Abstract
COVID-19 continues to have severe repercussions on children and pregnant women. The repercussions include not only the direct impact of COVID-19 (ie, children getting infected by COVID-19) but also indirect impacts (eg, safeguarding from child maltreatment, obesogenic behaviors, language and socioemotional development, educational consequences [eg, interrupted learning]; social isolation; mental health; behavioral health [eg, increased substance use in adolescence]; health and economic impact of COVID-19 on caregivers and family relationships. It has also shed light on long-standing structural and socioeconomic issues, including equity in nutrition and food security, housing, childcare, and internet access. Using a socioecological, life course, and population health approach, we discuss the implications for pregnant women and children’s health and well-being and give recommendations for mitigating the short and long-term deleterious impact COVID- 19 on women, children, and their families.
Introduction
Children and pregnant women are facing a generation-defining disruption from the coronavirus disease 2019 (COVID-19) pandemic, which has exposed and exacerbated pervasive inequities in health and healthcare. 1 Although the clinical course of COVID-19 infection in children is generally mild, a significant minority are hospitalized, require intensive care unit (ICU) care, or experience serious complications due to COVID-19. 1 Pregnant and postpartum women with COVID-19 are more likely to be admitted to the ICU compared to non-pregnant women of reproductive age, and infection during pregnancy is associated with adverse outcomes, including preeclampsia, preterm birth, and stillbirth.2,3
Children and pregnant women have borne some of the highest indirect impacts of the pandemic. For children, these impacts include disrupted education, reduced social interactions with peers, missed routine child health checks, reduced physical activity and adverse mental health. 4 One in four children has lost a caregiver to COVID-19, and many more lost other beloved adults, such as grandparents. 5 Similarly, the mental health repercussions of COVID-19 during the perinatal period have posed significant challenges for pregnant women. 6 Importantly, the impact of COVID-19 has not affected all children and families equally but instead has magnified enduring inequities based on race, ethnicity, disability, gender identity, geography, and socioeconomic status.
The multi-faceted impact of COVID-19 highlights the need to consider the pandemic from socioecological and life course perspectives. The socioecological model recognizes that individual health is a product of multiple influences at the individual, family, community, and societal levels (see Figure 1). The pandemic has created new pressures at each level. In many cases, these pressures are driven by social determinants of health (SDoH), which differentially and disproportionately impact individuals from minority and marginalized communities. For example, children and pregnant women in low-income households are more likely to live in overcrowded housing, which increases the risk for COVID-19 transmission and infection both within families and the broader neighborhood.
7
Conceptual Model for Understanding the Multi-level Factors Influencing Child and Pregnancy-Related Health and COVID-19-Related Health Outcomes. This is based on a socio-ecological model that considers multiple factors operating at the individual (1), family (2), community (3), and society (4) levels. From a lifespan perspective, these factors interact and influence health across the lifespan, from preconception onwards. In many cases, these factors have exacerbated challenges to equitable healthcare access and outcomes. Bold text indicates COVID-19-related factors.
A life course perspective implies that we should consider the impact of COVID-19 in the context of other exposures and stressors that can have persistent and long-lasting effects on health, including systems of oppression and discrimination. 8 For example, Black children and pregnant women continue to experience adverse living conditions such as overcrowded housing at higher rates than White families, reflecting not only historical practices (eg, residential segregation) but also racism that continues to be deeply woven into the fabric of U.S. society. Marginalized populations are not only at greater risk for the direct impact of COVID-19 (eg, becoming infected and seriously ill) but also indirect effects (eg, poor mental health) as a result of prior (and accumulated) exposures to adversity that affect health and well-being over the life course. 9
Informed by socioecological and life course perspectives, this paper provides a call to action to enhance the promotion of prenatal and child health during the pandemic and beyond. We offer recommendations in three salient areas of impact: healthcare, childcare, and research.
Healthcare
Since the onset of the pandemic, there have been fundamental changes to health and healthcare for children and pregnant women. Preventive and routine healthcare utilization declined over the pandemic, including antenatal 10 and well-child visits, vaccinations, and screening services. 11 Moreover, there is an emerging public health crisis within the pandemic– as seen by increases in mental health, substance use disorders (SUDs), 12 and adverse childhood events (ACEs). 13 Of note, there has been a rise in deaths by suicide among teenagers. 14 Many teens have gone without care15,16 or had to go to the emergency room for care. 17
Health coverage was also impacted by changes to people’s employment and the changing policy landscape. Importantly, every state agreed to stop disenrolling people from Medicaid as a result of the Families First Coronavirus Response Act (FFCRA) of 2020, and many states adopted similar options for the Children’s Health Insurance Program (CHIP). As a result, enrollment in Medicaid/CHIP grew by about 24% between February 2020 and April 2022. 18
Recommendations
Promote timely identification and treatment of mental health and SUDs, ACEs, and SDoH
The profound impacts of COVID-19 on mental health point to the need to move beyond a traditional health care approach, which often focuses narrowly on diseases and symptoms, to a whole-person, integrated model that improves access and quality by recognizing the interconnectedness of physical, mental, and behavioral health and the impact of SDoH. 19 We recommend that healthcare and mental health providers screen children and pregnant women for mental health problems, substance use, suicidality, ACEs, and SDoH. A holistic approach could include embedding social workers and psychologists into healthcare, child care, and school settings. 20 Moreover, partnering with community-based organizations and other stakeholders is critical to ensuring an appropriate, high-quality, and sustainable approach to treatment.21,22 The ability to offer referrals or appropriate treatment for children and pregnant women with positive screens can be developed through partnerships between health plans and community-based organizations that can provide appropriate interventions.
Improve measurement of whole-person care
To establish the benefits of whole-person care, we need to measure the entire continuum of care, from access and care coordination to patient outcomes. To drive quality improvement and promote joint accountability for outcomes, the use of meaningful quality metrics should be aligned and coordinated across accountable entities. Additionally, there is a need to improve the measurement of health equity. 23 Current measurement approaches commonly consist of stratifying quality measures by race and ethnicity. 24 New measures should consider and incorporate the health equity impacts of other social, emotional, and economic risk factors that communities experience and the intersectionality of such risk factors.
Expand use of telehealth and promote health and digital literacy
The pandemic has accelerated health and healthcare technological innovations. Telehealth can be effectively deployed to provide multi-faceted and accessible care more flexibly for some patients.25,26 For example, during public health emergencies like COVID-19, telehealth has been critical for ensuring access to services like obstetric care. 27 To improve access to needed health interventions and education, we should continue developing, testing, and building on health innovations and technology (eg, growth in telehealth and broadband access initiatives). These technologies must be accessible to children and pregnant women at the highest risk for adverse outcomes.
Facilitate continuity of Medicaid coverage
Strategies to ensure continuity of healthcare coverage for all children and pregnant women at the state and federal level can improve continuity of Medicaid coverage when the public health emergency ends. 28 For example, many states are providing funding for community-based outreach and application assistance for Medicaid and enacting federal options to expand coverage for children 29 and postpartum women. 30
Promote value-based payment approaches
The pandemic has created payment challenges as a result of reductions in healthcare utilization and highlighted the ability of value-based payment (VBP) arrangements to strengthen provider resilience. For example, revenue was less stable for those paid primarily through fee-for-service payments and more stable for providers who received capitated payments (not contingent on utilization of services). Providers offered upfront and global payments had more flexibility to innovate during the pandemic. For example, they could substitute in-person care for virtual without worrying about telemedicine compensation rules. 31 Further VBP reform is needed to incentivize integrated and holistic pediatric and pregnancy-related care.
Childcare
Childcare barriers have been exacerbated by COVID-19. The Census Bureau’s Household Pulse Survey reported that 18.7% of U.S. families reported childcare disruptions for children under 5, and 8.3% of families reported that they were still experiencing childcare disruptions as a result of COVID-19 in July 2022. 32 The pandemic led to systemic mass child care closures leaving reduced supply to fill the demand. 33 Moreover, remaining providers, particularly in unlicensed programs, are unlikely to be trained to respond to ACEs. 34 Disruptions in childcare can have a snowball effect on child and family well-being, causing disruptions to child development and parental employment and potentially impacting a family’s economic situation.
Recommendations
Ensure childcare is accessible and affordable
Families at or below the federal poverty line may be eligible for childcare services through the federal Head Start or Early Head Start programs or state-funded programs. For families not eligible for publicly funded programs, childcare costs for preschool-aged children can rival college tuition. 35 Childcare is a critical social infrastructure, and we strongly urge authorities to look for areas of bipartisan agreement on how to increase state funding for childcare.
Leverage policy to increase the availability of free or subsidized child care
States should leverage publicly available funding to increase the availability of free or subsidized childcare for low-income families who do not qualify for Head Start or Early Head Start. Increasing the availability of high-quality, affordable childcare will require input from multiple stakeholders, including families, to ensure that childcare programs are affordable and meet their needs (eg, availability during non-traditional hours such as nights and weekends).
Ensure providers can identify COVID-19-related trauma and are trained in trauma-informed care
Early childhood education settings are ideally positioned to identify and support children who have been adversely impacted by the pandemic and are experiencing impacts on their physical and mental health or school readiness. However, teachers and child care professionals may be inadequately trained in trauma-informed care. Professional development related to trauma occurs on a broad spectrum, from light touch to resource-intensive and evidence-based interventions such as mental health consultation. 36 Ongoing and consistent support is needed for child care providers to learn how to respond to trauma and nurture resilience. 37 They also need appropriate systems to refer children to community-based services. 38
Improve childcare access and quality measurement
Identification and assessment of families’ childcare needs provide the foundation for effective, high-quality childcare. There is a paucity of data on the impact of COVID-19 on child care. Child care measure domains could include access, attendance, and staffing needs. These measures should consider and incorporate equity in early childhood education programs.
Research
We must have robust data and studies to effectively shape COVID-19-related policy and promote evidence-based interventions for pregnant women, children, and their families. Changes are needed in the approach, design, analyses, and application of the findings for research, policy, and practice. These changes will support efforts to implement targeted, effective and sustainable interventions and funnel resources where most needed. Figure 2 highlights the critical methodological resources needed to study the impact of COVID-19 on pregnant women and children. These approaches stand to identify the root causes of adverse childhood and adult outcomes as a result of the pandemic and underlying inequities. Methodological Resources Needed to Research the Impact of COVID-19 on Pregnant Women and Children. This figure shows the research trajectory for generating and propelling COVID-19 research in maternal and child health.
Research should consider the intergenerational effects of COVID-19 to look at the rippling effects across the life course. Research studies are needed to examine the impact from pregnancy through adulthood. Contextual factors must also be considered, including SDoH.
Recommendations
Ensure community representation and equity in all aspects of research
Promoting community participation in the research process matters.39-41 Studies of the impact of the pandemic must include community members at all stages of research– from the formulation of questions to the implementation of interventions. National leadership that promotes equity in research is of great need and importance.
Use rapid cycle and longitudinal study designs and innovative data sources
The long-term impacts of COVID-19 on pregnant women and children are unknown. Rapid data are critical for providing timely information, while nationally representative cohort studies are needed to understand the impact of the pandemic over children’s lifespans. Of note, there are likely critical and sensitive periods whereby COVID-19 impacts pregnant women and children differently. 42 Qualitative data are also needed to understand families’ experiences, knowledge, behavior, and beliefs about COVID-19. These studies can enrich quantitative studies by providing insights into the lived experience of families during the impact of COVID-19, particularly among high-risk populations.
The selection of data sources should be grounded in equity and the socioecological model and continuously re-examined. Data sources at all levels (ie, Individuals, family, community, society) are needed. Self-reported, community-level and big data are increasingly used to collect COVID-19-related information from public and private sources.
Link to innovative data
Data linkage stands to uncover the fundamental causes of the effect of COVID-19 on outcomes. Of note, a deeper understanding of the role of SDoH is of critical importance. Population health data (eg, surveys, claims, and electronic health record data) and linkage to SDoH data (eg, AHRQ’s SDoH database) are powerful tools to examine the role of these factors and living environments on children’s health. These data can be linked to other datasets that would provide great insight into the role of the SDoH in people’s lives and how SDoH impacts COVID-19 outcomes. 2 43
Use appropriate data analytics and tools
Innovative data analytics are needed to comprehend the impact of COVID-19 on pregnant women, children, and families. Wider use of multilevel modeling is warranted to examine these factors on outcomes. In addition, using artificial intelligence and advanced data analytics ethically, with machine learning and natural language processing techniques, allow for additional data elements to be included in studies. Moreover, the use of predictive and prescriptive analytics can inform the mode of data collection, the creation of digital tools (eg, screening), and the most effective, feasible, and sustainable forms of interventions.
Invest in implementation science
Implementation science, the study of the translation of research into practice, is of critical importance in the spectrum of future COVID-19-related research studies on pregnant women and children. This nascent field should be extended to studying real-world COVID-19 interventions (eg, community and policy-level interventions) that aim to address the SDoH. The evaluation of these studies will provide vital information about effectiveness and sustainability in the community.
Invest in Research
Understanding the impact of COVID-19 on children requires a multi-organizational financial investment in maternal and child health research, spanning from the formulation of questions to the translation of research into practice and across the lifecourse. There is precedence for this approach. State and federal governmental investments in programs have proven successful (eg, SNAP, WIC and public health insurance), albeit the lack of knowledge about these studies and the cutbacks to many of these programs. Other investments have provided a significant return on investment both financially and socially in improving health outcomes and reducing costs.44,45,46
Conclusions
Time is of the essence to address the impact of COVID-19 on pregnant women and children. While the pandemic has affected all aspects of American life, we provide recommendations for three salient areas of impact: healthcare, child care, and research. The pandemic has highlighted the importance of improving these three areas and created an opportunity to leverage broad stakeholder support for reinforcing these systems. In Figure 3, we summarize recommendations centered on three focal areas with the potential to have a maximal impact on child health promotion as we move out of the COVID-19 pandemic in each priority area. Health equity is central and a critical component of all the recommendations. Recommendations for improving child and pregnancy-related health and wellbeing and eliminating preventable COVID-19-related health disparities. Healthcare, child care, and research represent the focal areas with the greatest potential for improving health outcomes. All aspects of health promotion reform should be grounded in equity and recognize the differential impact of COVID-19 on minority and marginalized communities.
Our recommendations should be understood in light of the following considerations. First, we do not discuss relevant initiatives and policies in all sectors that touch the lives of children and pregnant women, such as education, child welfare, housing, and food and nutrition. There is a need for cross-sector collaboration to ensure the health-related social needs of children and pregnant women are fully met. Second, more intensive interventions will be necessary for individuals who require complex and high levels of support (eg, those with special health care needs) or who have experienced acute trauma (eg, children orphaned as a result of COVID-19). Third, we recognize that efforts to reform child health and childcare face substantial challenges, particularly in today’s deeply politicized climate. Bipartisan support will be essential for operationalizing the recommendations in this paper, particularly for ensuring there is sufficient investment and opportunities to combine funding streams flexibly, as appropriate. Finally, future studies and initiatives may vary based on emerging priorities and are likely to be multi-disciplinary. This could be challenging to implement, requiring significant investment and cross-sector collaboration including the integration and harmonization of data across datasets and having the right variables for data linkage.
In summary, we argue that healthcare and childcare systems are uniquely positioned to help address adverse outcomes associated with COVID-19, reduce inequities, and foster lifelong health and well-being. To bolster health care promotion for children and pregnant women, we need to develop integrated, whole-person healthcare systems and expand access to affordable, high-quality childcare. Concurrently, we need timely, high-quality data to better understand the impacts of COVID-19 across the lifespan and to evaluate efforts to improve healthcare and childcare. Thus, we need greater investment in data and research, including advanced data analytics, rapid data collection methodologies, and implementation science research. Efforts also must be made to foster greater collaboration with families and communities to identify their unique strengths while simultaneously working to address health-related social needs. Not acting on these and other priorities could be detrimental to the health and well-being of pregnant and children. Imminent action is needed.