Nearly overnight, the coronavirus pandemic transformed health care, including perinatal care. Anticipating more and more COVID-19 patients, hospitals needed to create space quickly, both to manage the influx of patients with the disease and to protect non-infected patients from exposure to SARS-CoV-2.
Elective surgeries were postponed, telehealth was utilized when possible, and some care shifted to outpatient with remote monitoring. One procedure that cannot easily be postponed or managed remotely, though, is childbirth. And, even as the pandemic dramatically reshapes parents’ expectations of labor and delivery, the coronavirus is colliding with crises already affecting pregnant people and new mothers and parents — namely, the struggles to reach families in rural or remote areas and to prevent the unnecessary perinatal deaths of Black people.
Melicia Escobar, BSN, MSN, CNM, WHNP-BC, believes this complex moment in perinatal health is one that nurse-midwives, trained to move through a crisis without forgetting the client at the heart of it, are more than prepared to meet.
“This is why I think midwife leaders are really shining in this time, across academic settings, medical centers, and home birth, because that’s what we’re trained to do,” said Escobar, a certified nurse-midwife (CNM) and Women’s Health Nurse Practitioner (WHNP) and Clinical Faculty Director of Georgetown University’s Nurse-Midwifery/Women’s Health Nurse Practitioner (WHNP) and WHNP programs.
Intentional support provided by antenatal and birthcare providers is essential in helping families navigate this crisis safely — as well as mitigating the potential negative effects that the pandemic’s social and economic consequences could have on perinatal health in the future. Escobar considers these and offers action steps for supporting people in pregnancy, birth, and the postpartum period below.
Parents Have Fewer Choices About the Birth Experience
Parents tend to have better outcomes when they are empowered to make choices about their birth experiences.
“Having options, offering unbiased guidance around those options, and listening to clients is so important. When people have options for where to birth, for example, and have information to weigh pros and cons, then they know where they should be,” said Escobar. “They know what’s best for them. We just need to listen.”
Consider one key decision parents have to make: Where should I have my baby? In many rural areas, birthplace options can be extremely limited. Options for out-of-hospital care may be rare, and even when parents choose an in-hospital birth, they may only have one hospital accessible to them. Some community hospitals have discontinued childbirth services completely, forcing families who want a hospital birth to travel elsewhere for care.
A CNM in Philadelphia, Escobar set the scene of the pandemic’s early days: “People were afraid of being in a hospital and exposing themselves or their babies to COVID-19. They were also afraid of being subject to hospital policies around COVID-19.”
At some hospitals, one such regulation was limiting the number of support people allowed at the birth to reduce providers’ exposure. But there was an unintended — and unjust — effect, as detailed in the article “Reflecting on Equity in Perinatal Care During a Pandemic” in Health Equity: “A policy of no support persons unduly impacts marginalized communities and implicitly reinforces the ‘sacrificial’ or expendable status of Black and Indigenous parents, who have long borne the consequences of mistreatment and abandonment in their health care experiences.”
Protecting parents’ options and respecting their choices surrounding the birth experience is especially important in a crisis. Options should be safe, affordable, and respectful — in other words, a real choice among viable options.
Whether because of the coronavirus or biased, inequitable treatment, “it’s not really a choice when going into the hospital can mean real and present danger,” said Escobar.
Existing Risk Factors May be Compounded, Especially for Women of Color
Prior to the pandemic, pregnant and birthing people in marginalized groups were already at higher risk of complications and death, as explored in [email protected]’s “How Does Race Impact Childbirth Outcomes?” Perinatal mortality rates are highest among Black women in the United States, as are rates of severe maternal morbidity (SMM), an unexpected labor and delivery outcome that may create significant short- or long-term consequences for a person’s health.
~42 non-Hispanic Black women die for every 100,000 live births, compared to 13 deaths for non-Hispanic white women.Source: CDC, “Pregnancy Mortality Surveillance System.”
70 cases of severe maternal morbidity events, or “near misses,” occur for each maternal death of a non-Hispanic Black woman.Source: The American Journal of Managed Care, “Racial Disparities Persist in Maternal Morbidity, Mortality and Infant Health.”
