Q&A: How the COVID-19 pandemic affects women’s health

During the COVID-19 pandemic, physicians across the United States have reported seeing fewer patients, who are fearful of presenting to the office due to the virus.

In a recent survey of 773 primary care clinicians, 38% reported that they expected to see deaths not related to COVID-19 as a result of delayed or lack of access to care.

For women, not undergoing regular health care visits due to the pandemic may have long-term implications for their health stemming from missed cancer screenings, lack of access to birth control and fertility treatments.

In honor of National Women’s Health Week, Healio Primary Care spoke with Dee Ellen Fenner, MD, chair of the department of obstetrics and gynecology at the University of Michigan, to learn more about the challenges to women’s health created by the COVID-19 pandemic. – by Erin Michael

Q: How has the COVID-19 pandemic affected OB-GYN visits?

A: Obviously, obstetric care must go on — it’s not an elective part of our health care. During the normal course of a pregnancy, we would have nine to 10 prenatal visits that would be in person and, in most cases, with a physician or midwife. Maybe the first call would be an intake over the phone to get the patient’s history, but usually it would be the expectant mother coming in and having her visits at various stages, and then having certain testing — ultrasounds, lab work, BP check, etc. For our lower-risk patients, those who don’t have expected complications, we have converted about half of those visits to virtual care. We’ve done a lot to standardize that to make sure that we’re asking all the normal questions, that the woman checks her BP at home, making sure the baby is moving, asking her about her weight and how she is feeling, and then giving her opportunities with an online chat with other mothers, our social workers on stress management and dietitians.

On the OB side, I would say antepartum has changed a lot. Much of that will probably continue for certain mothers if they chose to have that type of prenatal care that will keep them from having so many in-person visits. In labor and delivery, when a woman comes in, you worry first if she is COVID-positive or COVID-negative. That impacts a lot; what kind of [personal proactive equipment (PPE)] — masks, shields, gown, gloves, etc. — that is used during labor. Initially here, like most places, we weren’t able to test all of our patients. We were only testing symptomatic women. Now we can test every patient, so it enables us to determine what we have to do to protect our health care workers and to be prepared for the labor and the baby. Initially we weren’t allowing visitors with a mom who was positive for COVID, and obviously that caused a lot of angst and difficulty for our families. Fortunately, that is no longer true. If a woman tests positive, she can have her significant other with her throughout labor and delivery.

In terms of the GYN side, we’ve continued taking care of women who have cancers. We have tried to modify and do some of those visits virtually if we didn’t have to do an examination. While we weren’t able to do surgeries for some women, we have postponed their surgery when we felt it was safe. We’ve given some women hormonal treatments rather than chemotherapy or surgery while we’ve waited a few weeks; but again, all of that has been very carefully thought out. For those who absolutely needed surgery, we have proceeded. The good thing is now, we’re able to start to open things up a little bit with COVID-19 stability and the ability to test patients who come into the hospital. Here in Michigan, we’ve obviously been hit very hard and have a lot of suffering and deaths. Our hospital had been over half full with COVID-19 cases — over 300 patients. We’re down now, so that has impacted what we could and couldn’t do

Q: Should women with regularly scheduled appointments postpone them? Why or why not?

A: For most of our patients, unless there was a real need, we have delayed our regular health care screening. We want to be able to get our women back in the office if they’re in need of a pap smear, mammogram or a colonoscopy for regular health maintenance and screening. We’ve continued to see patients for things that are really not elective, like contraceptives, pain, abnormal bleeding and infections. But we certainly have seen that women have been delayed in seeking care. In the emergency room, many of them are sicker than normal because they’ve been afraid to come to the hospital. We’re seeing that across the system — people staying home with heart attacks and fractures because of the fear of COVID. Certainly, that [fear] is realistic, but we have the ability to safely take care of folks. We’re trying to get that word out — don’t stay home if you’re sick, let us help you. With being able to continue social distancing, we’ve changed completely what our waiting rooms look like; we’re staggering patients differently, having them wear masks, checking their temperature, asking if they’re symptomatic or if they’ve been with some who’s COVID positive. We’re doing proper bleach cleaning and making sure we have as few people who need to be in contact with us. We are complying with best practices to prevent COVID, and we’ll continue to do that to safely see patients.

Q: How is the pandemic affecting fertility treatments?

A: Certainly, it has impacted that area of gynecology as well. We are following the [American Society for Reproductive Medicine (ASRM)] guidelines. We completed our cycle of women who are in the middle of fertility treatment, who are already planning in vitro fertilization and other procedures. We completed those and we had a pause. The things we are worried about are for women who have certain conditions, including those who were doing something to preserve fertility because they’re getting a cancer treatment or they have a low ovarian reserve. If it is something where time is of the essence, then we have tried to continue to take care of that group of patients. We’re just now — again, according to the ASRM guidelines— starting to increase care for our couples with infertility. We will test for COVID-19 before we would start a cycle. We want to make sure that patients are healthy before we start treatment.

Q: What are the long-term implications of forgoing OB-GYN visits during the pandemic?

A: We’re a broad specialty, so many things can be delayed a few months. Some things such as bowel and bladder control are really quality of life, and so being able to hold off on some of those things until its announced safer for patients to come in, I don’t think will have long-term implications. It’s been challenging for women, just like all of us during the pandemic. There has been a challenge to get adequate birth control in certain areas of the country. There’s been challenges to getting abortion services in certain areas. Most of the time, the courts and others have upheld the rights that abortion services should not have been halted during the pandemic. So fortunately women have, by and large, been able to get the services they needed.

In terms of checking for cancer and abnormal bleeding that has the potential to be endometrial or ovarian cancer — I have no doubt that there are women who have stayed home over the last couple of months who normally would have come in with those symptoms, and a percentage of them will have a cancer.

Q: What other health challenges are women facing during the pandemic?

A: It’s not just OB-GYN care — we’ve seen men and women stay home with strokes out of fear of COVID-19. Many women are the primary care takers of children and grandparents. So I think that’s challenging for women, and often women put themselves second or third when it comes to priorities. Women who are on the lower socioeconomic part of the curve or women of color are disenfranchised, as we’ve seen in the awful rampage through our African American and Hispanic communities with the pandemic. In Michigan, we know that a huge disproportion — over 40% of the deaths— are African Americans, yet only 17% of our population is African American. I think women of color — whether they’re young or old — have had a disproportionate challenge. That is something that we always need to keep in mind and work hard to right the disparities.

Women should not be afraid now to go visit their physician. We are all taking the right precautions in testing and social distancing and wearing masks, and so unless they or someone in their household are at extremely high risk for a COVID infection, they shouldn’t delay getting the care they need. We can’t have women dying of strokes and heart attacks and ovarian and breast cancer because of COVID. Patients, their health care system, their doctors and their nurses should take the right precautions. We can’t have these COVID-related, but not COVID, catastrophes. We need to make sure that we continue to provide good care for our women.

Reference:

PCPCC. Quick COVID-19 primary care survey. https://www.pcpcc.org/sites/default/files/news_files/C19%20Series%208%20National%20Executive%20Summary%20with%20comments.pdf. Accessed May 8, 2020.

Disclosure: Fenner reports no relevant financial disclosures.