Fertility, pregnancy, and COVID-19 in sub-Saharan Africa — How does COVID-19 affect women’s reproductive health?

Backgrounder

Introduction

The COVID-19 pandemic is a major health crisis caused by a virus that appeared in China in late 2019. In January 2020, this infectious disease began to spread to Europe and the Americas and eventually reached Africa, with Egypt announcing the continent’s first confirmed case on February 14, 2020. (1) Less than two weeks later, Nigeria confirmed the first case of COVID-19 in sub-Saharan Africa. (7) This news created panic and countries began implementing measures to control the spread of the disease. These included:

• Restrictions on travel and movement
• Bans on large-scale events
• Closure of places of worship such as churches and mosques
• Closure of educational institutions
• Full or partial lockdowns
• Mandatory mask wearing (16)

Despite these measures taken in sub-Saharan Africa and elsewhere, the disease has continued to spread in waves across the world. As of early June, 2022, there were nearly 530 million confirmed cases and 6.3 million deaths globally. Perhaps because of Africa’s efficiency in responding to public health emergencies and immunity gained through previous exposure to other coronaviruses, it has had the smallest number of confirmed cases and deaths of any continent. (4, 13) However, the 11.5 million known cases and 253,000 reported deaths in the 55 African Union Member States (2) as of early June, 2022 highlight the need to follow safety measures and achieve higher rates of vaccination to limit the spread of the virus.

Impact of the pandemic on sexual and reproductive health care and services   

The World Health Organization (WHO) Regional Office for Africa reported that, in 2021, 40% of African countries experienced disruptions in sexual, reproductive, maternal, newborn, child, and adolescent health services due to the pandemic. A WHO survey conducted in 11 African countries showed that in six, maternal deaths in health facilities were 16% higher in 2020 than at the same time in 2019 and 11% higher in 2021 than 2019 levels. The actual number of maternal deaths is estimated to be much higher since deaths more commonly happen at home rather than in health facilities. WHO data from late 2021 shows that in nearly half of African countries, the number of facility-based births was lower than before the pandemic. (22)

The use of reproductive health supplies has also been affected:

• WHO Africa reported that between June and September of 2021, contraceptive use dropped in 10 of 21 African countries.
• According to a 2021 report, pregnancy rates doubled among secondary-school girls who were out of school for six months during Kenya’s COVID-19 lockdown.
• A study in five South African provinces found that the number of teenage pregnancies had risen 60% since the pandemic began. (22)

In March 2022, Dr. Matshidiso Moeti, WHO Regional Director for Africa, observed: “Two years on, the COVID-19 burden still weighs heavily on women. Africa’s mothers and daughters are struggling to access the health care they need. The pandemic’s disruptive force will be felt by women for many years to come.” (22)

Risks for pregnant and breastfeeding women

It does not appear that pregnant women are at greater risk of being infected with COVID-19 than the general population. However, according to WHO, pregnant women are more likely than non-pregnant women to develop severe forms of the disease once infected, especially in the third trimester* of pregnancy. (14) The physiological changes that women experience when they are pregnant and breastfeeding make it easier for them to become seriously ill from respiratory viruses like the one that causes COVID-19. (5, 10)

A recent US study found that pregnant women infected with COVID-19 were twice as likely to experience severe illness and infections. (6) They were also more likely to experience complications such as premature birth, low birth weight, and stillbirth, especially if they had severe COVID-19. (10) Infection with COVID-19 during pregnancy may also cause problems with the placenta*, leading to newborn illness and death. Some variants of the virus, particularly the Delta strain, seemed to be more damaging than others. (9)

People with severe COVID-19 infections may require hospitalization, admission to an intensive care unit (ICU), and/or a ventilator to help them breathe. (5)

In general, some groups seem to be at greater risk of developing a severe form of COVID-19, including:

• Pregnant women or women whose pregnancy has recently ended,
• People who are older than 25,
• People who are overweight, and
• People who have pre-existing conditions such as hypertension or diabetes. (5)

Research indicates that pregnant women with COVID-19 are between two (10) and five times (11) more likely to be hospitalized, as well as three (10) to six times (11) more likely to require ICU care than non-pregnant women who become infected with the virus. Hospitalization and social isolation are added stresses for pregnant women, putting them at risk of developing post-traumatic stress disorder. (18)

Fortunately, the chance of a mother passing the virus on to her unborn child during pregnancy appears to be quite small. Although most COVID-19 infections in infants have been passed from infected caregivers, there is no evidence that COVID-19 was transmitted through breast milk or breastfeeding. (10) A recent study found that COVID-infected mothers who consistently wore medical masks and kept their hands and breasts clean were able to breastfeed without passing the virus to their infants. (10)

Recommendations during and after childbirth for women with COVID-19 

In cases of confirmed COVID-19 infection, there are no specific recommendations for the timing of delivery and whether the birth should be vaginal or caesarean. Instead, the choice should be individualized, based on a woman’s preferences, condition, and medical risk factors. (10)

