infected parents test positive in the first 24 to 96 hours after birth. In all reported cases of infants testing positive right after birth, the babies recovered from their infection and were well. A recent review by Kreis et al. (2020) discusses the human placenta’s defense against SARS-CoV-2 virus in great detail. They describe how the placenta has many immune defense mechanisms and how it provides a strong physical barrier to protect the fetus from maternal infections. For these reasons, they think vertical transmission of SARS-CoV-2 is probably quite rare; however, they mentioned that pregnant people with chronic inflammation from high body mass index (BMI), high blood pressure, and preeclampsia might be more susceptible to SARS-CoV-2 placental infection.

Canadian Medical Association News Brief on gaps in early pregnancy care due to COVID-19 fears

  • Some Toronto doctors are reporting seeing fewer pregnant patients in the emergency department. Typically in Ontario, about 1 in 3 pregnant people use the emergency department at some time during their pregnancy, usually during the first 12 weeks when they may not yet have a maternity care provider. Many people (about 80%) seek emergency care when they experience signs of a miscarriage in early pregnancy. The doctors are concerned that the pandemic is causing some people to avoid seeking medical care in early pregnancy.
  • Many people can miscarry at home without complications, but 1-2% of pregnancies are ectopic and may require surgery to prevent life-threatening bleeding. An ectopic pregnancy is when a fertilized egg attaches outside of the uterus. According to the NHS, symptoms of ectopic miscarriage include long-lasting and severe pain, usually on one side of the belly, vaginal bleeding or spotting, pain in your shoulder tip, diarrhea and vomiting, and feeling very faint and lightheaded. Symptoms usually appear between 5 and 14 weeks of pregnancy. So, if you think you are experiencing pregnancy loss, monitor your symptoms, and seek medical attention as needed despite the pandemic. 

Links to more interesting research that has come out over the last few weeks

Q and A Section

Question:  I was wondering if there is any research on the incidence of spontaneous abortions in pregnancy? 

Answer: So far, there is no evidence to suggest an increased risk of miscarriage if you are in early pregnancy and become infected with SARS-CoV-2. 

Case reports on fetal outcomes with maternal COVID-19 refer mostly to pregnant people who were infected in the third trimester, close to the time of birth. There have been several case reports of mothers with COVID-19 who experienced miscarriages or stillbirths related to their infection, but since these are individual reports (not from a larger study), researchers have not been able to determine if there is an increased risk of these outcomes with COVID-19, or if these are very rare events.

Question: What precautions should pregnant teachers take if/when we return to the classroom? 

Answer: The American Academy of Pediatrics released a guidance document called COVID-19 Planning Considerations: Guidance for School Re-entry. They encourage schools to make accommodations for pregnant teachers, teachers with medical conditions that put them at higher risk for serious illness with COVID-19, those who live with higher risk family members, and those with mental health conditions that make it harder for them to cope with the additional stress of the pandemic. However, they did not elaborate on what those accommodations might look like.

The U.S. Centers for Disease Control does not specifically mention pregnancy, but they advise schools to offer protections for staff at higher risk for severe illness from COVID-19 (e.g., telework, modified job responsibilities). They say pregnant people “might be at an increased risk” for severe illness from COVID-19. The CDC also released a Readiness and Planning Tool to Prevent the Spread of COVID-19 in K-12 Schools, which you can access here.

 If you are pregnant and deciding how or when to return to the classroom, it might be helpful to consider the rate of cases in your county, what accommodations can be made to reduce your exposure, any other underlying health conditions in your household, and your stage of pregnancy. Pregnant health care workers in the U.K. are advised to take extra precautions and work from home after 28 weeks of pregnancy (there are more guidelines on COVID-19 and pregnant health care workers than pregnant teachers). I expect we’ll be seeing more guidance on accommodations to protect vulnerable school staff in the coming weeks.

Question: What does the research say about wearing a mask while pregnant? Does wearing a mask pose any risks to mother or baby?

Answer: The physiologic effect of mask wearing is a really hot topic right now. Some people are concerned that wearing a mask might cause physical harm by restricting airflow. The amount of airflow resistance that you experience really depends on what type of mask you are wearing. Cloth face coverings and surgical masks do not impose very much airflow resistance because the fabric allows for the exchange of gases and they aren’t tightly fitted to the face.

The research on physiologic changes with mask wearing during pregnancy focuses on pregnant people wearing N95 respirators as personal protection equipment. A review of four studies with a total of 42 pregnant people examined physiologic changes with limited duration N95 use (Roeckner et al. 2020). They found that wearing a N95 for about 1 hour resulted in “a minor impairment of gas exchange that does not ultimately lead to notable physiologic changes to the mother or fetus.” Unfortunately, there is no evidence on prolonged N95 respirator use in pregnancy (e.g., wearing a N95 for a work shift).

This concludes the research update for August 3, 2020. I hope you found it helpful! Our next research update will come out on September 7.

References

Comeau, N. (2020). COVID-19 fears may widen gaps in early pregnancy care. 192(30), E870. Click here. Free full text!

Kreis, N.-N., Ritter, A., Louwen, F., et al. (2020). A Message from the Human Placenta: Structural and Immunomodulatory Defense against SARS-CoV-2. Cells, 9, 1777. Click here. Free full text!

Molina, L. P., Chow, S-K, Nickel, A. et al. (2020). Prolonged Detection of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RNA in an Obstetric Patient With Antibody Seroconversion, Obstetrics & Gynecology: July 21, 2020. Click here. Free full text!

Niles, P. M., Asiodu, I. V., Crear-Perry, J., et al. (2020). Health Equity, Jul 2020, 330-333. Click here. Free full text!

Roeckner, J. T., Krstić, N., Bradley, H., et al. (2020). N95 Filtering Facepiece Respirator Use during Pregnancy: A Systematic Review. Am J Perinatol, 37(10), 995-1001. Click here. Free full text!

Vivanti, A. J., Vauloup-Fellous, C., Prevot, S., et al. (2020). Transplacental transmission of SARS-CoV-2 infection. Nat Commun, 11, 3572. Click here. Free full text! 

Yeo, K.T., Oei, J.L., De Luca, D., et al. (2020), Review of guidelines and recommendations from 17 countries highlights the challenges that clinicians face caring for neonates born to mothers with COVID‐19. Acta Paediatr. Accepted Author Manuscript. Click here. Free full text! 

Research Update for Monday, July 13 + Detailed Q&A!

This week we share findings from a prospective cohort study of a universally tested population in New York City, details about the COVID-19 management set up in an obstetrics and gynecology unit in Italy, survey findings on the mental health impact of lockdown on pregnant and early postpartum parents in Belgium, and survey findings on rates of anxiety and depression among health care workers in Ireland during the pandemic 

Today’s questions (answered in a Q&A section at the bottom of this email) include: 

  • Do pregnant people have different symptoms of COVID-19 compared to people who are not pregnant?  
  • Which activities pose the greatest risk of infection and which are least likely to result in infection? 
  • What counts as a “case” in the COVID-19 case numbers for the United States?   

To ask a question for consideration for future newsletters, submit your question here. 

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University 

As of 10 AM EDT on July 13, 2020, there are about 13 million confirmed cases of COVID-19 around the world. The highest number of cases is still in the U.S. (over 3.2 million), and the U.S. just experienced it worst two-week period with more newly confirmed cases than at any point since the outbreak began. After the U.S., the countries with the next highest number of cases are Brazil, India, Russia, Peru, Chile, Mexico, and the United Kingdom.   

Prospective Cohort Study of a Universally Tested Population in New York City, U.S. 

  • Three hospitals in New York City tested everyone upon hospital admission for birth over 28 days (Prabhu et al. 2020). They used a nasopharyngeal (NP) swab for SARS-CoV-2 and reverse transcriptase polymerase chain reaction (RT-PCR). All infants born to mothers with COVID-19 were also tested.  
  • A total of 675 pregnant people were tested, and of these 10.4% tested positive.  
  • People with chronic high blood pressure, diabetes prior to pregnancy, and pre-pregnancy BMI ≥ 30 were more likely to test positive. 
  • At the time of admission, most (78.6%) of the infected mothers reported no symptoms of fever, cough, sore throat, shortness of breath, diarrhea, other gastrointestinal symptomsrunny nose, or muscle achesHowever, 24% of people who tested positive but did not have symptoms reported having prior symptoms, and 13% developed symptoms in the first 7 days after birth. 
  • Cough was the most commonly reported symptom among the pregnant people with symptomatic COVID-19 (occurring in 47%).  
  • The researchers looked for differences in birth outcomes between pregnant people with and without COVID-19, and infected mothers with and without symptoms.  
  • The Cesarean rates were 47% in people who had symptomatic COVID-19, 46% in people who had COVID-19 but no symptoms, and 31% in people who tested negative for COVID-19. The authors are not sure why the Cesarean rate was higher among people with COVID-19, since there was no difference in indications for Cesarean between the groups. They think fevers from COVID-19 may have been treated as infection of the membranes (chorioamnionitis) during labor and increased the risk of Cesarean. They also proposed that mothers with COVID-19 might have had more risk factors for Cesarean.  
  • There was no difference in the pre-term birth rate between people with and without COVID-19.  
  • There were no maternal deaths and none of the birthing people received mechanical ventilation. One patient was admitted to the intensive care unit (ICU).  
  • There was one fetal death at 37 weeks of pregnancy in a mother with asymptomatic COVID-19 and type 2 diabetes. The cause of death has not been determined. There were six stillbirths between 20 and 25 weeks among pregnant people without COVID-19. 
  • None of the infants born to mothers with COVID-19 tested positive (0/71 infants tested). In other words, there was no mother-to-baby transmission (i.e. vertical transmission). Healthy infants roomed in with their mothers. They took precautions: isolettes were placed 6 feet away from the bed, the parent wore a mask at all times, and breastfeeding/chestfeeding parents practiced careful hygiene prior to feeding.  
  • Placentas from infected birthing people were less healthy (there was increased fetal vascular malperfusion) compared to placentas from people without COVID-19 (48% versus 11%). However, the placental pathologist who evaluated the placentas was not blinded to the mothers’ COVID-19 status, and this may have led to bias. Although newborn outcomes were good in this study, the authors expressed concern about infections occurring earlier in pregnancy. They think, “Consideration for antenatal testing and serial growth ultrasounds may be warranted given these findings. 
  • Complications after birth (such as fever, readmission, or low oxygen levels) occurred significantly more often among people with COVID-19 compared to people without COVID-19 (13% versus 5%). Given these findings, the authors suggest that postpartum parents with COVID-19 may benefit from home pulse oximetry monitoring and frequent health visits over phone/video.  

The COVID-19 Management Set Up in an Obstetrics and Gynecology Unit in Italy 

  • In this report, care providers from a university hospital in Milan, Italy described their management set up during the pandemic (Alfieri et al. 2020). Their hospital hosts about 1,200 births per year. 
  • When pregnant people entered the hospital, providers performed triage using a 13-item questionnaire available in 12 languages. Brochures with info about COVID-19 were available in English, Arabic, Spanish, Chinese and Sinhalese. Interpretation services were provided via Tablet computer to reduce the number of people in the clinic.  
  • Prenatal visits were delayed if test results and blood tests were normal. People with low-risk pregnancies had visits every 6 to 8 weeks. The frequency of visits for people with higher risk pregnancies was determined based on individual circumstances and email communication.  
  • The amount of time dedicated for each prenatal visit was increased by 10 to 15 minutes to avoid contact between pregnant people in the waiting area in case of delays 
  • Chairs in the waiting room were spaced at least 1 meter (about 3 feet) apart and all patients were provided with a facemask and gloves. Care providers did not enter the waiting area. After triage, the pregnant person disposes of the gloves and washes their hands with an alcohol solution.  
  • Pregnant people at this Italian hospital could attend a virtual course with six 90-minute lessons featuring a midwife, a doctor, and a pediatrician. This temporary solution replaced regular in-person counseling during the pandemic. The course also included a virtual visit to the labor & delivery rooms since mothers could not tour them in person.   
  • On April 6, the hospital started testing everyone at the time of admission (universal testing). People planning elective Cesareans or inductions were tested 24 to 48 hours before hospitalization.  
  • Pregnant people with negative test results (and their support person) were still asked to wear a surgical mask and gloves during labor and birth.   
  • No visitors were allowed in the maternity unit during the postpartum stay, not even the parent who did not give birth. 
  • Healthy birthing people and infants were discharged early with access to mental health services and virtual postpartum support. 

The Mental Health Impact of Lockdown on Pregnant and Early Postpartum Parents  

  • Researchers in Belgium conducted an online survey to investigate maternal mental health status after a few weeks of lockdown (Ceulemans et al. 2020). They used the Edinburgh Depression Scale (EDS) and the Generalized Anxiety Disorder 7-item Scale. Before the pandemic, mental health problems affected about 10% to 20% of pregnant and early postpartum parents. The researchers were concerned that lockdown measures to control the pandemic might have increased anxiety and depression due to sudden changes in private and professional life, fear of infection, and social isolation.  
  • A total of 5,866 respondents completed the survey (2,421 were pregnant and 3,445 were early postpartum).  
  • Nearly half of the survey respondents reported depressive or anxiety symptoms during the lockdown period. The rate of major depressive symptoms was significantly higher than before the pandemicaffecting 24% to 25% of respondents. More than 40% of respondents had symptoms of anxiety, and 14% met the criteria for high anxiety 
  • In summary, the researchers found increased symptoms of depression and anxiety among pregnant and early postpartum parents during the lockdown in Belgium. They issued a “call for action” to care providers to conduct routine depression and anxiety screening.   

The Mental Health Impact of the Pandemic on Maternity Health Care Workers (HCWs) 

  • A survey from Ireland found that the pandemic is also taking a toll on the mental health of health care workers (Corbett et al. 2020). The researchers offered an anonymous online survey to all 600 HCWs at a maternity hospital in Dublin, Ireland. The survey assessed the severity of anxiety and depression among the respondents.  
  • A total of 240 hospital staff completed the survey. Over 20% of the HCWs had moderate to severe depression and 21% had moderate to severe anxiety.  
  • Younger HCWs experienced significantly higher levels of depression and anxiety compared to older health care workers. The researchers think this could be due to older HCWs having developed more mature coping mechanisms to deal with stressors compared to their younger colleagues. Younger HCWs may also worry more about becoming infected and exposing older relatives.  
  • Hospital administrative staff had higher anxiety and depression scores compared to midwives, nurses, and doctors. The researchers suggested that professional training might have helped to prepare medical staff to cope with risk of exposure at work.  
  • Depression scores were similar between males and females, but females had significantly higher anxiety scores. Nearly half of all respondents reported that they experienced low mood triggered by loneliness from social isolation. One in five respondents reported tensions at home with members of the household including children.  
  • The authors urged healthcare leaders to support the mental health of HCWs by preventing burnout and building their confidence through trainings.   

The CDC has advice for mental health and coping with the stress of the pandemic, including numbers to call for immediate health in a crisis, and where to find help with substance use. (SourceThere is also info specifically for health care workers and first responders about how to cope with stress during the pandemic. (Source)

Q and A Section 

Question:  Do pregnant people have different symptoms of COVID-19 compared to people who are not pregnant?  

Answer: In a report from the U.S. Centers for Disease Control (Ellington et al. 2020), symptomatic pregnant people and nonpregnant females of reproductive age with COVID-19 reported similar frequencies of cough (53%), shortness of breath (30%), runny nose (9-10%), and loss of taste or smell (17%).  

Compared to nonpregnant females, pregnant people were less likely to report headache (41% versus 52%), muscle aches (38% versus 47%), fever (34% versus 42%), chills (29% versus 36%)sore throat (27% versus 31%), abdominal pain (10% versus 12%), and diarrhea (14% versus 23%).  

Pregnant people were more likely to report nausea or vomiting (20% versus 16%); however, it’s important to consider that some of the symptoms of COVID-19 overlap with symptoms of normal pregnancy (e.g., shortness of breath, nausea/vomiting). You can read more details about this CDC report in our last research update, archived here. 

Question: Which activities pose the greatest risk of infection and which are least likely to result in infection? 

Answer: The Texas Medical Association COVID-19 Task Force and Committee on Infectious Diseases created a chart that ranks activities according to their risk level for contracting the SARS-CoV-2 virus that causes COVID-19. A Spanish version of the chart is also available. The Task Force is chaired by the Dallas County Health and Human Services chief epidemiologist and includes 14 other medical doctors.  

The Task Force considers the lowest risk activities to be opening the mail, getting takeout, pumping gas, playing tennis, and going camping. The highest risk activities include going to a bar, attending a religious service with 500+ people in attendance, going to a sports stadium event, attending a large music concert, going to a movie theater, going to an amusement park, exercising at a gym, and eating at a buffet.  

In a recent article, health experts weighed in on the safety of outdoor group fitness classes during the pandemic. They agreed that exercising outside carries less risk of infection than exercising indoors. Classes like yoga and Pilates were considered lower risk than exercises involving heavy breathing or yelling. One of the physicians interviewed recommended that class participants be spaced six or more feet apart and consider wearing face coverings. Instructors can use a sound system so they don’t have to yell, and hold class in the shade to avoid using a fan (which could potentially spread droplets between people).  

Question: What counts as a “case” in the COVID-19 case numbers for the United States?   

Answer:  In each research update, we report the total number of confirmed cases by country from the Johns Hopkins University COVID-19 dashboardBut what does that mean? 

Confirmed cases include “presumptive positive” cases and “probable” cases.  

A presumptive positive case is when the person tested positive at a local or state level laboratory, but the results are pending confirmation at the Centers for Disease Control.  

A probable case is defined as: 

  • The person meets clinical criteria for COVID-19 AND there is epidemiologic evidence of infection, but there is no confirmatory laboratory evidence where SARS-CoV-2 RNA was detected in a clinical specimen using a molecular amplification detection test; 
  • The person meets presumptive laboratory evidence (a specific antigen was detected in a clinical specimen, or a specific antibody indicating a new or recent infection was detected using a serology test) AND there is either clinical criteria OR epidemiologic evidence of infection; 
  • The person is deceased with no confirmatory lab test, but the death certificate lists COVID-19 or SARS-CoV-2 as a cause of death or a significant condition contributing to death.  

In addition to the total number of confirmed cases, you can get a more complete picture of the impact of COVID-19 in a particular state by looking at trends for three key measures: the number of confirmed new daily cases, the testing rate (daily tests per 100,000 people), and the positivity rate (the daily percentage of tests that are positive). You can find all of these numbers for your particular state here 

Also, here is recently updated map of where cases are rising and falling in the U.S. 

This concludes the research update for July 13, 2020. I hope you found it helpful! Our next research update will come out on July 27.  

References 

Alfieri, N.Manodoro, S., Marconi and AM. (2020). COVID-19 does not stop obstetrics: what we need to change to go on safely birthing. The experience of a University Obstetrics and Gynecology Department in Milan [published online ahead of print, 2020 Jul 7]. J Perinat Med. Click here. Free full text! 

Ceulemans, M., Hompes, T. and Foulon, V. (2020). Mental health status of pregnant and breastfeeding women during the COVID19 pandemic: A call for action. Int J Gynecol Obstet. Click here. Free full text! 

Corbett, GA., Milne, SJ., Mohan, S., et al. (2020). Anxiety and Depression Scores in Maternity Healthcare Workers during the Covid-19 Pandemic [published online ahead of print, 2020 Jul 2].Int J Gynaecol Obstet. Click here. 

Ellington, S.Strid, P., Tong, VT., et al. (2020). Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status – United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep. 69(25), 769-775. Published 2020 Jun 26. Click here. Free full text! 

Prabhu, M.Cagino, K., Matthews, KC., et al. (2020). Pregnancy and postpartum outcomes in a universally tested population for SARS-CoV-2 in New York City: A prospective cohort study [published online ahead of print, 2020 Jul 7]. BJOG. Click here. 

June

Research Update for Monday, June 29 at 3:36 PM + Detailed Q&A!

This week we share the latest COVID-19 pregnancy data from the U.S. Centers for Disease Control (CDC), a summary of updates to the Royal College of Obstetricians & Gynecologists (RCOG) guidance, and new guidance on inpatient management of COVID-19 in pregnancy from New York clinicians.

Today’s questions (answered in a Q&A section at the bottom of this email) include:

  • I have school age children. Have any countries kept schools open during the pandemic? If so, what precautionary measures are they taking? Have they seen a higher rate of infection?
  • What are the current projections for the pandemic moving into the fall months?
  • What do we know about people’s experiences so far giving birth during the pandemic?

To ask a question for consideration for future newsletters, submit your question here.

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.


Research Update for June 29, 2020

Numbers Update from Johns Hopkins University

As of 10 AM EDT on June 29, 2020, there are more than 10 million confirmed cases of COVID-19 around the world. The highest number of cases is still in the U.S. (over 2.5 million), followed by Brazil, Russia, India, the United Kingdom, Peru, and Chile.

Weekly COVID-19 Pregnancy Data From the U.S. CDC

  • The U.S. Centers for Disease Control (CDC) is now publishing weekly COVID-19 pregnancy data to its website here. The cases only include confirmed cases of SARS-CoV-2 (those with laboratory evidence of infection). They caution that these numbers likely do not include all pregnant people with COVID-19 in the U.S. because info on pregnancy status is often missing when cases are reported.
  • The tracking data was last updated June 25, 2020.
  • Between January 22 and June 23, 2020 data were collected from 9,989 pregnant people with confirmed COVID-19 in the U.S. There were 26 maternal deaths among these cases; however, it’s not clear whether these deaths were related to COVID-19 or from unrelated complications.
  • Data on race/ethnicity was only available for 84% of the cases. Hispanic or Latinx pregnant people disproportionately accounted for a large number of reported cases (3,883), followed by White Non-Hispanic (1,891), and Black Non-Hispanic (1,698) people (see Note from EBB under next study).
  • Data on hospitalization status was available for 83% of reported cases. From the available data, there were 2,997 pregnant people hospitalized with COVID-19. Some were hospitalized for COVID-19-related problems (e.g., worsening respiratory status) and others were hospitalized for pregnancy-related reasons (e.g., admitted for birth).
  • Data on ICU admission and mechanical ventilation were available for less than 30% of the reported cases. There were 144 pregnant people admitted to the ICU and 56 who received mechanical ventilation.

