For over the last year and a half, the pandemic has caused many delays and back ups in our life—delays in weddings, family reunions, or class semesters. But one particular area of delay has caused massive ramifications and that is the delay in medical care, routine or otherwise. This back up in care has had significant costs for many people. Those delayed or canceled routine appointments were possible chances for finding the early signs of cancer or heart disease. But once missed, resulted in later detection and a quicker, earlier death. All of these deaths indirectly caused by COVID has its own terminology—excess mortality, the total number of deaths in a crisis compared to those expected under normal conditions. According to the World Health Organization, 1.8 million COVID deaths worldwide were reported in 2020 but there have been at least 3 million in excess mortality. And as the death toll rises, there is one vulnerable population that has become only more vulnerable as the pandemic rages onward—mothers and children. The number of stillbirths jumped in 2020 and continues to grow along with the rate of maternal deaths. Some countries are even seeing a spike in child deaths. Are these numbers part of the excess mortality count or is COVID mutating into something much more terrifying and dangerous?
In August of 2020, The Lancet published the largest study to report a rise in the stillbirth rate. The study was based on data from more than 20,000 women who gave birth in nine hospitals across Nepal. It was reported that stillbirths increased from 14 per 1,000 births before the country went into lockdown to prevent the spread of the coronavirus in March 2020, to 21 per 1,000 births by the end of May 2020. This was a 50% increase with the sharpest rise observed during the first four weeks of lockdown, when people were only allowed to leave their homes to buy food and receive essential care.
And these upticks in stillbirths can be seen across the globe, all beginning when countries began enacting lockdown measures. In London at St. George’s Hospital, the stillbirth rate went from 2.38 per 1,000 to 9.31 per 1,000. Scotland and Ireland have also detected an uptick in the rate of stillbirths during the months of the pandemic as well. A study of four hospitals in India also reported a jump in the stillbirth rate during the country’s lockdown period.
Most of these stillbirths were not caused by COVID infections but rather, by the result of how the pandemic affected access to routine prenatal care which otherwise might’ve picked up on complications that can lead to stillbirths. During the early days of lockdowns, when many officials were still trying to figure out how exactly this novel virus worked, many pregnant people found their appointments delayed or even cancelled to prevent exposure. But those who still had delayed appointments to meet found themselves facing difficulty in finding safe public transport during a pandemic. And many others avoided hospitals altogether out of fear of infection.
Healthcare providers tried to adjust with the restrictions of lockdown and offered online or phone appointments to expecting patients but it is impossible to take a patient’s blood pressure or listen to the baby’s heartbeat or do an ultrasound over the phone. And because of this, high risk pregnancies might’ve flown under the radar, particularly amongst first time mothers who are less likely to know what an abnormality feels like. For instance, St. George’s Hospital reported a drop in the number of pregnant women presenting with high blood pressure during the UK lockdown, despite not having a drop in patient count. Hypertension is a risk factor for stillbirths. This suggests that women with hypertension weren’t being managed as they normally would or going completely undetected due to less or restricted appointments. These undetected complications and the unfortunate consequences of stillbirths are part of COVID excess mortality.
But nowhere in particular shows the dangerous impact of COVID on pregnant women and babies better than Brazil. While most stillbirth counts during this pandemic have been counted as excess mortality, Brazil is one of the few places where they are also experiencing fetal death due directly to COVID.
Amongst pregnant women who had been infected by COVID, studies found that most reported mild forms of the disease. There are few reports of miscarriages or fetal deaths related to COVID during pregnancy. Only one previous publication reported placental histology and COVID results found in the stillborn fetus. But in Brazil, a report was published on five cases of fetal death in women with COVID over a two month period. These women had no other pre-existing conditions and COVID was detected in the amniotic fluid in one case and placental specimens in two others. All five cases had intense placental inflammation. This report raised the alarming possibility of direct effect of COVID on the placenta. This has also highlighted just how little we still know about the direct dangers COVID poses on pregnancy. Early on in the pandemic, evidence suggested that pregnancy posed no greater risk in terms of catching COVID or suffering worse symptoms than the general public. But by June 2020, the US Center for Disease Control added pregnancy to the list of health conditions that make COVID patients more likely to be hospitalized and admitted to the intensive care unit.
And Brazil seems to be following suit in recognizing how vulnerable pregnant people are during this pandemic. Brazil is currently reporting 13 million confirmed cases and nearly 400,000 deaths. They are also the place the P.1 variant—a more deadly and easily transmissible strain—was discovered. Hospitals in Brazil are attributing a higher number of pregnant and postpartum deaths to this variant. The numbers have been getting so severe that in April 2021, the Brazilian government took the unusual step of asking women to avoid getting pregnant.
Unfortunately Brazil is all too familiar with a pandemic, especially one that seems to target pregnancy. Brazil was the epicenter to the Zika virus pandemic in 2016. And what many Brazilians learned during the Zika pandemic was just how much of a perfect setting Brazil was for a pandemic to take hold. Brazil has historically lacked proper access for medical care and outreach for decades now. From a combination of political instability to economic recession to poorly managed austerity policies, Brazil’s health care system has been crumbling every year. And no one feels it more than the poor, especially poor Black women. Data shows that on average, 58% of poor Black women were unable to find necessary health services of any kind during the pandemic, compared to 23% of wealthier White Brazilian women who experienced a similar neglect. This kind of poor medical coverage means a higher count of excess mortality, more deaths that could’ve been avoided had adequate care been available. We can see this in the unusual and unfortunate high number of child deaths reported in Brazil. Since the start of the pandemic, Brazil’s health ministry reported that 832 children aged five and under have died of the virus. Comparably in the United States which has a far larger population than Brazil and a higher overall death toll from COVID, 139 children aged four and under have died. And many Brazilian officials feel the number is substantially higher as there is a lack of widespread testing and counting. Experts are concluding that many Brazilian kids aren’t directed towards and provided serious medical care until their symptoms become life threatening. Instead of coming in when they have a cough, they are coming in when they need a ventilator.
But this lack of medical care also means a lack of testing and that means more infections are happening, allowing for more opportunities for mutations, like the P.1 variant. Many experts are saying that the P.1 variant appears to be leading to higher death rates among pregnant people. Some women with COVID are giving birth to stillborn or premature babies already infected with the virus. Dr. Andre Ricardo Freitas, an epidemiologist at Sao Leopoldo Mandic College in Campinas, reported, “We can already affirm that the P.1 variant is much more severe in pregnant women. And oftentimes, if the pregnant woman has the virus, the baby might not survive or they might both die.” Brazil is suffering from both excess mortality and an excessive COVID mortality.
While in many parts of the world, the pandemic seems to be waning and on its way out, especially with vaccine roll outs, it is important to remember that until the poorest, slowest country is vaccinated, no one is truly safe. The Delta variant which has been wreaking havoc across Europe and Asia is now becoming the most dominant strain in the U.S. The P.1 variant could also begin making its way up north as well. The best form of protection for yourself, pregnant or otherwise, is to get vaccinated. The US CDC, along with many other countries, has approved the COVID vaccines for pregnant people. The quicker we can protect ourselves, the better we can protect our neighbors, and the faster we can truly end this pandemic.