Recently, concerns have been raised about a possible association between ethnicity and incidence and outcomes of COVID-19, following observational data released from the Intensive Care National Audit and Research Centre (ICNARC, 2020), published on 10 April 2020. The data showed that of 3883 patients with confirmed COVID-19, 14% (486) were Asian and 12% (402) were black, demonstrating a high prevalence in these ethnic minority groups (Abuelgasim et al, 2020).
The evidence of increased risks of COVID-19 in BAME groups is concerning. In a cohort study of UK biobank data including 415 582 participants with 2 886 tested and 1 039 positive for COVID-19, it was found that rates in England were higher in BAME communities and in those living in deprived areas (Prats-Uribe et al, 2020).
There is also startling evidence of the high risk of BAME individuals contracting COVID-19 because of pre-existing health conditions, which is the case for all individuals. However, BAME individuals are prone to higher rates of hypertension, cardiovascular disease and diabetes and are subject to adverse healthcare disparities, compared to their white counterparts (Abuelgasim et al, 2020). Multiple studies have confirmed that the most common comorbidities associated with severe cases of COVID-19 are hypertension, cardiovascular disease, diabetes (Wu et al, 2020) and obesity (Yates et al, 2020), establishing the link between underlying health conditions and COVID-19. In addition, BAME individuals are more likely to die after contracting COVID-19; as shown in the UK Institute for Fiscal Studies reports, which stated that the death rate for people of black African descent was 3.5 times higher than for white British people, while for those of black Caribbean and Pakistani descent, death rates were 1.7 and 2.7 times higher, respectively (Kirby, 2020).
COVID-19 and risks to pregnant BAME women
Pregnant women were placed in the ‘vulnerable group’ by the UK Government on Monday 16 March 2020 (Royal College of Gynaecologists [RCOG] and Royal College of Midwives [RCM], 2020). During pregnancy, the immune systems changes, and it is hypothesised that this can lead to susceptibility to some pathogens (Ryean et al, 2020). In addition, the physiological changes occurring during pregnancy makes the woman more vulnerable to severe infections (Goodnight and Soper, 2005). The RCOG and RCM (2020) state that pregnant women do not seem to be at higher risk of severe COVID-19 infection requiring hospital admission than non-pregnant individuals. However, evidence shows that, in some cases, pregnant women may suffer adverse outcomes.
The COVID-19 pandemic has drawn attention to the health disparities that black, Asian and minority ethnic women face during pregnancy and in midwifery care
A review of the literature summarising 14 case studies involving 108 pregnant women who had contracted COVID-19 during pregnancy found associations with severe maternal morbidity and the possibility of maternal-fetal transmission could not be ruled out completely (Zaigham and Andersson, 2020). Most of the studies originated from China, but cases from Sweden, USA, Korea and Honduras were also included. Crucially, it has been found that pregnant women admitted to hospital with COVID-19 are more likely to be of black or other minority ethnicity (RCOG and RCM 2020; ICNARC 2020), suggesting that pregnant BAME women are disproportionately affected with COVID-19.
In a review of 427 pregnant women admitted to hospital with confirmed COVID-19 infection between 1 March 2020 and 14 April 2020, 233 (56%) were from black or other ethnic minority groups (Knight et al, 2020). This association with BAME women reflects previous findings that UK BAME pregnant women have poorer pregnancy outcomes. Black women have a fivefold risk and Asian women have a twofold risk of dying during pregnancy (Nair et al, 2014; Knight et al, 2019). Similarly, BAME women admitted to UK critical care units are more likely to die from COVID-19 (ICNARC, 2020; Knight et al, 2020). The issue of BAME women experiencing poorer pregnancy outcomes has been an ongoing concern for decades.
Unfortunately, the COVID-19 pandemic draws further attention to the health disparities for BAME women during pregnancy. The reason for this association is unclear, but in the case of COVID-19, it has been postulated that it is related to socioeconomic or genetic factors, or differences in response to infection (Knight et al, 2020).
Disruption to maternity services
Pregnant women are often among the most vulnerable groups during public health emergencies (Gausman and Langer, 2020). The focus in the COVID-19 pandemic is on critical care services and ensuring that there are adequate intensive care beds. There has been some criticism that the ongoing needs of other vulnerable groups that require healthcare should not be ignored or abandoned. Amid a rapidly evolving outbreak that could have significant effects on public health and the medical infrastructure, the unique needs of pregnant women should be included in preparedness and response plans (Rasmussen et al, 2020).
Advice for pregnant women has been guided by medical evidence and government recommendations on social distancing, resulting in the formation of new methods of delivering maternity services. It was acknowledged that disruption of maternity services and diversion of resources away from essential pregnancy care because of prioritising the COVID-19 response was expected to increase risks of maternal mortality (Hall et al, 2020; Rasmussen et al, 2020).