~4.2% of non-Hispanic Black women experience a severe complication compared to 1.5% of white women.Source: American Journal of Obstetrics and Gynecology, “Site of Delivery Contribution to Black–White Severe Maternal Morbidity Disparity.
Some methods of adapting perinatal care during the pandemic could ultimately prove harmful to women, especially women of color, according to the aforementioned Health Equity article. For example, some providers have encouraged early inductions and elective cesarean births (C-sections) to help manage “hospital census and staffing.”
However, these procedures often require increased close contact between patients and providers, increasing the risk of COVID-19 exposure. They can also lead to longer inpatient stays, creating a higher risk for both the parent and newborn.
“Given that women of color already experience higher rates of inductions and cesareans, these policies are likely to further exacerbate the disparities in outcomes,” wrote the article’s authors.
Traumatic Experiences Could be Worsened
Most people bring trauma into the childbirth experience to begin with, said Escobar. COVID-19 adds another layer of stress and fear that may be especially difficult for expectant parents.
~14% of women are affected by perinatal depression.Source: National Institute of Mental Health, “Perinatal Depression.”
~9% of women experience post-traumatic stress disorder (PTSD) after childbirth caused by real or perceived trauma during delivery or postpartum.Source: Postpartum Support International, “Postpartum, Post-Traumatic Stress Disorder.”
“Then there’s a second-layer trend where Black, Indigenous, and people of color (BIPOC), who already enter our health system at a disadvantage and carrying trauma, are forced to choose between COVID risk and a system in which they perceive they are unsafe due to racism and bias,” said Escobar.
“The baseline level of trauma that Black birthing people in particular experience is already so high,” said Escobar. “For folks opting to stay out of care or seeking out-of-hospital birth, it is very easy to understand the logic: Why compound things by introducing either of those two factors, COVID risk and racism?”
Action Steps for Supporting Maternity Care in a Crisis
Giving birth during a pandemic can be traumatic, especially for those who have already experienced trauma in the health care system. With trauma comes fear. When people — both patients and providers — start making fear-based decisions, “that’s when you start getting bad outcomes,” Escobar said.
Still, a negative outcome does not have to be traumatizing. Listening to and empowering the person giving birth can transform the experience.
“There have been clients I’ve been caring for in labor who have had obstetric emergencies, like postpartum hemorrhages or uterine abruptions, where my perception was that the experience was probably traumatic for them,” said Escobar.
However, the patient tells a different story. “Afterwards when we were debriefing, one of those clients said to me, ‘Thank you so much. That was the most empowering experience in my life,’” she said.
Escobar believes the difference between a traumatic childbirth and a difficult but empowering birth is in listening, sharing information, and partnering together even in the midst of a crisis. When people start from a place of listening to expectant parents, they can understand and mitigate their fears. They can work through or around the trauma to comfort the client and overall have better outcomes — even if the childbirth has scary elements.
Below, find suggestions for providers, loved ones, and communities to better listen to and support women in pregnancy and the postpartum period during the coronavirus pandemic and beyond.
- Adopt a midwifery-model mindset: Nurse-midwives are trained to stay calm in difficult births, create an action plan, and move through it with the person “always centered,” said Escobar.
- Treat listening and clear communication as vital clinical skills, as essential as doing an abdominal exam or listening to heart sounds.
- Listen to the client, especially when discussing sexual health history and gender-based violence.
- Find ways to communicate empathy and understanding, even through layers of personal protective equipment.
- Share information and partner with the patient throughout their care, especially in potentially traumatic childbirths.
How Can Family and Friends Offer Support When You’re Expecting During a Pandemic?
Reserve judgement and honor the choices being made around childbirth and coronavirus precautions.
- Before visiting, ask about the family’s comfort level with in-person interactions, and again, avoid adding to guilt or shame about those precautions.
- Identify alternative ways to be helpful, such as sending takeout meals or taking care of yard work.
- Consider offering financial support if needed and requested.
- Check in if you have not heard from a new parent and ask if they need any support or reassurance.