CDC Morbidity and Mortality Weekly Report (MMWR)

  • On June 26, the CDC published a MMWR that analyzed confirmed SARS-CoV-2 infection by pregnancy status between January 22 and June 7, 2020 in the U.S. (Ellington et al. 2020).
  • 8,207 pregnant people tested positive for SARS-CoV-2 and were reported to the CDC by June 7, 2020. Of these, 2,587 (31.5%) were hospitalized, 120 (1.5%) were admitted to ICU, 42 (0.5%) received mechanical ventilation, and 16 (0.2%) died.
  • In comparison, 83,205 non-pregnant females in the same age group (15 to 44 years) were: 4,840 (5.8%) hospitalized, 757 (0.9%) admitted to ICU, 225 (0.3%) ventilated, and 208 (0.2%) died.
  • To date, there has been very limited evidence on whether pregnancy increases the risk of severe illness or death with COVID-19. After considering maternal age, presence of underlying conditions, and race/ethnicity, this report found that infected pregnant people were 1.5 times more likely to be admitted to the ICU and 1.7 times more likely to receive mechanical ventilation compared to infected non-pregnant females of reproductive age. There was no difference in the risk of death. The authors concluded that pregnancy might increase someone’s risk for severe illness from COVID-19.
  • “To reduce occurrence of severe illness from COVID-19, pregnant women should be counseled about the potential risk for severe illness from COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for pregnant women and their families,” the authors wrote.
  • Data on race/ethnicity was available for 80% of pregnant people with confirmed infection during the study period: 46% were Hispanic, 22% were Black, and 23% were White. The authors reported that in 2019, 24% of people who gave birth in the U.S. were Hispanic, 15% were Black, and 51% were White. So as you can see, even though data on race/ethnicity was missing for 20% of pregnant cases, these findings show that Hispanic and non-Hispanic Black pregnant people are disproportionately affected by SARS-CoV-2 infection in pregnancy.
  • Note from EBB: In recent weeks, articles are continuing to be published about the disparities in infection rates, particularly among the Hispanic community. In an NPR article, Dr. Marcella Nunez-Smith, a professor of medicine at Yale, stated, “We know that these racial ethnic disparities in COVID-19 are the result of pre-pandemic realities. It’s a legacy of structural discrimination that has limited access to health and wealth for people of color.” Dr. Fernandez, a professor of medicine at UCSF, shared, “In the early stages, when we were noticing increased Latino hospitalization at our own hospital and we felt that no one was paying attention and that people were just happy that San Francisco was crushing the curve, it felt horrendous,” she says. “It felt as if people were dismissing those lives. … It took people longer to realize what was going on.”
  • Note from EBB: Take some time to look at information and resources provided by these social justice organizations (and support their work!):

Summary of Updates in the RCOG Guidance

  • The Royal College of Obstetricians & Gynecologists updated their guidance on COVID-19 infection and pregnancy on June 19, 2020. You can access the full text here. A page with Q&A’s relating to this guidance was updated June 26, 2020 and is available here.
  • They changed their advice on face masks to reflect national guidance from NHS England, which says that face masks and coverings should be worn by all NHS hospital staff and visitors. Specifically, all pregnant people and any visitors are advised to wear face coverings at prenatal appointments. In addition, they specified that babies should not be advised to wear face masks because of the risk of suffocation.
  • The latest guidance states “women should be supported and encouraged to have birth partners present with them during active labour and birth if they wish to do so, unless the birth occurs under general anesthetic, in accordance with local or national hospital policies.” Previously, the language was “women should be supported and encouraged to have one birth partner present with them…”(emphasis ours).
  • The guidance now includes UK government recommendations based on the interim (early) results of the RECOVERY (Randomized Evaluation of COVid-19 thERapY) trial.
  • The RECOVERY trial was set up to test a wide variety of potential treatments for COVID-19, including low-dose steroid treatment with dexamethasone (Horby et al. 2020). Over 11,500 participants enrolled from over 175 NHS hospitals in the UK; only 6 of the participants were pregnant. They stopped recruiting participants to the dexamethasone arm of the trial on June 8, after detecting a significant reduction in death for individuals with COVID-19 requiring oxygen who were given steroid therapy.
  • The guidance is that steroid therapy should be considered for 10 days or to hospital discharge, whichever is sooner, for adults unwell with COVID-19 and requiring oxygen. The study protocol for pregnant people was that they should use oral prednisolone 40 mg once a day or, if unable to take oral medicine, intravenous (IV) hydrocortisone 80 mg twice a day instead of dexamethasone treatment. So, even though pregnant people were not well represented in this study, health authorities in the UK think steroid therapy could be a beneficial treatment for mothers unwell with COVID-19 requiring oxygen.

Guidance on Inpatient Management of COVID-19 in Pregnancy

  • A recent article in AJOG MFM reviewed guidance on testing, admission criteria, and inpatient medical management of pregnant people with COVID-19 (Vega et al. 2020). The authors are New York clinicians and they shared their clinical experiences of caring for mothers with COVID-19 in the U.S. epicenter. This resource includes tables with specific clinical guidance for providers:
  • Table 1: Checklist for COVID-19 screening: Universal testing of all pregnant people admitted to labor and delivery units should be based on the prevalence of the disease in the community and resource availability. The authors presented a universal screening alternative to universal testing that uses broad screening criteria with testing for those who screen positive.
  • Table 2: Admission Criteria for COVID-19 Pregnant Women and Patients under Investigation, PUIs: If a pregnant person meets any of the criteria in Table 2 (e.g., severe shortness of breath), admission should be considered on a case-by-case basis.
  • Table 3: Checklist for initial management and evaluation of PUIs for Covid-19: All PUIs should have basic labs and imaging performed during their initial evaluation upon admission.
  • Table 4: COVID-19 in Pregnancy Management after Admission Checklist: Confirm isolation precautions are in place in the in-patient room and order daily labs and every other day labs. Note that worsening of symptoms may occur 6 to 10 days after the start of symptoms.
  • Table 5: Tip Sheet: Hypoxia in COVID-19 Pregnant Patients: Pregnant people with COVID-19 who have hypoxia (low oxygen in the body’s tissues) have a separate checklist. Some of the care instructions include:
    • Diagnosis with COVID-19 alone is not a medical indication for induction or Cesarean.
    • Severely symptomatic COVID-19 patients should avoid nonsteroidal anti-inflammatory drugs (NSAIDs).
    • Breastfeeding with COVID-19 should be encouraged as it likely provides antibodies against SARS-CoV-2 for the baby.
    • Postpartum patients with COVID-19 can improve but later develop more severe symptoms. Therefore, it’s important to discharge COVID-19 patients with a pulse oximeter and clear guidance on when to call their provider or return to the hospital. In addition, providers should regularly call/text/video people recovering from COVID-19 until their signs and symptoms have fully resolved.

Q & A Section

Question: I have school age children and I’m worried about the fall. Have any countries kept schools open during the pandemic? If so, what precautionary measures are they taking? Have they seen a higher rate of infection?

Answer: The United Nations Educational, Scientific and Cultural Organization (UNESCO) reports that schools closed because of the pandemic in more than 190 countries, affecting nearly 1.6 billion children and youth, which is about 90% of students in the world. As of early June, the United Nations Children’s Fund (UNICEF) reports that more than 1 billion students are still out of school, but more than 70 countries have announced plans to reopen schools and hundred of millions of students have already returned.

The country of Sweden is a notable exception because they kept most schools open during the pandemic, without making major changes to class size or school policies (Wise, 2020). They also allowed bars, restaurants, gyms, and shops to remain open, but encouraged social distancing precautions.

Sweden’s death rate from COVID-19 is far higher than its neighboring countries, which shut down schools and other gathering places. The latest figures from Johns Hopkins University show 51.9 COVID-19 deaths per 100,000 in Sweden, 10.4 in Denmark, in 5.9 in Finland, and 4.7 in Norway. The death rate in Sweden is higher than in the U.S. (38.2 per 100,000), but lower than in the UK (65.4), Spain (60.7), and Italy (57.4).

It’s likely that Sweden’s open-for-business policy contributed to the high death rate in the country. Because so much of their society was open, it’s impossible to tell what impact open schools had on hospitalization and death rates. A study of pediatric hospital admissions in Sweden found that the Swedish strategy did not increase severe illness and deaths among schoolchildren (Hildenwall et al. 2020), but it may have had negative impacts on the general population, especially older adults in nursing facilities.

However, supporters of the Swedish policy point to other possible explanations for the high death rate, such as travel patterns, conditions in Swedish nursing homes, and differences in health care systems between the Scandinavian countries. In an interview, Anders Tegnell, the epidemiologist responsible for Sweden’s controversial policy, said “If we would encounter the same disease, with exactly what we know about it today, I think we would land midway between what Sweden did and what the rest of the world did.” In other words, he thinks Sweden should have done more, but perhaps other countries went too far with their strict lockdown strategies.

In mid-April, Denmark became the first country in Europe to reopen day cares and elementary schools. They reopened with many precautions in place to stop the spread of infection: parents weren’t allowed inside the school; the teacher’s lounge remained closed; the library remained closed; children sat at desks and stood in lines two yards (6 feet) apart; no playing in large groups at recess; no physical contact between students (e.g., no hugs or high fives); much of the teaching was done outdoors; the school was disinfected throughout the day; and hand washing was done at least once an hour. In addition, classes were divided into several subgroups of children with a designated teacher and each subgroup isolated from the others. Health authorities in Denmark monitored infection rates after the schools reopened and reported no negative effects—daily infections in Denmark continued to decline, as did hospital admissions and deaths.

As schools reopen around the world, we will begin to gain a better understanding of how reopening affects local infection rates.

Question: What are the current projections for the pandemic moving into the fall months?

Answer: The number of new cases is going up in the U.S. (see a visual of the trend here). There has especially been an increase in new cases in June, likely due to easing social distancing measures. What’s coming next?

In our research update from April 13, 2020, we shared a resource from The Institute for Health Metrics and Evaluation. This group makes COVID-19 projections for the U.S. (nationally and by state) and for every other country. You can see projected hospital resource use (ICU beds, ventilators), daily infections and testing, easing of social distancing, deaths per day from COVID-19, and total deaths from COVID-19.

On June 25, they updated their projections for most countries out to October 1, 2020. For the first time, they also released two alternative scenarios that accompany the current projection (what they think is most likely to happen).

For the current projection, the model assumes that social mandates will continue to relax and mask use will continue at observed rates until the daily death rate in a location exceeds a threshold of 8 deaths per million. If that happens, the model assumes that mandates (i.e. closing schools, closing non-essential businesses, stay-at-home orders, large gatherings banned, and mandatory mask use) will be re-imposed for a six-week period to lower infections. Currently in the U.S., only Texas and Florida are predicted to reach this level before October 1st and face either re-introduction of strong social distancing rules or devastating impacts from COVID-19.

The current projection model assumes that locations not exceeding this threshold will continue their trend without new mandates. The model also assumes that locations already past this threshold will be subject to new mandates within one week.

The first alternative scenario is a worst-case scenario where new mandates to lower the infection rate are never imposed no matter how high the daily death rate gets.

The second scenario makes a projection of what would happen if 95% of the population always wore a mask in public. This model still assumes that new social mandates will be imposed if the daily death rate exceeds the threshold of 8 deaths per million.

To take the U.S. for example, there have been 125,803 deaths from COVID-19 in the U.S. as of June 28. The U.S. is projected to reach nearly 180,000 deaths from COVID-19 by October 1, 2020. That number falls to about 146,000 if at least 95% of people wear masks in public. So, they are estimating that more than half of the predicted deaths between now and October 1st could be avoided if 95% of people wore masks in public.

Question: What do we know about people’s experiences so far giving birth during the pandemic?

Answer: On the EBB COVID-19 resource & pregnancy page we share several research studies seeking participants. One of these is the COVID-19 and Reproductive Effects (CARE) Study from Dartmouth. This study is starting to publish results from their analyses of the survey data.

The CARE study was posted on social media platforms and sent via email to birth workers for distribution. Pregnant people over 18 years and living in the U.S. were eligible to complete a survey assessing how the pandemic was affecting their prenatal care and birth plans. Unfortunately, the researchers did not obtain a diverse or representative sample; out of the more than 1,400 participants, 86% were White.

The findings from this study found:

  • 1 out of 5 respondents were not comfortable speaking about their COVID-19-related worries with their care provider
  • 40% of respondents, including 25% in their third trimester, said that their provider had not discussed how the pandemic would affect their labor and birth experience
  • 45% of respondents reported changing some aspect of their birth plans because of the pandemic; for all the details on reasons for birth plan changes see Table 1 here (Gildner & Thayer, 2020)
  • The percentage of respondents who preferred out-of-hospital birth (5.4%) was higher than the national average before the pandemic (1.6%)

Based on these findings, CARE Study researchers created a free handout with provider-patient discussion questions for use during prenatal appointments.

If you’d prefer to listen to personal stories about giving birth during the pandemic, we recommend listening to recent birth stories published at these podcasts: Birth Stories in Color (Episode 45), All About Pregnancy and Birth (Episode 71 and 68) and The Birth Hour (Multiple episodes!)

This concludes the research update for June 29, 2020. I hope you found it helpful! Our next COVID-19 research update will come out on July 13.

References

Ellington, S., Strid, P., Tong, V. T., et al. (2020). Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020. MMWR Morb Mortal Wkly Rep, 69, 769–775. Click here.

Gildner, T.E. and Thayer, Z.M. (2020). Birth plan alterations among American women in response to COVID‐19. Health Expect. Click here.

Hildenwall, H., Luthander, J., Rhedin, S., et al. (2020). Paediatric COVID-19 admissions in a region with open schools during the two first months of the pandemic [published online ahead of print, 2020 Jun 21]. Acta Paediatr. Click here.

Horby, P., Lim, W. S., RECOVERY Collaborative Group, et al. (2020). Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. medRxiv [Pre-print] 2020.06.22.20137273. Click here.

Vega, M., Hughes, F., Bernstein, P. S., et al. (2020). From the Trenches: Inpatient Management of COVID-19 in Pregnancy. American Journal of Obstetrics & Gynecology MFM, 100154. Advance online publication. Click here.

Wise, J. (2020). Covid-19: Sweden should have done more, says architect of country’s strategy. BMJ, 369, m2227. Click here.

Research Update for Monday, June 15 at 11:59 AM + Detailed Q&A!

This week we share info from a new systematic review on how rates of newborn infection relate to mode of birth, method of feeding, and isolation practices; details from a study that found an independent link between Cesarean birth and complications among pregnant people with COVID-19; results from the latest systematic review of maternal and newborn complications with COVID-19; and results from a meta-analysis (many studies combined into one large study) of COVID-19 in children.

Today’s questions (answered in a Q&A section at the bottom of this email) include:

  • You mentioned a few cases of newborns testing positive but not showing any symptoms of COVID-19. Does this mean that some newborns are not negatively affected despite becoming infected, or were they just too recently infected at the time of the report to have symptoms (pre-symptomatic)? Also, if the mother is infected but asymptomatic then is the baby more likely to be asymptomatic if infected?Is there any data on the long-term effects of newborn infection? I’m wondering how worried I should be about newborn infection!
  • Wearing masks seems to have become politicized. In some places everyone is wearing masks, and in other places wearing a mask is frowned upon. What is the latest research on face coverings and whether or not they are effective at preventing the spread of SARS-CoV-2?
  • Do we have any new evidence on the accuracy of tests for SARS-CoV-2 infection?

To ask a question for consideration for future newsletters, submit your question here.

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.

Research Update for June 15, 2020

Numbers Update from Johns Hopkins University

As of 10 AM EDT on June 15, 2020, there are more than 7.8 million confirmed cases of COVID-19 around the world. The highest number of cases is still in the U.S. (over 2 million), followed by Brazil, Russia, India, the United Kingdom, Spain, Italy, and Peru.

New systematic review on how rates of newborn infection relate to mode of birth, method of feeding, and isolation practices

  • A systematic review was published on Friday in BJOG, an international journal of obstetrics and gynecology (Walker et al. 2020). The intent of the review was to estimate the risk of a newborn becoming infected with SARS-CoV-2 after being born to an infected mother. They looked at the effect of vaginal birth versus Cesarean, formula feeding versus breastfeeding, and separation versus rooming in.
  • Altogether the review included 49 studies from China, the U.S., Europe, Honduras, Korea, Australia, Peru, Canada, the U.K. and Iran. These studies included 655 infected birthers and 666 newborns. The authors made every attempt to avoid duplicates (cases reported in more than one case series); they said there has been a significant amount of duplicate reporting of cases from China.
  • Overall, out of the 666 newborns born to infected mothers, 28 (4%) had confirmed infection after birth. Only 8 of the 28 infants had symptoms with their infection, and in 4 of these newborns their symptoms may have been related to prematurity. All COVID-19 positive newborns recovered from their infection.
  • Broken down into Cesarean birth versus vaginal birth, 2.7% of the newborns were positive after vaginal birth and 5.3% of the newborns were positive after Cesarean birth. The data do not show an increase in the rate of infection with vaginal birth.
  • Overall, of the 666 newborns, 22% were breastfed, 8% were formula fed, <1% was given expressed breast milk, and 69% did not have data available on type of infant feeding. Of the 28 positive newborns, 7 were breastfed, 3 were formula fed, 1 was given expressed breast milk, and 17 did not have data available on the method of feeding. The data do not show an increase in the rate of infection with breastfeeding.
  • Overall, of the 666 newborns, 8% were kept isolated from their mother, 16% practiced rooming in, and 76% did not have data available on rooming in versus separation after birth. Of the 28 positive newborns, 7 were isolated from the birther, 5 practiced rooming in, and 16 did not have data available. The data do not show an increase in the rate of infection with rooming in. Furthermore, newborn infection has been shown to occur despite isolation.
  • In summary, newborn infection is uncommon and rarely causes symptoms. In this study, the rate of infection was not increased when the baby was born vaginally, breastfed/chestfed, or had contact with the infected birther. According to the authors, “Newborn infants can be infected in the first few hours of life, but as very few are severely affected it is likely that the benefits of contact with the mother and the ability to breast feed outweigh the potential benefits of separation.”
  • Note from EBB: The authors were very clear that although their review is based on the best available data, the data are still extremely limited, and this analysis only includes 28 infected newborns. There could still be benefits or risks that differ by mode of birth, method of feeding, or isolation practices that we can’t determine from the limited observational data.

Study found an independent link between Cesarean birth and complications among pregnant people with COVID-19

  • A study from Spain was published on June 8th in JAMA (American Medical Association) that assessed the association between mode of birth and outcomes among pregnant people with COVID-19 (Martínez-Perez et al. 2020). The authors questioned whether the Chinese reports that found an 8% rate of severe complications among pregnant people with COVID-19 might have been related to the extremely high Cesarean rate (>90%) in those reports.
  • The study included 82 pregnant people in Spain who gave birth within 14 days of testing positive for SARS-CoV-2. Some pregnant people were tested because of universal screening, some were tested because of symptoms, and some were tested because they reported a history of potential exposure to the virus.
  • Of the 82 pregnant participants, 4 had severe COVID-19 symptoms (including one who also had preeclampsia); all 4 gave birth by Cesarean and required ICU admission.
  • The other 78 participants were asymptomatic or had mild COVID-19 symptoms. Of these participants without severe COVID-19, 41 (53%) gave birth vaginally and 37 (47%) by Cesarean. Most of the Cesareans were for indications other than COVID-19; only 8 of the 37 Cesareans were for COVID-19 symptoms without other indications.
  • Of the 78 participants, none developed a severe poor outcome after vaginal birth. However, 5 (13.5%) who gave birth by Cesarean required ICU admission. In addition, 2 birthers (4.9%) experienced “clinical deterioration” after vaginal birth (defined as an increased need for oxygen after birth) versus 8 (21.6%) who experienced clinical deterioration after Cesarean. The authors considered many factors in their analysis that could have influenced the link between mode of birth and outcomes: maternal age, body mass index, maternal health conditions, need for oxygen supplementation at admission, abnormal chest x-ray findings at admission, parity, smoking status, and gestation. After the authors took all of these other factors into account Cesarean was significantly linked to increased risk of clinical deterioration. Cesarean was also significantly linked to increased risk of NICU admission after taking these other factors into account.
  • 72 newborns were tested within 6 hours after birth and 3 (4.2%) tested positive. Repeat testing at 48 hours was negative and none developed COVID-19 symptoms within 10 days. Two infants who initially tested negative developed symptoms within 10 days of birth and repeat testing was positive. In both of these babies symptoms resolved within 48 hours.
  • The authors concluded that Cesarean birth is independently linked to increased risk of postpartum maternal complications and newborn complications among birthers with asymptomatic or mild COVID-19.
  • Note from EBB: This study cannot determine cause and effect, and it’s possible that there were other factors that the researchers did not consider that help to explain the increased risk of clinical deterioration and NICU admission with Cesarean birth.

Latest systematic review of maternal and newborn complications with COVID-19

  • Researchers published a systematic review of the available literature on COVID-19 in Obstetrics & Gynecology on June 9 (Huntley et al. 2020). The review identified 538 infected pregnant people with reported outcomes on 435 births. They only included reports with at least 10 pregnant cases, which helped to minimize publication bias of rare poor outcomes in case reports. The cases came from China, Italy, and the U.S.
  • About 75% of infected pregnant people were symptomatic; the two most common symptoms were fever and cough, which occurred in nearly half of symptomatic cases.
  • About 1 in 3 pregnant people with COVID-19 had a preexisting medical condition. Maternal ICU admission occurred in 3% of cases and maternal critical disease with COVID-19 occurred in just over 1% of cases. There were no maternal deaths reported.
  • The preterm birth rate was 20.1% and the Cesarean rate was 84.7%. The authors think that the high preterm birth rate and high Cesarean rate seem related to geographic practice patterns, rather than complications inherent to COVID-19.
  • The overall NICU admission rate was 65%; however, the NICU admission rate was largely influenced by the Chinese reports. Despite the high NICU rate, the rate of 5-minute Apgar scores less than 7 was only 0.5%. One newborn death was reported (a death rate of 0.3%).
  • There was zero evidence of vertical transmission (defined as a positive newborn swab immediately after birth or a positive immunoglobulin M result for SARS-CoV-2 infection in cord blood).
  • The authors think the low rate of maternal and newborn death and the absence of vertical transmission is reassuring. The majority of poor outcomes relate to increased preterm birth and high Cesarean rates, both of which were influenced by geographic practice patterns and will likely decrease. The data are very limited and will need to be updated when the results from multiple large registries becomes available.

Meta-analysis of COVID-19 in children

  • A meta-analysis was published in Pediatric Pulmonology on June 10 to summarize what we know so far about COVID-19 in children (Zhang et al. 2020). They included 551 lab-confirmed cases of COVID-19 in children aged 1 day to 17.5 years. The cases came from 46 research articles: 35 were from China, and the other articles came from Iran, Italy, Korea, Malaysia, Singapore, Spain, the U.S., and Vietnam.
  • Of the 551 children with lab-confirmed COVID-19, 57% were male and 48% were under 5 years of age. Seven cases were newborns under 28 days.
  • 87% had household exposure to COVID-19. The most common symptoms and signs were fever (53%), cough (39%), and sore throat (14%); 18% of cases were asymptomatic.
  • Nine out of the 551 children with lab-confirmed COVID-19 had severe/critical COVID-19. All 9 of the children with severe COVID-19 had major underlying medical conditions. Six of these children needed mechanical ventilation. One 10-month-old with a rare medical condition called intussusception (bowel obstruction) died while hospitalized for COVID-19.
  • The authors concluded that previously healthy children in this study had mild symptoms with COVID-19. Children with major underlying medical conditions are more likely to have severe disease with COVID-19.

Q & A Section

Question: You mentioned a few cases of newborns testing positive but not showing any symptoms of COVID-19. Does this mean that some newborns are not negatively affected despite becoming infected, or were they just too recently infected at the time of the report to have symptoms (pre-symptomatic)? Also, if the mother is infected but asymptomatic then is the baby more likely to be asymptomatic if infected?Is there any data on the long-term effects of newborn infection? I’m wondering how worried I should be about newborn infection!

Answer: The available evidence on newborn infection is actually quite encouraging! The majority of newborns born to infected mothers do not acquire the infection; when they do become infected, most newborns remain free of symptoms with their infection; when they do develop symptoms, they remain well and recover from the infection.

In the systematic review that we discussed today, only 4% of newborns born to infected mothers acquired the infection after birth. Of these, only 14% to 29% developed symptoms with their infection (Walker et al. 2020). All COVID-19 positive newborns recovered from their infection. The newborns in these case reports were monitored for sufficient time after birth to detect symptoms, when they occurred.

