The coronavirus pandemic is a shock of global proportions, but its impacts – both current and future – are unlikely to be felt equally. While pregnant women and children have so far been largely spared from the direct health effects of COVID-19 (Sutton et al. 2020),1 the associated uncertainty, disruption in economic activity and reduction in essential services are causing increased stress and economic burden on parents. These costs are unlikely to be borne equally: vulnerable parents and children – be it of low socioeconomic status, disabled, at risk of harm, in poor quality or overcrowded housing, or single parents – are at particular risk.
It has been noted that, unlike previous recessions, the current crisis has two particular features: it is harming women’s labour market prospects more than men’s; and it is increasing the volume of home production, currently widening existing gender inequalities, for example in relation to childcare (Hupkau and Petrongolo 2020). What are the likely consequences for children? While an evolution of gender norms and a speedy economic recovery are possible, the existing literature shows that profound shocks at critical stages of development can have long-term consequences (Conti et al. 2019). However, preventing longer term damage is possible, if we act promptly.
Possible impacts of COVID-related shocks
The COVID-19 pandemic is an unprecedented mix of shocks. In addition to the public health threat, there is the stress associated with possible personal losses, the health risk in case of key workers, the risk of facing unemployment with related income loss, the reduction in vital services, and the increase in isolation following the social distancing restrictions. While there is no directly comparable precedent, the existing literature can provide some insights.
- Stress. Several studies have examined different sources of stress experienced in the prenatal period and in the first years of life, ranging from wars and terrorist attacks, to natural disasters and extreme weather events, or to the death of a family member. They have shown adverse impacts not only on physical health and cognition, but also on mental health – usually affecting to a greater extent women of lower socioeconomic status (SES) (Almond et al 2018, Conti et al. 2019).
- Economic hardship. Plenty of evidence exists on the adverse impacts of the Great Recession. A study from the US (Currie et al. 2015) shows an increase in health disparities between more and less advantaged mothers, with the former reporting increased prevalence of unhealthy behaviours and worse physical and mental health, while the latter even show benefits. Changes in labour market conditions also affect intrahousehold conflict, domestic violence and child abuse (Doyle and Aizer 2018).2 The costs could be high: for example, the lifetime costs of child maltreatment in UK amount to £89,390 and £940,758 per victim for non-fatal and fatal cases, respectively (Conti et al. 2017).
Hence, the covid-19 pandemic is likely to increase inequalities in multiple inputs in the production of child development, with low-SES, vulnerable parents less able to provide safe, stable and stimulating home environments, food security, nurturing care, appropriate time investments or sensitive parenting.3
Policies to mitigate the effect of COVID-19 on parents and children
What can be done to mitigate the negative effects of COVID-19? Protecting workers against income losses is obviously critical, and the government has implemented a series of reforms to this effect (Adam et al. 2020); further actions will likely be needed to prevent an increase in child poverty. However, it is now crucial to also provide direct support to parents whose economic security is threatened, or who have lost vital sources of support, such as nurseries and children’s centres, or networks of relatives and friends.
Home visitation for parents is a widespread early-intervention strategy in many countries. I have contributed to recent evidence on a flagship programme targeting first-time disadvantaged mothers, the Nurse Family Partnership (NFP) in the US, showing long-term improvements in maternal and child outcomes and reductions in government welfare expenditures (Kitzman et al. 2019, Olds et al. 2019). In face of the COVID-19 pandemic, the NFP has switched to telehealth to ensure the continuity of services; however, in some sites, family nurses are being redeployed.4 In England, where NFP is present since 2007 under the name Family Nurse Partnership, most services continue via telehealth to help first-time teenage mothers.5
In addition to more targeted programmes, in England there is also a universal health visiting service.6 While no evaluation to date exists, evidence from the Scandinavian countries on similar universal programmes shows long-term impacts on health and socioeconomic outcomes (Conti et al. 2019). Notwithstanding the evidence, councils have seen a £531 million cash terms reduction to their public health budgets between 2015/16 and 2019/20. Figure 1 shows new data on the extent of the cuts experienced in health visiting services between 2016-2019 in England (Conti 2020).
Figure 1 Percentage change in health visitors in England, 2016-2019
Note: Total number of health visitors that hold caseload.
Prior to the pandemic, a third of health visitors were already responsible for 500-1000 children, instead of the 250 recommended. In face of the pandemic, many community health services (including health visiting, but excluding safeguarding) have been partially or completely stopped.7 Home visits are now carried out mostly virtually, with the number of universal contacts reduced and prioritised, face-to-face contacts only carried out in case of a compelling need, and with a focus on vulnerable families. However, there is substantial variation, within and across sites, due both to differences in operationalisation of the national guidelines, definitions of vulnerabilities, and available technology.8 This increases the risk that newly vulnerable parents and children are undetected and left without help. Additionally, in some areas, health visitors have been redeployed in large numbers, possibly as many as 50-70% for up to six months.9 This increase in inequality of access to universal services is likely to translate into increases in inequalities in child development, hence it is imperative that redeployment calculations account for potential increases in local demand due to increased needs.10 While available evidence is scarce, a study from Denmark (Kronborg et al. 2016) shows that a two-months nurse strike which caused a reduction in care around birth increased the number of general practitioner (GP) contacts in the first month of life11 and reduced exclusive breastfeeding.
