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Contents: Current Commentary

Examining Inequities Associated With Changes in Obstetric and Gynecologic Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic

Onwuzurike, Chiamaka MD; Meadows, Audra R. MD, MPH; Nour, Nawal M. MD, MPH

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doi: 10.1097/AOG.0000000000003933
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Coronavirus disease 2019 (COVID-19) is a respiratory viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), whose severe complications include pneumonia with risk of progression to acute respiratory distress syndrome and death. Since its identification in December 2019, it has rapidly spread across the world and was declared a pandemic by the World Health Organization in March 2020.1 Whereas community-based efforts to mitigate the spread of COVID-19 infection in the United States have focused on social distancing, physician–leaders have been forced to urgently institute massive changes in hospital operations and health care delivery to minimize the risk of COVID-19 transmission to healthy patients and health care workers.

Hospital-level changes include those listed in Box 1. In addition, obstetric care delivery has been specifically modified to minimize the potential exposure of patients and health care workers to SARS-CoV-2 (Box 2). For example, antenatal and postpartum visit schedules have been pared down, particularly for low-risk patients. Telehealth visits by phone and videoconference have increasingly replaced in-person visits, and self-care practices, such as home blood pressure monitoring, have been encouraged to further decrease the number of ambulatory visits. Initiatives to eliminate the use of paper in clinical settings as a means of reducing virus transmission have shifted critical screenings for perinatal depression, illicit substance use, and intimate partner violence from private, self-administered questionnaires to verbal interviews. In-person childbirth education has been replaced with virtual meetings, losing the opportunity for hands-on instruction. Group prenatal care, which, in our practice has been associated with lower rates of cesarean delivery and neonatal intensive care unit admission, has been suspended altogether. Loss of this important source of support for a subset of our patients—in addition to other abrupt changes in care delivery—may disproportionately disadvantage vulnerable populations and worsen not only their pregnancy experiences but their birth outcomes as well.

Box 1.

Hospital-Wide Policies and Initiatives During the Coronavirus Disease 2019 (COVID-19) Pandemic

  • Standardized COVID-19 symptom screening of all patients and visitors on entry to the hospital and at all points of contact
  • Protocols for COVID-19 testing and patient isolation
  • Restriction of visitors in both inpatient and outpatient settings
  • Separation of COVID-19 and non–COVID-19 care sites within institutions
  • Use of telecommunication systems for inpatient care of patients with COVID-19 infection
  • Increased utilization of telemedicine, including videoconferencing
  • Postponement of elective or nonurgent surgical procedures
  • Enhanced hand hygiene protocols for employees
  • Universal masking of employees
  • Universal masking of patients and visitors
  • Employee self-monitoring of symptoms and daily attestation to lack of symptoms to receive clearance to work
  • Employees allowed to work from home when possible
  • Minimize group meetings for employees
  • Restricted domestic and international travel for employees

COVID-19, coronavirus disease 2019.

Box 2.

Obstetrics and Gynecology–Specific Policies and Initiatives During the Coronavirus Disease (COVID-19) Pandemic

  • Visitor restrictions for ambulatory visits, obstetric triage visits, labor and delivery, and antepartum and postpartum inpatient admission
  • Protocols for isolation and PPE use in labor and delivery units for patients with COVID-19 infection and Persons Under Investigation for infection
  • Expanded availability of PPE supply in labor and delivery units
  • Universal testing for COVID-19 infection on admission to the labor and delivery unit
  • Consideration of separation of mother and newborn in cases of confirmed maternal COVID-19 infection and for Persons Under Investigation for infection
  • Reduced antepartum and postpartum visit schedule
  • Screening patients for symptoms of COVID-19 infection by telephone before in-person visits or scheduled admissions
  • Increased use of telemedicine, including videoconferencing
  • Encouragement of self-care (eg, home blood pressure check)
  • Screening for perinatal depression, illicit substance use, and domestic violence by verbal report
  • Childbirth education classes held virtually
  • Group prenatal care suspended or transitioned to virtual space
  • Postponement of nonurgent or elective gynecologic surgeries

PPE, personal protective equipment; COVID-19, coronavirus disease 2019.

The major challenge in delivering gynecologic care during this pandemic has centered on decision making about the timing of surgical procedures. The U.S. Surgeon General suggested that all elective surgical procedures be suspended during the COVID-19 pandemic.2 However, as put forth in the American College of Obstetricians and Gynecologists' statement on the subject, the vast majority of surgical procedures performed by obstetrician–gynecologists (ob-gyns) are medically indicated, although of varying urgency. Therefore, postponing nonurgent procedures may be considered if it would not result in significant harm to the patient.3 However, there is no comprehensive guidance on which procedures should be considered nonurgent, leaving hospitals and individual physicians to independently determine the urgency of a broad range of services, from routine gynecologic procedures to abortion services to infertility treatment. We will return to this topic later.

