C. Maxwell
ASSOCIATE EDITOR COMMENT
In this edition of “Excerpts from the World Medical Literature: Obstetrics,” we will focus on the COVID-19 pandemic, health equity, and their impact on pregnant people. Important themes related to equity and pregnancy are emerging as rapidly as the proliferation of COVID-19 clinical data. These themes include the need for better data, data that identify and report on groups most at risk, and data that are generated with the intentional inclusion of pregnant people at inception.
Ellington S, Strid P, Tong VT, et al. 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 2020;69:769–75.
Summary: Ellington et al. report data on reproductive-age people with COVID-19 in the United States over the first half of 2020 from the Centers for Disease Control and Prevention. In over 300 000 people identified as women who tested positive for the virus, pregnancy status was available for 28%. Of these, 9% or 8207 were pregnant. Symptom-wise, pregnant people reported similar frequencies of cough and dyspnea, whereas other symptoms were less common (e.g., headache, fever, muscular aches, and gastrointestinal symptoms). When comparing pregnant and non-pregnant people, the former were more likely to have chronic conditions such as lung disease, heart disease, and diabetes.
In terms of hospitalization, COVID-19–positive people were more likely to be hospitalized, admitted to the intensive care unit, and receive mechanical ventilation. Of note, mortality did not differ significantly.
The data on health and pregnancy status, as well as laboratory confirmation of SARS-CoV-2 infection, were confirmed in a standardized fashion using national reporting systems.
With regard to race, several findings are striking. Admission to intensive care was more frequently reported for Asian pregnant people than other groups. Pregnant people of Hispanic and Black ethnicities were overrepresented in the COVID-19–affected cohort, suggesting that these individuals might be disproportionately affected by the virus during pregnancy.
Comment: This report is in keeping with the European data from the same time period, as well as with more recent Canadian data, suggesting that a segment of pregnant people with COVID-19 are more at risk for severe outcomes when compared with their non-pregnant counterparts. In contrast to European and Canadian reporting, the Centers for Disease Control and Prevention reports provide the first evidence of racial differences in pregnancy outcomes affected by COVID-19. The dataset is imperfect because data on race and ethnicity were absent for 20% of pregnant people in the report. Nonetheless, the data provide us with important reminders regarding race and the impact the pandemic may have on at-risk populations. Having similar data for Canadian pregnant people will be important for this and future pandemics in predicting our own groups at risk and potentially mitigating medical and social risk factors to reduce adverse outcomes.
Yusuf KK, Dongarwar D, Ibrahimi S, et al. Expected surge in maternal mortality and severe morbidity among African-Americans in the era of COVID-19 pandemic. Int J MCH AIDS 2020;9:386–9.
Summary: Yusuf et al. describe a theoretical framework exploring how severe maternal morbidity and maternal mortality could surge because of the COVID-19 pandemic. The scientific literature has established that, in the United States, Black people are affected disproportionately by COVID-19, have higher rates of chronic conditions that predispose them to COVID-19 (e.g., obesity, diabetes, and hypertension), and, pre-pandemic, had higher odds of pregnancy-related mortality compared with White Americans. The authors hypothesize that COVID-19 will likely exacerbate disparities in pregnancy outcomes and severe morbidity.
Using a methodology called rapid mini-review, in keeping with the phenomenal pace with which pregnancy and COVID-19 data are emerging, the authors reviewed six studies that focused on determinants of maternal morbidity and mortality likely to affect Black American pregnant people disproportionately. “Proximal” determinants included factors that directly affect outcome, such as financial limitations (in the United States, this would include access to health insurance), reduced and/or underutilized access to pregnancy care, and the presence of chronic medical conditions such as pre-pregnancy obesity and diabetes mellitus. “Distal” determinants included entities such as heightened unemployment rates, fear of contracting the virus, difficulties with travel and transportation, and isolation restrictions.
A theoretical framework based on proximal and distal determinants of health was constructed, showing the extensive intersectionality of these determinants. For example, public health decrees for people to stay at home may relate to rising obesity rates in all populations, including pregnant people. Fear and reduced access to public transport could have a negative impact on pregnancy care because comparatively more Black American households do not own a vehicle.
Comment: Although we must be cautious in interpreting U.S. data in the Canadian context, this study provides many examples of the intersections of social determinants of health. Parallels in our country could include similar increased rates of chronic conditions in people of Black, South Asian, and other racial groups. Another example could include the challenges faced by those people inhabiting rural and remote areas, as well as many Indigenous communities. Although our universal health coverage eliminates the insurance question for most citizens, financial resources and access to care remain significant barriers. The social determinants of health exacerbated by the effects of the COVID-19 pandemic could lead to a theoretical state in which those most at risk for adverse pregnancy outcomes will experience even more severe rates of adverse outcomes. The authors conclude that advocacy for policy change will hold answers to these challenges. In the Canadian context, such advocacy will mean better access to care both for pregnancy visits and for primary care before, during, and after pregnancy to manage chronic conditions; support for travel to and from distant communities, ideally allowing for provision of care closer to patients and families; leveraging community and social resources to promote good health behaviours before pregnancy; and culturally safe racial data collection to inform health interventions and monitor progress.
Malhamé I, D'Souza R, Cheng MP. The moral imperative to include pregnant women in clinical trials of interventions for COVID-19. Ann Intern Med 2020;173:836-7.
Summary: Malhamé et al. review the published research on COVID-19 and pregnancy outcomes based on data available as of the spring and summer of 2020. They note that data reported at that time, which are consistent with current date in late 2020, suggest that most pregnant people have the mild form of COVID-19.However, for the subset of symptomatic patients who develop the severe form of this disease, the maternal outcomes are striking in terms of need for intensive care and potential for maternal mortality. Although the Institute of Medicine and Tri-Council Policy Statement on the Ethical Conduct of Research Involving Humans both support the inclusion of pregnant people in clinical studies, this has not occurred consistently with research related to COVID-19. Without this inclusion, pregnant people potentially face delay in treatment with medication, inappropriate dosing, or possibly unanticipated fetal or maternal toxicity. The authors offer suggestions for consideration of the participation of pregnant individuals in studies, such as inclusion at phase 3 of clinical trials.
Comment: Malhamé et al. provide thoughtful commentary on the challenges faced by providers and pregnant people when making medical decisions in the absence of adequate data. This has come into sharp focus during the COVID-19 pandemic, especially with the introduction of the COVID-19 vaccine in Canada more recently. Controversy and confusion over the safety of providing this vaccine to pregnant people prompted many professional organizations to issue advisory statements, including the Society of Obstetricians and Gynaecologists of Canada. Central to this confusion is the lack of pregnancy vaccine safety data to guide us as providers and for our patients and families. As the authors recount, the best protection for pregnant people may be “through research” rather than protecting these individuals “from research.”