It’s not clear from the limited data whether infected newborns born to infected but asymptomatic birthers are more likely to remain free of symptoms themselves. There have been reports of newborns with asymptomatic infection born to mothers with symptomatic COVID-19(Patanè et al. 2020) and newborns with asymptomatic infection born to mothers with asymptomatic or mild COVID-19 (Martínez-Perez et al. 2020).

To the best of our knowledge, and according to the Royal College of Obstetricians and Gynecologists (Q&As, updated June 12), in all reported cases of newborns developing COVID-19 with symptoms soon after birth, the babies were well and recovered from the infection. This is a very new virus, so we don’t have any studies on long-term follow-up of babies who recovered from infection.

Question: Wearing masks seems to have become politicized. In some places everyone is wearing masks, and in other places wearing a mask is frowned upon. What is the latest research on face coverings and whether or not they are effective at preventing the spread of SARS-CoV-2?

Answer: A new study was just published June 11 in The Proceedings of the National Academy of Sciences (Zhang et al. 2020). The researchers looked at different strategies for reducing viral transmission and determined that wearing a facemask may be the key factor in preventing the spread of the virus.

They analyzed the disease trends and mitigation measures in three epicenters: Wuhan China, Italy, and New York City, from January 23 to May 9. The analysis found that the difference with and without mandated face covering largely determined the shape of the trends at these epicenters. When face covering was mandated, there was a significant reduction in the number of infections (by over 78,000 in Italy from April 6 to May 9 and over 66,000 in New York City from April 17 to May 9). Social distancing without mandated face covering was not an effective strategy to reduce the number of infections at the epicenters.

The researchers concluded that wearing face masks in public is the single most effective way to prevent SARS-CoV-2 transmission, especially when it takes place alongside social distancing, quarantine, extensive testing, and contact tracing. This is because airborne transmission is the dominant route for the spread of COVID-19.

The U.S. Centers for Disease Control has sew and no sew instructions on how to make cloth face coverings here.

We covered the evidence on facemasks (including the best materials to use) in our research update on April 6. You can access archives of all the past newsletters here on our COVID-19 resource & pregnancy page!

Question: Do we have any new evidence on the accuracy of tests for SARS-CoV-2?

Answer: We answered a question about the accuracy of SARS-CoV-2 tests in the April 27 Q&A, which you can access here on our COVID-19 resource & pregnancy page.

Since then, there has been more research on the accuracy of the reverse transcriptase-polymerase chain reaction (RT-PCR) tests being used to diagnose COVID-19. A team of scientists from Johns Hopkins published a review and meta-analysis in the Annals of Internal Medicine on May 13 (Kucirka et al. 2020). They reviewed 7 previously published studies on RT-PCR performance with over 1,330 samples from the upper respiratory tract.

The likelihood of getting a false negative test result (testing negative when you are actually infected) was 100% on the first day of infection. By day 4, the probability of a false negative result decreased to 67% (still very high). The lowest chance of getting a false negative test result was on day 8 (20%), after which point the probability of false negatives increased again. So, even when the timing is optimal, tests may miss about 1 in 5 infections. People who get symptoms with infection usually develop their symptoms around day 5 of infection. This means the test is most accurate at detecting an actual infection when it’s taken around 3 days after the start of symptoms or around 8 days after exposure. Taking the test before or after that point results in a higher rate of false negatives.

False positive results (testing positive when you don’t actually have the infection) are thought to be much less of an issue with RT-PCR tests for COVID-19 compared to false negative results. However, in a pre-print of an article that has not yet been through peer review, researchers caution about the possibility of false positives. They say that although SARS-CoV-2 tests are widely reported to produce 0% false positives, this refers to the test’s analytic abilities, not the potential for incorrect results in the real world (due to contamination or human error in collection, transport or analysis). It is the authors’ opinion that restricting testing to individuals most likely to have COVID-19 and requiring confirmation of positive results by a second test might be prudent to help avoid false positives.

This concludes the research update for June 15, 2020. I hope you found it helpful! Our next research update will come out on June 29.

References

  • Huntley, B. J. F, Huntley, E. S., Di Mascio, D., et al. (2020). Rates of Maternal and Perinatal Mortality and Vertical Transmission in Pregnancies Complicated by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Co-V-2) Infection: A Systematic Review [published online ahead of print, 2020 Jun 9]. Obstet Gynecol. Click here.
  • Kucirka, L. M., Lauer, S. A., Laeyendecker, O., et al. (2020). Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction-Based SARS-CoV-2 Tests by Time Since Exposure. Annals of internal medicine, M20-1495. Advance online publication. Click here.
  • Martínez-Perez, O., Vouga, M., Cruz Melguizo, S., et al. (2020). Association Between Mode of Delivery Among Pregnant Women With COVID-19 and Maternal and Neonatal Outcomes in Spain. JAMA. Published online June 08, 2020. Click here.
  • Patanè, L., Morotti, D., Giunta, M. R., et al. (2020). Vertical transmission of COVID-19: SARS-CoV-2 RNA on the fetal side of the placenta in pregnancies with COVID-19 positive mothers and neonates at birth. Am J Obstet Gynecol MFM 2020;100145. Click here.
  • Walker, K. F., O’Donoghue, K., Grace, N., et al. (2020). Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: A systematic review and critical analysis [published online ahead of print, 2020 Jun 12]. BJOG. Click here.
  • Zhang, L., Peres, T. G., Silva, M. V.F., et al. (2020). What we know so far about Coronavirus Disease 2019 in children: A meta-analysis of 551 laboratory-confirmed cases [published online ahead of print, 2020 Jun 10]. Pediatr Pulmonol. Click here.
  • Zhang, R., Li, Y., Zhang, A. L., et al. (2020). Identifying airborne transmission as the dominant route for the spread of COVID-19 [published online ahead of print, 2020 Jun 11]. Proc Natl Acad Sci U S A. Click here.

Research Update for Monday, June 1 at 3:04 PM + Detailed Q&A!

This week we share new guidance from the American Academy of Pediatrics (AAP) on newborn care during the pandemic, details from several studies on placental infection with SARS-CoV-2, and reports from a few U.S. hospital labor and delivery units about their experiences so far with universal testing for SARS-CoV-2.  

Today’s questions (answered in a Q&A section at the bottom of this email) include: 

  • As some locations ease restrictions and begin to reopen, are there any recommendations regarding social distancing as the due date approaches (~2 weeks out)?
  • Can I refuse to be tested for SARS-CoV-2 on admission? Can I refuse to wear a mask during labor?   

To ask a question for consideration for future newsletters, submit your question here. 

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University 

As of 10 AM EDT on June 1, 2020, there are more than 6.1 million confirmed cases of COVID-19 around the world. The highest number of cases is in the U.S. (1.7 million), followed by Brazil, Russia, the United Kingdom, Spain, Italy, and India.  

New guidance from the AAP on newborn care during the pandemic 

  • On May 21, the American Academy of Pediatrics (AAP) issued new guidance on the care of infants whose mothers have suspected or confirmed COVID-19. The guidance addresses questions about precautions for birth attendants, rooming-in, breastfeeding, testing, newborn intensive care, visitation and hospital discharge. Some of the recommendations (for babies whose mothers have confirmed or suspected infection) include: 
  • “Delayed cord clamping practices should continue per usual center practice.” The birthing parent can wear a mask and hold the baby during delayed cord clamping. 
  • “While difficult, the safest course of action from the perspective of minimizing the likelihood of the infant becoming infected is to separate mother and infant, at least temporarily.” The AAP says that if the parent chooses to room-in or if rooming-in is necessary, then maintain a distance of 6 feet from the infant, have a non-infected caregiver provide hands-on care to the infant when possible, wear a mask, practice careful hand hygiene, and consider using an isolette to help protect the infant from respiratory droplets. 
  • Note from EBB: The World Health Organization does not recommend separation, and the Centers for Disease Control took a more neutral stance on the topic. EBB has created a sample informed refusal of newborn separation document that you can download at our COVID-19 resource page. 
  • “Mothers may express breast milk after appropriate breast and hand hygiene, and this may be fed to the infant by other uninfected caregivers. If the mother requests to nurse her infant, she should comply with strict preventive precautions, including the use of a mask and breast and hand hygiene.” 

Evidence of placental infection with SARS-CoV-2 

  • Most placenta samples taken from infected people have tested negative for the virus, but there have been a few cases where the virus was identified in the placenta.  
  • In our May 11th newsletter, we shared details from a study by Penfield et al. where they detected the SARS-CoV-2 virus in 3 out of 11 placental and fetal membrane samples. All of the birthing people had moderate to severe COVID-19 and none of their infants were born with the infection.  
  • A case report by Baud et al. described a Swiss patient with confirmed COVID-19 who had a second-trimester miscarriage.  
  • The patient was a 28-year-old, first time mother with a body mass index (BMI) over 30 kg/m2. She developed a fever, fatigue, pain with swallowing, diarrhea, and dry cough at 19 weeks of pregnancy. She tested positive for SARS-CoV-2 and was discharged home with oral acetaminophen.  
  • Her symptoms grew worse over the next couple of days and she developed severe uterine contractions. Her stillborn infant was born vaginally after 10 hours of labor.   
  • Samples taken from the placenta were positive for SARS-CoV-2; other samples from the fetus, amniotic fluid, cord blood, maternal blood, and vaginal swabs all tested negative.  
  • The authors think the miscarriage was related to placental infection with SARS-CoV-2 because no other cause was identified.  
  • Note from EBB: There is currently no evidence of increased risk of pregnancy loss with COVID-19.  
  • Another case report by Hosier et al. presented details of a second trimester pregnancy in the U.S. that ended in fetal death due to maternal complications with COVID-19, severe preeclampsia and placental abruption.  
  • The patient was a 35-year-old mother at 22 weeks of pregnancy. Her medical history included psoriasis and gestational hypertension with a previous pregnancy. She experienced fever, cough, nausea, and diarrhea for 10 days and then awoke with vaginal bleeding and abdominal pain. She tested positive for SARS-CoV-2 on admission.  
  • The mother was diagnosed with severe preeclampsia and had to end the pregnancy in order to avoid severe maternal complications or death.  She was discharged three days later with close telemedicine support.  
  • SARS-CoV-2 was detected in the placenta and there was placental inflammation distinct from typical preeclampsia. The authors think COVID-19 contributed to placental inflammation that ultimately resulted in early-onset preeclampsia. 
  • A third study by Patanè et al. reported on 22 people with COVID-19 who gave birth at a hospital in Italy. Two of the 22 newborns tested positive for SARS-CoV-2 –one immediately after birth and the other at day-7 after birthIn both cases, the fetal side of the placenta was also positive for the virus.  
  • The first infected infant experienced a spontaneous vaginal birth at 37 weeks of pregnancy to a mother with symptomatic COVID-19. The mother wore a mask during the entire labor and there was no close contact after the birth. The baby tested positive immediately after the birth but remained healthy and free of symptoms.  
  • The second infected infant was born by Cesarean to a mother with symptomatic COVID-19 at 35 weeks of pregnancy. The Cesarean was performed for non-reassuring fetal status. The baby tested negative after birth but tested positive on day-7, with no contact between mother and baby over that week. The baby was healthy and did not have symptoms of COVID-19. 
  • This is the first study to report positive SARS-CoV-2 test results from the mother, newborn, and fetal side of the placental tissues. The findings support the possibility of vertical transmission with SARS-CoV-2 (birther-to-baby transmission during pregnancy or childbirth).  
  • A final case series by Shanes et al. examined 16 placentas from people who gave birth with COVID-19 and compared them to control placentas from people who gave birth before the pandemic.   
  • 15 of the patients with COVID-19 had a live birth and one experienced a second trimester fetal death. The researchers don’t know whether the miscarriage was linked to COVID-19. 
  • Ten of the 16 patients with COVID-19 were symptomatic (two required oxygen).  
  • None of the placentas were tested for the virus; all of the infants were tested at birth and found to be negative. 
  • Compared to the control placentas, third trimester placentas from mothers with COVID-19 were more likely to show signs of placental injury (maternal vascular malperfusion, or MVM). Placental injury has been linked to problems with fetal growth, preterm birth, and stillbirth. Major risk factors for placental injury are gestational hypertension and preeclampsia; however, only one of the patients with COVID-19 was hypertensive in this study.  
  • The authors concluded that pregnant people with COVID-19 might require increased prenatal surveillance.  
  • Note from EBB: It’s not clear at this point whether infection with SARS-CoV-2 led directly to placental injury or if there is some other underlying cause for both placental injury and susceptibility to COVID-19. It’s also too early to tell whether placental injury with COVID-19 affects birth outcomes. Most of the infants in this case series were born healthy and without complications.  

Universal testing for SARS-CoV-2 at labor and delivery units 

  • Universal testing for SARS-CoV-2 means testing all pregnant people when they are admitted for labor or birth, regardless of whether or not they have symptoms of COVID-19. Many hospitals have implemented this practice in recent weeks.  
  • What prompted hospitals to implement universal testing at L&D units? You might recall that in April, Sutton et al. published a report in the New England Journal of Medicine describing the experience of two New York City hospitals. (We covered the details of that study in the April 20th webinar, which you can access on our COVID-19 resource & pregnancy page here.)  
  • These hospitals reported a 15.4% prevalence of SARS-CoV-2 infection among everyone admitted to give birth—and the majority of those infected were asymptomatic!  
  • The authors cautioned that their findings might not be generalizable to geographic regions with lower rates of infection (these two New York City hospitals were at the height of the epicenter of the pandemic in the U.S.).  
  • Still, their study sparked widespread universal testing protocols. Hospitals everywhere were concerned that they were missing asymptomatic infections, potentially putting health care workers and other patients at risk of exposure to the virus.  

Universal testing experience at in Los Angeles (Naqvi et al. 2020) 

  • In April, the Cedars-Sinai Medical Center in Los Angeles, California changed their policy from testing only symptomatic pregnant people to testing everyone on admission regardless of symptoms, called universal testing.  
  • They screened 82 pregnant people over a 7-day period. Two women had symptoms on intake; of these, one tested positive for SARS-CoV-2. None of the 80 asymptomatic people tested positive and all remained symptom-free throughout their stay.  
  • The hospital discontinued universal testing after the 7-day period because they couldn’t justify continuing the policy when they weren’t detecting any asymptomatic cases of infection. There were also downsides to universal testing: it led to more use of valuable personal protective equipment (PPE) and, in some cases, mother-newborn separation until test results were available.  
  • The authors concluded that hospitals should base the decision to implement universal testing on local rates of infection in the community, when possible, and conduct a trial period of universal testing to make sure it makes sense. For this hospital, universal testing didn’t make sense at this time.  

Universal testing experience at three hospitals in Southern Connecticut (Campbell et al. 2020) 

  • Three Yale New Haven Health hospitals in Southern Connecticut reported their experience with universal testing.  
  • Between April 2 and April 29, these three hospitals screened 782 people presenting for childbirth. Of these, 12 pregnant people (1.5%) had already been diagnosed with COVID-19. The remaining 770 people were tested on admission; 30 people out of 770 (3.9%) tested positive. Most of the people who tested positive were asymptomatic (22/30). The overall rate of positive test results among asymptomatic people admitted to the hospital to give birth was 2.9%.  
  • No clinical outcomes were reported.  
  • These findings suggest a low (<3%) prevalence of positive test results among asymptomatic pregnant people giving birth at these three hospitals in Southern Connecticut. Connecticut has one of the higher rates of per capita infection in the United States.  

Universal testing experience at a hospital in Chicago (Miller et al. 2020) 

  • On April 8, Northwestern Memorial Hospital in Chicago, Illinois implemented universal tested for all pregnant people on admission.  
  • They tested 635 pregnant people between April 8 and April 28 and 23 (3.6%) tested positive for SARS-CoV-2. Of the 23 people with positive test results, 10 were asymptomatic. The overall rate of positive test results among asymptomatic people presenting for childbirth was 1.6%.  
  • No clinical outcomes were reported.  
  • These findings suggest a low (<2%) prevalence of positive test results among asymptomatic pregnant people admitted to give birth at this Chicago hospital.  

An editorial in Obstetrics & Gynecology asks: Is universal testing needed on all L&D units? (Metz, 2020)  

  • The author mentioned several important benefits from universal testing. Knowing every laboring person’s infection status allows: 
    • Health care workers (HCWs) to wear appropriate PPE; 
    • Infected mothers to be counseled about ways to decrease transmission to newborns; and 
    • Infected mothers to be monitored closely, with a low threshold for clinical intervention. 
  • Dr. Metz wrote that the decision to implement universal testing is very complex; it depends on the disease prevalence in the community and the availability of valid testing: 
  • The main benefit is the ability to protect HCWs from unintended exposures. This is especially important in hot spots where HCWs are in short supply.  
  • There are also concerns about negative consequences of universal testing for birthing people.  
  • Pregnant people who test positive face stigmatization and may be pressured to separate from their newborn. 
  • HCWs spend more time donning appropriate PPE before caring for people with SARS-CoV-2, and this could lead to delays in care.  
  • Positive infection status could affect clinical decision-making, potentially resulting in harm. 
  • Dr. Metz concluded that decisions regarding universal testing should take the regional prevalence of COVID-19 in account. In settings with low population prevalence of COVID-19 or limited ability to test, universal testing may not be appropriate. In settings with high prevalence of COVID-19 in the population, universal testing may be a valuable tool to help protect HCWs and patients from infection. There is no “one-size-fits-all” approach.  
  • Note from EBB: As we discussed, the Cedars-Sinai Medical Center in Los Angeles had no positive tests after testing 80 asymptomatic laboring people, and so they decided to stop universal testing. In contrast, Northwestern Memorial Hospital in Chicago and the three Yale New Haven Health hospitals in Southern Connecticut both found an asymptomatic positive rate under 3% (not insignificant, but still far lower than the rate of 13.5% seen in the New York City hospitals.) The big question is: What prevalence of positive test results among asymptomatic pregnant people justifies universal testing?  

Q and A Section 

 

Question: Are there any recommendations regarding social distancing as the due date approaches (~2 weeks out) versus relaxing social distancing as states ease restrictions and reopen?  

Answer: In the U.S., many states are easing restrictions and reopening businesses. You can find specific info on current restrictions in your state here. The move to reopen states is very controversial! Some public health experts are concerned that it could lead to a second wave of infections.  

There are a lot of mixed messages about social distancing coming from state leaders and federal authorities. Basically, the precautionary measures you decide to take to protect yourself and your baby from COVID-19 will depend on your own personal perception of risk.  

The U.S. Centers for Disease Control (CDC) continues to recommend social distancing for everyone, including during pregnancy. This means staying home or staying at least 6 feet away from people who do not live in your home. In situations where you can’t practice social distancing (grocery shopping, for example), the CDC recommends wearing a cloth face covering. It is still important to attend prenatal care appointments, although care providers might cancel or postpone visits, or conduct the visit over phone or video.  

Question: Can I refuse to be tested for SARS-CoV-2 on admission? Can I refuse to wear a mask during labor?   

Answer: Yes, you have the right to refuse testing. We did a quick web search and found that some hospitals are anticipating that pregnant people might refuse to be tested. For example, Penn Medicine Lancaster General Health answers the question: What if I decline the COVID-19 test? “After a discussion about the risks and benefits of your choice, your decision will be respected. Your healthcare team will take extra precautions to protect themselves from the potential risk while caring for you.”  

You also have the right to refuse to wear a mask during labor. The groups issuing guidance on requiring understand that laboring people may not be able to comply with the recommendation to wear a mask, especially during the pushing phase of labor. You could try to wear the facemask when HCWs are in the room, but if it affects your ability to cope with labor, then you have the right to refuse it. Ideally, HCWs could wear appropriate PPE to protect themselves from exposure. However, the unfortunate reality is that many HCWs do not have adequate PPE during this pandemic.  

It’s important to keep in mind that universal testing and requiring laboring people to wear facemasks is in large part to protect health care workers. Instead of refusing to be tested, consider having a discussion with your care provider about what a positive test result would mean. Importantly, pregnant people who test positive for COVID-19 still have the right to room-in with their infant and breastfeed (see our Sample Informed Consent Form for Refusal to Separate Birthing Parent and Infant here.)  

Also, one of the risks of refusing to be tested is that it could create discord between you and your birth care team. Depending on infection rates in their communities, many nurses and other HCWs are justifiably scared and anxious about becoming infected and bringing an infection home to children or vulnerable/high-risk family members. If you refuse to be tested, staff may not be allowed to wear adequate PPE to protect themselves. There is a possibility that refusing to be tested could make staff more nervous to be in your room, which could lead to less hands-on care and a decreased quality of your care.  

May

Research Update for Monday, May 18 at 1:03 PM + Detailed Q&A!

This week we share details from the first report to come out of a United Kingdom COVID-19 registry, info from a medical anthropology paper about childbirth and the pandemic, and links to non-profit organizations and others who are raising funds for traditionally marginalized groups during the pandemic. 

Today’s questions (answered in a Q&A section at the bottom of this email) include:

  • What precautions should be made once home with a newborn? Should family members remain 6 feet from baby, wear masks, etc.?  
  • Is there any evidence of birth defects if someone gets infected while pregnant? 
  • Is the high Cesarean rate with COVID-19 due to viral complications, or is it more about cultural practices in certain areas? 

To ask a question for consideration for future newsletters, submit your question here. 

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), a sample informed consent form to refuse mother-newborn separation, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University 

As of 10 AM EDT on May 18, 2020, there are more than 4.7 million confirmed cases of COVID-19 around the world. The highest number of cases is in the U.S. (1.5 million), followed by Russia, the United Kingdom, Brazil, Spain, Italy, and France. 

