key: cord-0909502-8sydx2su authors: Lucas, D. N.; Bamber, J. H. title: Pandemics and maternal health: the indirect effects of COVID‐19 date: 2021-03-07 journal: Anaesthesia DOI: 10.1111/anae.15408 sha: bf20e10f5560957bd6f33c43ea97c8a391cba2b1 doc_id: 909502 cord_uid: 8sydx2su Infectious diseases can directly affect women and men differently. During the COVID‐19 pandemic, higher case fatality rates have been observed in men in most countries. There is growing evidence, however, that while organisational changes to healthcare delivery have occurred to protect those vulnerable to the virus (staff and patients), these may lead to indirect, potentially harmful consequences, particularly to vulnerable groups including pregnant women. These encompass reduced access to antenatal and postnatal care, with a lack of in‐person clinics impacting the ability to screen for physical, psychological and social issues such as elevated blood pressure, mental health issues and sex‐based violence. Indirect consequences also encompass a lack of equity when considering the inclusion of pregnant women in COVID‐19 research and their absence from vaccine trials, leading to a lack of safety data for breastfeeding and pregnant women. The risk‐benefit analysis of these changes to healthcare delivery remains to be fully evaluated, but the battle against COVID‐19 cannot come at the expense of losing existing quality standards in other areas of healthcare, especially for maternal health. Infectious diseases can directly affect women and men differently, as has been demonstrated by the COVID-19 pandemic [1] . A wealth of data has confirmed a male bias in mortality associated with COVID-19 [2] . Higher case fatality rates in men have been seen in most parts of the world, with notable exceptions including India, Nepal, Vietnam and Slovenia, where higher fatality rates have been observed in women [3, 4] . The reasons behind the male preponderance in mortality are not clearly established. Relevant factors may include biological aspects, such as stronger immune responses in women and behavioural patterns, for example, smoking, placing men at a greater risk for health complications and death due to COVID-19 [2, 5] . Previous pandemics have had greater morbidity or mortality for women (2009 H1N1 pandemic and the avian influenza (H5N1) pandemic, respectively). In contrast, the 1918 H1N1 pandemic was characterised by higher mortality rates in young adult men. With any pandemic, the indirect as well as direct health effects need to be evaluated. There is growing evidence that the COVID-19 pandemic's indirect effects have had a more significant adverse impact on women's health. A United Nation Policy Brief commented that "the pandemic is deepening pre-existing inequalities, exposing vulnerabilities in social, political and economic systems which are in turn amplifying the impacts of the pandemic. . .with women being disproportionately affected" [6] . During expanding or replicating innovative pilot or small-scale projects to reach more people or broadening the effectiveness of an intervention) [13, 14] . It has evolved to be used to understand and define the causes of measured or and heterogeneous maternity service modifications [16] . These primarily affected antenatal and postnatal services, but also some intrapartum services. In total, 70% of respondents reported a reduction in antenatal appointments and 56% reported a reduction in postnatal appointments, with 89% using remote consultation methods. There were significant changes in specialist maternity care services with widespread uptake of home two stated that it was due to personal protective equipment availability; one stated it was due to delivery unit management; and one attributed it to equipment/drug availability issues [20] . [41] . A further indirect consequence of the COVID-19 pandemic relates to sex-based violence. One in four women will experience domestic violence in their lifetime, with abuse during pregnancy or soon after the birth of their baby occurring in nearly 10% of all women [42] . It is well recognised that pregnancy triggers and frequently accelerates domestic violence, with women from ethnic minorities and marginalised groups being particularly vulnerable [43] . There is some evidence of an increase in domestic violence against women during the pandemic, with factors including stay-at-home orders and economic dependence contributing [43, 44] . This has been alongside a pandemic-related reduction in essential support services such as crisis centres and hotlines [45] . Routine enquiries should be made to every woman during antenatal appointments where their partner is not present; the increase in remote appointments has led to concern by healthcare professionals that violence will be masked during the pandemic. Together this acts as a perfect storm to further increase the risk of sex-based violence towards pregnant women and new mothers. Finally, it is recognised that social deprivation, which can be compounded by ethnic minority status, leads to inequalities in maternal mortality and maternal morbidity. These inequalities and the risk that they pose for maternal health are likely to be exacerbated by the COVID-19 pandemic. Beyond the direct effect of illness, the COVID-19 pandemic will amplify and accentuate existing health and socioeconomic inequalities both in the UK and globally. These inequalities will lead to increased risk of indirect adverse effects on women's well-being and were recognised by the United Nations early during the pandemic [6] . Women are vulnerable to these inequalities and are likely to bear the health burden of the indirect effects of COVID-19, with these effects continuing to remain imprinted long after the rollout of a vaccination program. 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