In December 2019, several pneumonia cases of unknown origin emerged in Wuhan, Hubei province, in the Republic of China. On 11 March 2020, the World Health Organization (WHO) labelled the disease associated with the novel coronavirus 2019 (COVID-19) a pandemic. The global spread was sudden, and many questions remain unanswered.
The virus is highly contagious via direct contact and droplet spread with a mortality rate of 3.4% according to the WHO. As of 27 April 2021, South Africa (SA) had 1 576 320 positive cases of COVID-19 resulting in 54 186 deaths. Recently two mutated variants have been identified in SA, 501Y.V2 (or B.1.351) and 501Y.V1 or (B.1.1.7) respectively. The new variants may help the virus spread more easily and affect the antibody response. The government implemented a strict lockdown of the country to help curb the spread of the virus in March 2020. Since then, the lockdown has been eased but the country remains in varying degrees of lockdown.
South Africa is a low-middle income country (LMICS) with very dense informal settlements areas that may represent a challenge when considering the transmissibility of COVID-19. Of concern is the huge local burden of other diseases like tuberculosis (TB) and Human Immunodeficiency Virus (HIV). The WHO was initially hopeful that those who have achieved viral suppression through highly active antiretroviral therapy (HAART) may show less severe symptoms of COVID-19. In SA, only 63% of HIV positive population are on HAART. The South African maternal population is very different to Asia, Europe or the United States (US). Approximately 28.6% of our mothers are HIV positive and only about half of the mothers are on HAART. TB is also prevalent in pregnant women.[5, 6] It was also found that Bacille Calmette-Guerin (BCG) childhood vaccination might offer broad protection to respiratory infections and it may reduce the number of COVID-19 cases in the country. 
The clinical presentation of COVID-19 in adults commonly includes fever, cough, fatigue, shortness of breath, and rarely diarrhoea. At time of diagnosis approximately 80% of cases are mild or moderate in adults, 15% of cases are severe requiring hospital admission and 5% of cases are critical requiring intensive care. Studies have shown that children tend to have milder disease than adults.[8, 9] Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 )(the virus causing COVID-19) is diagnosed from genetic material ribonucleic acid (RNA) in samples from the respiratory tract.
Of increasing concern is the pregnant women population that are more susceptible to COVID-19 and are likely to have complications.[10–13]
The unanswered questions:
Whether pregnant women are more severely affected or may be asymptomatic than the general population? Whether intrauterine or perinatal transmission occurs is largely unknown?
Whether SAR-CoV-2 is transmitted in breast milk. Limited information has suggested that SARS-COV-2 is not transmitted through breast milk but the numbers on which to determine this evidence is small?
Lastly, postnatal transmission from an infected mother to a well new-born. This is controversial as it raises the question of temporary separation of infected mothers and their neonates?
Several case reports have looked at outcomes of pregnant mothers with COVID-19 and their neonates.[13–16] Reassuringly, mothers and their babies generally appear to do well.[17, 18] Strong evidence suggests amniotic fluid, placental swabs and cord bloods have consistently tested negative for SARS-CoV-2.[12, 14, 19–21] However, further investigation is required to determine if COVID-19 may damage the placenta. A few cases of neonates delivered to mothers with COVID-19 had increased SARS-CoV-2 immunoglobulin M (IgM) levels.[14, 19, 20] This may suggest intrauterine transmission, however reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 from these neonates was negative, the IgM may be a false positive. It is not known if the developing foetus is exposed to a community of viruses (virome). Looking more closely at the virome in the amniotic fluid may detect COVID-19.
The question of vertical transmission is especially relevant given the recent history of vertical maternal-fetal transmission of such emerging viral infections as the Zika virus, Ebola virus, Marburg virus and other agents which can threaten the health and survival of an infected mother and foetus . In many studies, most neonates have not acquired COVID-19. Information from nine Chinese mothers revealed there was no evidence of vertical transmission of COVID-19 during pregnancy. The impact of COVID-19 in pregnancy still remains unclear but in addition to the potential for vertical transmission the disease may lead to neonatal complications such as preterm birth as a consequence of maternal fever.
All the breast milk samples from these mothers after the first lactation tested negative for SARS-CoV-2. In LMICS breastfeeding has been traditionally a protective factor against diarrhoea and respiratory infections and death. The benefit of breastfeeding especially with no cases of COVID-19 being transmissible through it still outweighs risks associated with formula feeding. Alternatives to breast feeding are expressed breast milk or donor breast milk. The mothers should adhere to strict hand hygiene, wear a mask, and routinely clean and disinfect surfaces during breastfeeding to reduce the risk of transmission.
There is uncertainty if a well-baby should be isolated from COVID-19 positive mothers.[26, 27] In LMICS there are not enough isolation areas to cohort well babies. The WHO advocates that mothers should not be separated from their neonates, unless medically indicated. This will also minimize the disruption to breastfeeding during stay in facilities providing maternity and neonate services
The definition for neonates suspected to have COVID-19 infection is those neonates born to mothers with a history of COVID-19 infection in the 14 days prior to delivery and/or 28 days after delivery, or the neonate is directly exposed to those infected with COVID-19 (including family members, caregivers, medical staff and visitors). The diagnosis of COVID-19 neonatal infection should meet the following criteria [28, 29]:
At least one clinical symptom, including unstable body temperature, low activity or poor feeding or shortness of breath.
Chest radiographs showing abnormalities, including unilateral or bilateral milled glass opacities.
A COVID-19 diagnosis in patient’s family or caregiver
A close contact with people who may have or have confirmed COVID-19, or patients with unexplained pneumonia.
Clinical findings, especially in premature infants, are not specific. Therefore, it is necessary to closely monitor vital signs, respiratory symptoms, and gastrointestinal symptoms. Laboratory findings may be non-specific. COVID-19 can be detected in samples taken from the upper respiratory tract (nasopharyngeal and oropharyngeal), the lower respiratory tract (endotracheal aspirate, bronchoalveolar lavage), blood and stool. Currently, the principles of treatment are supportive care and treatment of complications.
This study aimed to identify the incidence of neonatal COVID-19 within our unit, and to describe the clinical characteristics and outcome of mothers and neonates delivered to COVID-19 positive mothers.