It is Sadia’s second pregnancy. This time round, the nausea is incessant and harder to endure in her first trimester. Previously, Sadia would distract herself by dropping by at her parents’ house or she would make plans with friends. But now, with the lockdown, she fears meeting her ageing parents lest they get infected, and neither can she plan meet-ups with friends. Frequent visits to the hospital are also not possible because of the fear of getting infected.

At night, lying in bed, Sadia imagines how dreadful it would be if she were to become infected with the dangerous virus. She imagines breathing difficulties and being stuck alone in an isolation ward or by herself in a separate room at home. These thoughts keep her awake, causing panic attacks and increased vomiting. Having postponed her next hospital visit to avoid exposure to infection, Sadia cannot help thinking how she can give birth in an environment so bleak and uncertain. She tries her best to convince herself that things will get better, both for her and the baby.

She is not alone. An estimated 116 million babies will be born across the world in the 40-week period between March 11 and December 16, with almost a quarter of them in South Asia.According to a report released on May 6 by the United Nations Children’s Fund (Unicef), an estimated 29 million babies will be born in South Asia in the nine months after the Covid-19 outbreak, while an estimated five million births will be reported in Pakistan.

The report also warns that lockdown measures imposed to curb the spread of the coronavirus may cause disruptions in life-saving health services, “putting millions of pregnant mothers and their babies at great risk.”

For most Pakistani women, pregnancy is a hard journey on its own, but a pandemic such as Covid-19 can cause both physical and mental problems. Previously, researchers thought that if an expecting mother did catch the virus, most cases would be mild. However, the recent death of a 29-year-old, pregnant woman in the UK raises questions whether expecting mothers are more vulnerable to the virus compared to everyone else.

Pregancies can be a time of stress for expectant mothers. The pandemic and its resultant lockdowns have added to their mental strain and sense of isolation. But there are ways to reduce anxiety

“For pregnant women who already have underlying health conditions, such as diabetes, the risk is definitely higher,” says Dr Rizwana Shoaib, a gynaecologist at Karachi’s South City Hospital.

“But this virus attacks each patient differently,” Dr Shoaib adds. “The woman who died in the UK was young, with no aforementioned health conditions, so there’s a lot of uncertainty. We’re learning from each case, and only time will unravel knowledge.”

For now, it’s clear that since pregnancy causes changes to the immune system, that can be associated with more severe symptoms for some women who contract the virus, especially those in their last trimester.

“Safety is paramount, for all pregnant women,” says Dr Shoaib. She advises her patients to avoid close contact with people in general at this time, not just someone who is manifesting symptoms. “Someone who is infected may not show signs straight away but their respiratory secretions can enter your eyes, mouth, nose or airways to infect you. Expectant mothers must make a conscious effort to reduce risk by washing their hands repeatedly and to avoid touching their faces.”

Social distancing is necessary to reduce risk for pregnant women, but that does not mean antenatal care should be avoided. “Hospital visits, when needed, are a must,” says Dr Fauzia Rasool, a gynaecologist at Dr Ziauddin Hospital. “Missing appointments is not a good idea, even in the context of the coronavirus. You must keep in contact with your maternity team and attend your scheduled routine even if you are keeping well. If you have an appointment or an ultrasound scheduled, wear full-sleeved clothing for your visit along with a mask and gloves. Afterwards, take a shower and change your clothes. This will ensure that you are free from any possible exposure to the virus.”

If a woman is self-isolating because someone in their household has possible symptoms of Covid-19, however, routine appointments can — and should — be deferred for 14 days. “In case the woman shows symptoms of coronavirus, appointments can be deferred until seven days after the start of symptoms, unless signs [aside from a persistent cough] persevere,” says Dr Shoaib. “If a Covid-19 infection is confirmed during pregnancy, you should call the maternity unit for advice.”

With most cases on record, self-isolation is enough for recovery. If you are nearing your due date, a full maternal and fetal assessment should be conducted to include an assessment of your symptoms and temperature, your respiratory rate and oxygen saturations. If you choose to have a caesarean birth, your doctor will likely advise you to delay it as much as possible, subject to the baby’s health, to reduce risk of infectious transmission to other women, healthcare workers and, potentially, to your baby.