After delivery, close contact between the mother and newborn is very important. Skin-to-skin contact has important benefits for the newborn and poses minimal risk of serious illness. (10) Skin-to-skin contact helps regulate newborns’ temperature and improves their chances of survival. It also encourages breastfeeding, which helps babies thrive, giving them lifelong health and development benefits. Research shows that breastfeeding is beneficial to the mother’s health as well. (15) For these reasons, WHO recommends that mothers with confirmed or suspected COVID-19 be supported to hold their newborn skin-to-skin, breastfeed while observing standard preventative measures such as wearing a mask, and share a room with the baby. (21)

How can pregnant and breastfeeding women protect themselves from COVID-19? 

To protect oneself and others from COVID-19, WHO recommends that everyone follow the following precautions whenever possible:

• Keep a physical distance of at least one metre from others.
• Wear a mask indoors—and outdoors when physical distancing is not possible.
• Cover coughs and sneezes when not wearing a mask.
• Regularly wash hands with soap or clean with hydro-alcohol solutions.
• Stay home when feeling unwell.
• Get vaccinated against COVID-19. (20)

Because of their greater risk for more severe COVID-19 infections, women who are pregnant or breastfeeding should avoid going out unless it is absolutely necessary. This includes classes, medical appointments, and work. They should also:

• Avoid using public transportation whenever possible.
• Stay away from large gatherings.
• Avoid touching their eyes, nose, and mouth with unwashed hands.
• Avoid anyone known to have COVID-19 or symptoms of the infection. (5)

Common COVID-19 symptoms include fever, cough, tiredness, and a loss of taste and/or smell. Less common are sore throat, headache, diarrhoea, and difficulty breathing. Anyone experiencing severe symptoms should go to a health centre as soon as possible. (5)

Vaccination against the COVID-19 virus

Vaccination lowers the risk of developing COVID-19 and lessens the severity of the disease in the case of a breakthrough infection*. (3) As of early June, 2022, over 4.6 billion people, 59% of the world’s population, had been fully vaccinated against COVID-19. (2) However, Africa CDC data indicate that as of June 19, 2022, only 17.6% of Africa’s population had been fully vaccinated. As long as this gap in vaccination rates persists, it seems likely that COVID-19 will remain a threat to global health, with new variations of the virus continuing to emerge. Along with improving access to vaccines, it is essential to debunk myths about their safety and effectiveness.

Effects on fertility due to COVID-19 

A US National Institutes of Health (NIH) study involving more than 2,000 couples found no difference in pregnancy rates between unvaccinated couples and couples in which at least one person had been vaccinated. (19) Dr. Oluwatosin Goje, an obstretrician/gynaecologist and reproductive infectious disease specialist at the US-based Cleveland Clinic, says: “Most of the data coming out agrees with initial information that vaccines do not affect fertility.” (8) Dr. Goje said that research has found no evidence that the vaccine negatively affects sperm and that there has also been no increase in miscarriages among vaccinated women. (8)

However, being infected with COVID-19 can affect fertility. Researchers found that couples had a slightly lower chance of conceiving if the male partner had been infected with COVID-19 within 60 days before the female’s menstrual cycle during which she became pregnant. (19) Also, along with decreasing male fertility, the COVID-19 virus can have a negative impact on women’s fertility. Research shows that being sick with COVID-19 can cause inflammation of the thyroid gland, which triggers hormonal changes that affect a woman’s ability to get pregnant. Dr. Goje explains, “Thyroid disorders affect menstrual cycles and fertility, so it’s possible that dysregulation of the thyroid due to COVID-19 can indirectly affect fertility.” (8)

The NIH researchers concluded that, thanks to being vaccinated against COVID-19, men could potentially prevent any decrease in fertility resulting from being sick with COVID-19. In other words, because vaccination against COVID-19 helps prevent COVID-19 infections, it could help to prevent the negative impacts of COVID-19 infections on male fertility, while also helping to reduce the risk of exposure to the virus by female partners. (19)

Vaccine benefits to pregnant women

Recent research by Dr. Kiera Murison and her colleagues at the University of Toronto found that pregnant women were 50% less likely to be hospitalized or be treated in an ICU after just one dose of the vaccine. Their chances of avoiding hospitalization were even better with two or more doses of the vaccine. (11) Another recent study showed that the chance of losing a baby through stillbirth or during the first month of life was four times higher for women who gave birth within four weeks of having a COVID infection. All of the deaths in the study occurred among unvaccinated women. (17)

Dr. Lauren Wise, an epidemiologist involved in the NIH study, affirmed: “There’s a wealth of information that COVID infection has … a harmful impact on pregnancy outcomes and birth outcomes … Taking into account all the available information right now … I think the evidence is weighing for vaccination.” (12)

Definitions

Breakthrough infection: A COVID-19 infection in a fully vaccinated person

Placenta: The mass of veins and tissue inside the womb of a pregnant woman that provides oxygen and nutrients to the unborn baby

Third trimester: Weeks 28 through 40 of pregnancy

Where can I find more resources on this topic? 