- Extend compassion to new parents in the postpartum period. “We’re going through a collective grieving process in this pandemic,” said Escobar. “That loss and fear juxtaposed with the excitement, joy, and hardship of transition is a really intense nexus.”
How Can Communities Better Preserve Perinatal Health in a Crisis?
Develop a trauma-informed approach to every level of health administration and public service, from intake to birth to discharge.
- Consider how to address the external factors that affect pregnant and birthing people and their families. “Pregnant people don’t exist in isolation,” said Escobar. “They have housing needs, they have food needs.”
- Have a nurse-midwife on maternal health leadership teams. “It improves outcomes, culture, and patient satisfaction everywhere,” said Escobar.
- Create policies that make perinatal care more holistically accessible. For Escobar, accessibility includes having a hospital to go to that offers safe, effective, unbiased, and respectful care.
Citation for this content: [email protected], the online Women’s Health Nurse Practitioner program from the Georgetown University School of Nursing & Health Studies
The Medscape 2020 nurse job satisfaction survey dove into fears, PPE woes, and other highs and lows of life in the workplace during the pandemic. Medscape surveyed 10,400 nurses across all regions of the US and analyzed responses from 5130 RNs, 2002 NPs, 2000 LPNs, 500 clinical nurse specialists (CNS), 401 nurse-midwives (NMs), and 391 CRNAs. Most respondents fell within the 35-54-year-old age group.
Despite the hardships of 2020, most respondents are still quite happy with their choice of career. A full 98% of NMs and CRNAs are glad they chose nursing, closely followed by 96% of CNS, 95% of LPNs and NPs, and 93% of RNs.
Given the chance of a do-over, though, some are not sure they would make the same choice. 85% of NMs and CNS say they would pick nursing again. Among RNs and CRNAs, 76% and 78% would stick with nursing.
The Impact of Covid-19
Among CRNAs, 73% have treated Covid-19 patients. Midwives came in second, with 60% of NMs saying they had treated Covid patients, followed by NPs (57%), RNs (53%), LPNs (50%), and CNS (38%). Have they had sufficient PPE? Responses were almost evenly divided, with a majority of LPNs (59%) and RNs (56%) affirming that they have enough PPE.
Who was furloughed? CRNAs were at the front of the line, with 34% saying they had been furloughed during the pandemic. NPs came in second, at 18%, followed by LPNs (15%) and RNs (14%). On average over 30% of the nurses surveyed lost income last year, but CRNAs took the biggest hit, with 59% saying they lost money in 2020.
Telehealth is becoming routine for nurse-midwives and NPs. In the 2020 survey, 77% of NMs and 75% of NPs told Medscape that they met with patients online or by phone, and 53% of the LPNs surveyed made virtual visits.
Fears and worries during this scary year were to be expected, of course. Nurses’ greatest concerns during the pandemic were concentrated on the fear of transmitting Covid to family and oneself, but 38% singled out the discomfort of wearing extra PPE as their main woe, and 23% worried most about higher patient loads.
Best and Worst Parts of the Job
Asked about their main source of job satisfaction, nurses offered a range of answers, but helping people and making a difference in their lives was the top choice for RNs, LPNs, and APRNs (click charts to enlarge).
Least satisfying aspect of the job: Workplace politics ranked first for RNs and LPNs at 23% and 21% respectively, and for 26% of CNS’s. LPNs also pointed to their paychecks as a source of dissatisfaction.
See the full report on Medscape.
Even before hard data was available, many pregnant women were taking extra precautions against COVID-19, and a new CDC report indicates that they may indeed face additional risks from infection. “Although the absolute risks for severe COVID-19–associated outcomes among women were low,” the report states, “Pregnant women were at significantly higher risk for severe outcomes compared with nonpregnant women.” Another recent report found that pregnant women with Covid were also more likely to have pre-term births.
