So much is still unknown about pregnancy and COVID-19. We do know that contracting the disease comes with increased risk of severe illness, and a higher risk of preterm birth. But how an infection affects a person at different stages of pregnancy? Or a developing fetus? No one knows for sure. Would vaccination help mitigate these risks? The vaccines were never tested on pregnant people. Unlike elective surgeries, many of which were rescheduled during surges of the disease, having a baby cannot be postponed. How much additional danger is associated with labor and delivery during this pandemic? And the decisions that parents of newborns face—how to manage the demands of a child’s early life, in isolation—what added toll does that stress take?

Even in the darkest days of the pandemic, new life has found a way. But COVID-19 has made this most basic of human endeavors more fraught and more dangerous this year, everywhere the disease has touched.  

Pregnant women often bear the brunt of shifting health resources, and past epidemics have made women and babies that much more vulnerable. During the Ebola outbreak in West Africa, researchers estimate that more women and children likely died from the indirect effects of the epidemic than from the disease itself. Women were unable to access family planning, completed fewer care visits during pregnancy, and were more likely to give birth at home—which is riskier for both mom and baby. It became harder for women to access health-care facilities due to increased physical and financial barriers, as well as a fear of infection. Others were denied care if they were suspected of having Ebola.

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That seems to be happening again, says Tim Roberton, an international-health researcher at Johns Hopkins’ public-health school. Back in the spring, Roberton modeled various scenarios of COVID-19 intensity in 118 low- and middle-income countries, and found that the least severe scenario would result in an additional 12,200 maternal deaths over six months. The most severe scenario would kill an additional 56,700 pregnant women—an increase of up to 38.6 percent in maternal deaths per month.

The greater share of these deaths is not associated with actually catching COVID-19. Sixty percent would be attributable to four childbirth interventions—parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments. That is, nearly all of those causes of death are preventable with adequate medical care.

Have those models come true? “It’s very hard to measure maternal mortality empirically because the methods are complicated,” Roberton says. “We are not going to have any actual measurements for a while.”

What he can say is that fewer people overall have been coming to health facilities for care: He has seen unpublished data showing a 10 to 20 percent decline for the period of April through June. Labor and delivery is following this same trend—fewer women have come in to deliver babies, Roberton says.

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More deliveries at home means more people giving birth without access to medicines that can halt common problems, such as hemorrhaging after birth. “If they have complications, they are not able to get quickly to a health-care facility,” Roberton says. Even if they do come in, COVID-19 has disrupted supply chains for medicines, so clinics may not have the drugs available to help those in labor. A survey by the World Health Organization showed that 90 percent of countries experienced disruptions to their health-care system, including medications and family-planning services, both of which can affect maternal mortality.

For pregnant people who do contract COVID-19, the complications multiply. To begin with, a positive case can bring stigma. In India, a family abandoned a pregnant woman after she tested positive for the coronavirus. In Guyana, a nurse who contracted COVID-19 while pregnant says that her family was shunned, according to the Pan-American Health Organization (part of the WHO).

Pregnant people are at high risk of developing severe COVID-19, and have a higher rate of preterm birth if they get the virus. They also have been excluded from vaccine safety and efficacy tests, although the American College of Obstetricians and Gynecologists recommends that pregnant and breastfeeding women receive a vaccine as soon as they are able. “Experts believe [the vaccines] are unlikely to pose a risk for people who are pregnant,” the CDC advises. “mRNA vaccines do not contain the live virus that causes COVID-19 and therefore cannot give someone COVID-19.”

Even for pregnant people who are able to stay healthy, carrying a child in a pandemic brings a whole new level of worry and stress—especially for those already at the low end of the socioeconomic spectrum. “Everywhere pregnant people turn, it’s a little harder to make a decision,” says Marta Perez, an ob-gyn at Washington University School of Medicine in St. Louis, who is also due in the first months of 2021. “That can really wear on you.”

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Perez treats many women who are worried about losing their homes or jobs during the pandemic, and who already struggle to access health care. “This has been a year full of disappointment and hard decisions for families—not having family and friends around, not having child care—[and] making decisions brings an extra weight in terms of keeping yourself safe and boundaries for family members after the baby comes,” she says. “And now we have this decision about vaccine if it’s offered to them.”

Scientists are just starting to understand how pregnant people are coping—or not—with the added mental load of a pandemic. HOPE COVID-19 is an international study of how the disease itself, as well as the associated stresses, are affecting pregnant people and babies. Investigators are studying 200 women, but hope to enroll several thousand more women in the study—at least half of whom will be Black, Hispanic, or low-income—and follow them for 18 months after birth.

The initial data show that more than 84 percent of women reported moderate to severe anxiety about giving birth during a pandemic. There’s just no comparison with stress associated in previous years with labor and delivery—people are so fearful about being alone, says Laura Jelliffe-Pawlowski, a UCSF epidemiologist who leads the study. “People are also afraid of testing positive, because they want to be with their babies and they are afraid they’ll be separated.” Early in the pandemic, some hospitals suggested that mothers who test positive isolate from their infants; most no longer do, but policies vary from place to place. “It’s like every decision carries a mortal weight.”

One way that women are getting around the burden of being pregnant this year is to freeze their eggs, if they can afford it. New York University’s Langone Fertility Center has seen a 41 percent increase in women freezing their eggs compared with the same period in 2019—and its business would likely have climbed higher if it hadn’t shut its doors for three months. Who can blame anyone for wanting to delay carrying a child? There is enough strain to manage in a society with eroding social support, job losses, and economic insecurity without having a baby this year. Or next.