First report from the UK Obstetric Surveillance System (UKOSS) COVID-19 registry 

  • The first report from the UKOSS COVID-19 registry included 427 pregnant people admitted to the hospital with confirmed SARS-CoV-2 between March 1, 2020 and April 14, 2020 from all 194 obstetric units in the UK (Knight et al. 2020).  
  • This prospective national population-based cohort study is larger than all previous studies of SARS-CoV-2 infection in pregnancy combined! It’s also the first population-based study. Interestingly, this study was actually designed in 2012 with the intent to be activated in response to a future pandemic. UKOSS studies were also activated for Influenza A/H1N1 and Zika virus in pregnancy. 
  • UKOSS collects national data about specific severe pregnancy complications from all 194 hospitals in the UK. For this study, clinicians were asked to report all pregnant people with confirmed SARS-CoV-2 admitted to their hospital. During the study period, pregnant people were only tested if they had symptoms, so the registry didn’t capture asymptomatic people with COVID-19. The study is limited because people admitted to the hospital with symptoms have more severe illness (and increased risk for poor outcomes) compared to those without symptoms and those with symptoms who are not hospitalized 
  • They compared the 427 infected pregnant people with 694 people who gave birth between November 1, 2017 and October 31, 2018. The comparison group came from a previous study of seasonal influenza in pregnancy; comparison cases consisted of the two people who gave birth immediately prior to someone with confirmed influenza. The reason the researchers used a historical comparison group was to make sure that no one in the comparison group had asymptomatic or mild SARS-CoV-2 infection.  
  • Findings: During the study period, 427 pregnant people were hospitalized with confirmed SARS-CoV-2 infection across the UK out of over 86,293 pregnancies. This means that the incidence of hospitalization with SARS-CoV-2 was 4.9 per 1,000 pregnancies, or fewer than 1 woman hospitalized with SARS-CoV-2 for every 200 people giving birth.  
  • The median time during pregnancy for symptoms to begin and lead to hospitalization was 34 completed weeks of pregnancy. This finding supports U.K. guidance to practice social distancing in the late second and third trimesters of pregnancy. The most common symptoms were fever, cough, and shortness of breath.  
  • In the study, 55% of the pregnant people hospitalized with SARS-CoV-2 were Black, Asian, or from another minority ethnic background, and these groups comprise only 13% of the UK population. The increased risk persisted even when taking other factors into account, such as body mass index (BMI), age, smoking status, and any previous medical problem. The authors say this finding “requires urgent investigation and explanation.” Dr Christine Ekechi, Consultant Obstetrician and Gynecologist, and spokesperson on racial equality for the RCOG, said, “healthcare professionals should be aware of this increased risk, and have a lower threshold to review, admit and consider multidisciplinary escalation.”  
  • Note from EBB: Severe health disparities with COVID-19 have also been found among Black and minority birthing people in the U.S. The UKOSS study shows that racial and ethnic disparities persist even in a country with universal free access to health care. So, regardless of the type of health care system, implicit racial biases and structural racism still have detrimental effects on health outcomes, as we’re seeing with COVID-19. For a great resource on this topic, check out the webinar “Black Feminist Perspectives on COVID-19” hosted by Black Women Radicals. They include a reading list of podcasts, webinars, books, and articles from the event. 
  • Other risk factors included maternal age 35 years and older, BMI> 25kg/m2, and having pre-existing health problems.  
  • During the study period, 247 (58%) pregnant people out of the 427 gave birth; the rest of the pregnancies were ongoing at the time of the report. Of the 243 people who gave birth, 180 (73%) gave birth at term. There were 63 people who gave birth preterm, most (79%) due to medical intervention. The reasons for medical intervention leading to preterm birth were maternal COVID-19 status (46%), fetal compromise (14%), and other obstetric conditions (19%).  
  • 144 people (59%) had a Cesarean—27% for maternal compromise with COVID-19, 24% for concerns about fetal compromise, 19% for failure to progress or failed induction, 15% for other obstetric reasons, 11% because of previous Cesarean, and 4% at maternal request. Of those who had Cesareans, 20% had general anesthesia due to maternal respiratory compromise or the need for urgent birth. In the comparison group of people who gave birth without SARS-CoV-2, the Cesarean rate was 29% and 7% gave birth with general anesthesia.  
  • Overall, the vast majority of pregnant people hospitalized with SARS-CoV-2 infection had good birth outcomes. However, about 1 in 10 hospitalized cases required level 3 critical care with respiratory support—approximately one person out of every 2,400 people giving birth. This rate is similar to that seen in the general population hospitalized with SARS-CoV-2. Sadly, five pregnant people died while hospitalized with SARS-CoV-2, but it is still under investigation whether COVID-19 was the cause of death. The case fatality rate was 1.2% and the maternal death rate was 5.6 deaths per 100,000 pregnancies (or 1 death per 18,000 people giving birth).  
  • There were 5 perinatal deaths: three stillbirths and two newborn deaths. The authors reported that three of the deaths were definitely unrelated to SARS-CoV-2 infection. The rate of NICU admission was 26% and most of these infants were preterm (72%).  
  • Transmission of SARS-CoV-2 to newborns was rare. Twelve (5%) of newborns tested positive for the virus after the birth, six of these infants within the first 12 hours after birth. Half of the babies who tested positive were admitted to the NICU.  

Study considering childbirth and the COVID-19 pandemic from a medical anthropology perspective 

  • Medical anthropology is defined as “the study of how health and illness are shaped, experienced, and understood in light of global, historical, and political forces.” In this article, Robbie Davis-Floyd, PhD, researcher, author, and international speaker, explains with her colleagues how U.S. maternity care practices are changing in light of the pandemic (Davis-Floyd et al. 2020).  
  • Between March 27 and April 11, 2020, the authors sent an email survey to members of the Council on Anthropology and Reproduction as well as multiple birth workers, including certified nurse-midwives, certified professional midwives, doulas, and obstetricians. They received 41 responses for the analysis.  
  • Before summarizing and analyzing the responses to the online questionnaire, the authors discussed the fragmented state of the U.S. midwifery profession and how the COVID-19 pandemic highlights the need for more integration in U.S. maternity care. In the U.S., there are several different midwifery certifications: certified nurse-midwives (CNMs), certified midwives (CMs), certified professional midwives (CPMs), and traditional midwives. Misunderstanding about the different midwifery certifications has led to a lot of debate about whether out-of-hospital community birth should be considered a safe alternative to in-hospital birth for low-risk people during the pandemic. Importantly, the CPM is the only midwifery credential in the U.S. that requires knowledge about and experience in out-of-hospital settings, which makes them uniquely qualified to respond to disasters of all sorts (pandemics, extreme weather events—any emergency that makes the hospital birth setting unsafe or difficult to access). However, CPMs are not legal, licensed, and regulated in every state (currently they are legally authorized to practice in 35 states). 
  • The authors used the responses to their email survey to guide a discussion about changes to maternity care practices with COVID-19. Some of the impacts of the pandemic include:  
    • Transport from the community setting to the hospital setting may become more problematic with COVID-19. CPMs already face challenges transporting their clients to the hospital because they are not legally recognized in every state. They are also not allowed to practice in hospitals, so they are often viewed with distrust by hospital staff. Now, with the pandemic, responses indicated fears that hospitals may be less willing to accept transfers and laboring people may be less willing to transfer because everyone is afraid of the risk of exposure to SARS-CoV-2. In addition, if hospitals are at capacity because of the pandemic, it could make community birth less safe because people with serious complications may not receive timely hospital transfers.  
    • The pandemic may lead to greater support for midwives in state regulations and an increase in community birth. In New York State, for example, CPMs are unable to be licensed, and the pandemic shut down efforts to pass a CPM licensure bill. However, in March 2020, Governor Cuomo issued an executive order allowing midwives licensed elsewhere in the U.S. or Canada to practice in New York State. You can read an analysis of this executive order by the Birth Rights Bar Association here. Several other states have petitioned their Governors for similar executive orders. The North American Registry of Midwives (NARM) is available to assist advocates in other states (i.e. Illinois, Massachusetts, Georgia) who would like to increase access to community birth providers during the pandemic. When asked if pregnant people are expressing anxiety and fear about exposure to hospitals and clinical settings for prenatal visits, the survey respondents overwhelmingly answered “YES”. The majority also responded “YES” they are seeing an increase in home birth and birth in freestanding birth centers. Respondents reported that they are not seeing their local hospitals becoming more supportive of community birth because of COVID-19. 
    • Community midwives and doulas are changing their practice in response to COVID-19. Survey respondents reported more use of masks and gloves; more sanitizing their workspace and equipment; and fewer in-person visits (lots of virtual visits).  
    • The pandemic may be causing some medical providers to move more toward the “technocratic model of birth.” With this model, the birthing body is viewed as dysfunctional and in need of constant surveillance, routine intervention, and technological rescue. The authors explained that times of crisis often cause us to revert back to deeply held belief systems. Believing that the benefits of intervening in the birth process usually outweigh the risks of the interventions can lead to an over-use of intervention and treatment-caused harm. 
    • Decades of effort by activists to get partners and labor companions routinely allowed in hospital birth rooms is being undone. Respondents expressed concern for the mental health implications of denying support to people during hospitalization for childbirth. One respondent noted that they have seen people switch to home births where they can have both a doula and their partner present for the birth.  
    • The pandemic is magnifying unequal access to safe and high-quality maternity care. Due to systemic racial bias, Black people are being hospitalized with severe COVID-19 and dying at rates much higher than their White counterparts.   
    • In summary, the authors describe quick and dramatic changes occurring in birth practices across the United States as a result of the pandemic. They agree with all of the recommendations from the Foundation for the Advancement of Midwifery (FAM) regarding community birth and pandemic planning. You can read the full statement from the FAM here.  

Non-profit organizations and others who are raising funds for underserved groups during the pandemic 

  • The COVID-19 Philadelphia Birth Fund, organized by Birth Fund Philly, is raising funds to provide 20 expecting parents with access to high quality midwifery care in the community birth setting. These funds will be prioritized for black and people of color, reducing virus exposure to those most vulnerable. Help them reach their $50,000 goal!  
  • The COVID-19 Emergency Response Fund was established by the First Nations Development Institute to respond to American Indian, Alaska Native, and Native Hawaiian emergency needs related to the pandemic. They distribute funds to Native nonprofit groups and tribal programs, prioritizing funds to go to COVID-19 hotspots. Donate now to support native communities during the pandemic! 
  • Donate to UNICEF to help support their work! They are rushing PPE, medical equipment and hygiene supplies to hotspots. They are also training health care workers and developing educational programing for children who are home from school.  
  • The NAACP is ready to respond to possible civil rights violations during the pandemic. They have developed resources to guide officials addressing impacts of the pandemic that are most affecting communities of color. You can help to protect civil rights during the pandemic by donating to the NAACP! 
  • The Mom and Baby COVID-19 Intervention and Support Fund was established by March of Dimes to support research, advocacy, education, and resources for pregnant people, babies and families during the pandemic. Donate to help March of Dimes protect moms and babies during the pandemic! 
  • The Neighborhood Funders Group has compiled a long list of groups doing amazing work to support underserved communities during COVID-19.  
  • Do you know of a non-profit that is serving traditionally marginalized groups that you’d like us to feature in our newsletter? Hit reply to let us know! 

Q and A Section 

Question: What precautions should be made once home with a newborn? Should family members remain 6 feet from baby, wear masks, etc.?  

Answer: COVID-19 disease in infants is rare, but children under the age of one appear to be at higher risk of developing severe illness from infection compared to older children and healthy adults. A study of more than 2,100 children with suspected or confirmed COVID-19 in China showed that about 1 in 10 infants developed severe or critical illness (Dong et al. 2020).  

The U.S. Centers for Disease Control (CDC) has a page with info on how to protect vulnerable members of the household from COVID-19, but they do not include infants among those at higher risk for severe illness. The people at the greatest risk of severe illness from infection are older adults (65 and older) and people of any age who have serious underlying medical conditions.  

Grandparents or other visitors from outside of the household who fit that description are at increased risk and need to be protected just as the newborn needs to be protected. In fact, if your family just recently gave birth in the hospital, then the members of your household (who stayed in the hospital) may pose a greater risk to vulnerable visitors than the visitors pose to you and the new baby.   

So, depending on your individual risk perception, you could decide to consider your newborn a vulnerable member of the household and take the additional precautions outlined by the CDC. If you decide to bring the baby into contact with people from outside of the household (grandparents, for example), then you can consider taking precautions such as using facemasks (not for children under age two) and keeping physical distance.  

The Royal College of Obstetricians and Gynecologists (RCOG) advises that family members who live in the household with the newborn take regular hygiene precautions, such as careful hand washing and keeping anyone with symptoms of illness away from the baby, if possible. Large family gatherings to celebrate the baby’s arrival are not recommended.  

The American Academy of Pediatrics (AAP) recommends special care for newborns born to parents who have confirmed or suspected COVID-19. 

Question: Is there any evidence of birth defects if mother is infected? 

Answer: No. There is currently no evidence that the virus causes birth defects or increases the risk of miscarriage. We expect more research to emerge on this topic to emerge in the next year.   

Question: Is the high Cesarean rate with COVID-19 attributed to COVID-19 related complications, or is it more due to regional clinical management? 

Answer: In the UKOSS study (described above) 59% of pregnant people hospitalized with COVID-19 had a Cesarean. Of these, 27% were for maternal compromise with COVID-19, 24% for concerns about fetal compromise, 19% for failure to progress or failed induction, 15% for other obstetric reasons, 11% because of previous Cesarean, and 4% at maternal request. In other words, about half of the Cesareans in that study were for maternal or fetal compromise and the other half were done for other reasons.  

It’s worth noting that many of the people hospitalized with COVID-19 in the UKOSS study had other risk factors that could have contributed to the high Cesarean rate. 

Cesarean rates were actually much higher in a Chinese case series than in the United Kingdom. Given these differences, when you see high Cesarean rates with maternal COVID-19, you’re probably looking at a combination of COVID-19 related complications as well as medical practices/traditions that impact Cesarean rates.  

This concludes the research update for May 18, 2020. I hope you found it helpful! 

References 

Davis-Floyd, R., Gutschow, K. and Schwartz, D. A. (2020). Pregnancy, Birth and the COVID-19 Pandemic in the United States [published online ahead of print, 2020 May 14]. Med Anthropol, 1‐15. Click here.  

Dong, Y., Mo, X., Hu, Y., et al. (2020). Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. Click hereFree full text! 

Knight, M., Bunch, K., Vousden, N., et al. (2020). Characteristics and outcomes of pregnant women hospitalised with confirmed SARS-CoV-2 infection in the UK: a national cohort study using the UK Obstetric Surveillance System (UKOSS). 2020 [Available from: https://www.npeu.ox.ac.uk/downloads/files/ukoss/annual-reports/UKOSS%20COVID-19%20Paper%20pre-print%20draft%2011-05-20.pdf] accessed online May 16, 2020. 

Research Update for Monday, May 11 at 9:55 AM + Detailed Q&A!

This week we share info from the largest study of pregnant people with severe COVID-19, a study comparing intensive care unit (ICU) admissions for pregnant and non-pregnant people with COVID-19, research on the psychological impact of COVID-19 in pregnancy, details from a study that detected the SARS-CoV-2 virus in 3 placental and fetal membrane samples, and details from some of the first studies examining human milk and the virus.  

Today’s questions (answered in a Q&A section at the bottom of this email) include: 

  • Is there any guidance on Neonatal Intensive Care Unit (NICU) visitation policies during the pandemic? Can parents still visit their babies in the NICU? 
  • Are newborns more likely to get COVID-19 if they room-in with an infected parent versus room separate from their parent? 

To ask a question for consideration for future newsletters, submit your question here. 

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University

As of 9 AM EDT on May 11, 2020, there are more than 4.1 million confirmed cases of COVID-19 around the world. The highest number of cases is in the U.S. (1.million), followed by Spain, Russia, the United Kingdom, Italy, France, Germany, Brazil, Turkey, and Iran.  

Largest study of pregnancy and severe/critical COVID-19  

  • Since COVID-19 is such a new disease, providers still don’t have much evidence-based guidance on how to manage severe or critical COVID-19 in pregnancy. This large U.S. cohort study was conducted to better understand the clinical course of COVID-19 in pregnancy (Rebecca et al. 2020).  
  • The participants were 64 pregnant people with positive lab tests for SARS-CoV-2 from 12 U.S. hospitals in Pennsylvania, New Jersey, New York, and Ohio between March 5 and April 20, 2020.  
  • Severe disease was defined as: “patient reported dyspnea [shortness of breath], respiratory rate >30 per minute, blood oxygen saturation ≤ 93% on room air, partial pressure of arterial oxygen to fraction of inspired oxygen <300 and/or lung infiltrates >50% within 24 to 48 hours on chest imaging.” Critical disease was defined as: “respiratory failure, septic shock, and/or multiple organ dysfunction or failure.” 
  • Findings: Of the 64 pregnant people hospitalized with COVID-19, 44 (69%) had severe disease and 20 (31%) had critical disease. One-fourth (25%) had a pre-existing lung condition, and 17% had heart disease. The average body mass index (BMI) was 34 kg/m2.  
  • The average gestational age when symptoms first began ranged from 17 weeks to 39 weeks. Most people were admitted to the hospital about 7 days after symptoms began. 
  • Half (32 people) gave birth while hospitalized for severe or critical COVID-19 infection. Most (75%) of the critical cases had preterm births because of medical intervention due to the mother’s disease status. Half of the people with severe disease gave birth vaginally, while over 90% of those with critical disease had Cesareans.  
  • The article includes some discussion of clinical implications for providers caring for mothers with severe or critical COVID-19 disease. People with severe disease required the most breathing support on day 8 of hospitalization; when intubation (inserting a tube into the airway to assist with breathing) was required, it occurred around day 9 of hospitalization. 
  • People with severe disease stayed at the hospital for about 6 days and those with critical disease stayed for about 11 days. There was one case of maternal cardiac arrest, but no maternal deaths. There were no stillbirths or newborn deaths, and none of the infants tested positive.  
  • The authors suggest that the clinical course of severe or critical COVID-19 infection may be shorter in pregnant people compared to non-pregnant adults, although more research is needed. Reassuringly, this is more evidence that pregnancy may not be an independent risk factor for a more severe course of COVID-19 disease. 

Study comparing intensive care unit (ICU) admissions for pregnant and non-pregnant women with COVID-19

  • Another recent study tried to determine whether pregnant people are more likely to be admitted to the ICU than non-pregnant people of reproductive age (Blitz et al. 2020).  
  • The data came from 7 hospitals in New York between March 2 and April 9, 2020. The participants were females between 15 to 49 years of age who tested positive for SARS-CoV-2 at the hospital. All of the participants in this study had symptoms of COVID-19 at some point during their hospital stay, which prompted the testing (it was not universal testing). The full text of this study is not yet available, so we don’t have all of the details, such as the reasons for hospitalization.  
  • Findings: There was no significant difference in the rate of ICU admission between hospitalized non-pregnant females with COVID-19 (15.1%, 50/332) and hospitalized pregnant females with COVID-19 (9.8%, 8/82).  
  • The authors concluded that pregnancy does not appear to increase risk of ICU admission. Like the previous study we discussed, this is more evidence affirming that pregnant people with COVID-19 may not experience more severe disease than non-pregnant people.  

Survey to evaluate the psychological impact of COVID-19 in pregnancy

  • Researchers in Napoli, Italy surveyed 100 pregnant people from March 15 to April 1, 2020 to evaluate the psychological impact of the COVID-19 pandemic (Saccone et al. 2020). The authors did not report if the mothers were tested for SARS-CoV-2 before completing the survey. We reached out to Dr. Saccone for more information and found out that they excluded anyone who tested positive for SARS-CoV-2. However, the study included both inpatients (who were routinely tested) and outpatients (who were not routinely tested), so some of the participants were not aware of their infection status.  
  • The participants were people with single pregnancies of various gestational ages: 17 people were in the first trimester, 35 in the second, and 48 in the third trimester. None of the participants had a history of postpartum depression in a previous pregnancy and no one was diagnosed with a psychiatric disorder.  
  • They completed several different questionnaires: The psychological impact questionnaire, a 22-item questionnaire with scores ranging from 0 to 88 (higher scores mean more psychological impact), the six-item anxiety questionnaire with scores ranging from 20 to 80 (scores over 36 are considered abnormally high levels of anxiety), and the visual analogue scale (VAS) for anxiety, where pregnant people were asked “How anxious are you regarding the coronavirus epidemic and the possibility of vertical transmission to your offspring?” Answers could range from 0 (not at all anxious) to 100 (extremely anxious).  
  • Findings: More than half (53%) of the survey respondents rated the psychological impact of COVID-19 as severe.  
  • About two-thirds reported higher than normal levels of anxiety. 
  • About half of the mothers reported high anxiety about the possibility of vertical transmission (becoming infected and passing the virus to the baby during pregnancy or birth).  
  • The psychological impact of COVID-19 and impact on anxiety was more severe among people in their first trimester of pregnancy.  

SARS-CoV-2 virus detected in 3 of 11 placental and fetal membrane samples 

  • Researchers reviewed the medical records of all pregnant patients who were diagnosed with COVID-19 and gave birth at a single hospital in New York between March 1 and April 20, 2020 (Penfield et al. 2020). They were looking for any cases where SARS-CoV-2 testing was done on either the placenta or membranes within 30 minutes after the birth.  
  • Findings: They identified 32 pregnant people with COVID-19 who gave birth during the specified time frame, and placental or membrane swabs were sent from 11 of these patients. Three out of the 11 swabs tested positive for the virus, all from mothers with moderate to severe COVID-19 at the time of birth. None of the infants tested positive and none had symptoms of COVID-19 during days 1 to 5 of life. 
  • The authors concluded that their findings raise the possibility of intrapartum viral exposure; however, more research is needed. Finding evidence of the virus in placental or membrane samples is not conclusive evidence that the virus can pass from the mother to the fetus during pregnancy or birth (vertical transmission).  

First sample of human milk tested positive in a case series of infections in 13 pregnancies  

  • On May 5, researchers published a case series of 13 infected pregnant people in Wuhan, China (Wu et al. 2020). In this study, 5 of the women were in their first trimester, 3 were in their second trimester, and 5 were in their third trimester. 
  • The 5 women in their third trimester all gave birth during the study. Two of the babies were premature and diagnosed with newborn pneumonia.  
  • One of 9 stool samples tested positive and 13 samples of vaginal fluids tested negative. They also collected 5 throat swabs and 4 anal swabs from the newborns and all were negative for the virus. 
  • Human milk samples were collected from three women on the 1st, 6th, and 27th days after birth. Iodine was used to disinfect the mother’s breast, and then milk was expressed into a sterile container. One of the samples from the first day after birth tested positive. When they re-tested this mother’s milk on the 3rd, 6th, and 27th days after birth, the samples were negative. We contacted the authors of this study to inquire about other infection control measures that were used while collected the milk samples. Dr. Wu told us that it is very unlikely that respiratory droplets contaminated the milk sample because the samples were collected in isolation rooms while the mothers wore masks.  
  • Note from EBB: More research is needed to tell us if SARS-CoV-2 can appear in human milk (like HIV and hepatitis B). To date, all other samples of human milk (from at least 26 mothers with COVID-19) have tested negative (Elshafeey et al. 2020). Most guidelines (with the exception of some guidance from Chinese health officials) encourage infected mothers to breastfeed or feed their infants with expressed human milk. The many benefits of human milk are thought to outweigh the potential risk of exposure to the virus. In addition, the infant may receive some protection from the mother’s antibodies to COVID-19, since human milk contains antibodies and other factors that protect against infection (see next study!) 

First study to show that human milk can provide antibodies against SARS-CoV-2 

  • On May 8Fox et al. published a preprint (meaning it has not yet undergone peer review) of a research study examining human milk from donors who were previously infected with SARS-CoV-2.  
  • The authors recruited 350 lactating people who had COVID-19 illness; they used samples from 15 donors for this preliminary report. All of the participants had laboratory-confirmed COVID-19 illness or a high likelihood of infection based on symptoms and close contact with someone who had COVID-19. Milk was pumped 14-30 days after symptoms lessened. The researchers also tested 10 samples of pre-pandemic human milk as a negative control.   
  • Findings: 12 of the 15 samples (80%) of human milk from people recovered from SARS-CoV-2 were positive for high reactivity for IgA antibodies to the virus.  
  • These preliminary findings suggest that people with SARS-CoV-2 infection may have a strong secretory IgA-dominant immune response in their human milk after infection. The results justify the need for further study—both so that we can understand the protective effects of human milk on babies of infected mothers, and also so that we can understand the potential of human milk to be used as a therapeutic for COVID-19.   
  • This news article describes how researchers are working to collect human milk samples from donors. A paragraph at the end includes contact info for people who had COVID-19 and are interested in donating human milk.  

Q and A Section 

Question: Is there any guidance on Neonatal Intensive Care Unit (NICU) visitation policies during the pandemic? Can parents still visit their babies in the NICU? 

Answer: Visitation guidelines vary by country and by hospital. The non-profit Human Rights in Childbirth published a report on May 6 documenting various human rights violations occurring in maternity units around the world. They reported that parents have not been allowed to visit their newborns in neonatal units at hospitals in Croatia, Czechia, and New Zealand.  

