A Recipe for Disaster

A shameful number of people die from pregnancy in the U.S. Thanks to COVID-19, it could get even worse.

Photo by Mustafa Omar on Unsplash

With more than 140,000 Americans dead, millions more out of work, and cases continuing to surge across the country, COVID-19 is painting an extremely bleak picture across the U.S. And I’m afraid it’s going to get much more bleak for people who can get pregnant thanks to a very unfortunate confluence of restrictions on care, loss of insurance, and more barriers to birth control and abortion. 

Over the past few weeks, I reported two stories about maternal health for What to Expect, for the brand’s annual Bump Day initiative that highlights the importance of prenatal care. The first was about how the coronavirus pandemic has upended prenatal care for pregnant people, and what that might mean in the long run, and the second looked at the factors that contribute to our country’s tragic record of maternal deaths. Every year, between 700 and 900 women die from pregnancy and another 50,000 have life-threatening complications like needing a blood transfusion or a hysterectomy.

READ: How COVID-19 Is Leaving Pregnant Women and New Moms Behind

COVID-19 restrictions at doctor’s offices and in hospitals may mean people miss prenatal appointments because they can’t bring their kid and can’t find childcare, or can’t have their doula, a key support person, present when they give birth. Concerns about contracting the virus itself could mean that pregnant people don’t get adequate care during pregnancy, which could make it harder to prevent and manage complications. Medical offices may have reduced staff and more rural providers may close amid budget crunches. People might have to try harder than they should to be seen in person versus having a telehealth appointment.

Losing health insurance

When it comes to preventing the serious complications and deaths from pregnancy, the experts I spoke to continually emphasized the importance of being able to get medical care well before pregnancy. In the U.S., a country that does not guarantee health insurance to every person, doctors diagnose people with diabetes at their first prenatal visit. In almost every state, people whose pregnancies were covered by Medicaid are booted off that health plan within 60 days of giving birth. The baby, meanwhile, is covered for a year. More than half of pregnancy-related deaths actually happen after childbirth. 

And now, with millions out of work and at least 5 million who’ve lost their job-sponsored health insurance, staying healthy will get a lot harder.

“We have not seen the extent to which this pandemic has affected us at all yet,” Meike Schuster, an assistant professor of obstetrics and gynecology at the Rutgers Robert Wood Johnson Medical School, told me. “With loss of income, loss of jobs, loss of [health] insurance, people will no longer able to keep up with their chronic conditions and of course if they're getting pregnant and don't have their chronic conditions controlled, that can put them in a very high-risk situation and make them very unsafe for that pregnancy. I think we will definitely see the fallout of that in the future.” 

And the economic and social changes spurred by the pandemic will have unequal impacts. As Laurie Zephyrin, an OB/GYN and the vice president of the Health Care Delivery System Reform at the Commonwealth Fund, told me, COVID-19 has unearthed the challenges in our healthcare system as well as the inequities in our society. The pandemic is predominantly affecting people of color. And in a country with bleak maternal mortality rates, particularly among Black and Native American women, it's like layering one crisis on top of another. “There's already structural racism and structural determinants of health that put people more at risk and the COVID-19 crisis on top of that makes people extremely fragile.”

Preventing pregnancy

These are some of the barriers facing pregnant people, whether the pregnancy was intended or not.

Yes, a recent survey from the Guttmacher Institute found that one-third of people wanted to get pregnant later or have fewer children because of the pandemic. But how effectively can they do that if they’ve lost their health insurance, which covers the most effective forms of birth control with no copay or deductible? Or, if they still have a job, do they work for an employer that might take advantage of the recent Supreme Court ruling allowing religious and moral exemptions to birth control coverage? Fewer people *want* to get pregnant right now, though given increased obstacles to preventing pregnancy, only time will tell if the “COVID baby bust” will become a reality, or if it’s...a bust.

For people who get pregnant and don’t want to be, they may have to deal with state officials exploiting the crisis to, say, temporarily stop abortions in their states or make abortion functionally inaccessible by requiring a negative COVID test within 48 hours of the procedure. Or they could simply be unable to afford the procedure during the recession. Abortion access is inextricably linked to maternal health, as Rachel Hardeman, PhD, MPH, an associate professor at the University of Minnesota School of Public Health explained to me: The more people who carry a pregnancy to term in our current system, the more people who could die or have a serious complication from pregnancy. (That’s to say nothing of the mental health effects of being unable to get an abortion.)

“There's already structural racism and structural determinants of health that put people more at risk and the COVID-19 crisis on top of that makes people extremely fragile.”

A bleak outlook

Taken together, there’s a nonzero chance that the pandemic will lead to more maternal deaths in the United States, as Bethany Kotlar, MPH, program manager for the Center of Excellence in Maternal and Child Health at the Harvard T.H. Chan School of Public Health, told me.

“It’s definitely in the realm of possibility that maternal deaths rise and there are many pathways that COVID-19 could be a contributor to that,” Kotlar said, “but I think it will be a while and will take some real scientific work to figure out why and how, if that does happen.”

Some of that possible increase could come from pregnancy-associated deaths, or deaths up to a year after birth, Kotlar said. That’s slightly different from the World Health Organization definition of maternal mortality, or deaths within the first 42 days after birth.

“A lot of those [pregnancy-associated] deaths are attributable to things like suicide and overdose, things that we wouldn't necessarily think are caused by the pregnancy, but they often are exacerbated by it.” And that’s where the mental health effects of the pandemic could really leave their mark.

There’s one postpartum checkup at 6 weeks, but a lot of providers focus on the baby and not the mom, Kotlar said. And now, new parents are isolated more than ever before, and if they have older kids, they might be attempting to manage distance schooling, too. “Even the grandparents in many cases can’t come over and help, we can't have the moms support group in person,” she said. People with substance use disorders also may not be able to go to Alcoholics or Narcotics Anonymous meetings and Kotlar says she wouldn’t be surprised if people relapse. And people are stressed out as furloughs and layoffs extend into a wide range of industries.

Start with a shameful maternal mortality crisis that disproportionately affects Black women, and add disruptions to getting medical care, record unemployment, loss of insurance, plus birth control and abortion pushed further out of reach, and you’ve got a world in which the U.S. sees even more people die from pregnancy.

We’re layering one crisis on top of another and it is truly a recipe for disaster.

For more writing and reporting, visit my website: susanrinkunas.com.