Changes have been implemented across the country that have significantly changed practice and imposed restrictions on services, staff, and women (Renfrew at al, 2020). This has created disruptions to antenatal care and postnatal care, with visits being reduced and regular face-to-face contact with a midwife not being provided to women. The RCOG and RCM (2020) advise that antenatal and postnatal care should be regarded as essential, and there have been changes to these services with revisions being made to schedule of care. Women are encouraged to attend antenatal and postnatal care, despite being advised to otherwise engage with social distancing measures. This leaves women in a dilemma of which advice to follow. Alternative arrangements for antenatal appointments are being offered by maternity units if a face-to-face consultation with the woman is deemed unnecessary. Maternity units in the UK are advised to rapidly seek to adopt teleconferencing and videoconferencing capabilities, and consider what appointments can be conducted remotely (RCOG and RCM, 2020). The RCOG and RCM (2020) has recommended restriction of visitors if the woman is admitted, only one birth partner is permitted during labour and postnatal visiting is reduced. The concern is that women are being asked to negotiate services when the socioeconomic impact of COVID-19 may have detrimental effects on their psychological and physical wellbeing (Esegbona-Adeigbe, 2020).
During pregnancy and the postnatal period, women seek support from family, friends and other pregnant women. However, with the recommended social distancing, this is reduced. In particular, single parent families and women who may be victims of domestic violence may be at increased risk during the pandemic, because of restricted access to their support systems. Hard-to-reach women, such as recent immigrants and asylum seekers, may encounter difficulties accessing or engaging with maternity services (Esegbona-Adeigbe, 2020). Women may not attend face-to-face antenatal appointments with their partners or children, meaning that there may be issues with travelling to hospitals, childcare, or there may be an impact on some ethnic minority women communicating their concerns. In addition, reduced antenatal care could risk pregnancy complications being missed. This may occur if women have remote appointments, as physical assessments are impossible through this approach.
Impacts of the pandemic on pregnant BAME women
Evidence published from past pandemics proves that ethnic minorities are disproportionately affected and experience worse health outcomes, compared to other groups (Abuelgasim et al, 2020). Studies from A(H1N1) influenza suggest that despite people from ethnic minorities expressing greater intention to make behavioural changes in response to recommendations and adopt protective behaviours, barriers exist that prevent this from translating into health-seeking actions (Haroon et al, 2011; Rubin et al, 2009).
In usual circumstances, there is a complex mix of socioeconomic and cultural factors that can impact on pregnant BAME women's access to healthcare, leading to failure to access and engage with antenatal care (Knight et al, 2019). The current pandemic will create even more barriers for BAME women accessing maternity care. The barriers are numerous and may range from employment issues, family responsibilities and pre-existing health concerns. Pareek et al (2020) suggest that ethnicity interplays with viral spread through cultural, behavioural, and societal differences, including lower socioeconomic status, health-seeking behaviour and intergenerational cohabitation.
It is important to consider how BAME women may experience stressors that are not encountered by the majority population, such as unfamiliarity with and issues accessing services because of language difficulties, discrimination and immigration status (Taylor, 2019). If these issues are overcome, then the uncertainty and instability surrounding COVID-19 creates other dilemmas, such as choosing to self isolate or continuing to work or engage with healthcare services. Emerging evidence on the impact of COVID-19 suggests that women's economic and productive lives will be affected disproportionately and differently from men. They may take on greater care demands at home and their jobs will also be disproportionately affected by cuts and lay-offs (United Nations, 2020). As well as facing the inherent worry of being pregnant in a pandemic, other issues may take priority, which may impact on BAME women's decision making when seeking health advice and care.
The fact that the COVID-19 pandemic is a unique stressor with potentially wide-ranging consequences for pregnancy is highlighted in a survey of 1 987 women, which included 0.7% Black women and 2.6% South Asian women (Lebel et al, 2020). Anxiety and depression levels during the COVID-19 pandemic were found to far exceed those normally expected during pregnancy and those experienced by other groups of people during the current pandemic. Although this study does not highlight that pregnant BAME women are at increased risk of stress during the pandemic, for people from BAME groups, there are already significant mental health inequalities (Smith et al, 2020). Therefore, the impact of the pandemic on the mental health of BAME women is an important consideration. Findings since the COVID-19 pandemic began highlight the severe choices created by social distancing and employee responsibilities faced by those in lower socioeconomic and high-risk groups and suggest that unless there is government intervention to support these individuals, the impact of this epidemic will likely be felt unequally (Aitchison et al, 2020). Pregnant women may face additional challenges during social distancing because of their contribution to the workforce, as caregivers, and the need to attend antenatal care (Hussein, 2020). Migrant women may face particular challenges, especially asylum seekers who are fearful of being billed for maternity care or of the Home Office being notified, which may put their immigration applications in jeopardy (Bragg et al, 2018). Migrant women are often in precarious employment, and they are less likely to be paid via furlough schemes, making any paid healthcare services they need difficult to obtain, exacerbating any existing risks during pregnancy (Paton et al, 2020). The challenge for BAME pregnant women in the current pandemic is undertaking the extensive task of engaging with maternity services, meeting work and financial commitments, undertaking caring responsibilities and adhering to government recommendations regarding social distancing.