In the U.S., we did a quick online search for hospitals with updated NICU policies because of COVID-19, and all the policies we found online stated that healthy parents are still permitted to visit their newborns. For example, New York-Presbyterian allows one healthy visitor per pediatric patient in the NICU. Visitors must be parents, guardians, or family care partners. If possible, designated visitors should remain the same for the entire hospital admission. Visitors to the NICU must wear appropriate personal protective equipment at all times.  

However, in practice, this does not mean that all hospitals have always allowed parents to visit their newborns in U.S.-based NICUs during the pandemic, and parents have expressed anxiety to journalists about this topic. For example, in early April, media reports documented that a Virginia hospital banned all visitors to the NICU, including parents. A change.org petition resulted in the hospital changing their policy (the organizers of the petition also stated that visitation bans had been in place in 9 other NICUs in Georgia, Wisconsin, Pennsylvania, Indiana, and New Jersey)It seems like that in the U.S., at least, the pendulum has swung towards recognizing the importance of the parents to the baby’s health in the NICU setting, as well as the unethical nature of forced separation between parents and their babies in the NICU.  

On April 2, the American Academy of Pediatrics (AAP) issued guidance on NICU visitation during COVID-19. They advised that mothers with COVID-19 not visit their infants in the NICU until they meet certain requirements: (a) no fever for 72 hours without use of medication, (b) respiratory symptoms are improved, and (c) consecutive negative test results (collected ≥24 hours apart)“Non-maternal parents” (i.e. parents who did not give birth) should also not visit their infants in the hospital until they are determined to not be at risk of infection 

Question: Are newborns more likely to get COVID-19 if they room-in with an infected parent versus separate from their parent? 

Answer: There is very little research on newborns born to mothers with confirmed SARS-CoV-2 infection. A review published April 24 described outcomes for 256 newborns that were born to infected mothers (Elshafeey et al. 2020). Four of the newborns tested positive for SARS-CoV-2. It’s not clear whether they acquired the infection from the mother, a health care worker, or someone else.  

Right now, we don’t have data that compares rates of infection between babies who were separated from their infected mothers after birth versus those who roomed in with precautions.  

A case series of infected pregnant people in New York described newborn outcomes for 18 infants (Breslin et al. 2020). None of the infants tested positive after birth. Three of the infants were admitted to the NICU and the other infants either roomed in with their mothers in isolettes or were cared for in an isolated nursery for babies of COVID-19 positive mothers.  

A case report from Australia was the first to give a detailed description of a mother with COVID-19 who was not separated from her infant (Lowe and Bopp, 2020). The mother developed upper respiratory symptoms at 40 weeks and 2 days of pregnancy. She was admitted to the hospital and tested positive (the other parent also tested positive). She went into labor spontaneously at 40 weeks and 3 days and had a vaginal birth. The newborn was breastfed and roomed in with the parents. Both parents practiced careful hand washing and wore surgical masks around their baby. The baby tested negative 24 hours after birth and remained well and free of symptoms.  

This concludes the research update for May 11, 2020. I hope you found it helpful! 

References 

Blitz, M. J., Grünebaum, A., Tekbali, A., et al. (2020). Intensive Care Unit Admissions for Pregnant and Non-Pregnant Women with COVID-19. Click here 

Breslin, N., Baptiste, C.Gyamfi-Bannerman, C.et al. (2020). COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals, American Journal of Obstetrics & Gynecology MFM. Click here.  

Elshafeey, F.Magdi, R., Hindi, N., et al. (2020). A systematic scoping review of COVID-19 during pregnancy and childbirth [published online ahead of print, 2020 Apr 24]. Int J Gynaecol Obstet. Click here. 

Fox, A., Marino, J., Amanat, F., et al. (2020). Evidence of a significant secretory-IgA-dominant SARS-CoV-2 immune response in human milk following recovery from COVID-19. Preprint available at medRxivClick here 

Lowe, B. and Bopp, B. (2020). COVID-19 vaginal delivery – a case report [published online ahead of print, 2020 Apr 15]. Aust N Z J Obstet GynaecolClick here. 

Penfield, C. A., Brubaker, S. G., Limaye, M. A., et al. (2020). Detection of SARS-COV-2 in Placental and Fetal Membrane Samples. American Journal of Obstetrics & Gynecology MFM. Click here 

Rebecca, Pierce-Williams, Burd, et al. (2020). Clinical course of severe and critical COVID-19 in hospitalized pregnancies: a U.S. cohort study. Click here 

Saccone, G., Florio, A., Aiello, F., et al. (2020). Psychological Impact of COVID-19 in pregnant women. AJOG. Click here 

Wu, Y., Liu, C., Dong, L., et al. (2020). Coronavirus disease 2019 among pregnant Chinese women: Case series data on the safety of vaginal birth and breastfeeding [published online ahead of print, 2020 May 5]. BJOG. Click here. 

Research Update for Monday, May 4 at 9:35am + Detailed Q&A

Welcome to this week’s research update on COVID-19 and pregnancy!  

This week we share guidelines published in the American Journal of Perinatologyrecommendations from the New York State COVID-19 Maternity Task Force, a new resource from the World Health Organization (WHO) on Breastfeeding and COVID-19, info on false-negative results with COVID-19 testing in obstetrical care, and (*trigger warning*) new research about maternal deaths and a second-trimester miscarriage from COVID-19. 

Today’s questions (answered in a Q&A section at the bottom of this email) include: 

  • I’m concerned about catching the virus from hospital staff. Do we know what percentage of health care workers have COVID-19?  
  • Should doulas wear personal protective equipment when they support their clients at home?  

To ask a question for consideration for future newsletters, submit your question here. 

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University 

As of 8 AM EDT on May 4, 2020, there are more than 3.5 million confirmed cases of COVID-19 around the world. The highest number of cases is in the U.S. (1.16 million), followed by Spain, Italy, the United Kingdom, France, Germany, Russia, Turkey, Brazil, and Iran.  

Another new resource at Johns Hopkins University is a map that shows the number of cases and deaths per county in the U.S.  

Summary of guidelines published online in the American Journal of Perinatology (April 28, 2020) 

  • This article by Stephens et al. discusses how hospitals can adapt during the COVID-19 pandemic. The authors’ suggestions include:  
    • Screen all pregnant people and visitors for symptoms on admission. 
    • No visitors should be allowed for persons under investigation (PUI) or pregnant people who test positive; consider allowing one visitor for everyone else. 
      • This recommendation to deny laboring mothers their support people is controversial and, as we will discuss, contrary to new recommendations coming from New York StateOn a personal note, I had the honor of listening to the story of a mother in New York City who had COVID-19 and was not allowed any support person to stay with her. She described being left alone by staff for the vast majority of her high-risk labor and postpartum stay, causing significant safety concerns. 
  • Isolate pregnant people with symptoms and use negative pressure rooms for those with positive test results. 
  • When caring for people with confirmed or suspected COVID-19, limit staff to only those necessary and use appropriate PPE. 
  • All birthing people and visitors should be encouraged to wear surgical masks at all times. 
  • Infection with SARS-CoV-2 is not a medical indication for Cesarean. 
  • Scheduled Cesareans and medically indicated inductions should not be delayed because of the pandemic. 
  • Consider delaying elective inductions at 39 weeks with a poor Bishop’s score (because the ARRIVE trial found longer labors with elective induction, which increases exposure time for laboring people and staff). 
  • Staff should limit frequency and duration of room visits, reduce the number of cervical exams, and use ultrasound assessment only when necessary to guide clinical management.  
  • The guidance cautions against longer second stages of labor during the pandemic, since forceful exhales during pushing could put staff at increased risk of exposure if the mother happens to be infected. They propose several policy changes that apply to pregnant people who may or may not be infected:  
    • Do not encourage active pushing (instead, encourage mothers to “labor down” and push if there is a strong urge to push). 
    • They say “it may be prudent to resume previous recommendations of a 1-hour second stage in a multiparous patient without an epidural (2 hours with an epidural) and a 2-hour second stage in a nulliparous patient without an epidural (3 hours with an epidural).”  
    • Note from EBB: They are suggesting that health care providers should give mothers about one less hour to push before diagnosing labor arrest in the second stage. Tightening time limits on pushing could increase the mother’s risk of a preventable Cesarean. Recommendations for the Safe Prevention of the Primary Cesarean call for allowing at least 2 hours of pushing for experienced mothers and at least 3 hours of pushing for first-time mothers, with even longer pushing stages with epidurals.  
    • The new guidance in the American Journal of Perinatology also recommends that care providers consider shortening the second stage with an operative vaginal birth (vacuum or forceps) for people with “a fully dilated cervix, fetal head engagement, low fetal station, adequate clinical pelvimetry, and patient consent.  
  • They recommend early cord clamping “given the potential increased risk of viral transmission to the newborn.” This recommendation is based on opinion, however, not evidence.  
    • Note from EBB: Professional guidelines such as the American College of Obstetricians and Gynecologists (ACOG) in the U.S. and the Royal College of Obstetricians and Gynecologists (RCOG) in the U.K. disagree. They say delayed cord clamping is still appropriate, even if the mother has suspected or confirmed COVID-19. So far, cord blood samples have all tested negative for the virus. Multiple randomized trials have shown that early or immediate cord clamping causes harm to the infant by decreasing iron stores in infancy.  
  • Use IV fluids cautiously because aggressive hydration can worsen oxygenation status (potentially harming mothers with COVID-19) 
  • Reconsider the use of antenatal corticosteroids after 34 weeks of pregnancy, since steroid administration may worsen COVID-19 infection. Also be cautious with magnesium sulfate use since respiratory depression is a potential side effect.  

Summary of recommendations from the New York State COVID-19 Maternity Task Force (April 29, 2020) 

  • A multi-disciplinary group of maternal and infant health professionals from across New York State formed the COVID-19 Maternity Task Force. The task force was charged with examining the best approach to provide pregnant people increased choice and access to safe maternity care during the COVID-19 pandemic. On April 29, Governor Andrew Cuomo accepted the task force’s initial six recommendations in full.  
  • Recommendation #1Diversify Birthing Site Options to Support Patient Choice 
    • Issue an Executive Order to immediately establish “birthing surge sites” operated by licensed hospitals and birth centers. 
    • Streamline the process to accept applications from community health centers and federally qualified health centers to convert unused space to dedicated labor and birth rooms during the emergency.  
    • To increase access to midwifery services, the task force recommends New York State Department of Health expedite, within the next 45 days, the licensure process to establish midwifery led birthing centers in New York State.  
    • The task force stated, “Approved birthing centers can provide New Yorkers with low-risk pregnancies an alternative and safe birthing option and may relieve the strain on hospitals during this state of emergency. Even prior to COVID-19, black women in particular voiced a desire to expand birthing options.” 
  • Recommendation #2Support Persons 
    • Authorize at least one support person to accompany a pregnant individual for the duration of their stay in any hospital, birthing facility, or postpartum unit, as medically appropriate. 
    • Clarify that doulas are considered an essential part of the support care team and should be allowed to accompany a pregnant individual during labor and delivery as an additional support person, as medically appropriate. 
  • Recommendation #3: Universal Testing of Pregnant Patients 
    • The task force recommends universal COVID-19 testing for all pregnant individuals and for all support persons accompanying pregnant individuals at birthing facilities, as testing becomes available.  
  • Recommendation #4: Ensuring Equity 
    • Include community members in work groups charged with developing standards, policies, and/or regulations related to birthing options. 
  • Recommendation #5: Messaging and Education 
    • Create and disseminate an educational campaign 
  • Recommendation #6: Department of Health Will Collaborate With Academic Institutions, Regional Perinatal Centers, And Medical Organizations To Review The Impact That Covid-19 Has On Pregnancy And Newborns. 

New resource from the World Health Organization (WHO) on Breastfeeding and COVID-19 (April 28, 2020) 

False-negative results with COVID-19 testing in obstetrical care  

  • An article discussing false-negative COVID-19 tests in obstetrical care was published in AJOG MFM April 28, online ahead of print (Kelly et al. 2020).  
  • Real-time reverse transcriptions-polymerase chain reaction (RT-PCR) of nasopharyngeal (NP) swabs tests are most often used to diagnose COVID-19, but there is limited information about the accuracy of these tests. (We shared info about the accuracy of COVID-19 testing in the April 27 newsletter, which you can access on our COVID-19 resource & pregnancy page here.) 
  • This article reports on a first-time mother at 33 weeks of pregnancy who became critically ill with symptoms of COVID-19. She tested negative THREE times with NP SARS-CoV-2 PCR tests before finally testing positive with a bronchoalveolar lavage (BAL) test performed after intubation by the ICU team. The mother was in critical condition for 11 days, but at the time of the report, both the mother and her premature baby were in good condition.  
  • In the non-pregnant population, rates of false negative results are estimated to be 17% to 63% for NP SARS-CoV-2 RT-PCR tests. The authors say that the potentially high rate of false negatives have important implications for pregnant people suspected of having severe COVID-19: 
    • Repeating NP SARS-CoV-2 RT-PCR testing may be required as much as 3-5 times to get a positive result.  
    • BAL testing appears to be more sensitive than NP swabs, but it is an invasive and aerosolizing procedure. It can be performed after negative NP results if there is high suspicion of COVID-19 and diagnosis is needed.  
    • Initially negative test results should not change clinical management. 
    • If there is high suspicion of COVID-19, a negative test should not allow for removal of precautions (i.e. take precautions as though the patient tested positive).  
    • All NP swab testing should be performed by a specialized team. 
    • Universal testing should not be the only strategy used to determine people’s risk status.  
    • Given the potentially high rate of false negatives, the true rate of COVID-19 in the population is likely underestimated. 
  • The bottom line seems to be that if a medical provider suspects a pregnant person is ill with COVID-19, they shouldn’t trust a negative test result.  

Maternal deaths from COVID-19 

  • An case report published in AJOG on April 26 described a series of maternal deaths from COVID-19 in Brazil (5 deaths), Iran (2 deaths) and Mexico (2 deaths) (Ramos Amorim et al. 2020) 
  • Another case series published in AJOG on April 28 included nine pregnant women in Iran diagnosed with severe COVID-19 disease in their late 2nd or 3rd trimester (Hantoushzadeh et al. 2020). At the time of the report, seven of the nine women had died, one woman remained critically ill on a ventilator, and one woman had recovered after a long hospitalization. 
  • At this time, it is thought that pregnant people are not any more likely than non-pregnant adults to develop severe symptoms or die from COVID-19. However, the authors propose that there could be an increased risk of maternal death from COVID-19 in mid to low resource countries.  
  • There are media reports of U.S. maternal deaths related to COVID-19 in recent weeks that have not yet been described in the research evidence.  
  • Andrea Circle Bear, a 30-year old woman of the Cheyenne River Sioux tribe, died from COVID-19 while in federal custody in the United States. Andrea was pregnant and began experiencing symptoms of COVID-19 in late March. Her family reported that Andrea’s complaints were ignored by authorities and her treatment was delayed. The baby survived an emergency pre-term Cesarean on April 1 while Andrea was on a ventilator, and the baby later tested negative. Andrea died on April 28. Advocates are outraged over how authorities are managing the vulnerable prison population during the COVID-19 pandemic.  
  • Another maternal death was reported in New York City. Amber Rose Isaac, a 26-year-old first-time Black mother, tweeted about her negative experience with her doctors and hospital. Later that same day, she died of HELLP syndrome. Although Amber did not have COVID-19, her family stated that she was not given sufficient in-person prenatal care during the last 6 weeks of her high-risk pregnancy. Advocates warn that the COVID-19 pandemic will worsen the already crisis-level disparately high maternal death rates among Black and Indigenous mothers in the U.S.  

Second trimester miscarriage to a mother with SARS-CoV-2 infection 

  • Researchers published a case report of a 28-year-old pregnant woman in Switzerland who gave birth to a stillborn infant at 19 weeks of pregnancy after testing positive for COVID-19 (Baud et al. 2020): 
  • The mother experienced fever, fatigue, mild pain with swallowing, diarrhea, and dry cough for two days before seeking medical attention. Her nasopharyngeal swab test was positive. She was given acetaminophen and discharged home. Two days later, she experienced severe contractions and her symptoms worsened. Her contractions continued and she gave birth to a stillborn infant after 10 hours of labor. 
  • All of the swabs from the infant tested negative for SARS-CoV-2, as well as swabs of vaginal fluid, maternal blood, and urine.  
  • However, samples from the placenta tested positive for the virus. The authors point out that with MERS and SARS (both coronaviruses), infection of the maternal side of the placenta caused acute or chronic placental insufficiency resulting in miscarriage or fetal growth restriction in 40% of maternal infections. More research is needed before we know if maternal infection with SARS-CoV-2 causes similar outcomes. This case report is not evidence that the virus can pass from the mother to the fetus during pregnancy (vertical transmission).  

Q and A Section 

Question: I’m concerned about catching the virus from hospital staff. Do we know what percentage of health care workers (HCWs) have COVID-19?  

Answer: Someone’s risk of exposure to the SARS-CoV-2 virus in the hospital setting depends on many factors including: where the hospital is located, length of hospital stay, frequency and types of interaction with hospital staff, and availability of appropriate personal protective equipment for staff and patients 

If the hospital is in a geographic region with a low rate of infection in the population, then the risk is much lower than if the hospital were in a hot spot such as New York, for example. Likewise, HCWs in New York hospitals are at greater risk of getting the infection from a patient compared to HCWs in an area with lower prevalence of COVID-19 in the population.  

We haven’t seen any evidence on the percentage of infected HCWs at the hospital level in the U.S., only at the national and statewide level.  

At the national level, the Centers for Disease Control and Prevention released data on health care workers with COVID-19 in the U.S. (CDC COVID-19 Response Team, April 17, 2020). During February 12 to April 9, 315,531 COVID-19 cases were reported to CDC. But only 49,370 (16%) of those cases reported whether the infected person was a health care worker. Altogether, 9,282 (3%) of the COVID-19 cases were identified as health care workers. However, among states with more complete reporting of HCW status, HCW accounted for 11% of reported cases. So, about 1 in 10 COVID-19 cases in the U.S. may be a health care worker. That number is higher is some states—in Ohio, one in five positive tests has been a HCW.  

This does not mean that 1 in 10 HCWs has the virus, only that 1 in 10 positive test results came from a HCW. 

If you are concerned about catching the virus during your hospital stay, it would be prudent for you and your support person to wear a mask whenever a staff member is in your room (whenever possible; knowing that sometimes it’s impossible to keep a mask on at all times during labor), to practice vigilant hand hygiene yourselves, and to ensure that any health care worker who enters your room and/or touches you or your infant has practiced hand hygiene and is wearing a mask and other personal protective equipment as appropriate (they will most likely already be doing this, but it’s your right to advocate that the safety rules are followed).   

Question: Should doulas wear PPE when they support laboring clients in the home setting 

Answer: The general recommendation from the CDC is that you should be social distancing when possible, or staying at least 6 feet from people outside your household. So, if doulas are meeting with their clients in person, they should allow for some extra space during their meeting. Many doulas inform us that they are doing all interviews and prenatal visits via video-chat to avoid unnecessary social contact (as a way of protecting their families and current clients).  

If supporting clients in labor at home, doulas should be using hand hygiene according to CDC guidelines and covering their mouth and nose with a medical mask or cloth face covering. We presented the evidence on cloth face coverings in our April 6 newsletter, which you can access on our COVID-19 resource & pregnancy page here.) Some doulas are reporting to us that they are using social distancing measures when they support a client in labor at home; wearing a mask while also staying 6 feet apart. 

DONA® International has a toolkit on Doulas & COVID-19, that includes a section on PPE for doulas. You can access that toolkit here. 

References 

Baud, D.Greub, G., Favre, G., et al. (2020). Second-Trimester Miscarriage in a Pregnant Woman With SARS-CoV-2 Infection. JAMA. Published online April 30, 2020. Click here 

CDC COVID-19 Response Team (2020). Characteristics of Health Care Personnel with COVID-19 – United States, February 12-April 9, 2020. MMWR Morb Mortal Wkly Rep, 69(15), 477481. Published 2020 Apr 17. Click here.  

Hantoushzadeh, S., Shamshirsaz, A. A., and Aleyasin, A. (2020). Maternal Death Due to COVID-19 Disease. Advance online publication. Click here.  

Kelly, J. C., Dombrowksi, M., O’neil-Callahan, M., et al. (2020). False-Negative COVID-19 Testing: Considerations in Obstetrical Care. American journal of obstetrics & gynecology MFM, 100130. Advance online publication. Click here.  

Ramos Amorim, MM.Soligo Takemoto, ML.and Fonseca, EB. (2020). Maternal Deaths with Covid19: a different outcome from mid to low resource countries? [published online ahead of print, 2020 Apr 26]. Am J Obstet Gynecol. Click here 

Stephens, AJ., Barton, JR.Bentum, NA.et al. (2020). General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic [published online ahead of print, 2020 Apr 28]. Am J PerinatolClick here.  

April

Research Update for Monday, April 27 at 9:43 AM + Detailed Q&A!

Welcome to this week’s research update on COVID-19 and pregnancy!  

This week we share key updates to the American College of Obstetricians and Gynecologists (ACOG) Practice Advisory on COVID-19, the latest COVID-19 guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG), and findings from a new report of 116 cases of COVID-19 pneumonia in pregnancy.  

We will also answer a few of your questions in a Q&A section at the bottom of this research updateToday’s questions (answered at the bottom of this email) include: 

  • How accurate are tests for SARS-CoV-2?  
  • What about the accuracy of antibody tests? 
  • Should we be worried about being discharged early from the hospital?  
  • Which prenatal visits should be face-to-face? Which should be by virtual appointment or omitted entirely?    

To ask a question for consideration for future newsletters, submit your question here. 

Last week our update was presented in a webinar. You can watch the recording of that webinar (and download the handouts) on our COVID-19 resource page here.   

Don’t forget that our COVID-19 resource & pregnancy page includes archives of these newsletters (including past Q & A’s), our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University 

As of 9 AM EDT on April 27, 2020, there are 2.99 million confirmed cases around the world. The U.S. has the highest number of confirmed cases (963,933) followed by Spain, Italy, France, and Germany.  

Summary of Key Updates to the ACOG Practice Advisory (April 23, 2020) 

  • The American College of Obstetricians and Gynecologists (ACOG) strengthened its recommendation regarding testing on admission to labor and delivery units. Pregnant people with suspected COVID-19 and those who develop symptoms during admission should be prioritized for testing. Additional testing strategies may be appropriate, especially in areas with high prevalence of COVID-19 in the population.   
  • Note from EBB: In a previous research update, we shared details from a study by Sutton et al. in New York that found a very high number of asymptomatic people with COVID-19 presenting to labor and delivery units. This study prompted many hospitals across the U.S. to start testing all pregnant people on admission rather than only testing those with symptoms suggestive of COVID-19.  
  • Note from EBB: There is wide variation in testing strategies between hospitals! You can call your hospital to find out if they are testing all pregnant people for COVID-19 on admission.    
  • ACOG encourages everyone caring for pregnant patients with known or suspected COVID-19 to submit info to a COVID-19 registry such as the PRIORITY registry in the U.S. 
  • ACOG added a section on health care inequities to its practice advisory. They point out that data shows higher rates of COVID-19 infection, severe illness, and death in some communities of color, especially among Black, Latinx, and Native American people. To better understand and address these health disparities, they recommend more research focusing on inequities in racial and ethnic minority populations. In addition, OBGYNs are urged to confront individual and structural biases that contribute to poor health outcomes.  
  • All medical staff caring for potential or confirmed COVID-19 patients are advised to use PPE, including respirators when available. When there are shortages of N95 respirators, they should be prioritized for aerosol-generating procedures, and medical facemasks used instead for other types of health care.  
    • ACOG says the potential for aerosolization with forceful exhalation during the second stage of labor (pushing) is still under review. They cited the CDC’s Obstetrical FAQs that say “forceful exhalation during the second stage of labor would not be expected to generate aerosols to the same extent as procedures more commonly considered to be aerosol generating.”  
    • Revised FAQs that accompany the practice advisory say “Although a person with suspected or confirmed COVID-19 would normally be instructed to wear a mask, active pushing while wearing a surgical mask may be difficult and forceful exhalation may significantly reduce the effectiveness of a mask in preventing the spread of the virus by respiratory droplets.” This is why it is even more important for health care workers to have access to appropriate PPE during the second stage. 