The COVID-19 pandemic is already disproportionately affecting low-income populations and racial and ethnic minorities similar to the 1918 and 2009 influenza pandemics.4,5 Data from these previous pandemics demonstrate that disparities in exposure, susceptibility, and access to treatment in those communities led to poorer outcomes.6 Preliminary data from major cities across the United States have revealed that members of these same communities are disproportionately more likely to contract COVID-19 infection and have more severe morbidity and mortality from the disease. Among deaths from COVID-19 infection reported in the state of Louisiana as of April 8, 2020, 70% were in individuals of black race, demonstrating a tremendous racial disparity in mortality, considering that African American individuals represent only 33% of the state's population.7 It is worth acknowledging that these data describe women who are patients in our practice and in obstetrics and gynecology practices across the nation. As ob-gyns, we have two major roles during this COVID-19 pandemic as it relates to the issue of health equity. The first is to be aware of the disparities in COVID-19 outcomes and potential inequities in screening, testing, and risk reduction that can and will affect our patients. The second is to consider the ways in which changes in obstetric and gynecologic care delivery, although applied universally, will have an effect on patients that is anything but uniform. Structural changes in the health care system and our larger society in response to the pandemic will make it more difficult for members of socially vulnerable or disadvantaged groups to obtain necessary obstetric and gynecologic care and, thus, potentially worsen outcomes.

With regard to risk of COVID-19 infection, patients from low-income households represent a particularly vulnerable population with limited ability to practice risk-reducing behaviors. Low-wage workers make up a significant portion of the essential workforce expected to continue to report to work during the pandemic. Those who rely on public transportation face additional risk of exposure simply traveling to work. Despite this, low-wage workers are also less likely to have benefits such as paid sick leave, which means that, if they cannot work because of illness or a recommendation to self-quarantine, they will assume a significant financial burden. Those who are not considered essential workers during such times rarely have the option to work from home and, thus, are at higher risk of actually losing their jobs, which may precipitate a downward spiral of consequences, inevitably undermining the health of their households. Finally, it can be challenging for individuals in low-income households to practice social distancing; they are more likely to live in crowded conditions and experience various forms of housing insecurity.

At additional risk of COVID-19 infection are populations at risk of communication inequality, that is, unequal exposure to public health messages and the capacity to process and act on that information.8 This includes individuals from immigrant and refugee populations, those with developmental delays or low literacy, and those who lack access to cellular phones or the internet. Much of the COVID-19 surveillance strategy relies on frequent and accurate screening of individuals for symptoms and then testing those who screen positive. However, communication barriers can reduce the ability to do this effectively. For example, it is critical that all screening for symptoms take place in a patient's primary language to ensure that they fully understand the questions being asked. This extends to patients with disabilities such as hearing impairment, some of whom rely on lipreading; that becomes impossible if all employees are masked. One approach to address this issue is to ensure that interpreter services are available to all health care professionals and staff for symptom screening, whether for previsit phone calls or in-person screening on entry to the hospital. Multilingual written materials are also essential to expedite and increase the fidelity of screening and reduce the risk of inadvertent exposure to symptomatic individuals.

Furthermore, individuals who are underinsured or uninsured, undocumented, or who otherwise feel disenfranchised by the medical system are less likely to seek care even if symptomatic. They are also less likely to feel empowered to advocate for the health services that they need. An example in our practice was a Person Under Investigation for COVID-19 infection whose testing was delayed because she was under the impression that, because she did not own a car, she could not receive testing at a “drive-through” testing site. It is clear that this is an example of a communication failure; to address this, one might train staff to refer to such a testing site as a “mobile site” offering drive-up or walk-up access. However, as physicians, we must go a step further and analyze this event within a broader context. Potentially, personal experiences of limited health care access and exclusion from the health care system have made this part of her lived reality, such that it may not have been surprising that a testing site was inaccessible to patients like her. Limited access to care, both real and perceived, increases risk of adverse outcomes.

In a recently published article, an emergency medicine physician discussed the role of racial disparities in underlying chronic conditions that may increase the risk of adverse outcomes among African American patients with COVID-19 infection, in addition to unequal testing access.9 Although inadequate testing due to shortages of testing materials has affected the entire U.S. population, it is important to consider the ways in which low-income populations, which are disproportionately communities of color, were affected even more directly. For example, the initial testing criteria emphasized a history of recent international travel, which was intended to identify a higher-risk population. However, we now know that there was likely already community spread in the United States;10 therefore, such a criterion served only to reserve testing for more affluent, white individuals, who were more likely to have a history of recent international travel than those in lower-income racial and ethnic minority populations. This delay in recognition of community spread may have disproportionately placed low-income communities at higher risk, because less testing translated into fewer diagnoses and, thus, continued spread within those communities and social networks.