It is now known that inequalities in many dimensions of child development emerge early, and if not promptly acted upon, tend to persist and widen. I have shown that inequalities in foetal development by neighbourhood deprivation emerge since the beginning of gestation (Conti et al. 2018), and that inequalities in socio-emotional skills at five years of age have increased between the 1970-2000 birth cohorts (Attanasio et al. 2020). To avoid further increases as a result of COVID-19, it is imperative to ensure sustainable delivery of early interventions in support of parents and children. Going forward, we should use this crisis to rethink the system towards a greater focus on prevention, greater integration between children’s education, health and social care services, and a cabinet-level Children and Families’ Minister in order to make our society more resilient for the next crisis – whatever its nature might be.
Author’s note: I acknowledge funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 819752 - DEVORHBIOSHIP - ERC-2018COG) and from the Leverhulme Trust. I thank Abigail Dow for outstanding research assistance with the health visiting data.
Adam, S, H Miller and T Waters (2020). “Income protection for the self-employed and employees during the coronavirus crisis”, IFS BN 277.
Almond, D, J Currie and V Duque (2018). “Childhood circumstances and adult outcomes: Act II”, Journal of Economic Literature, 56(4), 1360-1446.
Attanasio, O, R. Blundell, G Conti and G Mason (2020). “Inequality in socio-emotional skills: A cross-cohort comparison”, Journal of Public Economics, online 30 March.
Conti, G (2020). “Health Visiting in England”, Mimeo, University College London.
Conti, G, M Hanson, H Inskip, S Crozier, C Cooper and K Godfrey (2018). “Beyond Birth Weight: The Origins of Human Capital”, Human Capital and Economic Opportunity Working Paper No. 2018-089.
Conti, G, G Mason and S Poupakis (2019). “Developmental Origins of Health Inequality”, in Oxford Research Encyclopedia of Economics and Finance.
Conti, G, S Morris, M Melnychuk and E Pizzo (2017). The economic costs of child maltreatment in the UK. London: NSPCC.
Currie, J, V Duque and I Garfinkel (2015). “The great recession and mothers’ health”, The Economic Journal, 125(588), F311-F346.
Doyle Jr, J J and A Aizer (2018). “Economics of child protection: Maltreatment, foster care, and intimate partner violence”, Annual Review of Economics, 10, 87-108.
Hupkau, C and B Petrongolo (2020). “COVID-19 and gender gaps: Latest evidence and lessons from the UK”, VoxEU.org, 22 April.
Kitzman, H, D L Olds, M D Knudtson et al. (2019). “Prenatal and infancy nurse home visiting and 18-year outcomes of a randomized trial”, Pediatrics, 144(6).
Kronborg, H, H H Sievertsen and M Wüst, M. (2016). “Care around birth, infant and mother health and maternal health investments–Evidence from a nurse strike”, Social Science and Medicine, 150, 201-211.
Olds, D L, H Kitzman, E Anson et al. (2019). “Prenatal and infancy nurse home visiting effects on mothers: 18-year follow-up of a randomized trial”, Pediatrics, 144(6).
Sutton, D, K Fuchs, M D’Alton and D Goffman (2020). “Universal screening for SARS-CoV-2 in women admitted for delivery”, New England Journal of Medicine. doi:10.1056/NEJMc2009316. pmid:32283004
1 Sutton et al. (2020) screened all 215 pregnant women admitted to two New York City hospitals from 22 March to 4 April 2020, tested 210, and found 29 positive for SARS-CoV-2 (13.7%); 90% of those positive had no symptoms. This is in stark contrast with influenza pandemics, from which pregnant women are at higher risk of complications.
2 Since lockdown began charities supporting victims of domestic violence have seen a surge in calls to their helplines. Commander Sue Williams said charges and cautions were up 24% from 9 March, when people with coronavirus symptoms were asked to self-isolate, compared with last year, with the Metropolitan police arresting an average of 100 people a day for domestic violence offences during the Covid-19 lockdown.
3 There is actually one important input in the production of child development which has been improving in this period: pollution.
4 Virtual home visiting connects families to services via laptop, tablet, or smartphone, while safe at home. Telehealth may also include providing supports using texting or messaging services, and may also involve home visitors providing relevant information online. NFP guidance is for nurses to exclusively use telehealth, see https://www.nursefamilypartnership.org/blog/2020/03/18/covid-19/
5 For example, for Tower Hamlets, see https://www.gpcaregroup.org/Sites/Common/Private/Community_View_Responsive.aspx?id=467
6 The health visitor is the key professional responsible for promoting the health and wellbeing of the 0-5 year-olds. Health visitors are registered nurses or midwives who undertake further training in specialist community public health nursing (SCPHN). They are generally responsible for providing antenatal and postnatal support, assessing growth and development needs, teaching parents about the nutritional needs of infants and young children, encouraging the development of healthy lifestyles, reducing risks, and safeguarding and protecting children.
8 https://ihv.org.uk/wp-content/uploads/2020/04/Health-visiting-during-COVID19-Unpacking-redevelopment-decisions-report-FINAL-VERSION-17.4.20.pdf. The government has issued guidance defining vulnerable children, however - apart from already-known cases in the social care system or under an education, health and care plan - there is no clear definition for those “otherwise identified as vulnerable”, see https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-vulnerable-children-and-young-people.
9 Such redeployment decisions vary substantially across England, with some areas even strengthening their health visiting services.
10 Data recently released by the Office for the Children’s Commissioner shows that 167 per 1,000 0-4 year-olds in England live in households with multiple vulnerabilities, of which 112,000 are below the age of one.
11 Note this type of substitution of care might not be possible in the current circumstances.