RCOG and RCM provision for pregnant BAME women
The RCOG and RCM (2020) have made the following provisions for BAME women in their advice on COVID-19 and pregnancy for maternity services:
- When reorganising services, maternity units should be particularly cognisant of emerging evidence that BAME individuals are at particular risk of developing severe and life-threatening COVID-19
- Inform women of BAME background that they are at higher risk of complications of COVID-19 and advise them to seek help early if they are concerned about their health
- Clinicians should be aware of this increased risk, and have a lower threshold to review, admit and consider multidisciplinary escalation in BAME women
- Particular consideration should be given to the experiences of BAME women, particularly those from vulnerable groups, including lower socioeconomic status, when evaluating the potential or actual impact of any service.
Recommendations
Public health strategies are needed to reduce the incidence of COVID-19 among the most susceptible groups (Prats-Uribe et al, 2020). There is a need to ensure appropriate health advice and care in pregnancy is offered to BAME women, to decrease their risk of contracting COVID-19. This should involve relaying information to BAME women of the risks of COVID-19, with consideration of the social, cultural, psychological and physical factors that may impact on their health-seeking behaviour. Reducing barriers in accessing healthcare and providing culturally and linguistically appropriate public health communications is crucial (Aldridge et al, 2020). Governments and policy makers should consistently engage with ethnic minority populations, their service providers, and trusted community leaders, to effectively communicate information about pandemic status, affected communities, risks and recommended actions (Abuelgasim et al, 2020). The onus is on maternity units and midwives to identify and correctly advice pregnant BAME women on the risks of COVID-19. However, careful screening is required by midwives to ensure that all pregnant women who are experiencing any psychological or social stressors are provided with individualised care.
In particular, BAME women need to be provided with culturally appropriate information about signs and symptoms of COVID-19. Honest, transparent communication is vital; any health information that is confusing or contradictory leads to mistrust and individuals may seek information from unreliable alternative sources (Berger et al, 2020). It is important to dedicate time to relay health messages appropriately despite the increased pressures on health services during the pandemic. The creation of open channels for women to contact maternity services to discuss any concerns is important. Poor communication strategies have featured strongly as a major reason why adverse patient healthcare events, including clinical negligence, take place (Tingle, 2020). A better understanding of the knowledge that people have, and also the experiential, social, and cultural factors that drive COVID-19 risk perception, will help maternity units to create evidence-based risk communication strategies (Dryhurst et al, 2020).
Adapting maternity services
Maternity units should recognise the stressors that BAME pregnant women may be facing during the pandemic, and ensure that midwives are aware of the additional difficulties BAME women need to overcome in order to engage with maternity services. A focus needs to be placed on reducing barriers to care that could range from caring responsibilities, communication issues and financial pressures.
Maternity units need to ensure midwives have the key skills to assess women remotely, and there should be provision of services to allow women to access maternity care for rapid assessment in the event of any complications. In particular, antenatal care should involve careful screening of all BAME women and the provision of appropriate advice regarding frequency of visits. Consideration of women who have underlying health conditions and comorbidities, such as diabetes and hypertension, need particular risk assessment for their individual pregnancy needs, and appropriate referral for medical and obstetric management. Currently, the RCOG and RCM (2020) has advised maternity units to be cognisant of the increased risk of COVID-19 in BAME women during pregnancy, but have not explicitly stated how their care should be managed. Midwives need to be aware of assumptions made by BAME women regarding their risk of CVOID-19 infection during pregnancy and ensure that advice is tailored to dispel any myths. The first step for maternity units is to understand the usual barriers that pregnant BAME women face when accessing maternity care and mitigate for potential problems that are now occurring during the pandemic.
Conclusions
The increased risk to pregnant BAME women during the COVID-19 pandemic raises concerns about how their needs are being met. BAME pregnant women have poorer outcomes in normal circumstances. Unfortunately, the pandemic has created greater disparities for pregnant BAME women and requires careful consideration of their health needs.
The RCOG and RCM (2020) recognises that BAME pregnant women need special screening during pregnancy for any health concerns. Midwives need to be cognisant of the additional social, psychological and financial stresses that BAME women may be experiencing during the pandemic and how this may impact on their health-seeking behaviour. In addition, women with underlying health concerns need signposting to medical and obstetric care for appropriate management.
Maternity units should consider the increased risks to BAME women when reorganising their services, ensuring that appropriate advice and care is provided. Being conscious of the psychological, social and physical stressors that all pregnant woman may need to deal with during the COVID-19 pandemic is critical for provision of care.