Review of Related Literature

In accordance with this article it is indicated that pregnant women are more susceptible
to respiratory illnesses than most individuals, making them more susceptible to the coronavirus
and putting them at risk of COVID-19. There are numerous studies suggesting that the
indication of intrauterine vertical transmission is not proven. Nonetheless, delivering with
COVID-19 might increase the likelihood of other difficulties like any respiratory complications,
not excluding premature babies. In addition, seclusion and quarantine measures were
implemented worldwide in precautionary with regard to COVID-19, and all obstacles inherent in
pregnancy in complex conditions, making pregnant women vulnerable to post-traumatic stress
disorder. As a result, there should be more understanding of this population group as a target
for psychological support, as well as prompt and consistent psychosocial intervention. To have
better and more tailored access to the targeted demographic, communication campaigns should
leverage local officials and any community-based prevention media. Because of the virus's
novelty and the many unknowns surrounding COVID-19, there should be conspicuous
campaigns to educate and reassure the public about the security of health centers for pregnant
women during the pandemic. Women who have already had great experiences and outcomes
could be included in these efforts(H. Liu, 2020).

According to the United Nations Population Fund’s (UNFPA) report on major epidemics
the vast majority of infected persons, including pregnant women, are asymptomatic. To ensure
effective follow-up and protection, all pregnant women should be tested on a regular basis as
part of their antenatal care. Ensure that pregnant women with suspected, probable, or confirmed
COVID-19 have access to women-centered, respectful skilled care, including obstetric maternal
screening tests, fetal medicine, and neonatal care, as well as mental health and psychosocial
support with readiness to care for maternal and neonatal complications. All maternity units must
prepare dedicated areas for pregnant women with COVID-19 to give birth in.To ensure that
antenatal and postnatal care services continue, regardless of the extent or severity of the
pandemic, dedicated antenatal and postnatal care facilities/mobile clinics, including remote
consultations and follow-ups, can be established and adequately staffed. It is critical to develop
clear clinical guidelines on how to care for pregnant women with COVID-19. Such guidelines
should be available to and taught on by healthcare staff, including midwives. Annex 1 is a
detailed protocol prepared by French doctors for the management of suspected and proven
cases of COVID-19 in pregnant women. No evidence of the virus has been identified in the
breast milk of women with COVID-19. As a result, a breastfeeding mother should not be
separated from her child, but she should take precautions, such as wearing a mask when
feeding (UNFPA, 2020)

According to the study, Maternal and Newborn care with Government directives and
hospital policies limit the number of family members accompanying expecting women to
hospitals to prevent contagion. There is also a separation of COVID-19-positive women from
their newborns, instead of room-in as usual for these mothers and newborns. Though the
separation may minimize the risk of SARs-CoV-2 transmission from mother to infant during the
hospital stay, this precaution may do more harm than good. Evidence shows that separation
disrupts skin-to-skin care and breastfeeding and is associated with added physiologic stress to
both the mother and infant. Moreover, neonates born to COVID-19-positive mothers have to be
isolated from other babies to stop the spread of COVID-19 in newborn nurseries. This requires
extra healthcare providers to care for isolated mothers and newborns, which places increased
pressure on an already burdened health system. Though the Kenyan government has pledged
to hire new healthcare workers, the goal of this new workforce is to fill human resource gaps in
the COVID-19 pandemic, and it remains unclear how this would impact MCH services (Kimani
et. al, 2020).

In these extraordinary times, there is a benefit from avoiding sources of infection and
limiting health facility use to those who need it; therefore, it is of great importance to re-evaluate
whether it is appropriate for all women to give birth in health facilities Further, low- and middle-
income countries (LMICs) are encouraged to initiate public health innovations that are culturally
acceptable. Research shows that risk perception influences where women give birth. Given the
complexities posed by COVID-19, it is prudent to consider alternatives to existing delivery
options for women. This article proposes a strategic response to maternal and newborn care in
Kenya in the context of COVID-19. We recommend expanding and strengthening the existing
community midwifery model (CMM), integrating community health workers (CHWs) and informal
community networks, and creating midwifery centers run by qualified midwives that are closer to
communities. We consider these strategies to offer a viable long-term plan that will reduce the
burden on hospitals and decrease COVID-19 infection rates among pregnant women and their
newborns. (Kimani et. al, 2020)

