The NEW ENGLAND JOURNAL of MEDICINE|Perspective |November 26, 2020 pp2097-2099 Sonja A. Rasmussen, M.D., Anne Drapkin Lyerly, M.D., and Denise J. Jamieson, M.D., M.P.H.
Read the article for detail and access to references and also listen to the free interview of Dr. Rasmussen available on NEJM.org.
With the rise of the COVID pandemic the question of whether or not a public health agency like CDC should recommend delaying pregnancy is being evaluated. Two of the authors (SAR and DJJ) were in leadership at CDC during the 2009 H1N1 influenza and the 2016-2017 Zika virus outbreaks and that helped them in creating this Perspective article.
With H1N1, Zika and in the HIV epidemic ultimately CDC “...focused its efforts on educating women and their clinicians on ways to prevent infection, the importance of early treatment and the need for vaccination once a vaccine became available.” Regarding Zika in 2016 and 2017 the “CDC recommended that clinicians discuss with patient the risks of Zika virus infection during pregnancy and ways to avoid transmission and ask patients about their reproductive life plans, rather than recommending postponing pregnancy.”
With respect to COVID-19 there are some findings;
1) “a recent study found that pregnant women with COVID-19 have 1.5 times the risk of being admitted to an intensive care unit (ICU) and 1.7 times the risk of requiring mechanical ventilation faced by nonpregnant women of childbearing age with COVID-19 but that pregnant women aren’t at risk for death.
2) “Intrauterine transmission of SARS-CoV-2 appears to occur rarely, and no evidence has suggested an association between Covid-19 and birth defects; however, data suggest that preterm birth and admission to a neonatal ICU are common among infants born to SARS-CoV-2-infected women.”
The authors suggest as in the past “ In clinical contexts, advice regarding pregnancy avoidance has tended to rely on a doctrine or nondirective counseling in which a clinician offers information about risks and approaches to minimizing them and supports patients in making informed decisions.” If there are other severe risks to pregnancy the guidance could be appropriately more directive.
The ethical backbone underpins the nondirective guidance especially for a public authority. What is important is facilitating “reproductive autonomy”, “self determination”, “personal security” and “life course.” Another less obvious concern is the “potential for discrimination” that could result in “differential experiences according to race, ethnic group, or social class…and a final concern pertains to the interests of people with disabilities.”
The authors believe “that before public health agencies make a recommendation to avoid pregnancy during a public health emergencies, several criteria should be met.”
1) “The pregnancy-related risks…should be well understood.”
2) These risks stated in 1) “should be high and well above the risk associated with other conditions or exposures that are fairly common among pregnant women.”
3) It “should be that pregnancy-related risks cannot be reasonably minimized.”
4) “effective contraception should be readily available” so women wanting to avoid pregnancy “should be able to do so.
5) “educational programming that carefully and effectively lays out the risks and benefits associated with becoming pregnant during the public health emergency as compared with waiting until it ends to conceive should be widely available.”
Based on these criteria and current knowledge the authors end by noting “we don’t believe that the risks associate with COVID-19 meet the bar.”