Recommendations from the latest RANZCOG Guidelines (April 23, 2020) 

  • The Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) recently updated their COVID-19 message for pregnant people and their families. 
  • People with COVID-19 are advised to give birth in a hospital. 
  • Medical intervention, other than that required for infection control, should not differ from standard practice. There is no evidence that having a Cesarean or induction reduces the risk of passing the virus to the baby. People with COVID-19 should delay elective Cesareans and inductions, if possible. 
  • Active mobilization during labor, use of water immersion in labor, and epidurals are still options for people giving birth with COVID-19. 
  • Nitrous oxide should not be routinely given to people with suspected, probable or confirmed COVID-19 infection (if it is used, staff should wear appropriate PPE). People at low risk of COVID-19 may still be offered nitrous oxide during labor. 
  • The RANZCOG, like the World Health Organization, supports breastfeeding and keeping infected mothers together with their babies while taking appropriate precautions. They say that people with COVID-19 who wish to breastfeed their babies “should be encouraged and supported to do so.” In addition, they say the mother “should not be automatically separated from her baby, but should take enhanced precautions with general hygiene and consider a face mask when feeding.” 

The Australian Breastfeeding Association has a fact sheet for health professionals on COVID-19 and breastfeeding that you may find useful here 

Analysis of 116 Cases of COVID-19 in Pregnant People in China (Yan et al., published April 23, 2020) 

  • The authors examined the clinical characteristics and pregnancy/birth outcomes in 116 pregnant people with COVID-19 pneumonia. These included 65 cases of lab-confirmed COVID-19 and 51 cases of clinically diagnosed COVID-19 pneumonia. The clinical records came from 25 hospitals around Hubei province in China between January 20 and March 24, 2020. Ninety-nine of the pregnant people, including one twin pregnancy, gave birth during hospitalization for COVID-19 (99/116). Out of the 116 pregnant people, nine had gestational diabetes and four had preeclampsia.  
  • Since these patients were hospitalized with COVID-19, the findings do not apply to pregnant people with asymptomatic or mild illness with COVID-19.  
  • Findings 
    • The most common symptoms were fever (51%) and cough (28%); 23% of participants had no symptoms. 
    • There were no maternal deaths (0/116). 
    • 7% of patients developed severe pneumonia requiring ICU admission (8/116). This rate is similar to the reported rate of severe disease in non-pregnant adults.  
    • Eight women were infected before 24 weeks of pregnancy. One had an early miscarriage (1/8), and the other seven pregnancies were ongoing at the time of the report. Four of the seven ongoing pregnancies reached 20 weeks at the time of the report and all showed normal fetal anatomy and growth on morphology scans.  
    • Twenty-one of the 99 patients who gave birth had a preterm birth (21%), including six with spontaneous rupture of membranes between 34 to 37 weeks (6%). 
    • The Cesarean rate was 86% (85/99). The reasons given for the Cesareans were COVID-19 pneumonia (39%), previous Cesarean (19%), fetal distress (11%), and failure to progress (6%).  
    • There were no stillbirths. 
    • There was one newborn death (the baby died within 2 hours of birth). The mother developed severe pneumonia and septic shock requiring invasive ventilation and gave birth by Cesarean at 35 weeks of pregnancy.  
    • 47% of newborns were transferred to the NICU. 
  • Conclusion: 
    • The clinical characteristics of COVID-19 pneumonia during pregnancy are similar to those of non-pregnant adults with COVID-19 pneumonia. 
    • Reassuringly, there was no evidence of increased risk of miscarriage or spontaneous preterm birth with COVID-19 compared to the background risk in the general population.  
    • There was no evidence of parent-to-baby transmission during pregnancy or birth.  

Q and A Section 

We have received SO MANY QUESTIONS from you and we are reading every single one! We’ll try to answer some questions each week in our research update.   

Question: How accurate are tests for SARS-CoV-2? Do we know how often they produce false positive and false negative results?  

Answer: Lab tests should be able to detect a positive case (sensitivity) and determine a negative case (specificity). So, a test with high sensitivity identifies a high percentage of ACTUAL positives as being positive and a test with high specificity identifies a high percentage of ACTUAL negatives as being negative. 

There are many molecular polymerase chain reaction or “PCR” tests being used to diagnose COVID-19. They work by identifying the viral RNA in respiratory samples, such as from nasal or throat swabs. The test is supposed to tell you whether you are infected with the virus at the time the test is taken.  

Since the tests are based on the unique genetic sequence of SARS-CoV-2, they are thought to be highly specificgood at identifying actual negatives as being negative. This means that false positives are unlikely (a positive test means there really was SARS-CoV-2 viral RNA detected in the specimen). But as the World Health Organization explains, false positives can still result from mishandling (e.g. laboratory contamination), so every positive PCR test should be confirmed with a second test result from that sample.  

Unfortunately, there is very little information on the sensitivity of these diagnostic tests, since they were rushed and did not go through their usual approval process. The sensitivity of a test depends on both timing (ideally, samples should be collected soon after symptom onset) and the way the sample is collected (the swab should reach all the way back to the nasopharynx). Another factor to consider is specimen transport, since the viral RNA can degrade during shipping or storage. 

In an interview, Tom Taylor, a former CDC statistician, said most PCR tests usually detect over 90% of positive cases accurately. However, some heath experts think the sensitivity of the SARS-CoV-2 tests is lower than other PCR tests. Based on their clinical experience, they report that about 30% of patients they believe have COVID-19 are testing negative. Some patients test negative and then symptoms worsen, and then they test positive.  

In February, a study published in Radiology found that of 1,014 patients in Wuhan who were suspected of having COVID-19, only 59% tested positive for the virus with a PCR test even though 88% showed signs of COVID-19 in chest CT imaging (Ai et al. 2020). The bottom line on these tests is that a negative result does not conclusively rule out infection.  

Question: What about the accuracy of antibody tests?  

Answer: Another type of test (called a serology test) measures antibodies to COVID-19 in peoples’ blood. If antibodies are detected, it means they already experienced infection and now have partial or full immunity to the virus (whether or not infection confers full immunity is still up for debate). So, in theory, they could possibly tell us who is immune to COVID-19 and who is still at risk.  

To be useful, an antibody test for COVID-19 has to be very specific—meaning that it should be able to identify nearly 100% of people who do not have antibodies to SARS-CoV-2. In other words, it needs a very low false positive rate so that people don’t endanger themselves and others by mistakenly thinking they are immune to infection. It’s a problem if the test gives a false positive result after detecting antibodies to other coronaviruses (such as those that cause the common cold).  

Another concern is that a true positive result may not mean you have enough antibodies to be fully immune. And if you are immune, it is not yet known how long your immunity will last. Antibody testing has the potential to be a game changer in curbing the pandemic, but there are still lots of unanswered questions!  

Antibody tests are being rushed into use without independent verification and it’s all very controversial. In the U.S., the Centers for Disease Control and Prevention (CDC) is currently working with the Food and Drug Administration (FDA) as well as the National Institutes of Health (NIH) to evaluate these tests 

Question: I have concerns about hospitals encouraging early discharge after birth in light of the pandemic. Should we be worried that expedited discharge is unsafe?   

Answer: To limit risk of exposure to SARS-CoV-2, medical groups are encouraging providers to discharge the birthing person and infant early after birth if they are healthy. In the U.S., ACOG says that discharge may be considered after 1 day for people with uncomplicated vaginal births and after 2 days for people with Cesarean births, depending on their recovery status.  

In 2017, a systematic review of seven randomized controlled trials and two observational studies looked at how early hospital discharge policies might affect health outcomes after vaginal birth for healthy mothers and term newborns (Benahmen et al. 2017). They rated the quality of the data as low to very low and concluded that the current evidence neither supports nor discourages routine early postpartum discharge.  

There are certain warning signs to look for after giving birth. If you are discharged early and have any worrisome signs or symptoms, call your care provider right away because you could be having a complication that requires medical care.  

The Royal College of Obstetricians and Gynecologists (RCOG) published updated guidance on April 24 about prenatal and postnatal care during the pandemic. They recommend that care be individualized according to the birthing person and newborn’s needs. With regard to postnatal care,  

  • The minimum number of contacts between birthing people and their care providers should be three: day 1, day 5 and day 10.  
  • Prioritize face-to-face visits (over telehealth visits) for mothers with mental health concerns or social risk factors, those who had operative births, premature/low birth weight babies, or those with other medical concerns.  
  • The best candidates for telehealth visits (instead of face to face visits) are experienced mothers who are healthy and gave birth at term. 
  • Home visits can be considered. 
  • Mothers should be offered remote services from organizations that provide support for breastfeeding, mental health, and early parenting advice. 

Question: My OB clinic is delaying or eliminating some of my prenatal visits. Which prenatal visits should be face-to-face? Which should be by virtual appointment or omitted entirely?    

Answer: The RCOG guidance also has recommendations for how prenatal care can be modified during the pandemic for low risk people. Prenatal care guidelines vary from country to country, but you can discuss these proposed modifications with your care provider to come up with your specific plan.  

RCOG recommends that low risk people should have a minimum of 6 face-to-face prenatal appointments throughout pregnancy. The most important visits to maintain face-to-face are the dating scan and testing in early pregnancy (the first appointment), the 18-20 week visit, the 28 week visit, the 32 week visit, the 36 week visit, the 38 week visit (first-time mothers only), and the 40 week visit. Appointments after 41 weeks should be co-scheduled with offered outpatient or inpatient induction to avoid additional visits. See table 4.1.1 in the RCOG guidance for all the details.  

References 

Ai, T., Yang, Z., Hou, H., et al. (2020). Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases [published online ahead of print, 2020 Feb 26]. Radiology, 200642. Click hereFree full text! 

Benahmed, N., San Miguel, L., Devos, C., et al. (2017). Vaginal delivery: how does early hospital discharge affect mother and child outcomes? A systematic literature review. BMC pregnancy and childbirth, 17(1), 289. Click hereFree full text!  

Yan, J., Guo, J., Fan, C., et al. (2020). Coronavirus disease 2019 (COVID-19) in pregnant women: A report based on 116 cases. AJOG, available online April 23. Click hereFree full text! 

Research Update for Monday, April 13 at 10:58 AM

Welcome to this week’s research update on COVID-19 and pregnancy!  

This week we share info about recent changes to the Centers for Disease Control and Prevention’s (CDC) Considerations for Inpatient Obstetric Healthcare Settings, new CDC reports on U.S. COVID-19 cases and hospitalizations, and findings from a case series of infected pregnant women in New York.  

We will also answer a few of your questions in a new Q&A section at the bottom of this research update! To ask a question for consideration for future newsletters, submit your question here 

Next week our research update will take place via webinar and Facebook live rather than a written newsletter. You can register for that free, public event here. 

Don’t forget to check out our COVID-19 resource & pregnancy page that includes archives of these newsletters, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here. 

Numbers Update from Johns Hopkins University 

As of 10 AM EDT this morning, there are 1.86 million confirmed cases of COVID-19 around the world. For the third week in a row, the U.S. has the highest number of cases, with 557,590 positive test results. This number is much higher than the four countries with the next-highest number of cases: Spain (169,496), Italy (156,363), France (133,672), and Germany (127,854).  

**Change in CDC Guidelines** 

  • Importantly, on April 4, the CDC made revisions to their February 18 Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.  
  • A revision was made to reflect that the decision of whether to keep a mother with known or suspected COVID-19 and her infant together or separated after should be “on a case-by-case basis, using shared decision-making between the mother and the clinical team.”  
  • The CDC’s earlier guidance (now outdated) from February stated, “To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.”  
  • The language in that earlier guidance was widely interpreted as the CDC recommending separation, although rooming in was still possible in accordance with the mother’s wishes.  
  • In their April update, the CDC has shifted toward a more neutral stance on mother-baby separation and draws attention to the need for shared decision-making. 
  • They also added: “The many benefits of mother/infant skin-to-skin contact are well understood for mother-infant bonding, increased likelihood of breastfeeding, stabilization of glucose levels, and maintaining infant body temperature and though transmission of SARS-CoV-2 after birth via contact with infectious respiratory secretions is a concern, the risk of transmission and the clinical severity of SARS-CoV-2 infection in infants are not clear.” 

We updated the Evidence Based Birth® sample “Informed consent form for refusal to separate birthing parent and infant” with this new revised language from the CDC.  

We’ve had many requests for this form, both from hospital professionals and parents, and it can be downloaded for free on our COVID-19 resource page. I’ve attached the form here(We’re working on a Spanish translation!) 

First CDC Report on who Required U.S. Hospital Care with COVID-19 in March 

  • On April 8, the CDC published a Morbidity and Mortality Weekly Report (MMWR) that examined COVID-19 hospitalization data from 14 states—including statistics by race and sex (Garg et al. 2020).   
  • The data in the report come from a surveillance network called COVID-NET that is tracking COVID-19 in 14 states. The surveillance area represents about 10% of the U.S. population. 
  • The report includes 1,482 patients hospitalized with COVID-19 in the first month of U.S. surveillance (March).  
  • The statistics point to racial health disparities and suggest, “Black populations might be disproportionately affected by COVID-19.” In the surveillance data, 18% of people in the study population were Black, but 33% of hospitalized patients were Black. The CDC data on race were severely lackingrace wasn’t reported for the majority (60%) of people included in the analysis.  
  • Note from EBB: Our podcast episode coming out on Wednesday will focus on these racial disparities.  
  • They also found that more men than women have been hospitalized for COVID-19. In the COVID-NET surveillance population, 49% were male and 51% we female, but men made up 54% of COVID-19 hospitalizations and women made up 46%.  
  • The analysis also found that about 90% of people in the hospital with COVID-19 had at least one underlying health condition. Half of hospitalized patients had hypertension, half had a high body mass index, 36% had chronic metabolic disease (e.g., diabetes), and 35% had chronic lung disease (e.g., asthma). Rates of COVID-19 hospitalizations were highest among people 65 years and older.   

First CDC Report on Pediatric U.S. COVID-19 cases 

  • On April 10, the CDC published the first description of pediatric cases of U.S. COVID-19 (CDC COVID-19 Response Team, 2020).  
  • In the U.S., 22% of the population is made up of infants, children, and people <18 years. Out of 149,082 lab-confirmed COVID-19 cases in the U.S. occurring during February 12 to April 2, only 2,572 (1.7% of cases) were among children <18 years. The majority (57%) of cases were males. 
  • Fewer children than adults experienced fever, cough, or shortness of breath (73% of pediatric patients versus 93% of adults 18-64 years). 
  • Relatively few children with COVID-19 were hospitalized (5.7% of all pediatric infections); however, severe outcomes have been reported in children, including three deaths included in the analysis. There was no information provided about the three deaths, and the cases are still under review to confirm COVID-19 as the likely cause of death.  

Case Series of 43 Pregnant Women in New York with COVID-19 

  • A case series from New York of 43 women who tested positive for COVID-19 was published April 9 (Breslin et al. 2020). 
  • Infection was often asymptomatic (14 out of 43 women, 33%), leading the authors to recommend universal testing of pregnant people being admitted to the labor unit. Of the asymptomatic women, 10.14 (71%) developed symptoms over the course of their admission or shortly after discharge.  
  • The majority of women (60%) had a body mass index of 30 or greater. Many of the women (42%) had an additional comorbid condition (most commonly asthma).  
  • The women showed a similar pattern of disease severity to non-pregnant adults: 86% mild, 9% severe and 5% critical, although the sample size was too small to make a direct comparison.  
  • Newborns were tested on the first day of life and there were no confirmed cases of COVID-19. All 18 infants who were born during the case series had had Apgar scores ≥7 at 1 minute and ≥9 at 5 minutes. All 18 infants, including three who were initially admitted to the NICU for conditions unrelated to COVID-19, have since been discharged home. 

New Q and A Section!  

We have received SO MANY QUESTIONS from you and we are reading each and every one! We’ll try to answer a few of your questions each week and post them to our COVID-19 resource page.  

Question: I was trying to conceive, but now I am so concerned about COVID-19 and pregnancy. How do I weigh the potential risks of infection during pregnancy versus the risks of delaying trying to conceive at my advanced maternal age 

Answer: This is a deeply personal choice, but we can share a few factors you might consider when deciding whether or not to delay trying to conceive because of the pandemic. First, pregnant people are not any more likely to become infected with this virus or to develop serious illness with COVID-19 disease compared to non-pregnant adults. The majority of infected pregnant people will only experience mild or moderate cold/flu symptoms. No reports of maternal deaths have been published. There is no evidence to suggest an increased risk of miscarriage with COVID-19. Researchers aren’t sure yet whether the virus can pass from parent to baby during pregnancy; several babies in published case series have tested positive soon after birth, but all recovered without complication. The virus has not been detected in cord blood, amniotic fluid, vaginal fluid, or breast milk.   

Question: I am due in June. Do you have any idea what June will be like?  

Answer: The Institute for Health Metrics and Evaluation has a great website with COVID-19 projections for the U.S. (nationally and by state) and for European countries. You can see projected resource use (ICU beds, ventilators), deaths per day from COVID-19, and total deaths from COVID-19.  

Their projections go all the way out to August 1. The researchers state this is a model of the first wave of the epidemic, after which they state 97% of people will still be susceptible to the disease. The models assume social distancing will be in place through the end of May. The projections could change if social distancing recommendations are lifted before then. The model also assumes that appropriate measures will be taken in July and August to prevent further spread of the disease, including mass screening, contact tracing, testing of everyone who enters the country, and quarantine of positive individuals. 

Question: Is there any evidence that waterbirth should not be done now in light of COVID-19?  

Answer: We don’t have any published evidence yet on COVID-19 and waterbirth, but there are research efforts underway (if you are approached about participating in a study, please participate!) Guidance from the Royal College of Obstetricians and Gynaecologists (dated April 9) advises against waterbirth for anyone with suspected or confirmed COVID-19. However, this recommendation is based on theoretical risk, not evidence.  

The virus has been detected in feces, so there is a concern that the pool water could become contaminated, increasing the risk of infection for the baby and birth attendants.  

According to a CDC FAQs on Water and COVID-19, “There has been no confirmed fecal-oral transmission of COVID-19 to date.” The CDC goes on to say, “There is no evidence that COVID-19 can be spread to humans through the use of pools, hot tubs or spas, or water playgrounds. Proper operation, maintenance, and disinfection (e.g., with chlorine and bromine) of pools, hot tubs or spas, and water playgrounds should inactivate the virus that causes COVID-19.”   

Barbara Harper, RN, CLD, CCCE, Midwife, and Founder/Director of Waterbirth International, has a video and opinion piece called “Keeping Waterbirth Safe During COVID-19.” She also has a protocol for cleaning the tub between births and a sample informed consent form. Barbara recommends that anyone with a fever should avoid waterbirth (that was standard protocol before the pandemic). She explains that ideally, everyone would be tested, because knowing whether a person is infected is the key to creating policy on the use of hydrotherapy in labor. 

Question: How should labor and delivery personnel be protected from COVID-19 in the second stage of labor (the pushing stage)?   

Answer: The CDC recommends using N95 respirators for aerosol-generating procedures (AGPs). However, there has been disagreement over whether the second stage of labor is an AGP. The Centers for Disease Control dose not list the second stage of labor as an AGP.  

During the second stage of labor, birth attendants are at increased risk of exposure to fecal content as well as respiratory exposureoften spending three or four hours in close physical contact with the birthing person who may be coughing, shouting, breathing hard, or vomiting, and unable to keep a mask on themselves the entire time the staff are in the room. The International Society for Ultrasound in Obstetrics and Gynecology has included the second stage of labor, vaginal birth, and Cesareans as possible AGPs that should require appropriate PPE, including N95.  

Similarly, Labor and Delivery Guidance for COVID-19 published in AJOG MFM states, “The second stage of labor is likely high risk for aerosolization and N-95 mask should be used.” The authors recommend that health care workers should use an N95 and droplet precautions while caring for any patient in the second stage, regardless of whether or not the patient has respiratory symptoms. We reached out to these authors regarding questions we have received about patients having difficulty wearing masks (since it’s been advised that all laboring patients wear a surgical mask, regardless of whether or not they have respiratory symptoms). They confirmed that the difficulty in keeping a mask on a patient during the second stage makes it even more important for health care workers to wear an N95 or equivalent during the second stage.  

An article published in the American Journal of Perinatology on April 10 advises, “All staff and physicians in the room during the second stage of labor or cesarean delivery should be wearing full PPE including gown, gloves, eye protection, and N95 mask.” Again, this does not mean wearing PPE for patients with symptoms of COVID-19… instead, this means health care workers should be wearing full protection and N95 masks during the second stage for all laboring patients. Unfortunately, hospitals are attempting to conserve their equipment, and protocols for the second stage vary from hospital to hospital. The authors of this article state that their own hospital facility recommends that staff wear a surgical mask during the second stage with someone who is asymptomatic or suspected of having COVID-19, and to reserve N95 masks for COVID-19 positive patients.  

Yes, there are shortages of PPE, but it is not acceptable to deny labor and delivery staff adequate protection. Health care workers deserve to be protected while doing their job, and we are all safer if we have health care workers who are not infected.  

References 

Breslin N, Baptiste C, Gyamfi-Bannerman C, et al. (2020). COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals, American Journal of Obstetrics & Gynecology MFM (2020).  

 

CDC COVID-19 Response Team (2020). Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69:422–426.  

 

Garg S, Kim L, Whitaker M, et al. (2020). Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 April 2020.  

 

Palatnik A, McIntosh JJ. (2020). Protecting Labor and Delivery Personnel from COVID-19 during the Second Stage of Labor [published online ahead of print, 2020 Apr 10]. Am J Perinatol 

 

 

Research update for Monday, April 6 at 10:00 AM
Welcome to this week’s research update on COVID-19 and pregnancy! This week we share info about the new practice guidelines from the American Academy of Pediatrics, as well as the research evidence on homemade masks. 

I’ve been corresponding with quite a few people about the practice in the U.S. of separating newborns from parents with confirmed or suspected COVID-19. The practice guidelines from the CDC and AAP conflict with practice guidelines from the WHO, the United Kingdom, Canada, and other countries.

Because of the guidelines in the U.S., it is possible that a birthing parent with symptoms such as a fever or cough may be separated from their newborn, even if the parent tests negative for COVID-19. This can be problematic when you consider the fact that fever in labor can also occur due to chorioamnionitis (inflammation of the membranes) or a side effect of an epidural.

In light of this situation, we drafted a sample “Informed consent form for refusal to separate birthing parent and infant.” We’ve had many requests for this form, both from hospital professionals and parents, and it can be downloaded for free here.

Don’t forget to check out our COVID-19 resource & pregnancy page that includes archives of these newsletters, our virtual doula directory, a free birthing crash course, a link to find our comprehensive EBB Childbirth Class online, and other info you might find useful. You can access that page here.

