Pregnant women and COVID-19

Backgrounder

The COVID-19 pandemic is a major health crisis caused by an infectious disease that appeared in late 2019 in China. In January 2020, the disease began to spread to Europe and America and eventually reached Africa and then Burkina Faso. On March 3, 2020, Burkina Faso authorities announced the development of a plan costing billions. The plan covers several aspects of the fight against COVID-19, such as rapid response, epidemiological surveillance, diagnostics and communication. On March 9, 2020, Burkina Faso registered its first cases of COVID-19. This announcement created panic among the population and several measures were taken to control the disease. This was followed by a series of measures.

• Ban on all large-scale events in the country up to April 30, 2020;
• Closure of all places of worship, such as churches and mosques;
• Closure of educational institutions as of March 16, 2020;
• All cities with at least one case of COVID-19 placed on lockdown as of March 26, 2020;
• Mandatory mask wearing throughout the country as of April 27, 2020.

Despite these measures, COVID-19 has continued to spread around the country, as indicated by the increase in the total number of cases from 962 in June 2020 to 4,449 on October 17, including 73 deaths since the start of the pandemic.

These statistics underscore the need for compliance with barrier measures. Visits to health facilities now require more precautions for everyone in general, including pregnant and breastfeeding women.

The current status of COVID-19 in Burkina Faso

As of June 9, 2021, Burkina Faso has 13,454 confirmed cases distributed as follows: 1,328 recovered, 167 deaths, 19 active cases. Overall, since the beginning of December, there has been an increase in the number of cases per day compared to the period prior to early November. The upsurge in cases that we have noticed since early December could be attributed to the campaign for the presidential and legislative elections with its mass gatherings.

Some misconceptions:

• The coronavirus is transmitted from the mother the fetus,
• Breastfeeding transmits COVID-19 from mother to baby.

How are pregnant and breastfeeding women cared for at this time of COVID-19?

Pregnant and breastfeeding women are quite unique because of the different physiological changes, especially in their immune system. These changes are induced by pregnancy and breastfeeding which could potentially expose them to serious cases of infection and hence of the respiratory tract.

However, as of now, the available evidence does not show that pregnant women are at greater risk of COVID-19 infection than the general population. But, according to the WHO, “pregnant women or women whose pregnancy has recently ended, those who are older, overweight, or who have pre-existing conditions such as hypertension or diabetes appear to be at increased risk of developing a severe form of COVID-19.” It also appears that women in these groups “require intensive care unit management more often than non-pregnant women of childbearing age. » (2)
There are also very few data on a possible perinatal impact* after COVID-19 infection during pregnancy or in the postpartum period. There is no evidence of vertical transmission from mother to fetus during pregnancy or transmission of the COVID-19 virus through breast milk or breastfeeding. (2)

Concerning case management in Burkina Faso, there are two essential documents: the response preparedness plan and the COVID-19 management and prevention guide. These two documents provide the framework for the management of the pandemic. Since there is no evidence of a difference in infection between pregnant or breastfeeding women and the general population, management is based on the standard guideline and appropriate measures are followed to reduce COVID-19 transmission.

Even in cases of confirmed COVID-19, there is no specific prescription for delivery such as a change of delivery route or a switch from vaginal delivery to cesarean section. The most important thing is for health care professionals and patients to comply with preventive measures during labor. With regard to the management of the newborn baby, two scenarios should be considered. If the delivery has been performed in a facility where specialized care is available, the newborn baby may be separated from the mother until recovery. In the second scenario, if no specialized care is available, the baby is left with the mother, who must however scrupulously observe the usual preventive measures, including wearing a mask, physical distancing, regular hand washing and the use of soap or hydroalcoholic solution.

In any case, after delivery, it is essential to have skin-to-skin contact between mother and child. This contact helps regulate the temperature of the newborn. It is also associated with an increased survival rate among newborns, and encourages the initiation of breastfeeding, which also reduces mortality. Even for those with confirmed or suspected COVID-19, WHO recommends that mothers have immediate skin-to-skin contact with their newborn babies while observing COVID-19 barrier measures, if possible. (2)

What are the risks for pregnant and breastfeeding women?

COVID-19 infection in pregnant women is no higher than in non-pregnant adult women. However, giving birth with COVID-19 may increase the likelihood of complications, including premature birth, similar to any respiratory illness. (3)

Otherwise, isolation and quarantine measures “add to the inherent difficulties of pregnancy … [and] make pregnant women prone to post-traumatic stress disorder.” (3)

How can pregnant and breastfeeding women be protected from the pandemic?

There are no specific measures for these targets.

Barrier measures must be scrupulously respected as in the general population and these targets must be much more vigilant in respecting barrier measures, such as wearing masks, physical distancing, regular hand washing, use of soap or hydro-alcohol solution during consultations.

Promptly report any symptoms such as fever, cough, and difficulty breathing. If you have these symptoms, go to a health center as soon as possible.

Don’t go out unless it is absolutely necessary, such as going to classes, medical appointments, or just going to work.

Avoid gatherings, avoid touching your eyes, nose, mouth, and follow hygiene and breathing rules.

