India’s demographic dividend is largely dependent on its high birth rate. The number of births in India is ~ 72,000 per day; taking into account the 10 month duration of gestation and pregnancy losses, the number of pregnant women on any single day will be much larger. Currently, the number of new cases of COVID-19 per day and the number of daily COVID-19 deaths in India are among the highest in the world. Maternity services in India, both public and private, already overburdened with large numbers even in pre-COVID-19 times, face a crisis situation with the conditions caused by the pandemic.
A danger
Recent reports from Kerala ( The Hindu , May 14, 2021) on pregnant mothers, have uncovered many serious medical problems faced by pregnant women who contract COVID-19 and their new-born — pre-eclampsia, pre-term labour maternal infections, increased caesarean section rates, fetal growth restriction due to placental insufficiency, still births, neonatal infections and respiratory distress. According to a recent publication in the Journal of the American Medical Association , maternal mortality is several-fold higher in COVID-19 positive pregnant mothers than in non-COVID-19 pregnant women. Many pregnant women need admission to the intensive care unit and prolonged hospitalisation. Of all the COVID-19 deaths in the paediatric age-group, neonatal deaths are the most common.
All maternal and neonatal complications increase with maternal obesity and diabetes in pregnancy — problems that are common in pregnant women in India. These facts underscore the need for urgent action to minimise the impact of the coronavirus infection on pregnant mothers and new-born.
There is an urgent need for action from professional bodies to avert a serious calamity; the Government, in consultation with these bodies, should immediately facilitate counselling and care for women in the reproductive age group and provide resources to health-care professionals involved in their care.
Quite early during the course of the COVID-19 pandemic, we cautioned about the potential adverse effects of COVID-19 in pregnancy and urged pre-conceptional advice for women planning a pregnancy during COVID-19 times — a simple precaution that could have averted serious problems for large numbers of women in the reproductive age group.
Steps to be taken
With the massive increase in numbers of COVID-19 infections with the second wave of the novel coronavirus pandemic in India, and its effect on pregnant mothers, this important matter should be taken up on a war footing, alerting women in the reproductive age group and the medical profession.
Two important steps must be considered immediately: Advise all women to postpone pregnancy till both partners are vaccinated; Offer vaccination to all un-vaccinated pregnant women
Temporary and reversible contraception during COVID-19 times is a simple and effective way to postpone pregnancies and thereby decrease the number of women who would otherwise seek antenatal advice in crowded hospitals and risk exposure to infection. The demands on health-care personnel who provide antenatal care would decrease; they can be redeployed for COVID-19 care and the vaccination programme, public health measures that make huge demands on health-care professionals.
Reduction in the number of antenatal visits, online consultations, protocols for ultrasonography, glucose tolerance test and antepartum fetal evaluation have been introduced by many institutions. This must be followed by all caregivers.
Ultrasound scans are routinely done during pregnancy. Dedicated and safe ultrasound scan centres for pregnant women, manned exclusively by immunised personnel (either vaccinated or after recovery from previous COVID-19 infection) is a need of the hour.
Pregnant women with fever should be considered to have COVID-19 unless proven otherwise and be taken care of in triage areas with all personal protective measures in place till COVID-19 test results are available.
At present, COVID-19 and non-COVID-19 pregnant women coming for delivery are not strictly segregated in many hospitals, it is high time that COVID-19 pregnancies and non-COVID-19 pregnancies are handled in different settings to prevent infecting susceptible mothers. Both types of facilities should be manned by immunised personnel, the first to prevent infections in health-care personnel and the second to prevent infections in susceptible mothers. Unvaccinated health-care workers providing care for pregnant women should be quickly vaccinated.
Clear benefits of vaccination
The health authorities in the United Kingdom and the United States have realised the benefits and the safety of vaccinating pregnant women and have approved vaccination of all pregnant women with mRNA vaccines (https://bit.ly/3xYZIxX). These COVID-19 vaccines have been found to produce a good immune response and, maternal antibodies, demonstrated to cross the placenta and enter the fetus, confer protection against maternal to fetal transmission of the virus. The benefits of vaccination far outweigh the risks.
Pregnancy and the immediate postpartum period are pro-thrombotic states — they favour the formation of blood clots in veins. Of the two vaccines readily available in India, the vectored vaccine (Covishield) was found to be associated with rare but serious side-effects pertaining to thrombosis of the veins draining critical areas such as the brain and intra-abdominal organs, a feature shared by the single dose (Janssen) vaccine; indeed, this side-effect may be a feature of all vectored vaccines against COVID-19. In general, inactivated virus vaccines are safe during pregnancy and the World Health Organization has given a nod to the use of the inactivated Synovac vaccine . Therefore, the inactivated vaccine available in India (Covaxin) may have advantages over the vectored vaccines (Covishield and Sputnik) for vaccinating pregnant women.
The availability and advantages of the vaccine for pregnant women should be publicised and awareness should be created among the public. Vaccine hesitancy in pregnant women is likely to be much higher than in the general population — this should be addressed by information, education and effective communication. Professional bodies recommended to the Ministry of Health and Family Welfare that vaccination be offered to pregnant women after providing adequate information and counselling — and the Indian Council of Medical Research and the Ministry of Health have approved this, welcome steps in the right direction.
India will do well to enhance vaccination coverage of couples planning pregnancy and pregnant women on a priority basis in order to protect mothers and their new-born.
Lakshmi Seshadri, a former Professor of Obstetrics and Gynaecology, Christian Medical College (CMC), Vellore, is currently Senior Consultant Gynaecologist, Thirumalai Mission Hospital, Ranipet, Tamil Nadu. M.S. Seshadri, a former Professor of Clinical Endocrinology, CMC, Vellore, is currently Medical Director, Thirumalai Mission Hospital, Ranipet