Numbers Update from Johns Hopkins University

As of 10 AM EDT this morning, there are 1.29 million confirmed cases of COVID-19 around the world. For the second week in a row, the U.S. continues to have the highest number of cases at 143,532, followed by Spain, Italy, Germany, and France.

New Practice Guidelines out this Week

AAP Guidelines

  • On April 2, the American Academy of Pediatrics (AAP) released guidance on infants born to mothers with suspected or confirmed COVID-19 (Puopolo et al. 2020)
    • The full report and Q&As address topics including precautions for birth attendants, rooming-in, breastfeeding, testing, newborn intensive care, visitation and hospital discharge
    • They note that COVID-19 infection does not appear to be as serious for the pregnant person as infection with the coronaviruses that cause SARS and MERS, or infection with influenza
    • Evidence suggests that there is low risk of transmitting the virus to the baby during birth. It is still inconclusive whether the virus can pass from mother to baby during pregnancy (in utero)
    • Personal protective equipment precautions:
      • Wear gown, gloves, standard mask and eye protection (either face shield or goggles) during contact with infants born to mothers with COVID-19
      • Wear gown, gloves, and N95 respirator mask with eye protection or air-purifying respirator for aerosol-generating procedures with infants born to mothers with COVID-19 (e.g., newborn resuscitation)
      • Risk-assessment decisions may be necessary in centers with shortages of PPE
    • Delivery room precautions:
      • Institutions may reevaluate mandatory attendance policies by the neonatal team at low-risk births, and instead have the neonatal team “standby” to conserve PPE
      • Routine newborn care may need to be administered in a location separate from the infected mother
    • Maternal and newborn separation when infection is suspected or confirmed:
      • They state, “While difficult, temporary separation of mother and newborn will minimize the risk of postnatal infant infection from maternal respiratory secretions.”
      • They point out that all of the published research to date on newborns born to mothers with COVID-19 involves separation at birth, so we don’t actually know much about the risk of keeping infected parents together with their infants
      • The exact wording in the report is, “The likely benefits of temporary maternal and newborn separation at birth for decreasing the risk of newborn infection should be discussed with the mother, optimally prior to delivery.” They add that the benefits of separation may be greater in mothers with more serious illness. So, the AAP is recommending separation as standard practice, but the parent is free to accept or decline this recommendation after a discussion.
      • It’s disappointing that they mention discussing the “likely benefits” of separation but not the documented harms of mother-baby separation (which we discuss in our Evidence Based Birth® Signature article here)
      • After separation, the AAP recommends that healthy infants be admitted to areas that are physically separate from infants born to mothers without COVID-19. Ideally, infants requiring NICU should be admitted to a single patient room with an air filtration system
      • The newborns should be bathed as soon as possible to remove virus potentially on the skin
    • Maternal and newborn rooming-in:
      • If the parent chooses to room-in rather than be separated, or if the facility is not able to care for the infant in a separate area, then they propose recommendations for “alternative newborn care.”
      • The infant should be at least 6 feet from the mother at all times, with a physical barrier (a curtain or isolette), and direct breastfeeding is not recommended
    • Breastfeeding:
      • There is no evidence that the virus that causes COVID-19, SARS-CoV-2, is present in breast milk. The AAP affirms that there are known benefits of breastfeeding, and that “mothers’ milk may provide infant protective factors after maternal COVID-19.”
      • Infected mothers may express milk (with careful hygiene) and “designated caregivers” may feed the milk to the infant. OR, “If the mother also requests skin-to-skin contact with her infant, including direct breastfeeding, she should comply with strict preventive precautions, including the use of mask and meticulous breast and hand hygiene. Institutions could consider formal documentation of maternal decisions regarding the recommendations for separation.”
      • At Evidence Based Birth®, we’ve created a Sample Informed Consent Form for Refusal to Separate Birthing Parent and Infant that you can access here
    • Testing and hospital discharge:
      • The AAP recommends that infants born to mothers with COVID-19 should be tested at 24 hours and 48 hours after birth; if testing is not possible, infants should be treated as though they are positive for a 14-day observation period
      • If the infant is positive with no symptoms: outpatient follow-up through 14 days after discharge
      • If the infant is negative: discharge the infant to a healthy caregiver
      • After the infected mother is discharged, she is advised to maintain a distance of at least 6 feet from the newborn (or if that is not possible, use a mask and hand-hygiene for newborn care) until (a) she has not had a fever for 72 hours without use of medication, and (b) at least 7 days have passed since symptoms first appeared
      • If the newborn remains in the hospital, the mother should remain separated until (a) she has not had a fever for 72 hours without use of medication, and (b) her respiratory symptoms are improved, and (c) she has had consecutive negative test results (collected ≥24 hours apart)
      • “Non-maternal parents” (i.e. parents who did not give birth) should also not visit infants in the hospital until they are determined to not be at risk of infection

Comparison of AAP Guidelines with Other Practice Guidelines

  • The AAP’s recommendation to separate infected mothers from their infants is in line with Chinese officials, and Centers for Disease Control and American Congress of Obstetricians and Gynecologists guidance in the U.S.
  • However, many other organizations including the World Health Organization, UNICEF, Royal College of Obstetricians and Gynaecologists in the United Kingdom, and the Society of Obstetricians and Gynaecologists of Canada advise keeping mothers and babies together with precautions
  • On April 3, the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies published guidance recommending rooming-in and direct breastfeeding with COVID-19 positive mothers who have few or no symptoms (Davanzo et al. 2020). They advise separation and expressed breast milk when the mother is too sick to care for the newborn.

Research on Homemade Masks

  • On April 3, the U.S. Centers for Disease Control (CDC) made a major change to their recommendations. They now recommend that everyone wear a “cloth face covering” while in public. Before last week, the recommendation was to not wear a mask unless sick, caring for a sick person who is unable to wear one, or working in health care.
    • Why the change? There is increasing evidence that infected people without symptoms (pre-symptomatic and asymptomatic carriers) can spread the SARS-CoV-2 virus (the virus that causes COVID-19).
    • The CDC urges people to not use medical-grade masks (surgical masks or N95 respirators) because they are desperately needed in clinical settings right now.
    • They stress that wearing a cloth face covering is not a safe alternative to social distancing (maintaining a distance of 6 feet or more from people in public). But in situations where it is not possible to keep your distance from others (e.g. grocery stores, sidewalks), a cloth face covering offers some protection. Masks can also function as an important visual cue, reminding others to follow public health guidance.
    • Masks can be a source of infection when not removed correctly. A study published in the Lancet on April 2 found that the SARS-CoV-2 virus could be detected on cloth for at least a day and on the outer layer of a surgical mask for up to a week (Chin et al. 2020). So, it’s important to not touch your face or the front of the mask. Remove the straps from behind your ears and wash hands immediately after.
  • Are homemade cloth face coverings effective?
    • The main benefit of covering your nose and mouth is that you help to protect others if you happen to be contagious, but you don’t feel sick. If you cough or sneeze, the mask helps to contain your respiratory droplets.
    • A secondary benefit is that face coverings also help to protect the wearer from exposure to respiratory droplets. For example, if an infected person sneezed as they were passing you on the sidewalk, your face covering would help to block the droplets. The CDC says, “Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.” We don’t have evidence on this, but wearing sunglasses or eyeglasses might be better than no eye protection.
    • There has only ever been one published randomized controlled clinical trial on cloth masks (MacIntyre et al. 2015). The trial included 1,607 healthcare workers (HCWs) at 14 hospitals in Vietnam. Selected high-risk wards were randomly assigned to medical masks, cloth masks, or a control group (usual practice, which often included wearing medical masks). Cloth masks were made of two layers of cotton. The HCWs who wore cloth masks acquired more respiratory infections and influenza-like illnesses than those who wore medical masks. Lab tests showed that an astounding 97% of particles got through the cloth masks, compared to 44% with medical masks. The authors concluded that cloth masks should not be recommended for HCWs. They say that further research is needed to assess different types of cloth masks (perhaps with better filtration) and consider the effects of different cleaning methods.
      • The authors of this 2015 RCT published a response to their article in the BMJ Open on March 30, 2020. They say that they have been getting daily emails from HCWs concerned about using cloth masks. The authors recommend that HCWs should not work during the COVID-19 pandemic without adequate respiratory protection. “The physical barrier provided by a cloth mask may afford some protection, but likely much less than a surgical mask or a respirator.”
    • A 2013 study from the U.K. compared homemade masks to commercial surgical masks (Davies et al. 2013). Twenty-one healthy volunteers made their own masks out of a variety of household materials including cotton t-shirts, pillowcases, and vacuum cleaner bags. The volunteers completed a fit test using a commercial fit test system and coughed into a sampling chamber called a “cough box” to measure how many microorganisms got through the mask. The researchers also tested the filtration ability of each mask using an aerosol containing two types of bacteria, one smaller and one larger than an influenza virus particle. [FYI: Influenza viruses range from 60 to 100 nm and SARS-CoV-2 viruses ranges from 70 to 90 nm (Kim et al. 2020).] They found that all of the homemade masks blocked some microbes, but none of the materials worked as well as the surgical mask, which filtered out three times as many particles in the filtration test and blocked twice as many respiratory droplets in the cough box test. The pillowcase and the 100% cotton t-shirt were found to be the best household materials for a homemade mask.
  • The limited research on cloth face coverings does not show them to be very effective. However, new research in light of COVID-19 suggests they can be constructed to perform better.
    • Scott Segal, chairman of anesthesiology at Wake Forest Baptist Health in the state of North Carolina, has been comparing different materials and designs for homemade masks. His findings are not yet published, but he’s shared details of his work in interviews (NBC News, the New York Times). He says you should hold the fabric up to a bright light and if a lot of light passes through, it’s not a good fabric for a mask. It’s a challenge to find a material that both filters well and is breathable enough to actually wear. He found that the best masks were constructed of two layers of high-quality, heavyweight “quilter’s cotton,” two-layers of thick batik fabric, or an inner layer of flannel and an outer layer of cotton. These were as good as surgical masks (which filter 60% to 80% of small particles) or slightly better. For comparison, the best masks are N95 respirators, which filter at least 95% of particles as small as 0.3 microns.
    • Yang Wang, an assistant professor at Missouri University of Science and Technology, has also been researching homemade masks. In an interview he shared that an allergy-reduction HVAC filter sandwiched between two layers of cotton fabric blocked 89% of particles with one layer of filter material and 94% with two layers of filter material.
  • The CDC has posted sew and no-sew mask patterns They say homemade masks should be washed regularly and can be used on children as young as two. Johns Hopkins Medicine also posted a pattern here.
  • With PPE in short supply, some hospitals and clinical settings are running out of masks. The situation is so severe in some areas that hospitals are even asking the public to help create masks for clinical use. For example, University Hospitals in the state of Ohio is “looking for talented individuals who can sew homemade masks for our caregivers.” For now, they are planning to make the homemade masks available to patients and visitors (helping to conserve the standard masks for care providers). If you would like to get involved with making masks to donate, the org website has a list of locations needing masks.

References

Chin, A., Chu, J., Perera, M., et al. (2020). Stability of SARS-CoV-2 in different environmental conditions. Published online April 2, 2020. The Lancet, Microbe. Click here. Free full text!

Davanzo, R., Moro, G., Sandri, F., et al. (2020). Breastfeeding and Coronavirus Disease-2019. Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies [published online ahead of print, 2020 Apr 3]. Matern Child Nutr. e13010. Click here. Free full text!

Davies, A. Thompson, K-A, Giri, K. et al. (2013). Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic? Disaster Medicine and Public Health Preparedness, Available on CJO. Click here. Free full text!

Kim, J. M., Chung, Y. S., Jo, H. J., et al. (2020). Identification of Coronavirus Isolated from a Patient in Korea with COVID-19. Osong public health and research perspectives, 11(1), 3–7. Click here. Free full text!

MacIntyre, C. R., Seale, H., Dung, T. C., et al. (2015). A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open, 5: e006577. Click here. Free full text!

Puopolo, K., Hudak, M., Kimberlin, D., et al. (2020). Initial Guidance:

Management of Infants Born to Mothers with COVID-19. American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases. Click here. Free full text!

March

Research update from Monday, March 30 at 11:30AM

Numbers Update from Johns Hopkins University 

As of 10 AM EDT this morning, there are 740,157 confirmed cases of COVID-19 around the world. The U.S. now has the highest number of cases at 143,532, followed by Italy, Spain, China, and Germany.  

What new research has come out this week? 

Vertical Transmission 

  • There is new research showing that mother-to-baby transmission during pregnancy or birth (vertical transmission) may be possible with COVID-19. The evidence is not conclusive, and even if vertical transmission does occur, we don’t know how many pregnancies are affected or how infection during pregnancy affects the baby. An earlier case series of nine infected pregnant women in China found no evidence of mother-to-baby transmission, but researchers have continued to search for the possibility.  
  • Two articles came out this week in JAMA: 
    • A case report published March 26 describes a single mother-infant pair in Wuhan, China (Dong et al. 2020). The mother’s nasopharyngeal swab was positive for the virus. The baby was born by Cesarean in a negative-pressure isolation room (the reason for Cesarean was not reported). The mother wore an N95 mask during the Cesarean and was immediately separated from the baby without any physical contact. The baby had good Apgar scores but was quarantined in the NICU as a precaution. Results of 5 swabs from the infant were all negative for the virus. The baby did have SARS-CoV-2 Immunoglobulin G (IgG) and Immunoglobulin M (IgM) antibodies present in their blood two hours after birth. Since IgM does not typically cross the placenta, the researchers think this likely represents an immune response to in utero infection. IgG antibodies in the newborn could represent either maternal or infant infection with the virus. They think the baby was infected in utero because IgM antibodies usually do not appear until 3-7 days after infection, and the IgM antibodies in the newborn were detected in a blood sample drawn two hours after birth. The infected mother’s vaginal fluids and breast milk were tested and they were negative. There was no testing of amniotic fluid or placenta. Both mother and baby were discharged without any reported complications.  
    • A case series of six pregnant women with mild COVID-19 pneumonia in Wuhan, China was published March 26 (Hui Zeng et al. 2020). All six mothers had Cesareans (again, the reasons for the Cesareans were not reported). They all wore masks in negative pressure isolation rooms and the infants were isolated from their mothers immediately. All of the infants had good Apgar scores and they all tested negative for the virus. All six of the newborns had virus-specific antibodies detected in their blood at birth. Five of the infants had elevated IgG concentrations (IgG crosses the placenta) and two of the infants had elevated IgM (which is not usually transferred from mother to fetus through the placenta because of its larger structure). The authors propose two explanations for the elevated IgM: either the virus crossed the placenta leading the fetus to produce its own IgM, or, the mothers had damaged placentas and that allowed the IgM to cross to the baby. There was no information on the clinical outcomes of the infants or mothers.  
    • An editorial response to these two articles (also in JAMA) cautioned that “these data are not conclusive and do not prove in utero transmission” (Kimberlin and Stagno, 2020). They say that IgM is a challenging way to diagnose in utero infections because IgM tests can be prone to false-positive and false-negative results and other testing problems. So, it’s possible that the laboratory findings in the three infants with elevated IgM are not evidence of true in utero infection with SARS-CoV-2.  
  • A third article exploring the possibility of pregnant parent-to-baby transmission came out on March 26 in JAMA Pediatrics (Lingkong Zeng, et al. 2020).  
    • This article reviewed details of 33 infants born to mothers with COVID-19 pneumonia in a hospital in Wuhan, China. Unlike the other two studies, they didn’t examine virus-specific antibodies in the infants. However, they reported that three of the 33 infants tested positive for the virus on day two of life. All three of the infants who tested positive were born by Cesarean. No deaths were reported. 

The reported reasons for the Cesareans were 1) meconium-stained amniotic fluid and confirmed maternal COVID-19 pneumonia; 2) confirmed maternal COVID-19 pneumonia; and 3) fetal distress and confirmed maternal COVID-19 pneumonia. The authors think it’s likely that the three newborns acquired their infections from their infected mothers during pregnancy, since strict infection control and prevention procedures were in place during the Cesarean surgeries. However, since the babies were not tested until two days after birth, it’s possible that the infections did not happen inside the womb. For example, the infants could have contracted the infection from infected health care workers.  

First systematic review and meta-analysis of coronavirus infections during pregnancy 

  • An article published in AJOG MFM on March 25 explored pregnancy and birth outcomes of coronavirus infections occurring during pregnancy (Di Mascio et al. 2020).  
    • They included all reports of hospitalized pregnant people with three different confirmed coronavirus illnesses (SARS, MERS, or COVID-19). The authors note that since all of the included cases were hospitalized, they may not reflect the overall population (infected mothers with mild or no symptoms may have better pregnancy and birth outcomes compared to infected mothers who are hospitalized with their illness). Altogether 19 studies with 79 pregnant people were included: 41 pregnancies affected by COVID-19, 12 by MERS, and 26 by SARS.  
    • Focusing on COVID-19 (six studies, 41 hospitalized infected pregnant people):  
      • The rates of admission to ICU (9%), use of mechanical ventilation (5%) and maternal death (0%) were all significantly lower compared to the rates with MERS and SARS.  
      • The rate of preeclampsia was 14%. 
      • There was no data on miscarriage. 
      • There were no reported cases of fetal growth restriction. 
      • The most common poor pregnancy outcome was preterm birth <37 weeks (41% of cases). Note that it is unclear whether the infection caused early labor, or whether medical providers intervened with early birth out of concern for the mother’s health. We know that preterm prelabor rupture of membranes was reported to have occurred in 19% of cases, but the rate of Cesarean was also very high (91%). The authors advised that “…COVID-19 cannot be considered as an indication for delivery and therefore the timing and mode of delivery should be individualized according to maternal clinical conditions or obstetric factors as usual (and not COVID-19 status alone)… 
      • The rate of fetal distress was 43% and 9% of newborns were admitted to the NICU. 
      • The rate of stillbirth or newborn death with maternal COVID-19 infection was 7% (including one stillbirth and one newborn death).  
      • The authors concluded that pregnancies with coronavirus infections, including COVID-19, are at increased risk of miscarriage, preterm birth, preeclampsia, Cesarean, perinatal death, and admission to the NICU, compared to the general population. However, we think it’s important to point out that the limited data specifically on COVID-19 infection in pregnancy show better outcomes compared to SARS and MERS (grouping them all together may not be appropriate and could be unnecessarily anxiety-provoking for birthing families).  

Early lessons on COVID-19 and pregnancy published in AJOG MFM 

  • This article presents details of seven cases of confirmed COVID-19 in pregnancy at a single large New York City tertiary care hospital (Breslin et al. 2020).  
    • Five of the seven patients presented to the hospital with symptoms of COVID-19 including cough, fever, chest pain, muscle aches, and headache. Importantly, two of the seven patients had no symptoms—they came to the hospital for medically indicated labor inductions (the first for poorly-controlled type 2 diabetes and a liver disorder and the second for chronic hypertension). Both women started having symptoms of COVID-19 after birth and required intensive care unit admission.  
    • An estimated 15-20 healthcare workers were exposed to each of these two asymptomatic patients without adequate PPE prior to diagnosis with COVID-19. The authors write that, ideally, health care workers would wear N95 masks for all births, including those with unknown COVID-19 status. They also say that surgical masks should be worn at all times by patients coming to labor units and inpatient staff.  
    • The main takeaway from this case series is that “there is currently no easy way to clinically predict COVID-19 infection in asymptomatic people.” 

Updated guidance for pregnant healthcare workers (HCWs) 

  • The Royal College of Obstetricians and Gynecologists (RCOG) updated their guidance for pregnant HCWs on March 26, available here (Rimmer, 2020). 
    • They recommend that pregnant HCWs of any gestation be offered the choice of whether or not to work directly with patients during the pandemic. Alternative duties might include remote triage, telephone consultations, or administrative roles.  
    • Prior to 28 weeks of pregnancy, pregnant HCWs who choose to work directly with patients should follow established methods of reducing risk of transmission (i.e. the use of appropriate PPE and risk assessments). If possible, they should avoid working with patients with confirmed or suspected COVID-19 in environments where a higher number of aerosol-generating procedures are performed (e.g. operating rooms, respiratory wards, ICUs).  
    • Pregnant HCWs after 28 weeks of pregnancy or with underlying health conditions such as heart or lung disease should take more precautions. It is recommended that that they stay home and avoid direct contact with all patients. 
    • It is worth noting that RCOG updates their guidance on COVID-19 infection in pregnancy frequently. Access Version 5 here (updated March 28).  

Updated guidance on personal protective equipment (PPE) 

  • An expert review on “Labor and Delivery Guidance for COVID-19” was published online March 25 in AJOG MFM (Boelig et al. 2020).  
    • With regard to PPE, the review article recommends, “Given the risk of asymptomatic carriers and transmission, it should be the goal of every unit that every patient wear a surgical mask and every provider have a surgical mask for each patient encounter.” Obviously, this goal is limited by supply. They recommend that providers wear an N95 respirator instead of a surgical mask when they are caring for someone with suspected or confirmed COVID-19 or performing an aerosol generating procedure. 

 What is the difference between a surgical mask and a N95 respirator mask?  

  • The U.S. Centers for Disease Control (CDC) has a great infographic explaining the difference here 
  • N95 means that the mask can filter out at least 95% of particles of all sizes from the air. It must fit tightly to the user’s face. A surgical mask does not protect the wearer from inhaling small airborne particles and is not considered respiratory protection. It protects the user from microorganisms in large droplets and sprays.  
  • A systematic review and meta-analysis published online March 13 compared the effectiveness of N95 respirators versus surgical masks against influenza (Long et al. 2020) (Note: this study was about masks and influenza, not masks and COVID-19). They included six RCTs with 9,171 participants. There was no significant difference in the risk of laboratory-confirmed influenza with N95 respirators versus surgical masks. Thus they recommend that N95 respirator masks should not be used by the general public to prevent influenza, but instead reserved for those with close contact with influenza patients or suspected patients. They state that “surgical masks are primarily designed to protect the environment from the wearer, whereas the respirators are supposed to protect the wearer from the environment.” 

References

Boelig, R., Manuck, T., Oliver, E., et al. (2020). Labor and Delivery Guidance for COVID-19. American Journal of Obstetrics & Gynecology MFM. Click here.

Breslin, N., Baptiste, C., Miller, R., et al. (2020). COVID-19 in pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM. Click here.

Di Mascio, D., Khalil, A., Saccone, G., et al. (2020). Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM. Click here.

Dong, L., Tian, J., He, S., et al. (2020). Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA. Click here. Free full text!

Kimberlin, D. W. and Stagno, S. (2020). Can SARS-CoV-2 Infection Be Acquired In Utero? More Definitive Evidence Is Needed. JAMA. Click here. Free full text!

Long Y, Hu T, Liu L, et al. (2020). Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis [published online ahead of print, 2020 Mar 13]. J Evid Based Med. Click here.

Rimmer, A. (2020). Covid-19: doctors in final trimester of pregnancy should avoid direct patient contact. BMJ. Click here.

Zeng, H., Xu, C., Fan, J., et al. (2020). Antibodies in infants born to mothers with COVID-19 pneumonia. JAMA. Click here. Free full text!

Zeng, L., Xia, S., Yuan, W., et al. (2020). Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. Click here. Free full text!

