On Thursday morning, Jesse Robertson was admitted to a hospital in Denver, Colorado.
She was 38 weeks pregnant with twins, and the time had come to induce labor. “Thankfully, I’ve been off work for the last couple of weeks and just basically kind of put myself on not really official bedrest, but just trying to keep these little ones quiet,” she said before heading into delivery. “Keep them in there as long as possible.”
As the new coronavirus spreads across the country, the Centers for Disease Control and Prevention has put out “interim considerations” for preventing infection in inpatient obstetric settings, like the maternity ward Robertson checked into. Yet little is known about how the virus impacts pregnancy.
Meanwhile, the Trump administration’s hostility to reproductive rights and health care has weakened the family-planning safety net. Policies ostensibly enacted to ward off government funding for abortion have stretched thin budgets and led to staffing shortages across the system. Now, providers and experts are concerned that the added strain of the coronavirus outbreak could leave uninsured and marginalized people of reproductive age without ready access to basic health care.
Despite the heightened anxiety around spread of the virus, Robertson, who is a doctor and holds a master’s in public health, has kept her cool. “It’s just like the Brits say: Keep calm, carry on.”
In the Face of Uncertainty
During a CDC webinar for health care providers on March 12, Dr. Romeo Galang, part of the agency’s virus response team, reiterated that there is only limited information about how Covid-19 interacts with pregnancy. “What we know today about Covid-19 and pregnancy is based upon very few case reports and case series … from China,” he said. “The challenge with these reports is that reporting on maternal, perinatal, and neonatal outcomes have been inconsistent and details have varied.”
One case study, published by The Lancet in February, revealed no signs of “vertical transmission” of the infection — that it had spread from mother to child — though the study was limited to just nine pregnant women who had tested positive for the virus. A second report, also published in The Lancet, noted that two neonatal cases of the virus had been confirmed in China, but there was no indication that they were the result of transmission via umbilical cord blood, for example, or breastmilk.
The second report suggested that the new coronavirus — officially, SARS-CoV-2 — has some similarity to the previous SARS outbreak. Studies of that virus revealed a connection between infection and a higher risk of complications during pregnancy, including spontaneous miscarriage, preterm delivery, and intrauterine growth constriction. “However, pregnant women with Covid-19 infection in the present study had fewer adverse maternal and neonatal complications and outcomes than would be anticipated” based on SARS.
In all, Galang said, reports from China have included at least 34 pregnant women affected by the virus, with illness onset in a range of 13 days before delivery to three days after delivery. Almost all of the women delivered by cesarean section, some prompted by the illness and some due to other factors. Two were put in intensive care; of those, one woman delivered a healthy baby and the other delivered a stillborn. None of the mothers have died. There is no data on Covid-19 infection and early pregnancy, Galang said.
“The main take-home messages for me are that, No. 1, we just don’t know a whole lot yet,” said Dr. Michael Policar, professor emeritus of obstetrics, gynecology, and reproductive sciences at the University of California San Francisco School of Medicine, where he was a practicing OB-GYN for nearly 40 years. “There really hasn’t been anything published in the United States.”
But, he says, what he’s seen and heard so far suggests that Covid-19 “looks a lot like what happens during pregnancy with other kinds of flu virus infections.” That means that it “has a tendency to play out as a condition with significantly more symptoms” in pregnant women. “And that would be completely expected given the fact that any woman who’s pregnant already has some amount of immune compromise so that she doesn’t reject her own fetus.”
Policar agrees that there is nothing yet to suggest that the infection can be transferred from mother to child. But he says there are still things to watch out for, including a high fever, particularly in the first trimester, “during the time that the organ systems are developing in the embryo and then the fetus,” which can increase the likelihood of certain birth defects. “It’s way too early to know whether or not that’s going to be the case with coronavirus.”
Of greatest concern are women with high-risk pregnancies because of underlying health issues, as well as pregnant medical practitioners who may be on the front lines of the epidemic.
Of greatest concern are women with high-risk pregnancies because of underlying health issues, as well as pregnant medical practitioners who may be on the front lines of the epidemic. “Facilities may want to at least consider limiting exposure of pregnant health care personnel from patient care of those who have confirmed Covid-19 infections,” Galang said during the CDC webinar. “This is all, of course, if it is feasible and based on staffing availability.”
Dr. Denise Jamieson, chair of the department of gynecology and obstetrics at Emory University School of Medicine, who was also part of the CDC webinar, said that given the “paucity of data” about Covid-19, “pregnant women should be considered an at-risk population for strategies focused on prevention and management.”
“We know that pregnant women are a population who may be at increased risk of susceptibility to infection, severe illness, and mortality associated with other respiratory infections. This is because of the physiologic changes that take place during pregnancy, including increased heart rate and oxygen consumption, decreased lung capacity, and a shift away from cell-mediated immunity,” she said. “These changes may increase the risk of more severe disease in pregnant women compared with nonpregnant adults.”