In the midst of growing concern about the potential for COVID-19 case volume and acuity to overwhelm the capacity of health care systems, physician–leaders across the country have developed or adapted crisis standards of care to guide medical decision making. This encompasses criteria for allocation of scarce medical resources, which typically prioritize saving the most lives or life-years and, thus, preferentially allocate medical resources to the young and healthy. Because chronic medical conditions such as hypertension, diabetes, and asthma are disproportionately concentrated in black communities, criteria that, on the surface, may seem fair and appropriate may actually systematically deprive these communities of life-saving resources. Such policies fail to take into account the underlying structural inequities that afflict our health care systems and society at large, as well as ignore the subtle ways in which privilege and wealth are rewarded at the expense of those with fewer resources. These inadvertent effects also serve to heighten existing distrust of the medical system among vulnerable populations and will directly discourage a wide range of health care–seeking behaviors.

With regard to obstetric and gynecologic outcomes during the COVID-19 pandemic, several factors may differentially affect socially disadvantaged populations. Consider women in low-wage service-sector jobs (eg, public transit or hospital environmental services). They may have unequal access to the reliable and consistent phone or internet service required to participate in virtual care and, as a result, may have to come into the clinic more frequently, increasing their risk of SARS-CoV-2 exposure. Because they are considered members of the essential workforce, they may also be unable to attend an appointment to undergo COVID-19 testing before a scheduled procedure such as cesarean delivery or cancer surgery. As cities and counties cut back on public transportation services, if this same patient relies on these services, she may face further challenges in attending appointments. Finally, the care of patients with limited access to childcare, may be particularly affected by new hospital policies restricting visitors in the outpatient setting.

We know that there are perennial and persistent racial and ethnic disparities in birth outcomes among women with high-risk pregnancy conditions such as preeclampsia and diabetes.11 Furthermore, women with these conditions require more frequent office visits to monitor both maternal and fetal well-being, increasing the risk of SARS-CoV-2 exposure. We also know that there is an association between chronic stressors and poor pregnancy outcomes such as preterm birth.12 Unfortunately, this pandemic also exacerbates stress levels, not only by posing the obvious threats to one's health and safety, but, for some, also threatening income and housing stability.

With the rise in state-issued “stay-at-home” orders, women experiencing domestic or intimate partner violence may also be at increased physical risk. Globally elevated levels of anxiety and social isolation during these times may also increase risk of mood disorders such as depression and anxiety, especially during pregnancy and the immediate postpartum period, which are already times of heightened vulnerability. The limited number of in-person visits may make it more difficult to screen and identify women at risk, as well as connect them to resources, including psychiatric care and other social services.

Let us return to the topic of access to gynecologic surgery during this pandemic and who determines the urgency or elective nature of specific procedures. States including Ohio and Texas have ruled that abortion services are elective, nonessential procedures that should not be performed during this pandemic, despite statements to the contrary by the American College of Obstetricians and Gynecologists and the Society for Family Planning.13 The concerns raised above about bias against socially vulnerable groups in the allocation of limited medical resources likely also apply to the resource of gynecologic surgery. There is existing evidence of racial disparities in route of hysterectomy, such that black women are less likely to undergo minimally invasive hysterectomy than are white women, even after adjusting for confounding medical and surgical factors.14 The same individual-, physician-, and hospital-level factors that contribute to this disparity may influence who does and does not receive gynecologic surgery during the COVID-19 pandemic, and again disproportionately affect black women. Even though departments like our own have offered guidance, such as a recommendation to proceed with scheduled procedures for malignancy or to rule out malignancy, leaving such crucial determinations to be made on a case-by-case basis may ultimately allow for the introduction of implicit bias.

As health care systems rapidly enact new policies and procedures to respond to this public health crisis, it is critical to consider the risk of exacerbating existing health inequities. Now is the time to take proactive steps toward creating—and protecting—equity. First, let us acknowledge existing inequities in health outcomes among socially vulnerable populations and the historical systems that have raised the incidence of chronic conditions now associated with risk of death from COVID-19 infection. Next, we must identify at-risk populations in our communities and increase awareness of potential causes of disparities in birth and gynecologic care outcomes for these populations. This might include systematically identifying barriers or challenges to equitable care and proposing practical and feasible solutions, for example, providing culturally and linguistically appropriate means of communication for all patients or childcare services during appointments. It may also include efforts to enhance screening for domestic violence or peripartum depression to identify these particularly vulnerable women and establish robust systems for referral to support services. Finally, we must all remain cognizant of areas where bias or systematic discrimination against vulnerable populations may be introduced into protocols, such as allocation of limited medical resources or decisions about surgical urgency, and then take steps to correct those processes or compensate for any embedded bias. Ultimately, as new policies and protocols are being established for obstetric and gynecologic care in your facility in response to the COVID-19 pandemic, be proactive in creating policy that promotes equity.

REFERENCES

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