Covid 19- women’s health, occurrence of neural tube defects and severe acute malnutrition in children

Phadke M1,Nair R2,Menon P3,Jotkar R4, Saunik S5
Dear sir,

We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
India has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
India has now begun to see the ill effects of pandemic on nutrition as collateral damage.We report two important observations on occurrence of Neural tube defects and severe acute malnutrition in children during the years from 1st January to 31st December of 2020 and 2021. The study has been done in Maharashtra, India, where a team of doctors under the national health program of RBSK(Rashtriya Bal Swasthya Karyakram), examined children below 18 years for '4Ds' i.e. Defects at birth, Diseases in children, Deficiency conditions and Developmental delays including disabilities. The same districts and anganwadis were screened in 2020 and 2021. The year 2020 was a reflection of health and nutrition status of adolescent girls, who were married in the pre-Covid years and delivered babies in the year 2020 and children in precovid time. The year 2021 reflected the health and nutrition status of women in the Covid year of 2020 who had to bear the brunt of the pandemic. It also reflected the status of nutrition in children in 2020 i.e. precovid times and 2021 reflecting nutritional insult in 2020.
A total number of 2121564 children were examined in 2020. Out of them 112(0.005%) were detected to have neural tube defects ( NTDs-meningocoele, meningomyelocoele, spina bifida), though anencephaly with resultant still births do not get reported in this data. In 2021, a total of 516655 babies were examined and 101(0.02%) had neural tube defects which are four times that of 2020 as per records from RBSK .The difference is statistically highly significant.(p<0.001). The number of babies born with NTDs were probably affected by Covid induced collateral nutrition insult i.e. folic acid deficiency in women during periconceptional period. Severe acute malnutrition was detected by measuring weight for height below -3SD on WHO growth charts. 7482 children had SAM (0.353%) in 2020 and 7148 (1.38%) children had SAM in 2021.The difference is statistically highly significant (p<0.001).
Occurrence of SAM is a measure of nutritional status of children of the community. It also is indicative of acuteness of nutritional insult. Unimaginably, it stands to reason that inadequate nutrition in 2020 manifested in more children developing SAM and the number is four times more than previous year.
High incidence of NTDs is even more alarming. Covid 19 resulted in women consuming less folate rich green vegetables, and they could probably not receive iron folic acid tablets during lockdowns. This resulted in birth of more children with neural tube defects.
NTDs are a surrogate marker of micronutrient deficiency in mothers during periconceptional period ; highlighting the importance of adolescent pre pregnancy and antenatal health. This is probably the first report of micronutrient impact of Covid 19 in periconceptional women.
Both these results depict nutritional impact of Covid 19 on women and children from Maharashtra, India.

We declare no conflict of interest.

1. Sr. Adv, and former Vice Chancellor, MUHS, Mumbai, India
2. Nutrition Specialist, UNICEF, Mumbai, India,
3. Assoc. Prof, Ped and Med Edu, DYP. Med college, Pune,India
4. Sr. Consultant, Pub.health, RJNM,Mumbai, India
5. Addl Chief Sec. Govt of Mah,Mumbai, India.

References

1.Zeus Aranda, Thierry Binda, Katherine Tashman,Ananya Tadikon Daniel Maweu,Emma Jean Boley6,Isaac Mphande, Isata Dumbuya, Mariana Montaño, Mary Clisbee, Mc Geofrey Mvula, 
Melino Ndayizigiye Meredith Casella Jean-Baptiste, Prince F Varney,Sarah Anyango Karen Ann GrépiJean Bethany Hedt-Gauthier, Isabel R Fulcher  on behalf of the Cross-site COVID-19 Syndromic Surveillance Working Group. Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries BMJ Global Health 2021 Vol7 issue1http://dx.doi.org/10.1136/bmjgh-2021-007247)

To the editor,

With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.

The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Italy) and the Research Center in Emergency and Disaster Medicine (CRIMEDIM, Università del Piemonte Orientale, Italy)3. According to the triage classifications, most “red” indications were maternal/perinatal emergencies, making this the most important focus of the service3.

We have seen the contribution of NEMS in our rural 80-bed hospital in Yele, Tonkolili district, with a catchment population of 150.000. The 2 ambulances stationed in our catchment area, together with ambulances sending referrals from elsewhere, presented an average of over 2 patients per 24 hours to our hospital for emergency services. We used NEMS ourselves for referrals to third-line indications upon indication. As a response to this well-functioning service, have scaled down our ambulance services with the number of drivers and vehicles reduced as they were no longer needed. In line with the NEMS-focus, the majority of presentations were maternal/perinatal admissions; we saw frequent advanced stage diseases due to first delays and in some cases second delays in light of the Three Delays framework. Still, despite the impressive pathology, there were many mothers that could receive proper care and return home in stable condition with a healthy newborn.

