On March 11, I went home from work via the supermarket and bought a pregnancy test. An hour or so later, I learned I was pregnant again. I laughed with my toddler, who had seen me urinate on so many sticks before, this time she demanded her own test. I texted my partner the happy news. I tried not to think of my recent miscarriage. I hoped for the best.
That same day, the World Health Organization (WHO) upgraded the status of the COVID-19 outbreak from epidemic to pandemic.
Pregnancy can be a time of great joy and anticipation. It can also be a period of great stress, irrespective of how many times pregnant people are told to “relax”.
My immediate response was to search the internet for “pregnancy and COVID-19”. Information was – quite understandably – scant, emerging and variable in quality. These are unprecedented times; the “novelty” of this virus is its specific power.
In general, however, there are three dominant types of information for pregnant people at this point in time.
Firstly, medical advice for individual pregnant people based on what little information is currently known. In Australia, organisations like the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and our women’s hospitals are providing regular advisory updates.
At this stage, it does not appear COVID-19 presents additional risks to mother, foetus or child by virtue of pregnancy status itself, even as pregnancy is a unique immunological state and evidence to support this conclusion is necessarily limited. In some ways, it may be a protective factor that pregnant people are already bombarded with restrictions and advice regarding what they eat/drink/ingest and their social conduct in order to maintain optimal health for themselves and their babies.
Secondly, there is a mixed bag of news and news-lite articles usually over-promising “what our experts know” and under-delivering on “and what you should do about it”. Often, these articles quote selectively from the above constrained medical advice and add to it a picture of a distressed newborn. While these fulfil a particular function, at best this information is incomplete and confusing, at worst, it magnifies our collective panic. Responsible and ethical journalism is invaluable in these situations.
Thirdly, there is a small number of personal opinion pieces, predominantly from European- or United States-based writers who are pregnant and approaching imminent or hastened delivery of their babies. I thank these individuals for their willingness to share in challenging circumstances.
World of difficult, new choices
In a situation where no one knows the right thing to do, it is courageous for individuals to impart the messy, human decision-making that has informed their choices. Isolate, don’t isolate. Distance, don’t distance. Do you cancel your baby shower; attend ante-natal care in a hospital; stockpile nappies; cancel your home birth; induce your baby; prepare for shut down of maternity services; presume complete isolation in early parenting; worry, don’t worry? There is a world of new choices to be faced due to COVID-19, some of which will have individual and, others, mass consequences. There is a possibility that a potential vaccine may preclude pregnant people, as some vaccines have in the past. Much is unknown.
The physical, emotional and practical changes wrought by pregnancy and parenting are significant. Too much maternal stress has been shown to have negative short- and long-term outcomes for offspring, including cognitive achievement, disability and mortality. Not to mention the correlation between maternal stress and post-natal depression for parents of all genders.
There is also a great deal of evidence about the deleterious impact of humanitarian, natural, economic and health disasters upon the pregnant and unborn. From Spanish Flu to the trauma of war; through depression, famine and civil conflict; in the Global Financial Crisis or the Boxing Day Tsunami; from internal displacement to catastrophic bushfires: we know that there can be lasting effects of disaster on pregnant people and prenatal health. We are learning more about intergenerational harm and trauma all the time.
None of these situations is directly analogous to our current one, in the main because we are yet to see the full impacts of COVID-19.
The immediate considerations are obviously related to health and loss of human life. These are being discussed on round-the-clock news coverage, so let’s leave this (literally, vital) consideration aside for one moment, except to say that health inequity is real, even in Australia. If COVID-19 plays true to our past, then our immediate future may be one defined by disproportionate suffering on the part of people whose systematic disadvantage we are already well aware of.
The other dominant discussion relates to the disruption to global economic order. Borders are closing or closed. Supply chains are disrupted. Whole industries face collapse. Modelling varies between best- and worst-case scenarios, from “this is very, very bad but we could get over it” to “this is very, very bad”. Again, let us leave this critical issue to one side, due to its ample public discussion, but at least acknowledge that COVID-19 will underscore socio-economic inequality for pregnant people in Australia. Sick leave or the ability to work from home, (spacious and safe) home quarantine, home-delivered healthy food and on-demand entertainment cannot be assumed to be accessible by all, not even within our own country. Maternal socio-economic status impacts well-being across generations.