Avoid contact with anyone known to have COVID-19 or who has symptoms of the infection.

Avoid using public transportation as much as possible.

Midwives on the ground

For midwives in general, a lot has had to change since the outbreak of the pandemic and it has not been easy.

At the beginning, with the barrier measures of distancing it was not easy because the facilities are not adapted for the observance of these measures. At first, women came every day for weighing, but after sensitization, women were reorganized and split into groups throughout the week. They had to be constantly reminded to wear masks.
Prior to the pandemic, health workers received patients without masks. But now, they observe all barrier measures and require patients to wear masks. Moreover, they manage to impress upon pregnant and breastfeeding women who come for visits the need to wash their hands before going home, while setting an example themselves. As far as patient distancing is concerned, midwives admit that they often have difficulty enforcing it, as they are forced to sit together due to lack of seating space.

Some midwives believe that the risk to pregnant women during COVID-19 is due to their fragility. In cases where pregnant women contract COVID-19, it could create complications for the mother as well as the child. There is no conclusive knowledge on the subject yet, but an initial study suggests that pregnant women with COVID-19 are more likely to be exposed to maternal mortality or complications after birth compared to pregnant women without COVID-19. (4)

A breastfeeding woman who contracts the disease can infect her child, just as one adult can infect another. However, WHO states that women can continue to breastfeed their babies if they wish. Breastfeeding improves survival rates for newborn babies and infants and has lifelong health and development benefits. Research also shows that breastfeeding is beneficial to the mother’s health. WHO notes that it is important for mothers with confirmed or suspected COVID-19 who choose to breastfeed to strictly adhere to all barrier measures, as described. (2)

COVID-19 did not significantly reduce health center attendance rates in Burkina Faso, although in the early stages, there was fear among staff and patients alike. Some patients were afraid of being infected when they arrived at the health centre and were touched by health workers simply because the health workers are in the field and exposed to people infected with COVID-19. At the outbreak of the pandemic, there was anecdotal evidence of women refusing to come to health facilities. Those who came for visits were afraid of encountering an infected person in the hospital, and this reduced their attendance.

A recent report assessed more than 500 health facilities in 32 countries, including 24 African countries. The report found that in Africa, during the period of April to September 2020, first prenatal care visits decreased by 5% compared to the same six-month period in 2019, and there was a 23% decline in visits of under-five children to African medical institutions (1).

There is little data available on the effect of COVID-19 on sexual and reproductive health service delivery. However, a recent study assessed the potential impact of COVID-19 on these services. Although the report does not focus specifically on sub-Saharan Africa, it estimates that, in low- and middle-income countries, the impact of a 10% decrease in coverage of pregnancy and newborn care services could lead to:

• Additional cases of women suffering from major obstetric complications without receiving care;
• Additional maternal deaths;
• Additional cases of newborns suffering from major complications without receiving care; and
• Additional newborn deaths (3).

Patients speak out:

The views of patients:

1. “I can say that I have not encountered any major difficulties. As soon as he first cases were reported in Burkina Faso, I went to the village at once and was confined there. But I was able to do my prenatal consultations without any problems at the scheduled dates and today is my last appointment. So, I was able to honor the appointments.”

2. “One day I came to weigh my child; they drove me away because I had not worn a mask. That day … I left without weighing my child because they told me not to come if I did not wear a mask. I came back another day with a mask so I could weigh my child. During the pandemic, weighings were limited, each time they would only take about 10 people and beyond that number, all patients had to wait for the next session.”

To address these challenges, awareness-raising sessions on barrier measures, handwashing, nosewashing and distancing were also held. In addition, handwashing devices were placed at the various entrances to the health centers and mufflers were made available for women to wear before entering.

Definitions

Perinatal: The period immediately before and after birth. The exact definition of this period varies, but it is generally from a few weeks before birth to a few weeks after.

Postpartum: The period immediately following birth.

Bibliography

1. Le Fonds mondial de lutte contre le sida, la tuberculose et le paludisme, 2020. Impact du covid-19 sur les services de lutte contre le VIH, la tuberculose et le paludisme et les systèmes de sante : aperçu de la situation dans 502 établissements de santé en Afrique et en Asie. https://www.theglobalfund.org/media/10777/covid-19_2020-disruption-impact_report_fr.pdf
2. Organisation Mondiale de la Santé (OMS), 2020. Questions-réponses sur la COVID-19 et l’allaitement. https://www.who.int/fr/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-and-breastfeeding
3. Sall, M., et al., 2020. La santé reproductive, maternelle, néonatale et adolescente en temps de pandémie : Leçons apprises et conseils pratique. Fonds des Nations Unies pour la Population Bureau Régional pour l’Afrique de l’Ouest et du centre. https://wcaro.unfpa.org/sites/default/files/pub-pdf/fr-rmnah-web_2.pdf
4. Villar, J., et al., 2021. Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection. The INTERCOVID Multinational Cohort Study. (Disponible qu’en Anglais) JAMA Pediatrics, April 22, 2021, E1-10. https://jamanetwork.com/journals/jamapediatrics/fullarticle/2779182