The American College of Obstetricians and Gynecologists and the Society of Maternal-Fetal Medicine have developed an algorithm to help providers assess pregnant patients. It’s a colorful flow chart that guides clinicians through various questions to determine a patient’s health and risk potential. Does she have a fever? Is she short of breath? Does she have diabetes, hypertension, or HIV? And it comes with a warning printed in red: “Please be advised that Covid-19 is a rapidly evolving situation and this guidance may become out of date as new information on Covid-19 in pregnant women becomes available.”
Overburdened, Under the Gun
The coronavirus outbreak also has broader implications for the family-planning provider network and the low-income, uninsured or underinsured, and marginalized populations it serves.
“For women generally, many of them see their OB-GYN more often than they see a primary care doctor or view their OB-GYN as their primary care doctor. And that is certainly true with women who go to publicly funded family-planning clinics as well,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, which last week published a piece analyzing the possible fallout from Covid-19 on sexual and reproductive health. “It’s often their main entryway into the health care system; it’s often their primary source of care or their only source of care in a given year.” In addition to gynecological services and contraceptives, family-planning providers screen patients for a wide variety of issues. “And, you know, that’s clearly going to be a stepped-up role in a crisis like this,” Sonfield said.
Yet the network of clinics that does this work has come under increasing attack in recent years as conservative lawmakers have taken aim at the nation’s largest family-planning provider, Planned Parenthood. Take, for example, the so-called domestic gag rule that the Trump administration enacted last year, which, among other things, forbids any clinic receiving Title X funding — the nation’s only funding stream dedicated to basic reproductive health care — from referring patients to abortion providers.
While the restriction was aimed at Planned Parenthood, it has likely led to 981 clinics dropping out of the program. Those providers saw roughly half of the nearly 4 million people who rely on Title X for basic health care, Sonfield said. The rule has left six states without a single Title X provider. “Combine that with the added, intense strains of the Covid-19 epidemic, and it could be extremely harmful for millions of people who rely on that network for care,” he said.
During a lecture last week at the National Family Planning and Reproductive Health Association annual conference, Policar said the best way to mitigate any service-delivery issues would be to rely on telemedicine when possible and increase “phone triage” of patients before scheduled visits to determine potential risk factors. All elective services, like routine annual checkups, should be postponed when possible.
“This administration has pulled every lever within its control to undermine and weaken our nation’s health insurance infrastructure.”
The Trump administration’s war on the nation’s health care system is vast and ongoing. Among other insults, it supports dismantling the Affordable Care Act; has finalized work requirements for Medicaid that threaten to dump countless people from the rolls; and has continued to champion deep cuts proposed to the CDC budget amid the coronavirus outbreak.
“For the past few years, this administration has pulled every lever within its control to undermine and weaken our nation’s health insurance infrastructure, specifically targeting people who already face systematic barriers to care, including immigrants, people of color, young people, those with low incomes, and LGBTQ+ people,” Zara Ahmed, a senior policy manager at Guttmacher, told Bustle. “Now, the cumulative effect of years of attacks will heighten the challenges of combating an epidemic for communities that are already marginalized.”
Policar notes that access to reproductive health care will remain critical amid the viral outbreak, particularly if providers themselves become infected and further reduce the number of clinicians available to see patients. Individuals who need routine prenatal care or contraceptives to control underlying health issues, or who are trying to prevent unintended pregnancy, have serious and ongoing needs to be met. “Unintended pregnancy is both a huge personal issue, as well as a public health issue,” he said. Nearly half of all U.S. pregnancies are unintended. “From the point of view of the patient who is motivated to prevent unintended pregnancy, every time there’s a barrier in front of her being able to get the services she needs, that’s a problem,” he said.
Robertson said she understands that for many, accessing appropriate health care in the best of times can be difficult. Even with an excellent health insurance plan, getting the reproductive health care she’s needed hasn’t been easy. “I could go off on a tangent,” she said.
But she said that working in a hospital helped to frame her thinking as she prepared for delivery: Maintain good hygiene; limit the number of surfaces you touch and don’t touch your face; manage the number of people you come into contact with. In other words, deal squarely with the things you can control. “I think being an advocate and working in health care and knowing what should be going on, I’m definitely going to be like, ‘Hey, no offense, just want to make sure you washed your hands,’” she said.
And she has a plan to maintain those protocols once the babies are home. “It’s been such a waiting game and I have a herd of people who are so excited, but at the same time, it’s probably better that I’m like, ‘Oh, sorry guys! We’re just going to hole up and, you know, I’ll text you pictures.’”