The COVID-19 pandemic required the postponement of many non “essential” health
services to prevent transmission within clinics, which led to significant reductions in the
obtention of antenatal and postnatal care. In the US, an online survey of 4451 pregnant women
found nearly a third reported elevated levels of stress, with alterations to prenatal appointments
cited as a major reason for this elevation. A modeling study on the indirect effects of the
pandemic in 118 LMICs estimated a reduction in antenatal care by at least 18%, and possibly
up to 51.9%, and a similar reduction in postnatal care. (Kotlar et. al, 2021)

This estimate was supported by countries’ changes in perinatal care guidelines. A

consultant Obstetrician and Gynecologist at the Lagos University Teaching Hospital stated that
those in early pregnancy were urged to come in once in eight weeks rather than once in four,
and the number of antenatal care visits decreased from 10 to 15 to an average of 6. Women
also chose to forego visits due to lack of transportation, familial pressure to isolate, and
personal fears of the virus. Maternal health workers, such as midwives in Kenya, Uganda, and
Tanzania, reported low numbers attending maternal health clinics, and more women came into
hospitals late, without sufficient antenatal care. A survey by the Population Council sampling
heads of households across five Nairobi urban slums found that 9% of participants forewent
health services such as antenatal care and immunization/nutrition services for children. Further,
a rapid gender analysis by CARE West Africa found consistent reports of false rumors about the
virus and a general mistrust of health workers, leading to some men, especially in rural areas,
forbidding their wives from seeking health services. In Mali, most female respondents said they
were not accessing health services, out of fear of the virus and confusion about which services
were still being offered. A global, cross-sectional study of maternal and newborn health
professionals by Semaan et al. found a significant reduction in antenatal care services utilized
as clinics reduced hours, the number of visitors permitted, and in-person visits during
pregnancy. In some areas of the UK, women were provided with blood pressure machines and
urinalysis sticks to conduct their own antenatal checks. Some antenatal care was offered via
telemedicine, however, this varied regionally. Respondents from the UK expressed concerns
about the impacts of reduced contact on the quality of maternity care. Participants in LMICs
recognized women’s inadequate access to communication infrastructure, as telehealth was far
more elusive in rural areas, particularly for women. (Kotlar et. al, 2021)

Additionally, the stress associated with career and work-life balance should be mitigated
through specific family-friendly policies at organizational and national levels. The United States
still fails to provide adequate support for families because it does not have a national paid leave
policy after birth (Nunez, 2020). The increased strain on families during the pandemic may also
have adverse impacts on other indicators, such as abuse or neglect (Brown et al., 2020).

Pregnancy and birth during the pandemic were associated with anxiety and uncertainty
for many of the respondents. Not being able to have their partner or support person at the
hospital for birth—or having to choose between them—was a major point of concern.
Respondents also indicated that release from the hospital was quick due to the new pandemic
protocols. Additional research building upon these research findings should track the ways in
which early release or shorter hospital stays impact outcomes for new parents and infants in a
pandemic context or other major crisis event. One potential effect is that postpartum
complications may go undetected—from difficulties with breastfeeding to life-threatening issues.
There may also be other unanticipated mental health outcomes related to shortened hospital
stays. Some programs that carry out in-person home visits also had to adapt their protocols
during the pandemic, which may have an impact on screening for postpartum depression,
anxiety, and other postpartum mood disorders. Birthing in the pandemic may also increase
other negative spill-over impacts related to postpartum care, because of reduced time in the
hospital where many patients receive lactation and other support services (De Young, 2021).

According to Sarah E.D. isolation associated with the COVID-19 pandemic has adverse
outcomes for maternal mental health, specifically psychological trauma during the postpartum
time frame. This is not to say that social/physical distancing guidelines are not important, but
rather that birthing and postpartum parents should be supported through social networks in new
and creative ways. Many respondents reported that they found ways to continue socializing
through virtual networks. These strategies for facilitating social interactions and social support
networks should be considered by those working to provide care to families with infants and
young children.