Fast forward not even 2 years after the connection of the last district, when the NEMS service was released to the MoHS on the first of January 2021. While ambulances frequented the hospital in December 2020, this came to a total stillstand one month later. As of that moment, the number of presentations by NEMS dropped from over 2 patients per day to one patient in the 9 months after. Due to financial troubles, the whole service collapsed. NEMS ambulances are currently gathering dust on the parking lots of governmental hospitals. Inquiry with hospitals in other districts showed a comparable drop in NEMS presentations after release of the service.

The case of NEMS may be a positive and negative example at the same time. The development of a nationwide ambulance service in a low-income country with high maternal and neonatal mortality is to be applauded. During the time NEMS was in service, the authors demonstrate that a respectable percentage of patients can be transferred to a hospital in time despite large distances and poor road conditions. Furthermore, as shorter prehospital times lead to improved outcome, the service was an important part of the health infrastructure of Sierra Leone.
The current situation with a powerless ambulance service is worse than when NEMS came into service. Before, hospitals had their own ambulance services and drivers, and were sometimes able to pick up patients from peripheral health units through intensified communication. Nowadays, hospitals have scaled down on their number of drivers and ambulances due to the presence of NEMS, and NEMS itself is unavailable for transportation of the needy. To us, it is unclear whether mismanagement, a premature program release, actual financial constraints or perhaps even corruption brought the NEMS-program to its current state. As such, the contrary of the research implications came true: due to the unavailability of the service, a lower percentage of mothers is able to reach hospitals, which will inevitably lead to an increase in maternal and neonatal mortality.

In conclusion, the authors demonstrate the NEMS-service has resulted in swift transport of patients to the proper health facilities, thereby reducing the maternal and perinatal mortality. The premature program release to the local government however has resulted in the unavailability of ambulance services, both by NEMS and local hospitals, thereby likely increasing the already worrisome maternal and perinatal mortality. The important lessons are that the development and deployment of an elaborate ambulance service is possible in sub-Saharan African countries, but premature release of such programs to local government that lack sustainable and durable resources to continue programs, may result in a situation that is worse than before the service started.

1 Caviglia M, Putoto G, Conti A, et al. Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study. BMJ Glob Heal 2021; 6: e007315.
2 Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015. , 2015.
3 Caviglia M, Dell’aringa M, Putoto G, et al. Improving access to healthcare in sierra leone: The role of the newly developed national emergency medical service. Int J Environ Res Public Health 2021; 18: 1–12.

Dear Editor,

I am extremely puzzled by the lack of any response regarding my proposed comments regarding this article. I've submitted my comments twice, but they have not been published. I cannot imagine why. It appears to be a discretionary censorship, which is of course contrary to BMJ's published editorial policies which generally favor respectful discourse. I would greatly appreciate an explanation and an appeal to a larger panel of BMJ editors.

To repeat...for the third time,... regarding this article:

There is a growing interest in developing evidenced based standards for public health policy initiatives.[1] In response to this effort, Burris et al have put forward their own initial effort to identify the potential effects of laws regulating abortion on women’s health.[2] Unfortunately, they apparently failed to include in their research team anyone with familiarity with the literature regarding the negative physical and psychological effects of coerced and unnecessary abortions. This is not a minor oversight.

Regarding the issue of women’s autonomy, increasing legal access to abortion is a double-edged sword. Easier access makes it easier for women to choose abortion for their own self-interests, but it also makes it easier for those pressuring women into unwanted abortions to abuse women’s rights.[3]

Coerced abortions are especially common among women enslaved in sex trafficking.[4,5] But it is also common within households precisely because every pregnancy impacts not just the pregnant woman, but also male partners, parents, employers, and society at large . . . as evidenced by advocates of population control who have sought and implemented public policies that discourage birth.[3]

As many as 64% of American women acknowledging a history of abortion report having felt pressured to abort by others.[6] Similarly, a 2021 study of women seeking abortion found that only 42% described their pregnancy as never wanted.[7] The pressure to abort a pregnancy that might otherwise be welcomed typically comes from their male partners, parents, employers and social services officials.[8]

As might be imagined, negative psychological reactions to abortion are more common when women feel pressured into an abortion or have other conflicting maternal interests and moral beliefs.[6,9] These are just a few of the 15 risk factors identified by the APA for negative psychological reactions. They include: terminating a pregnancy that is wanted or meaningful; perceived pressure from others to terminate a pregnancy; perceived opposition to the abortion from partners, family, and/or friends; lack of perceived social support from others; various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life); a history of mental health problems prior to the pregnancy; feelings of stigma; perceived need for secrecy; exposure to antiabortion picketing; use of avoidance and denial coping strategies; feelings of commitment to the pregnancy; ambivalence about the abortion decision; low perceived ability to cope with the abortion; history of prior abortion; and late term abortion.[9] The best evidence indicates that the vast majority of women undergoing abortion have one or more of these risk factors.[9]

Even assuming that the negative psychological associated with abortion, including increased risk of substance abuse,[9] postpartum psychiatric risks,[10] sleep disorders,[11] posttraumatic stress disorder,[9] and suicidal ideation and other risk taking behaviors[9] are entirely due to coerced and unwanted abortions, the importance of laws intended to prevent unwanted abortions should not be ignored…but that is precisely what Burris et al have done.