Research update from Monday, March 23 at 9PM
 

SARS-CoV-2 is the 7th coronavirus known to infect humans (Mullins et al. 2020) 

  • 4 human coronaviruses cause the common cold 
  • 3 human coronaviruses cause more severe, acute illnesses; MERS-CoV causes Middle East Respiratory Syndrome (MERS), SARS-CoV causes severe acute respiratory syndrome (SARS), and SARS-CoV-2 causes COVID-19 

The main way the virus spreads is person-to-person. This virus can be isolated from respiratory secretions and feces. A new study found that the virus is also stable on surfaces for up to several days. The study was conducted by scientists from the National Institutes of Health, CDC, UCLA and Princeton University and was published March 17 in The New England Journal of Medicine (van Doremalen et al. 2020).  

  • SARS-CoV-2 was detectable in aerosols for up to three hours, up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel.  
  • The results suggest that people may acquire the virus through the air and after touching contaminated objects. 

A new study from Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, confirms that the median incubation period of the new virus is around 5 days, meaning that about half of the people who contract SARS-CoV-2 will start showing symptoms at that point in time.  

  • The study was published in the Annals of Internal Medicine on March 10. There were 181 confirmed cases with identifiable exposure and symptom onset windows to estimate the incubation period of COVID-19. The median incubation period was estimated to be 5.1 days (95% CI, 4.5 to 5.8 days), and 97.5% of those who develop symptoms will do so within 11.5 days (CI, 8.2 to 15.6 days) of infection. 

How long are you contagious? A retrospective review of adult patients in China with lab-confirmed COVID-19 found the median length of viral shedding was 20 days in survivors. The longest observed duration of viral shedding was 37 days (Fei Zhou et al. 2020).  

To date, no evidence of parent-to-baby transmission during pregnancy has been published. Samples of breastmilk, cord blood, placenta, and amniotic fluid from infected pregnant people have all been negative. 

  • An infected newborn could have acquired the infection from health care workers or the infected mother immediately after birth, not necessarily during the womb or during birth. 

Johns Hopkins University has a great resource for the latest COVID-19 figures (confirmed cases, deaths, recovered) here. 

Instead of large studies, we only have the details from individual reported cases at this point. Researchers are grouping these cases together to analyze the data. Mullins et al. in the U.K. published a “Rapid Review” of COVID-19 in pregnancy and birth.  

  • So far, there is no evidence that pregnant people are at greater risk of infection or severe illness with COVID-19 (they are only considered a ‘vulnerable group’ as precaution).  

Maternal outcomes: 

  • They reviewed reports from China on 32 infected pregnant women and 30 babies (one set of twins and three ongoing pregnancies).  
  • There have been no reported maternal deaths.  
  • 7/32 mothers (22%) were asymptomatic 
  • 2/32 (6%) were admitted to the ICU, 1 with severe pneumonia 
  • 27 mothers had Cesareans, 2 had vaginal births. We don’t know why the Cesarean rate was so high among these mothers.   
  • Women gave birth within 13 days of onset of illness. The authors mention that fetal growth is unlikely to be affected in this time period.  

Newborn outcomes: 

  • There was one stillbirth that occurred to a mother who presented at 34 weeks with a fever and sore throat; her condition worsened to severe pneumonia; she required ICU and life support (extracorporeal membrane oxygenation or ECMO). She had a stillbirth by Cesarean. (Yangli Liu) 
  • The one newborn death occurred when a baby died after being born at 34 weeks. The baby was admitted to ICU 30 minutes after birth with respiratory difficulties. The baby developed shock, multiple organ failure, and died at 8 days postpartum. (Zhu) 
  • This is not enough evidence to know if COVID-19 infection increased the risk of harm to babies. However, the high number of preterm births is concerning; it could mean tremendous pressure on newborn health services if the infection is widespread. With these case reports of preterm birth in women with COVID-19, it is unclear whether the preterm births were always because of medical intervention by Cesarean, or whether some were spontaneous preterm labors that resulted in Cesareans. Cesareans were predominantly for maternal indications related to the viral infection, although there was evidence of fetal distress in at least 7 reports (Mullins et al.) and prelabour PROM, in at least one report (Zhu et al.).  
  • We don’t have any data on outcomes with COVID-19 infection in the 1st trimester. 

To get evidence on which treatments are most effective, WHO and its partners are organizing a large international study, called the Solidarity Trial, to compare different treatments. They announced the trial on Friday, March 20. It will be a global megatrial of the four most promising coronavirus treatments. Click here. 

We recommend you watch the Royal College of Obstetricians and Gynecologists (RCOG) practice guidance on COVID-19 because they are updating it very often. The most current (fourth) version is here.  

References 

Lauer, SA.Grantz, KH., Bi, Q., et al. (2020). The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 [Epub ahead of print 10 March 2020]. Click here. 

Mullins, E., Evans, D., Viner, R. M., et al. (2020). Coronavirus in pregnancy and delivery: rapid review [published online ahead of print, 2020 Mar 17]. Ultrasound Obstet Gynecol. Click here. 

Schwartz, D. A. (2020). An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes [published online ahead of print, 2020 Mar 17]. Arch Pathol Lab Med. Click here. 

van Doremalen N, Bushmaker T, Morris DH, et al. (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 [published online ahead of print, 2020 Mar 17]. N Engl J Med. Click here. 

Zhou F, Yu T, Du R, et al. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published online ahead of print, 2020 Mar 11] [published correction appears in Lancet. 2020 Mar 12;:]. Lancet;S0140-6736(20)30566-3. Click here. 

Research Update from Monday, March 16 at 1:57pm
Last Friday, we sent out an email with the latest research evidence on COVID-19 and pregnancy. Our research team plans to send out updates on this topic every Monday, starting today. 

We also created a COVID-19 resource & pregnancy page that will include links to the most important websites, archives of our newsletters, and any other info we think you might find useful (such as resources for doulas who are encountering visitor bans). You can access that page here. 

Research Update from Monday, March 16: 

  • According to the World Health Organization’s (WHO) most recent situation report here, there are now over 153,000 confirmed cases and 5,735 deaths globally 
    • The WHO published interim guidance on March 13, 2020, here. 
    • There is little research on the clinical presentation of COVID-19 in pregnant women and children 
    • There have been a few cases of infants with COVID-19 and they experienced mild illness 
    • So far, there is no evidence of mother-to-baby transmission, and when researchers tested women who were infected, the samples of amniotic fluid, cord blood, vaginal discharge, newborn throat swabs, and breast milk have all been negative. 
    • Some reports of PROM (premature rupture of membranes), fetal distress, and preterm birth have been reported when mothers became infected in the third trimester 
    • The mode of birth should be individualized and Cesarean used only when it is medically justified 
    • Standard infant feeding guidelines should be followed with appropriate precautions for infection prevention and control. These standard guidelines include initiating breastfeeding within 1 hour of birth and continuing to exclusively breastfeed for 6 months, continuing breastfeeding up to 2 years or beyond. Infected mothers who are breastfeeding or practicing skin-to-skin should wear a medical mask, perform careful hand hygiene, and clean and disinfect all surfaces. Infected mothers should still be provided with breastfeeding support. If complications prevent the infected parent from breastfeeding, they should be encouraged and supported to express milk for the infant for someone else to feed to the baby or to maintain milk supply. There should be no promotion of breastmilk substitutes (formula) or pacifiers. 
    • “Mothers and infants should be enabled to remain together and practice skin-to-skin contact, kangaroo mother care and to remain together and to practice rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.” 
  • The Centers for Disease Control and Prevention (CDC) in the Unites States (U.S.) publishes situation summaries here 
  • The CDC has a pregnancy/breastfeeding and COVID-19 page here 
  • ACOG Practice Guidelines: ​The American Congress of Obstetricians and Gynecologists published a practice advisory on March 13, 2020. 
    • ACOG has worked with the Society for Maternal Fetal Medicine to develop an algorithm that can be used to assess and manage pregnant women with suspected COVID-19.  
    • They encourage care providers to read and familiarize themselves with the complete list of recommendations from the CDC about inpatient obstetric facilities (see below).  
    • ACOG refers to the CDC guidance on breastfeeding and COVID-19 infection. They state, “Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.”  
  • CDC Interim Guidance on Inpatient Obstetric Healthcare 
    • The CDC has released interim guidance on caring for pregnant women with suspected or confirmed COVID-19 in the inpatient hospital setting.  
    • In contrast to the WHO, the CDC recommends separation of a newborn from a mother with confirmed or suspected COVID-19: “To reduce the risk of  transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.”  
    • The guidance goes on to say, “If colocation (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19.” 
  • UpToDate® guidance for clinicians  here.
    • There is very little info regarding COVID-19 during pregnancy 
    • Mother-to-baby transmission during pregnancy or birth has not been identified 
    • There have been at least two newborn cases documented 
    • Pregnant people are more susceptible to infectious diseases due to immune suppression during pregnancy 
      • Other respiratory infections—(SARS)-CoV, (MERS)-CoV, and influenza—have been shown to develop into more severe disease in pregnant people 
    • Out of 18 pregnant women with confirmed or suspected infection, there was no laboratory evidence of transmitting the virus to the newborn 

New research on PubMed: A retrospective study reviewed the clinical and CT imaging features of 59 people in China with COVID-19. This group included 14 non-pregnant adults with lab-confirmed infection, 16 pregnant women with lab-confirmed infection, 25 pregnant women with clinically diagnosed infection, and 4 children with lab-confirmed infection (Liu et al.) 

  • All of the pregnant women had mild illness. None were admitted to ICU and none of the babies had abnormalities or evidence of mother-to-baby transmission. 
  • Compared with the non-pregnant adults, the pregnant women (both lab-confirmed and clinically diagnosed) had atypical clinical features, making early detection difficult. It was more common for pregnant people to have an initial normal temperature—only 36% to 44% had a fever. This means that fever may not be as useful of a screening tool with pregnant people. 
  • It was also more common for the pregnant people with infection to have leukocytosis (increase in white blood cells) and elevated neutrophil ratio (a marker of inflammation) compared to the non-pregnant people with infection. 

For other research updates that we sent out last week, view our COVID-19 resource page here. 

Sincerely, 

Rebecca 

Rebecca Dekker, PhD, RN
Founder, Evidence Based Birth® 

 

'Here's the Evidence on COVID-19 + an upcoming Relaxation session' Newsletter from Fri, Mar 13, 5:29 PM
At Evidence Based Birth®, we are continually monitoring the situation and our research team is examining the best available resources. Here is what we can share with you today:

> The latest evidence on COVID-19 and pregnancy:

  • Here is the CDC’s FAQ about pregnancy and coronavirus disease. You’ll notice that a lot of the answers start with “We do not know…” It is an unfortunate reality that very little research has been published on pregnancy, birth, and COVID-19. Due to the emerging nature of the situation, I anticipate more research will arise in the coming weeks.
  • The International Society of Ultrasound in Obstetrics & Gynecology issued new guidance for birth professionals on March 11, 2020 (Poon et al. 2020). This is the most recent professional guidance we were able to find today. For patients, their main recommendations were to:
    • Avoid close contact with others, i.e. avoid gatherings where a distance of 1 meter between individuals can not be maintained
    • Frequent hand washing or hand sanitizer (with 70% alcohol concentration)
    • Seek medical attention when experiencing symptoms such as fever and cough (but call first before going in; see if telehealth is an option)
    • Check out their article for detailed info about health care provider protection, suggestions on care for infected mothers and their babies, and more. They state that there is no evidence on the safety of mother-infant separation if the mother is infected. “If the mother is severely or critically ill, separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production. Precautions should be taken for the cleaning of the breast pumps. If the patient is asymptomatic or mildly affected, breastfeeding and [rooming-in] can be considered…Since the main concern is that the virus may be transmitted by respiratory droplets rather than breastmilk, breastfeeding mothers should ensure to wash their hands and wear a three-ply surgical mask before touching the baby.”
  • review article was published in the American Journal of Obstetrics and Gynecology on February 24 (Rasmussen et al. 2020). This article compares and contrasts the effects of SARS, MERS, and COVID-19 on pregnant women. They summarize the result from several small studies from China in which pregnant women with COVID-19 were followed. In one study with 9 pregnancies, 6 had intrauterine fetal distress, 7 gave birth by Cesarean , and 6 infants were born preterm. The symptoms in these women were similar to non-pregnant patients: fever, cough, muscle aches, sore throat, and fatigue.
  • A case report was just published March 12 [online ahead of print] that reports the first case of COVID-19 infection in a newborn whose mother was also diagnosed with COVID-19 in China (Wang et al. 2020). The researchers are not sure how the baby caught the virus, since the baby was separated from its mother at birth and there were zero traces of the virus in breastmilk, cord blood, and the placenta. We don’t know if the virus can be transmitted through the placenta before birth. Fortunately, in this case, the illness was mild in both the mother and baby, and the baby’s prognosis was good.
  • Dr. Aviva Romm, an MD specializing in integrative medicine, has posted some interesting articles on her website about pregnancy and COVID-19.

> Doula support in hospitals in light of the COVID-19 situation

Around the world, hospital visitation policies are becoming quite restrictive. It’s important to remember that doulas and partners are not visitors, rather, they are members of the health care team and their presence is critical to having safe birth outcomes. However, I know that parents are becoming anxious about the possibility of their doulas being turned away from the hospital (and doulas are worried, too!). As far as resources go…

> Anxiety

We’ve heard from countless doulas, nurses, childbirth educators, expecting parents, and others that their anxiety is running high! With school and event closings, jobs being disrupted, the fear of infection, preparing to give birth or to support birthers in hospital settings, there is plenty to worry about. With that being said, I think it’s important to calm down our nervous systems and practice some intentional relaxation. I can personally attest that even though I am generally a calm person, today I felt my heart rate going up and fight/flight hormones kicking in at times. This means it’s time for me to do some deep abdominal breathing and mental relaxation techniques!

Given that many of us are in need of some anxiety-reducing techniques, I am going to lead a public relaxation session sometime this weekend. I will read a relaxation and deep breathing script for professionals, and I will also read a relaxation script for expecting parents. These sessions will take place on Instagram Live and Facebook Live. I will send out an email about 30 minutes before I go live. You’ll have to forgive me for not knowing the exact time… I will need to work it around my kids’ schedule.

> Online education

I know that childbirth education programs are being cancelled at hospitals in many places around the world. Fortunately, our EBB Childbirth Class was already 80% online, and we took steps this week to create a fully online class that EBB Instructors can use– it will be rolled out this weekend where it is needed.

So, if you’re looking for a comprehensive class that includes an emphasis on self-advocacy methods, comfort measures for labor, and evidence based care, you can check out our Events page to find an EBB Instructor near you. If social distancing is appropriate in your geographic area, then the class can be offered online. If the registration page doesn’t state whether or not the class will be offered online, feel free to email the individual Instructor to find out which method will be offered (80% online or 100% online). This is a brand new option, so registration pages might not reflect the change in method!

For those of you who don’t have a local Instructor in your geographic area, we’re hoping to have an online option open for registration in the next few weeks. This full online class will be taught by our EBB Instructors who work at EBB Headquarters. We know that people who don’t live near an Instructor have really been wanting this option, and we’re working on getting it up and running as quickly as possible!

We are also working on getting all of our other EBB Instructor Professional and Parent events and workshops online, wherever social distancing is appropriate or required.

Thanks for being part of our community, and I’ll be in touch as soon as I know what time I can lead the relaxation session! It will be recorded for those of you who can’t make it.

Sincerely,

Rebecca

 

Rebecca Dekker, PhD, RN
Founder, Evidence Based Birth®
Author, Babies Are Not Pizzas: They’re Born, Not Delivered

 

 

COVID-19 Research Studies Seeking Participants

HOPE COVID study (UCSF California Preterm Birth Initiative)

Click here to learn more

PRIORITY Registry (UCLA Health)
VIDEO: COVID19 in Pregnancy | Yalda Afshar, MD, PhD, Rashmi R. Rao, MD UCLA

AVAILABLE FOR INTERVIEWS: STUDY PARTICIPANT (IN NYC) AND STUDY P.I.  

National Registry Quickly Set Up to Help Doctors Understand Risks COVID-19 Poses to Pregnant Women and Newborns

“It was a call to arms because we have a population of vulnerable folks for whom we have no data.”           Yalda Afshar, MD, PhD, UCLA Biodesign Fellow

LOS ANGELES (April 8, 2020) – A new national registry has been launched by specialists in obstetrics, gynecology and reproductive sciences at UCLA Health and the University of California, San Francisco, to determine COVID-19’s possible effects on pregnant women and newborns.

The registry is enrolling pregnant women and those who have been pregnant or postpartum within the past six weeks who have a confirmed diagnosis of COVID-19 or are being evaluated for that possibility. UCLA Health’s participation is aligned with the goals of UCLA Biodesign, a program that promotes health care innovation and partnerships that develop novel tools and technologies.

Within two weeks of going live, it had received more than 400 patient referrals from around the country.

The novel coronavirus quickly gained a reputation for being particularly dangerous to the elderly and those with preexisting medical conditions, but little is known about its potential impact on the course of pregnancies. The PRIORITY study – Pregnancy CoRonavIrus Outcomes RegIsTrY – is enrolling pregnant women and those who have been pregnant within the previous six weeks who have a confirmed diagnosis of COVID-19 or are being evaluated for that possibility.

“We expect this registry to provide data that will be critical in helping to improve care for pregnant women during this global pandemic,” said Yalda Afshar, MD, PhD, an obstetrician/gynecologist at UCLA Health and a UCLA Biodesign Fellow, who is co-principal investigator of the study.

Although it usually takes many months to develop a national registry, because of the rapidly evolving COVID-19 crisis, the PRIORITY study went from the initial concept to being open for enrollment in two weeks.

“It was a call to arms because we have a population of vulnerable folks for whom we have no data,” said Afshar.

According to Afshar, most of the available COVID-19 data are based on studies of the general population, but these data do not translate meaningfully to pregnant women and their babies.

“Pregnancy in and of itself makes significant changes to the physiology of the body,” Afshar said. “In fact, pregnant women are considered immune-compromised. An infection on top of that results in a potentially very different scenario for both mom and baby.  We wanted to have data relevant to women, for women, so we can take care of them better,” Afshar said.

“With the global reach of this disease, the findings resulting from this work have the potential to impact millions of lives in an entire generation,” said Johnese Spisso, president of UCLA Health, CEO of UCLA Health System, associate vice chancellor of UCLA Health Sciences, and a member of the UCLA Biodesign Program Advisory Board.

History suggests that the virus will make some pregnancies and deliveries more challenging.

“We know that in previous outbreaks of the regular flu, for example, there have been more deaths and poorer outcomes among pregnant women compared with nonpregnant women,” Afshar said. Infection with influenza also is known to increase risk of miscarriage, preterm delivery, fetal death and certain congenital abnormalities.

Afshar, a physician-scientist whose interests include high-risk pregnancy, prenatal ultrasound, genetic testing and congenital heart disease, is overseeing the study with Drs. Stephanie Gaw, Vanessa Jacoby, and Valerie Flaherman, at UCSF where the registry data will be coordinated.

“In addition to gaining a better understanding of the course of the disease, we will investigate disease transmission to determine if it can be passed from a mother to her baby in utero, and during the postpartum period, such as in breast milk,” said Gaw, whose research interest is infectious disease during pregnancy and is leading the bio-specimen core of the study.

“These are questions that we really have no guidance for right now,” Afshar added. “We’re creating protocols on labor and delivery units throughout the country – throughout the world – without really knowing if this is acquired in utero or not.”

Jacoby agreed. “There is an urgent need to address significant gaps in our knowledge about how pregnant women infected with COVID-19 will fare during pregnancy and how the disease may affect outcomes,” she said.

Beyond that, there also is a critical need to understand the affect of health disparities during this pandemic and how some pregnant women, particularly Black and Latina women, may be impacted more severely by COVID-19.

“A central part of the UCLA Biodesign mission is to deliver improved outcomes to patients locally and worldwide. This registry is a perfect example of the way we’re working with leaders in our state and throughout the nation to improve health care throughout the world,” said Jennifer McCaney, co-executive director of the program.

Desert Horse-Grant, senior director of UCLA Health Research and Innovation and co-executive director of UCLA Biodesign, added that UCLA Biodesign is structured to be both transformative and nimble, with the ability to adapt quickly in a rapidly changing world.

“To have a registry up and running in two weeks is a testament to the foresight, professionalism, expertise and dedication of Dr. Afshar and her colleagues, who recognized the significance of this problem and quickly pivoted to take it on,” Horse-Grant said. “Even a healthy pregnancy brings its own unique stressors; imagine adding those to the life-threatening issues the pandemic has created. This important initiative is an opportunity for us to gather valuable health information and learn how best to protect this vulnerable population.”

Women 13 and older, recruited through their health care practitioners – family physicians, midwives and obstetricians – throughout the U.S., will be contacted by phone by a study coordinator. Patients also may enroll in the study without a referral by visiting the website.

After enrolling, patients will complete questionnaires online, by phone or email to provide information on their symptoms, clinical course, pregnancy outcomes and neonatal outcomes. Researchers will collect data regularly from the time of enrollment through the second and third trimesters and postpartum, with the goal of following the mothers and babies up to one year. In addition to the questionnaires, the registry will obtain necessary medical records to collect data on key clinical and pregnancy outcomes.

Patients interested in information about the registry may contact the researchers by emailing Afshar at PRIORITYCOVID19@ucsf.edu. She has also created a “COVID-19 in Pregnancy” video with additional information.

# # # 

STUDY PARTICIPANT AND STUDY CO-PRINCIPAL INVESTIGATOR AVAILABLE FOR INTERVIEWS

  

MEDIA CONTACT:
Sandy Van
808.526.1708 (o) or 808.206.4576 (m)
sandy@prpacific.com

Doula Work During COVID-19 (DePauw University, Butler University)
Many thanks to Dr. Hillary Melchiors (of The Birth Geeks) for alerting us to the relevant work of two anthropologists Angela Castaneda at DePauw University & Julie Johnson Searcy at Butler University. They are collecting survey data research on doula services during COVID-19. We wanted to share this survey with our audience!

Click here to take the survey: https://docs.google.com/forms/d/e/1FAIpQLScVJAqIFZOPwczWBYZBqTsV1acR6yvvoPz0okUhSQWqeB6MSw/viewform?fbclid=IwAR2x9YHgw4catJXx2K_nBBC4NWBvMp9uti6wgmQBcR-2DRMxLFTecGltjnY

COVID-19 Pregnancy & Postpartum Experiences (COPE) Study (University of Illinois at Chicago)

University of Illinois at Chicago researchers are conducting a survey on how isolation, stress, and changes in healthcare related to COVID-19 affect pregnancy and the postpartum period. If you are currently pregnant or have given birth since January 2020, are at least 18 years old, able to read English and are in the United States, please consider taking our survey.

To participate please click the link below:

(Clicking the link will bring you to a questionnaire, where the first 3 questions will determine if you are eligible to participate.
If you are eligible and consent to participating, you will be asked to answer questions regarding your pregnancy and birth, taking about 15 minutes to complete. The questionnaire will be only be available until July 16.)

If you chose to click on the link, please be aware that social media almost universally collects information about user behavior while on the site, as well as tracking user behavior initiated on the site, presenting issues of privacy and confidentiality.

👉 Survey link:
https://bit.ly/2XKMNka

Please feel free to share the link with anyone you think may be interested. If you have any questions, please Dr. Kylea Liese: kylea3@uic.edu

COVID-19 and Reproductive Effects (CARE) Study (Dartmouth)

The purpose of the CARE study is to understand how the COVID-19 pandemic is affecting pregnant women’s wellbeing and their healthcare experiences.

Must be over 18, currently pregnant, and living in the U.S. to participate. 

Click here: https://sites.dartmouth.edu/care2020/interested-participants/

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