Women who are delivering at this time need additional support at the hospital. Usually, their families would accompany them, but hospitals are now restricting the number of attendants and visitors. “A birth partner is allowed for birthing support, of course,” says Dr Rasool. “However, to reduce the risk factor, hospitals check the [expecting mother’s] partner for [symptoms such as] fever, persistent cough, shortness of breath or a sore throat in the previous week, before allowing them into the labour room. I understand that a new baby is, naturally, a time of celebration. Yet, hospitals must ensure compliance with social distancing measures, and must restrict the entry of visitors to decrease the chances of a spread. Family and friends should understand that,” she adds.

But for a pregnant woman, who needs support from family and friends, isolation can significantly affect her mental health. “A general increase in anxiety is to be expected in the current situation,” says Tehmina Waqas, a psychologist at Dr Ziauddin Hospital. “Increased anxiety during pregnancy is not good,” she continues. “Studies show that when a pregnant woman experiences intense fear, anxiety or negative moods, physiological changes occur that might affect her baby.”

According to Waqas, the foetus, prone to high levels of cortisol in the mother’s body, may later be at a higher risk of developing emotional or cognitive problems of its own, such as ADHD and delay in language acquisition. Maternal depression and anxiety, that is enhanced by fear and isolation caused by the virus, must be tackled.

Expecting mothers must avoid falling into a negative spiral. “The strategies that I am providing are helpful, not just for pregnant women, but for anyone who needs help in coping with isolation and unhealthy stress,” says Waqas. “Firstly, stop catastrophising. It is irrational to think that something is far worse than it actually is.”

Avoid using words like ‘devastated’, ‘all over’, ‘terrible’, ‘doomsday’ and similar terms that the media is using right now. Instead, use enabling quotes that can help discover the positives in adversity such as ‘coronavirus is helping us build family bonds’ or ‘life has become slower and more manageable,’ etc.

Several Obsessive Compulsive Disorder (OCD) rituals can be triggered by this virus, so it’s important to keep a balance when hand-washing or using sanitisers. If the fear still gets to you, tell yourself that all pandemics before this one have ended, right? This one will too, very soon. We just have to wait it out.

“Anxiety usually correlates to a sense of losing control,” says Dr Rasool. “You might have planned things for yourself, like having a baby shower, or a ‘babymoon’, or going baby shopping with your loved ones, and everything’s been put on hold or cancelled. It’s terrible, definitely anxiety-provoking. But ask yourself, can you control any of these things — the shops not opening, the airlines not operating? It’s okay to worry about them, and I would recommend having a worry time, but perhaps for just 10 minutes a day. Afterwards, try to determine whether you can do anything about the things on your worry list. If not, shrug your shoulders and tell yourself it’s not in your control. That will decrease anxiety substantially.”

Waqas recommends yoga and exercise. “Walk around the house for a few minutes to de-stress,” she recommends. “If you have a garden or access to more space, that is even better. Make it a routine to breathe deeply daily, for 10 minutes. It is an excellent time for you to bond with your baby, especially when you are away from the hustle and bustle of daily life. Both of you are in this together, you should be grateful for the life that is growing inside you. A little gratitude works wonders to calm you down.”

Finally, the best way to disengage from stress is by talking to friends and family members via video or audio call. “Social distancing does not mean you can’t engage with your family at all,” says Dr Rasool. “Pregnant women need all the support they can get. Talk to your friends, video call your mother. Share your thoughts and feelings with them.”

The bottom line is that, while it is not yet known whether Covid-19 can be transmitted from a mother to her unborn baby, Unicef recommends that all pregnant women closely monitor themselves for Covid-19. Moreover, it is the health system overload that threatens pregnant women and newborns. “Just remember,” says Dr Rasool, “that very soon, you will have a new baby to love and take care of — virus or no virus,” she smiles. “That, and your safety, is what should matter the most.”

Published in Dawn, EOS, May 17th, 2020