a Authors contributed equally.
* Correspondence to: Hongbo Qi (Address: Department of
Obstetrics, The First Affiliated Hospital of Chongqing Medical
University, No. 1 Youyi Road, Yuzhong District, Chongqing 400016, China.
E-mail: qihongbocy@gmail.com. Telephone: +86 13808376116); Xin Luo
(Address: Department of Obstetrics, The First Affiliated Hospital of
Chongqing Medical University, No. 1 Youyi Road, Yuzhong District,
Chongqing 400016, China. E-mail: lxcqmu@outlook.com. Telephone: +86
15826109160)
Running title: Appropriate Prenatal Care During COVID-19 and
PHEs
Key words: SARS-CoV-2; COVID-19; prenatal care; public health
emergencies
In late December 2019, an outbreak of a coronavirus disease, later
termed COVID-19, emerged in China.1 Till March 31,
2020, this disease has affected over 690,000 people worldwide and caused
more than 33,000 deaths.2 WHO authorities alarmed an
“very high level” of public health emergency of international concern
(PHEIC).3
Pregnant women are vulnerable to this respiratory epidemic, because of
their immunosuppressive state, and physiological adaptive changes (e.g.,
diaphragm elevation, increased oxygen consumption, and oedema of
respiratory tract mucosa), which could cause hypoxia
intolerance.4 As new evidences came to light, and
based on lessons learnt from other similar diseases (SARS and MERS),
China’s National Health Commission issued a notice on February 8. This
announcement claimed that pregnant women and new-borns should be
regarded as a susceptible population to COVID-19, and called for the
prevention and management strategies for them.5
At
present, the limited reports on pregnant women mostly focus on their
risks of infection, clinical characteristics, and the management of
suspected infection.4,6,7 To the best of our
knowledge, there are approximately more than 100 pregnant women with
confirmed COVID-19 nationwide.
In
consideration of the fact that the annual number of births in China was
much considerable, 14.65 million (2019) and 15.23 million
(2018),8we
can modestly infer that the majority of pregnant women were not infected
but affected. It also alarms us of the rationality of attention-shift to
the regular care of pregnant women during this particular period. During
this epidemic and other potential PHE henceforth, improving prenatal
care to prevent evitable adverse pregnancy outcomes and to improve the
quality of births became paramount.9
The impact of COVID-19 on prenatal status raised many obstetrical
concerns. In response to the outbreak, all provinces in mainland China
with confirmed cases of COVID-19 have adopted the first-level PHE
responses since January 29, 2020.10 These measures
include travel restrictions and executive orders on daily life. However,
the restriction had its dual effects. Since the epidemic was gradually
under control, the negative effects on psychological and physical
aspects started to appear, especially for pregnant mothers, who are
scheduled to make prenatal visits with obstetrical guidance.
Mental health is of great concern. Anxiety has been documented as a
common psychological problem during pregnancy.11Influenced by both accurate and erroneous news, pregnant mothers are
suffering an excessive level of prenatal anxiety from carrying baby,
epidemical threat, and strict restrictions. According to our preliminary
data, the rate of prenatal anxiety during earlier period (from February
3rd to 9th) was elevated to about
25% in the central area of this epidemic (Wuhan). The influence factors
of this anxiety during this time was different from those in the non-PHE
situation. Notably, prenatal anxiety was also demonstrated to alert
long-term outcomes, such as postpartum depression.12
Crucially, physical health was inevitably affected. Firstly, home
confinement reduced routine physical activities. IFG (impaired fasting
glucose) and IGT (impaired glucose tolerance) due to undue weight gain
have already been observed in clinical practice, which is of great
concern to the obstetricians. Besides, the emergency traffic bans have
made some medical resources inaccessible, and anxiety may deter women
from attending routine prenatal care.13 Overall, the
scheduled prenatal check and hospitalized delivery of pregnant women
were postponed or cancelled. In our recent study, many pregnant women
reported that they would rather miss vital check-ups than go to a
hospital within one month. Although we have anticipated this phenomenon,
the actual situation is still far beyond our cognition. In our
hospitals, for example, about 6859 outpatient visits were completed to
the First Affiliated Hospital of Chongqing Medical University is count
in February 2020 (Figure 1), while in last February, it was 16120. This
figure change in outpatient visits of pregnant mothers to Maternal and
Child Health Hospital of Hubei Province was more unreasonable (Figure
2), and it was 5410 and 27254 during this and last February.
Even
if they came for the prenatal visit, exaggerated self-considered
”protective measures” were commonly taken (Figure 3 and 4). The short-
and long-term impacts of lack of prenatal care are of great
concern.9
According to the Development Report on Chinese Maternal and Child
Health (2019) ,14 in the past two decades, the rate of
accessing prenatal care in China has steadily increased: overall, from
83.7% in 1996 to 96.6% in 2018; as for rural areas, from 80.6% to
95.8%. Such improvement in prenatal care is closely related to the
policy-making of the authorities and the prominent efforts from national
obstetricians. The corresponding author, Professor Qi, has participant
in the draft of Guideline of Preconception and Prenatal Care
(2018) .15 Referring to the guidelines from the US,
the UK, Canada, and WHO, the 2018 version of the guideline was under the
basis of the Guideline of Preconception and Prenatal Care
(2011) ,16 followed relevant Chinese laws and
policies, and considered the requirements for Health Economics in China.
The contents of this guideline include: health education and guidance,
routine health care, and auxiliary examination items (including required
items and optional items). Over the past few years, Chinese
obstetricians have been working on the nationwide promotion of this
guideline and calling for standardized prenatal care to reduce adverse
pregnancy outcomes. However, on this unpredictable period of COVID-19
outbreak, an appropriate update of recommendations is needed urgently.
To standardize the management during the outbreak of COVID-19, the
National Health Commission has already published seven versions of
guidelines for diagnosis and treatment, and many institutions have also
formulated their own management manuals. Under this context, our group
has put forward a contingency plan for the management COVID-19 outbreak
in NICUs.17 However, as for pregnant women, there is
still a lack of evidence-based advice or strategies for prenatal care.
There are many undetermined problems for prenatal care during this
period. Above all, the indications and strategies for the screening of
SARS-CoV-2 among pregnant women varied in different institutions. For
instance, in the epicentre, some hospitals perform a routine workup for
all pregnant women waiting for delivery, including chest CT scan and
virus detection test for SARS-CoV-2 (e.g., nucleic acid test from
nasopharyngeal and oropharyngeal swab, antigen and antibody detection
test). These sequacious screenings squandered medical resources and
potentially aggravated the anxiety of pregnant women.
Moreover,
consequences
of restrictions and lack of activities on prenatal health (e.g., GDM,
macrosomia, excessive amniotic fluid, shoulder dystocia, and the
increased CS rate) deserve attention. Additionally, the schedule changes
of prenatal care caused by various reasons, and following potential
adverse pregnancy outcomes, invoke immediate action. Last but not least,
under this inconvenient situation, how to perform prenatal care and to
relieve the workload of medical staff, is hotly discussed.
Here, we call for an appropriate contingency plan for prenatal care
during the PHE to minimize the potential risk of adverse maternal and
foetal outcomes.
The following recommendations we put forward were based on the existing
experience: