A pregnant woman wearing a face mask as a precautionary measure walks past a street mural in Hong Kong, on March 23, 2020. (AFP/Anthony Wallace)
Jamie Chui has been a virtual prisoner in her Hong Kong home for most of her nine-month pregnancy.
Trapped intially by violent pro-democracy protests and tear gas, and then by the coronavirus -- she now faces giving birth alone, with her husband unlikely to see his child until days later.
Asia is facing a second wave of COVID-19 infections and as cases spiral globally with one million confirmed positive and half the planet on lockdown, women are having to give birth in unprecedented circumstances.
Hong Kong and China have imposed some of the world's strictest measures to prevent infections in maternity units: birthing partners are banned from labor units, delivery rooms and post-natal wards in public hospitals.
That has left many women struggling not only with normal pregnancy anxieties and infection fears, but also the new reality of hospital deliveries, at a time when experts warn resources are more stretched than ever.
"The most stressful part for me is that hospitals have suspended the visiting arrangements and accompanied labor," says Chui, adding: "I will need to fight alone."
"I'm nervous, to be honest. But I don't know what else I could do."
Hong Kong's protests began as Chui fell pregnant.
Fearful of the violence and tear gas might do to her unborn child, she stayed indoors. Now she is doing the same thing because of the coronavirus.
"I have been staying at home for almost my whole pregnancy," the 33-year-old photographer explains.
Women should have choices
Banning labor companions goes against the World Health Organization's 'Safe Childbirth Checklist' recommendations that women should have a trusted person with them during the process.
A similar move was attempted by some hospitals in New York but governor Andrew Cuomo issued an executive order to ensure 'no woman would give birth alone', after a huge public outcry and 600,000-strong petition.
In China and Hong Kong, women are instead left having to choose between spending upwards of HKD 100,000 (US$10,000) for private hospital delivery, where partners are still allowed to attend, or going it alone in the public system.
"I have had to mentally and physically prepare to deliver without my husband's support," says 36-year-old Lidia Inês Cardoso Ribeiro, adding that she has written to the Hospital Authority to urge them to reconsider.
"I believe all women should have the choice to have a person they trust to empower and support them through labor," she explains.
Christina Kimont, a Canadian midwife and public health researcher, now in Macau, which operates similar restrictions, agrees the situation could be problematic.
"The human body cannot easily do what it is designed to do while in a state of stress," she says.
She warned that adding extra anxiety to people already worrying about their baby contracting the virus or exhausted medical teams, could make labor "longer, more difficult and likely to end up in unplanned surgical procedures."
Irma Syahrifat, a trained doula in Indonesia, says women there have had to attend appointments with physicians in full-suited hazard gear -- an instantly distressing situation.
Currently, Indonesian hospitals allow one birth support person but, with rules constantly changing as cases spike, she insists "mental preparedness" for delivery without an advocate is a necessary addition to ante-natal classes.
There has been little research into the impact of COVID-19 on pregnant women, but the WHO says current evidence suggests that while vulnerable to respiratory infections, they are no more at risk of serious illness than the general population.
A small Chinese study following 33 expectant mothers in Wuhan found it was possible, though rare, to pass the infection in utero after three newborns tested positive for the virus.
While infants and children account for a low proportion of documented infections and deaths, a six-week-old baby in the US died this week from complications relating to the disease.
Begging for help
Across Asia, it has become the norm for routine pregnancy check-ups to be replaced with telehealth consultations, while traditional ante-natal group sessions have been replaced by online courses.
As infections soar in America and Europe the knock-on effects for maternity and postpartum care are already visible, with wards in California being used for virus cases instead.
Britain's Royal College of Midwives reported that one in five midwife posts are now empty in maternity units -- double the figure before the virus crisis started as staff fall sick, self-isolate, or are redeployed to care for COVID-19 patients.
WHO has warned dwindling supplies of personal protective equipment (PPE) for frontline workers will put lives at risk.
At Manila's Jose Fabella Memorial Hospital, where women are sometimes three to a double bed, doctors now worry about a lack of isolation units and rely on donations for protective gear.
Cynthia Anzures, who chairs the obstetrics department, says: "If we don't have enough donations, like for our n95 masks, we reuse them. We use raincoats if we don't have PPEs."
There are fears this will soon be the reality in many more Asian cities, as a recent surge in cases creates fresh waves of panic-buying, while new country-wide lockdowns could impact supply chains.
Chui says she has no choice but to stay inside even after delivery to protect her newborn.
"I think it is better to just stay at home. Just like what I'm doing right now."
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