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Robin had always wanted to give birth at home — she planned carefully for it even before she became pregnant, and long before the coronavirus upended daily life. Now, at 25 weeks pregnant, she can feel the baby “moving and shaking,” and she’s even more grateful to have that birth plan firmly in place.
“I am feeling extra comforted in my decision to give birth at home,” she says. “The level of genuine care, support and attention I receive from my midwife is unparalleled, which is perhaps why I am not worried about my delivery.” Her next prenatal appointment is in a couple of weeks, and she may move it to a FaceTime call.
Even in the best of circumstances, pregnancy can be a crash course in navigating the unexpected. But women who are expecting against the backdrop of a global pandemic face uncharted stressors as doctors and hospitals rewrite the rules for getting care during pregnancy.
“Almost overnight, we have had to revamp the way that we provide maternity care,” says Dr. Judette Louis, chair of the department of obstetrics and gynecology at the University of South Florida and president of the Society for Maternal-Fetal Medicine. Physicians are spacing out in-person visits and increasing their reliance on technology. “We have had to remove some components of care that are great [for the] patient experience but may increase the risk of exposure to coronavirus.” For women who are tempted to completely revamp their birth plan — for example, by switching to a home birth — she emphasizes that, “although the coronavirus is scary, the safest place for delivery is still in the hospital.”
Pregnant women are advised to follow the same protocols as the rest of us: social distancing, avoiding anyone who might be sick and endless hand washing. As of now, researchers cannot definitively say if pregnant women are at greater risk than the general population for becoming seriously ill with COVID-19; experts I spoke with consider pregnant women to have the same level of risk of infection as everyone else. There is still so much to learn about this novel virus.
It’s not clear yet if a mother can transmit COVID-19 to her baby during pregnancy or childbirth; the research is emerging. A report published March 26 in JAMA Pediatrics found that of 33 newborns born to mothers with COVID-19, three tested positive for the disease. (All were in Wuhan Children’s Hospital, in Wuhan, Hubei Province, China.) Another JAMA report found elevated coronavirus antibodies in one baby born to a mother with COVID-19. The baby tested negative for the disease and didn’t exhibit symptoms of illness, but they exhibited antibodies that indicated a possible infection in utero. So far, the data on coronavirus in pregnant women is mainly drawn from C-section deliveries, although in at least two studies, doctors also tested vaginal secretions for the presence of the virus.
Two other coronaviruses, the ones that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), can lead to miscarriage, premature delivery and even maternal death. While COVID-19 is also caused by a coronavirus, experts don’t know if it carries similar risks for maternal or fetal health.
At this early stage of the pandemic, with so little concrete information about vertical (parent-to-child) transmission, doctors are continually revising clinical protocols and guidelines for patients.
The American College of Obstetricians and Gynecologists has developed an algorithm to help providers assess a patient’s risk of having the virus and then choose between proceeding with routine prenatal care or recommending further evaluation. Women who test positive for the virus, but are either asymptomatic or only mildly ill, should be monitored with bimonthly fetal growth ultrasounds, according to recently published recommendations in The Lancet.
For women dealing with infertility, the coronavirus means delaying any treatment plans. Earlier this month, the American Society for Reproductive Medicine issued recommendations for patients to suspend IVF cycles and egg retrievals and cancel embryo transfers. (The CDC, as well as several medical organizations, has recommended postponing all elective surgeries and nonurgent medical visits.)
“The best thing a mom can do to protect their baby,” says Louis, “is to adhere to the safety precautions provided by their care team and focus on other ways to stay healthy that are within their control,” like diet and exercise.
For the sake of patient safety, hospitals across the country have adopted new rules regarding partners and support people, like doulas, being in the delivery room. After two major New York City hospitals began requiring women to give birth alone, New York State ordered hospitals to allow every woman to have one support person present.
With hospital rules changing weekly, and sometimes daily, many providers are advising patients to take a breath and prepare for the unexpected so as not to be blindsided by last-minute surprises. Jennie Joseph, midwife and founder of Commonsense Childbirth, posted a video to Facebook and Instagram, in which she tells women, “Regardless of what plan your hospital has in place for you, you can make a plan for yourself. You may be separated from your doula. If you’re thinking ahead, you can be ready.”
She tells women to arrive at the hospital with a fully charged phone, have a charger in your birth bag, and FaceTime with your doula or family members. Many doulas are now offering free virtual services to women who may find themselves in the delivery room alone, save for the medical staff.
Women of color are already at a higher risk, with a maternal mortality rate three or four times higher than their white counterparts. “These facts do not disappear in the face of the pandemic,” says Louis. Patients may have to advocate more for themselves in the healthcare system than they otherwise would. Joia Crear-Perry, physician and president of the National Birth Equity Collaborative, adds that “women of color are more likely to work in service industry jobs, be un- or underinsured and have no paid leave. Even when they have education, income and health insurance, they’re more likely to be treated with disrespect.” Healthcare providers must be especially vigilant, by acknowledging their own biases and listening to their patients.
If a mother feels alone in the delivery room, those feelings can be compounded after coming home from the hospital. “People often feel isolated after giving birth at baseline,” says Neel Shah, assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. “Not being able to accept help from grandparents and other loved ones and community members makes it so much harder.”
“Postpartum anxiety and depression are going to increase,” says Crear-Perry. “We have to acknowledge that. Make room for the grieving of the loss of what they wanted the birth and postpartum to be, to what our current reality is.” To stay connected, she encourages new mothers to keep doing regular check-ins and attending virtual gatherings on platforms like Zoom.
It’s also wise to have contingencies in place, Louis advises, just in case someone in the household becomes sick. Parents should familiarize themselves with COVID-19 symptoms and have a back-up plan in place, with someone who will be able to care for the infant if they fall ill.
It’s not yet clear if COVID-19 can be transmitted through breast milk, according to the CDC. But it can be passed through respiratory droplets (tiny packages of mucus or saliva that contain viral particles), which theoretically could spread during breastfeeding.
Robin lives in California, one of many states with some type of stay-at-home order in place. “Overall, I’m feeling okay,” she says. But still, these are uncertain times for everyone and she has ups and downs. “I did have one day last week when I was feeling all the feelings and allowed myself to cry it out as long as I needed to. After I got it out of my system, I feel more levelheaded about the circumstances we are in and how to deal with the day to day.” She’s feeling comforted by the support of her husband (and their dog).
“The hardships we are all facing as we aim to get through this are even harder on those who are pregnant, giving birth, or parenting infants,” says Shaw. “Know that this is temporary. We will get through this. You will get through this. Things will get better.”