The Pandemic's Global Impact on Obstetric and Fertility Services
The pandemic has changed our lives, both in temporary and permanent ways. Over the last year and a half, these changes have impacted access to healthcare services across the world. Lockdowns due to coronavirus delayed medical treatment, personal protective equipment (PPE) and increased healthcare costs, and access to healthcare, became more difficult to find in rural communities.
Access to obstetric and fertility care also became a bigger issue. Research shows the pandemic contributed to a global trend in worsening pregnancy outcomes. Let's take a deeper dive into the ways COVID-19 impacted reproductive healthcare.
Delay in seeking care
At the start of the pandemic, many people were hesitant to leave their homes and seek medical care. According to an October 2020 study published in the International Journal of Gynecology and Obstetrics, the pandemic had an indirect adverse effect on maternal and child health.
A July 2021 study published by The Lancet in EClinicalMedicine states that from January 1, 2020 to April 17, 2021, there was an increase in maternal mortality, stillbirth and maternal depression.
The precise cause of this is unclear, but globally, people delayed seeking obstetric care because of lockdowns and fear of contracting the virus, which is theorized to have contributed to these worsening pregnancy outcomes.
According to the October 2020 study referenced above, from April to August 2020, there was a 45.1 percent reduction in institutional deliveries, "a percentage point increase of 7.2 in high-risk pregnancy, and 2.5-fold rise in admission to the intensive care unit of pregnant women during the pandemic." Additionally, researchers estimate one-third of women had inadequate prenatal checkups, resulting in 44.7 percent of pregnancies with complications.
The long-term impact of these negative outcomes is unclear, and more research is needed going forward. However, if one thing is clear, it's the importance of obstetric care, perhaps especially during a pandemic.
Increasing costs in obstetric care
COVID-19 also contributed to a rise in healthcare costs, in part due to the increased use of PPE. (When the New York Times asked readers to submit their hospital bills in 2020, it was revealed some patients were being charged nearly $1,000 in protective gear fees.) The Centers for Disease Control & Prevention (CDC) and World Health Organization (WHO) have recommended hospitals and healthcare providers use additional PPE to help prevent the spread of the coronavirus. This impacted the cost of healthcare, which, depending on your economic status and where you live, may be the difference in being able to afford healthcare at all.
According to a September 2020 essay in the Pan African Medical Journal, implemented COVID-19 measures caused an increase in the cost of surgical and obstetric care in Nigeria. Mandatory preoperative COVID-19 testing, use of PPE by all operating room personnel, and the use of PPE kits by radiologists/sonologists all contributed to the increased cost, which was passed on to patients.
There are concerns the increased cost in obstetric care could be creating another barrier for women to access healthcare.
In the hospital studied, women scheduled for a C-section had to bear the additional cost of PPE used by the doctors and nurses, which totaled $70—almost the cost of the surgery itself. This doesn't include the additional cost of the mandatory COVID-19 test. Considering 90 percent of Nigerians live on less than $2 a day, this is a significant cost to patients and their families.
The full impact of these increased costs is largely unclear. However, it is a cause for concern, particularly for Nigeria because the country has the second-highest number of stillbirths in the world.
While the reasons for this are complex, a hospital-based 2015 study published in Pediatric Reports found the main causes of stillbirth in the country were antepartum hemorrhage, hypertensive disorders of pregnancy, uterine rupture, low birthweight and congenital fetal malformations. Most of these conditions are preventable if mothers have access to healthcare. There are concerns the increased cost in obstetric care could be creating another barrier for women to access healthcare.
Obstetric care in rural communities
The WHO stresses the importance of social determinants of health (SDH). These include the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life.
Nearly everyone has felt the negative impacts of the pandemic, but rural and urban communities fared differently, largely because of the difference in SDH. Rural communities often face additional challenges, such as a lack of access to healthcare, transportation challenges, lack of educational and employment opportunities and poverty.
According to the Society of Rural Physicians of Canada, the pandemic has highlighted the gap in access to higher levels of care in rural areas. The gap encompasses a variety of health services, including access to obstetric and maternal healthcare—particularly because maternity care is largely dependent on hospital infrastructure.
During the pandemic, several hospitals in Canada closed their birth wards, including St. Luke's Jerome, Stanton, Pontiac and Norfolk General Hospital (NGH). NGH's birthing ward had served Norfolk County's rural southern Ontario community for more than 100 years. The hospital stated the closure was due in part to a nursing shortage across Canada.
"We are all very saddened by this," said Brian Ferguson, D.C., D.Ap., M.D., FRCSC, an OB-GYN at NGH. "It's something that none of us wanted to do."
The closure of obstetric care units in rural communities is the continuation of a pre-pandemic trend. According to researchers at the University of Minnesota's Rural Health Research Center, the percent of all rural counties in the U.S. without hospital obstetric services increased from 46 percent in 2004 to 55 percent in 2014.
During this time period, the closure of 14 rural hospitals left the people within those communities without access to obstetric care. This doesn't include the closure of obstetric units themselves. In the same decade, 165 hospitals closed their obstetric units, leaving even more patients without services.
Additionally, as of 2020, in the United States, there is a shortage of 9,000 OB-GYNs, which is projected to increase to 22,000 by 2050. This shortage leaves an estimated 10 million women in the U.S. to travel long distances in order to receive obstetric care, which isn't always possible for women without transportation, access to childcare services, or the ability to take time off work.
Fertility services
In addition to obstetric care, access to fertility services was also negatively impacted because of COVID-19. During the pandemic, fertility centers were closed because they were deemed a nonessential service. This left many couples struggling with infertility without treatment options.
This is problematic for patients because timing plays a crucial role in fertility, explained Jennifer Lam, M.D., MSHS, FRCSC, a women's healthcare provider finishing her fellowship training in reproductive endocrinology and infertility at Western University in Ontario.
"Unfortunately, for many of our patients time is a crucial factor," Lam said. "Increased age can lead to decreased success of treatments, as there are fewer eggs. Additionally, government funding has age restrictions, and for some patients, costs can otherwise be prohibitive."
Fortunately, in the case of fertility services, the impacts felt from the pandemic seem to have been short-term. Lam was part of a team of researchers who looked at the impact of the pandemic on fertility services. She noted their research found the impacts in 2020 were not sustained in 2021.
"We saw a drop in annual volumes during 2020, which was anywhere from 10 to 40 percent from baseline rates, depending on the procedure performed," Lam stated. "However, to our surprise, our analysis of early 2021 data showed not only a recovery but an increase in first quarter procedure rates up to 60 percent higher than levels from the years prior to the pandemic."
"This was very reassuring," Lam continued, "indicating that while our patients missed out on time and procedures in 2020, the delays were not being seen in this new year."
Lam's research shows the recovery of fertility healthcare looks promising post-pandemic. As the research has shown, availability and accessibility of obstetric and fertility care is imperative to the health of mothers and babies. In its press release, Norfolk General Hospital stated, "If the COVID-19 pandemic has taught us anything, it's the importance of healthcare."
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