As a group of pregnant physicians in the United States during the COVID19 pandemic, we ask for your support in petitioning ACOG to protect all pregnant healthcare workers and their care teams. Please see the draft letter below that we hope to send by 4/3/20. 

 

Dr. Maureen Phipps, Chief Executive Officer, and Dr. Ted Anderson, President

American College of Obstetricians and Gynecologists

 

Dear Drs. Phipps and Anderson, 

Situation: We are writing on behalf of all undersigned pregnant healthcare personnel (HCP) and allies regarding our concerns about pregnant healthcare workers continuing to work in-person and in high-risk settings during the COVID-19 pandemic. We believe the current Centers for Disease Control and Prevention (CDC) and ACOG guidance to “consider limiting exposure of pregnant HCP to patients with confirmed or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures) if feasible based on staffing availability” is not sufficient to protect pregnant HCP and their own healthcare teams from CO\VID-19 infection.1

Background: Viral pneumonias are known to cause a variety of adverse maternal and fetal outcomes.  As has been seen with other coronavirus infections such as SARS-CoV-1 and MERS, there is potential for significant morbidity and mortality in pregnancy.2,3 Recent studies suggest that COVID-19 infection could have serious implications for both pregnant people and their babies including higher rates of preterm birth, preeclampsia, and NICU admission.4-7 While current absolute risk of COVID-19 infection and serious complications during pregnancy is largely unknown, lack of evidence does not equate to lack of harm. 

Compared to other pregnant people who may be able to practice more strict social distancing, pregnant healthcare workers are at higher risk of contracting COVID-19 because of repeated exposure to multiple patients and healthcare worker colleagues, some of whom may be asymptomatic but still infectious.  National PPE shortages and discrepancies in PPE use guidelines across healthcare institutions may also put pregnant HCP at increased risk of acquiring COVID-19 while working. Moreover, there have been increasing case reports of pregnant women presenting in labor who then go on to develop symptoms of COVID-19, exposing entire labor and delivery teams to infection.4 Thus, pregnant healthcare workers may be at increased risk of exposure to and infection with SARS-CoV2 as well as at increased risk of spreading the infection to their own healthcare team during prenatal visits or labor. 

For these reasons, RCOG recommends that all pregnant HCP be offered the choice of whether to work in direct facing roles during the COVID-19 pandemic versus remote or non-clinical work such as telehealth or administrative duties.8 The same recommendations state that during the third trimester (after 28 weeks gestational age), healthcare workers should stay at home. In the United States, several healthcare systems have implemented this policy but it has not been universally adopted. 

Assessment: CDC and ACOG recommendations are vague in guidance and proposed action. This allows individual healthcare institutions to determine whether limiting exposure of pregnant healthcare workers is “feasible” and if so, how best to do so.  Additionally, we believe there are several problematic issues with the current advice:

These recommendations are based on a very limited number of cases and almost all of the cases were third trimester pregnancies requiring extrapolation to the different setting of first and second trimester infection which each have their own set of potential consequences. Under any other circumstances, such a small amount of inconclusive evidence would not be considered sufficient to establish standard practice.
Pregnant people have identified and time-sensitive healthcare needs in the form of prenatal care, labor and delivery, and postpartum care. Pregnant people are, in this sense, guaranteed patients needing the healthcare system during the immediate future. If these individuals become ill with COVID-19, this will strain the healthcare system in numerous ways, as both the woman and her newborn must be kept in isolation, require use of PPE, require hospital beds, require use of healthcare personnel, and expose the L&D team to infection risk.
COVID-19 experimental therapies are not all suitable for pregnant people to take (many are category C drugs).
Absence of clear society-issued guidelines will differentially affect vulnerable workers who may not have the means or tools to advocate for themselves without institutional protection.

Recommendation: We ask ACOG to follow the example set by RCOG and issue a strong statement advocating for the protection of pregnant frontline essential workers, such as healthcare workers, by limiting their in-person clinical exposure. We ask ACOG to officially recommend that all pregnant healthcare workers be offered either lower-risk or remote working options in order to limit the chance of exposure otherwise experienced in direct patient care. Additionally, we ask ACOG to recommend that pregnant healthcare workers in the third trimester not have any direct patient contact and have the option to stay at home, minimizing risk to pregnant persons as well as risk of preterm birth and other adverse fetal outcomes.

If enacted, we believe these policy changes will have numerous positive effects. These policies can prevent an increase in maternal and neonatal morbidity and mortality, maintain the health of pregnant HCP so they can return to work as rapidly as safely possible after delivery in the setting of an anticipated healthcare worker shortage, and reduce exposure of ACOG members and labor and delivery teams to infected pregnant HCP. We are confident that ACOG can update its recommendations in order to continue to fulfill its stated mission of improving women’s health and advocating on behalf of members and patients. As your members, colleagues, and patients, we are counting on ACOG’s leadership.

Sincerely,

Undersigned 

Citations 

1. Centers for Disease Control and Prevention. 2020. Coronavirus Disease 2019 (COVID-19). [online] Available at: <https://www.cdc.gov/coronavirus/2019-ncov/hcp/pregnant-women-faq.html#pregnant> [Accessed 29 March 2020].

2. Schwartz DA, Graham AL.  Potential Maternal and Infant Outcomes from Coronavirus 2019-nCoV (SARS-CoV-2) Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections. Viruses. 2020 Feb; 12(2):194.  doi: 10.3390/v12020194

3. Wong SF, Chow KM, Leung TN, Ng WF, Ng TK et al.  Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol. 2004 Jul; 191(1):292-7.

4. Breslin N, Baptiste C, Miller R, et al. COVID-19 in pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM. Published online March 27, 2020. doi: 10.1016/j.ajogmf.2020.100111

5. Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. Published online March 26, 2020. doi:10.1001/jamapediatrics.2020.0878

6. Liu Y, Chen H, Tang K, Guo Y.  Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect. March 4, 2020, DOI: https://doi.org/10.1016/j.jinf.2020.02.028

7. Di Mascio D, Khalil A, Saccone G, Rizzo G, Buca D, Liberati M, Vecchiet J, Nappi L, Scambia G, Berghella V, D’Antonio F, Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis, American Journal of Obstetrics & Gynecology MFM  (2020), doi: https://doi.org/10.1016/j.ajogmf.2020.100107

8. Royal College of Obstetricians and Gynaecologists. COVID-19 virus infection and pregnancy. Occupational health advice for employers and pregnant women during the COVID-19 pandemic. Published online March 26, 2020. Available at <https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-26-covid19-occupational-health.pdf>