In mainstream Australian society, we can sometimes sideline pregnancy as a temporary concern. We think of child-bearing as something only women do. Pregnancy is something only some women do. Only some women are pregnant some of the time. These assumptions reflect profoundly gendered dynamics in our society. How would our actions change if we considered meaningful care in conception, pregnancy, maternal and child health, and early childhood as investments in every single person who has been and will be born? Some 300,000 or so babies will be born in Australia this year – what will be the potential legacy of COVID-19 upon them?
It takes a village, but when the village is missing?
The adage reminds us that “it takes a village” to raise a child, but what does that mean for reproductive, maternal and child health when the village is missing? As businesses, schools and services shut down; as we impose new constraints on movement and gatherings; as our politicians adopt the language and rhetoric of war, my questions as a pregnant person are increasing by the minute. My anxiety levels are keeping step. Some of my concerns include:
- Conception and pregnancy are already a minefield of overwhelming information. How can we ensure clear, coordinated public health advice based on best-known information with regards to conception, antenatal, intrapartum and postnatal care, and into early childhood? What support is required for the whole workforce in this time to enable coordination? No one is expecting anyone to have all the answers but the more we work together, the more transparent we are about what we know and don’t know, the more likely people will be able to make informed choices.
- Around half of all pregnancies in Australia are unplanned, and up to one in three Australian women will choose abortion in their lifetime. What implications will COVID-19 have on access to safe abortion if elective surgeries are deprioritised? Reproductive rights still matter, even in a pandemic.
- Not all planned pregnancies continue as planned. I am grateful for the exceptional care I received during miscarriage. Will pregnant people experiencing miscarriage, ectopic, molar and or other pregnancy loss feel hesitant to access care for fear of contracting COVID-19? Will they avoid what could be life-saving care and monitoring? What measures can be made to support people in this time? Is there adequate support for counselling services to continue in these changed circumstances?
- I am grateful that my current relationship is not abusive. I wish I could say that for all of my previous intimate partnerships. Women are at an increased risk of experiencing violence from an intimate partner during pregnancy. Unplanned pregnancy can be an outcome of exiting an abusive relationship. I recognise the government’s efforts to support industries that will experience shut down during this period. Please, can we also increase support to vital frontline services that may in fact be experiencing increased need at this time?
- In my first pregnancy, I made a number of decisions based on continuity of care. I will remain lifelong grateful for that care: not every pregnant person in the world is respected, cared for and treated with dignity by trusted health workers. As we shift to telehealth options, how can we support those health workers and the pregnant people seeking care to build and maintain the meaningful relationships required for continuity of care? Pregnant friends in remote and rural areas have communicated their anxiety to me about the capacity of already fragmented services in this period of high stress. Can this shift to broader-based telehealth models offer us an opportunity to do what we can for continuity for care across the whole country? Telehealth and remote servicing still have access, equity and inclusion issues.
- Like so many, I found pregnancy hard. I’ll spare you the details, but mental health support has been critical for me. The Royal Women’s Hospital states about 15 per cent of women will have depression or anxiety during pregnancy and an even larger number in the postnatal period. Even people who are not pregnant are affected by anxiety and depression as a human response to a rapidly changing, volatile world, which now includes COVID-19. Mental health support will be essential for pregnant people at this time. Remote support will be better than nothing, but human connections matter.
All going well, my child will be born in mid-November. As hopeful and joyful as I am at that prospect, it is likely the global effects of COVID-19 will be ongoing at that time, even if there is no current way to predict the magnitude of these effects.
We hope and pray the economy will recover, but will vulnerable people be forgotten in that recovery as we move on to celebrating our “triumph” over COVID-19?
Maybe we will move on to the next big thing – the next crisis, the next drama – as we have done so many times before. What will that mean for those already impacted?
My hopes are, however, that we will do more and better. That the magnitude and scale of this pandemic – its multidimensional effects – will propel us to learn from the past, what we know about people-centred, intersectional care, and work together to secure the future.
I hope we will remember pregnant people at this time and we will think about additional support and consideration to them as a meaningful investment in intergenerational equity. I’m not the only pregnant person in Australia right now, I can’t anticipate all the ways this pandemic will affect every one looking to conceive, or currently pregnant, or about to parent a child. Ask us what we need and involve us in this new journey of care. We are all in this together.