Considering the mode of delivery during the COVID-19 pandemic, recommendations

were found to be generally the same on both non-country-specific and national levels; however,
for low-income countries, concerns have been raised about the applicability of the
recommendation. Confirmed or suspected COVID-19 status alone in most recommendations
was not an indication for cesarean section (CS), except in cases where there were absolute
obstetric indications and health reasons related to SARS-CoV-2 infection. Both on the non-
country-specific and national levels, preferential vaginal delivery (VD) or no contraindications to
VD were recommended. As was previously reported, planned and emergency cesarean section
substantially adversely impacted the initiation and continuation of breastfeeding. So, it is
particularly important to avoid performing a cesarean section when it is not clinically indicated in
terms of breastfeeding and strengthening the immature immune system of the newborn, thanks
to bioactive factors present in breast milk. (Wesolowska et. al, 2022)

Upholding current recommendations in this field are based on reliable knowledge and
the results of scientific research indicating a minor risk of virus transmission during vaginal
childbirth if all the rules of the sanitary regime are followed. Moreover, research has shown that
the risk of a SARS-CoV-2 positive newborn was even slightly increased after a cesarean section
birth. (Wesolowska et. al, 2022) Recommendations regarding the mode of delivery were not
always in compliance with the recommendations on the availability of companions of relatives
during labor. In the analyzed cohort of papers, only 12 out of 22 on the non-country-specific
level and 14 out of 23 on the national level provided detailed recommendations in that aspect.
Few included specific recommendations on the course of family childbirth except those that
made it dependent on the decision of the hospital authorities. Likewise, it appears that visitors’
policy might be considered a subject for the hospitals’ broader visitors management policy
during the pandemic, not limited to neonatal and obstetric wards. Surprisingly, as many as 43%
of papers counseling on breastfeeding did not provide detailed information about precautions
concerning breastfeeding. What is worse, in seven publications direct breastfeeding was
suspended. According to the AAP and WHO recommendations, fresh breast milk is the first
option when a baby cannot be put into the breast. The nutritional value and biological activity of
expressed mother’s own milk are also important for the baby’s development, and the process of
pumping allows the mother to maintain lactation and return to breastfeeding as soon as
possible. Unfortunately, this option was too rarely recommended in the analyzed papers. On the
other hand, the involvement of third parties in the process of feeding the newborn can be
supportive for COVID-19-infected mothers and bring them relief and reduce stress; otherwise, it
is unrealistic in the time of other pandemic restrictions with no visitors in hospitals, social
distancing, and shortage of health professionals in the maternity ward. Ten papers indicated this
option for asymptomatic mothers; seven recognized it as the best way of feeding newborns of
mothers who are severely ill or separated because of pandemic restrictions.

While it was assumed that these policies were intended to protect infants from COVID-
19 infection, they may not fully address the long-term consequences of separation and not
putting the baby onto the breast just after delivery. Breastfeeding on demand from the first hour
after delivery keeps enough mother’s milk supply and addresses a baby’s psychological and
emotional needs. Therefore, we recognized recommendations to diminish the frequency of
direct breastfeeding to one to two days as unreasonable and damaging to the well-being of
mother and child. (Wesolowska et. al, 2022)
References:

United Nations Population Fund. Reproductive, maternal, newborn, and adolescent health
during pandemics. United Nations Population Fund; 2020.
https://reliefweb.int/sites/reliefweb.int/files/resources/en-rmnah-web_2.pdf.

RW Kimani, R Maina, C Shumba & S Shaibu. Maternal and newborn care during the COVID-19
pandemic in Kenya: re-contextualizing the community midwifery model. 2020. https://human-
resources-health.biomedcentral.com/articles/10.1186/s12960-020-00518-3

Bethany K., Emily G., Sophia P., Ana L. & Henning T. The impact of the COVID-19 pandemic
on maternal and perinatal health: a scoping review. 2021. https://reproductive-health-
journal.biomedcentral.com/articles/10.1186/s12978-021-01070-6

Sarah E. D., Michaela M. Pregnancy, Birthing, and Postpartum Experiences During COVID-19
in the United States. 2021. https://www.frontiersin.org/articles/10.3389/fsoc.2021.611212/full

Aleksandra W., Magdalena O-P., Agnieszka B.-J.,Małgorzata G., and Bartłomiej W. Protecting
Breastfeeding during the COVID-19 Pandemic: A Scoping Review of Perinatal Care
Recommendations in the Context of Maternal and Child Well-Being. 2022.
https://pubmed.ncbi.nlm.nih.gov/35329035/