1. Africa Centres for Disease Control and Prevention (Africa CDC), 2020. Africa identifies first case of Coronavirus disease: Statement by the director of Africa CDC. https://africacdc.org/news-item/africa-identifies-first-case-of-coronavirus-disease-statement-by-the-director-of-africa-cdc
2. Africa Centres for Disease Control and Prevention (Africa CDC), 2022. Outbreak brief 125: Coronavirus disease 2019 (COVID-19) pandemic. https://africacdc.org/download/outbreak-brief-125-coronavirus-disease-2019-covid-19-pandemic
3. Berghella, V., and Hughes, B. L., 2022. COVID-19: Overview of pregnancy issues. UpToDate. https://www.uptodate.com/contents/covid-19-overview-of-pregnancy-issues
4. Bwire, G., et al, 2022. The COVID-19 pandemic in the African continent. BMC Medicine 20(167). https://doi.org/10.1186/s12916-022-02367-4
5. Centers for Disease Control and Prevention (CDC), 2022. Pregnant and recently pregnant people at increased risk for severe illness from COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant-people.html
6. Ferrara, A., Hedderson, M. M., and Zhu, Y., 2022. Perinatal complications in individuals in California with or without SARS-CoV-2 infection during pregnancy. JAMA Internal Medicine 182(5), pages 503–512. https://doi.org/10.1001/jamainternmed.2022.0330
7. Haileamlak, A., 2020. COVID-19 pandemic status in Africa. Ethiopian Journal of Health Science 30(5), pages 643–644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047260
8. How COVID-19 (and the vaccine) can impact your fertility, 2022. Cleveland Clinic. https://health.clevelandclinic.org/covid-vaccine-and-fertility
9. Huynh, A., et al, 2022. SARS-CoV-2 placentitis and intraparenchymal thrombohematomas among COVID-19 infections in pregnancy. JAMA Network Open 5(3), e225345. https://doi.org/10.1001/jamanetworkopen.2022.5345
10. Jamieson, D. J., and Rasmussen, S. A., 2022. An update on COVID-19 and pregnancy. American Journal of Obstetrics & Gynecology, pages 177–186. https://www.ajog.org/article/S0002-9378(21)00991-1/fulltext
11. Kirby, T., 2022. Pregnant women with COVID-19 face greater risk of hospitalisation and ICU admission, strengthening case for vaccination. EurekAlert! American Association for the Advancement of Science (AAAS). https://www.eurekalert.org/news-releases/950558
12. Most, D., 2022. Do COVID vaccines affect the menstrual cycle? Question of the Week Podcast. Boston University. https://www.bu.edu/articles/2022/do-covid-vaccines-affect-menstrual-cycle
13. Murewanhema, G., 2022. Emerging SARS-CoV-2 variants, inequitable vaccine distribution, and implications for COVID-19 control in sub-Saharan Africa. COVID 2022(2), pages 341–349. https://doi.org/10.3390/covid2030023
14. Nana, M., et al, 2022. Diagnosis and management of COVID-19 in pregnancy. BMJ 2022(377), e069739. https://www.bmj.com/content/377/bmj-2021-069739
15. Organisation Mondiale de la Santé (OMS), 2020. Questions-réponses sur la COVID-19 et l’allaitement. https://www.who.int/fr/iergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-and-breastfeeding
16. Osseni, I. A., 2020. COVID-19 pandemic in sub-Saharan Africa: Preparedness, response, and hidden potentials. Tropical Medicine and Health 48. https://doi.org/10.1186/s41182-020-00240-9
17. Rabin, R. C., 2022. Unvaccinated women with Covid are more likely to lose fetuses and infants, Scottish data show. New York Times. https://www.nytimes.com/2022/01/13/health/unvaccinated-women-with-covid-are-more-likely-to-lose-fetuses-and-infants-scottish-data-show.html
18. 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 
19. Wesselink, A. K., et al., 2022. A prospective cohort study of COVID-19 vaccination, SARS-CoV-2 infection, and fertility. American Journal of Epidemiology. http://doi.org/10.1093/aje/kwac011
20. World Health Organization (WHO), 2022. Coronavirus disease (COVID-19). https://www.who.int/health-topics/coronavirus#tab=tab_1
21. World Health Organization (WHO), 2022. Coronavirus disease (COVID-19): Pregnancy, childbirth and the postnatal period. Q&A. https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-pregnancy-and-childbirth
22. World Health Organization Regional Office for Africa, 2022. COVID-19 takes a heavy toll on women’s health. https://www.afro.who.int/countries/congo/news/covid-19-takes-heavy-toll-womens-health