For example, one of the reasons for laws requiring parental involvement or notification are to help prevent a minor from undergoing a coerced abortion at the behest of the male partner or his family. They are also intended to prevent a minor from fearfully consenting to an otherwise unwanted or unnecessary abortion because of a mistaken fear that the minor’s parents will reject her because of her sexual activity and will not support her desire to keep the pregnancy.

But in Table 1, the benefit of “prevention of unwanted, unnecessary or unsafe legal abortions” is not identified in the list of “plausibly related outcomes” for any of the types of laws considered. Nor is there any consideration of “saved costs” and in regard to fewer treatments for the negative health effects associated with unwanted abortion.[9]

Numerous studies have also found a strong link between induced abortion and subsequent pre-mature and low-birth weight deliveries.[12] In the context of the United States, the increased medical costs in treating subsequently pre-maturely born children just to the point of hospital discharge apportions out to approximately $100,000 per 100,000 abortions. Therefore, any reduction in abortion rates that may result from laws that reduce the risk of coerced and unwanted abortions would produce significant health care savings, would reduce the risk of lifelong health complications associated with premature and low birth weight deliveries, and would save numerous lives among later planned pregnancies. But again, none of these benefits appear in Table 1.

Moreover, literally every record linkage study (eleven in total) examining reproductive outcomes associated with mortality has shown that abortion is associated with an increased risk of premature death among women exposed to abortion.[13] There is even a dose effect, with each abortion increasing the risk of an early death by approximately 50 percent.[13] At least a part of this increased risk is due to the increased risk of within a year of an abortion.[14,15] But even if we again assume that all these risks attach only to unwanted abortions (presuming that if a woman truly wants an abortion according to her own guiding lights, she will experience no psychological harm), the fact remains that any law which may help to reduce the rate of unwanted abortions is likely to reduce mortality rates and thereby increase work productivity and gross national product. But, yet again, the positive plausible outcomes have been omitted from Table 1

Notably, “unintended childbirth” is one plausible outcome that Burris et al have associated with every type of law identified in Table 1. But that outcome is poorly defined. When, and how often, is “unintended childbirth” a benefit to women and when is it a harm? Countless women report great satisfaction and blessing from their subsequent delivery of unplanned pregnancies. In fact, the Turnaway Study found that among all the women who were denied a late term abortion, 60% reported being happy about continuing their pregnancies, and by the time the child was born, only 12% still wished they could have had the abortion.[16] The bottom line is that many “unintended” and even “unwanted” pregnancies are associated with a mix of feelings, a mix that in the long run often result in a “welcomed” child, one that is valued not because the child was planned but simply it is the woman’s and her family’s child. Given that Burris et al are arguing for better research to support policy decisions, the importance of better research to identify when and how often unintended pregnancies result in a welcomed child should be a priority, as well as research to identify public policies that can help to make it easier for families to welcome unintended children.

Finally, Burris et al have failed to identify in the list of potential legal interventions laws governing informed consent, risk disclosure and pre-abortion screening for risk factors identifying women who may be at greater risk of being coerced or may feel pressured by social circumstance to agree to an abortion contrary to their moral beliefs and/or maternal desired.

In short, Burris et al’s analysis has failed to fully describe or analyze the plausible effects of statutes and public policies intended to protect women from unwanted, unnecessary and unsafe legal abortions. Simply declaring abortion legal does not necessarily render them safe and effective for all women in any and all circumstances of an “unintended” pregnancy.

Unfortunately, “unintended” pregnancies are often more unwanted by others (including population control activists) than they are by the pregnant themselves. In many cases, women are resiliently willing to embrace their unintended pregnancies as a welcomed-children. Often, it is only the hostility of others, and the accompanying pressure to submit to unwanted abortions, that is the true attack on women’s rights and autonomy.

Laws designed to identify and alleviate the pressures on women to undergo unwanted and unnecessary abortion should be pursued and implemented to save lives, reduce costs, and increase the well-being of both women and their children.

Competing Interest
David Reardon is the Director the Elliot Institute which sponsors peer reviewed medical research, promotes post-abortion healing programs, and advocates for laws requiring pre-abortion screening for coercion and other risk factors associated with negative outcomes for women.

References

1. Rehfuess EA, Stratil JM, Scheel IB, Portela A, Norris SL, Baltussen R. The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective. BMJ Glob Heal [Internet]. 2019 Jan 1 [cited 2022 Jan 13];4(Suppl 1):e000844. Available from: https://gh.bmj.com/content/4/Suppl_1/e000844
2. Burris S, Ghorashi AR, Cloud LF, Rebouché R, Skuster P, Lavelanet A. Identifying data for the empirical assessment of law (IDEAL): A realist approach to research gaps on the health effects of abortion law. BMJ Glob Heal [Internet]. 2021 Jun 1 [cited 2022 Jan 13];6(6):e005120. Available from: https://gh.bmj.com/content/6/6/e005120
3. Reardon DC. Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment. J Contemp Health Law Policy. 2003;20(1):33–114.
4. Coyle C. Sex Trafficking. In: MacNair RM, editor. Peace Psychology Perspectives on Abortion. Kansas City. MO: Feminism & Nonviolence Studies Association; 2016.
5. Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2014;23(1):61.
6. Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit. 2004;10(10):SR5–16.
7. Biggs MA, Neilands TB, Kaller S, Wingo E, Ralph LJ. Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS). Vaingankar JA, editor. PLoS One [Internet]. 2020 Dec 10 [cited 2021 Feb 8];15(12 December):e0242463. Available from: https://dx.plos.org/10.1371/journal.pone.0242463
8. Elliot Institute. Forced Abortion in America: A Special Report [Internet]. Springfield IL; 2004. Available from: https://afterabortion.org/new-elliot-institute-report-exposed-americas-f...
9. Reardon DC. The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities. SAGE Open Med [Internet]. 2018;6:205031211880762. Available from: http://journals.sagepub.com/doi/10.1177/2050312118807624
10. Reardon DC, Craver C. Effects of pregnancy loss on subsequent postpartum mental health: A prospective longitudinal cohort study. Int J Environ Res Public Health [Internet]. 2021 Feb 2 [cited 2021 Mar 17];18(4):1–11. Available from: https://pubmed.ncbi.nlm.nih.gov/33672236/
11. Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006;29(1):105–6.
12. Calhoun BC, Shadigian E, Rooney B. Cost consequences of induced abortion as an attributable risk for preterm birth and impact on informed consent. J Reprod Med. 2007;52(10):929–37.
13. Reardon DC, Thorp JM. Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis. SAGE Open Med [Internet]. 2017 Dec 13 [cited 2018 Aug 15];5:205031211774049. Available from: http://journals.sagepub.com/doi/10.1177/2050312117740490
14. Gissler M, Berg C, Bouvier-Colle M-H, Buekens P. Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. Eur J Public Health. 2005 Oct;15(5):459–63.
15. Reardon D, Strahan T, Thorp … J. Deaths Associated with Abortion Compared to Childbirth-A Review of New and Old Data and the Medical and Legal Implications [Internet]. J. Contemp. Health …. 2003. Available from: http://heinonlinebackup.com/hol-cgi-bin/get_pdf.cgi?handle=hein.journals...
16. Foster DG. The Turnaway Study: ten years, a thousand women, and the consequences of having--or being denied--an abortion. New York, NY: Scribner; 2020. p. 360.

A very informative and well-round study that gives a somewhat comprehensive explantation (as a pioneer study) on how scientists from different fields interact with policymakers during the COVID19-pandemic. It gives a good explanation of how difficult the “sandwich position” seems to be when you have to work in a field requiring interdisciplinary competencies.
Some critique points might include the fact that one of the interviewed scientists mentioned, that wearing a mask was not effective (P4, the Netherlands on page 5). Given the view from a very European perspective, a view over to the Asian neighbours would have or could have clarified this point. (1)
The European point is another thing that needs to be taken into consideration. Although the authors mentioned that the result might not apply to other parts of the world, it is crucial to mention that this issue needs to be addressed if we talk about a better interdisciplinary workforce globally during a pandemic.
Moreover, could a quantitative approach would have led to different results? Maybe the purview or range among scientists would have been more applicable with a fitting survey so that more scientists in related fields and positions could have been reached.
Fears and reservations about anonymity could be eradicated by this study design over a potentially large(r) study population.
However, I would like to thank you for this paper and hope that broader research on the field could bring also global perspectives and answers into account.

(1) Galvin CJ, Li YJ, Malwade S, Syed-Abdul S. COVID-19 preventive measures showing an unintended decline in infectious diseases in Taiwan. Int J Infect Dis. 2020 Sep;98:18-20. DOI: 10.1016/j.ijid.2020.06.062. Epub 2020 Jun 23. PMID: 32585283; PMCID: PMC7308751.