In a January-October 2020 study of symptomatic cases among over 400,000 women between the ages of 15-44, the CDC study found that pregnant women were up to four times more likely to require ventilation and two times more likely to die. The results varied depending on ethnicity. Pregnant Latina women faced a higher risk for infection and death compared with nonpregnant Latina women, and regardless of pregnancy status, non-Hispanic Black women experienced a disproportionate number of deaths. To view data on ICU admissions and invasive treatments (ventilation and ECMO life support) broken down by age, pregnancy status, race/ethnicity, see this table.
Based on these reports, the CDC advises pregnant women to
- Limit unnecessary interactions with persons who might have been exposed to or are infected with SARS-CoV-2, including those within their household, as much as possible.
- When going out or interacting with others, wear a mask, social distance, avoid persons who are not wearing a mask, and frequently wash their hands.
- Take measures to ensure their general health, including staying up to date with annual influenza vaccination and prenatal care.
Dr Denise Jamieson, chair of the gynecology and obstetrics department at Emory University School of Medicine, also commented, “Pregnant women need to be included in the different phases of vaccine trials, so that when a vaccine is available we understand the safety and efficacy of vaccines in pregnancy.”
The data on COVID-19 and pregnant women appeared close on the heels of an American Academy of Pediatrics report stating that infections among children are on the rise. The 61,000 new cases in children during the last week of October “is larger than any previous week in the pandemic,” according to the AAP. However, most cases in children still tend to involve milder symptoms. CDC studies have found that just 54%-56% of children experience fever and cough, compared to 71%-80% of adults, and only 13% suffer from shortness of breath, compared to 43% of adults. Pediatric cases requiring hospitalization, though, are as likely to require ICU care as adult cases, with one in three leading to the ICU.
Midwives as well as nurses are experiencing a momentous Year of the Nurse and Midwife. Back in April, the Pew Trusts noted, “Midwives across the country say they are stretched to accommodate additional deliveries because of the pandemic.” In May, a Cincinnati midwife remarked, “My inquiry rate for home birth has gone up 300% in the last month.” With COVID-19 cases on the rise in states such as Arizona, Texas, and Florida, the trend shows no sign of slowing down.
An understandable fear of the virus prompts many women to seek out midwives, according to Katie Bramhall, President of the Vermont Midwives Association. Bramhall told the Christian Science Monitor, “Pregnancy and birth and making a family is such a huge transformation for everybody involved; add the fear of a public pandemic, and that makes that transformation even more imperative in people’s hearts and minds. Fear on top of labor in a pregnancy can change an outcome, because fear will change any outcome in life if that’s the driving force.” The need for comfort and security is a decisive factor. Speaking to a local news station, Charlottesville, Virginia midwife Kelly Sicoli said a key consideration is “Just sort of the general level of anxiety and activity happening in the hospital setting right now… Wanting to stay at home and [be in] their own environment where they have more control and they’re healthy and there’s not anyone who’s sick.”
As the pandemic drives expectant mothers to seek out midwifery services, support for birthing centers is on an upswing and issues such debate over regulations and insurance coverage have taken on a fresh urgency. A hopeful indicator of change appeared on June 16, when Governor Andrew Cuomo and the New York State COVID-19 Maternity Task Force directed the State Department of Health to allow midwife-led birthing centers in New York for the first time. In May, Health Affairs suggested that CNMs be reallocated from hospitals to birthing centers and recommended, “As states consider options for increasing staffing at birth centers, they should consider scope of practice, malpractice coverage, and Medicaid reimbursement policies that will facilitate that change.” States such as Nebraska and North Carolina have also relaxed practice regulations for Certified Nurse Midwives, and widespread media notice of the spike in demand is likely to make midwives more accessible in other parts of the country.
Midwives themselves have naturally had to adapt during the pandemic. They are making fewer pre-partum and postpartum visits in-person, and are instead conducting appointments via telehealth whenever possible. Ultimately, though, the experience has changed less than you might expect: Christine Yentes, a midwife in Bangor, Maine noted, “There is still normalcy within the unprecedented. The babies are still coming out, they’re still nursing, they’re still doing everything they’re supposed to do. That’s kind of reassuring. Here’s something that’s happening that’s still normal.”
With the spread of the COVID-19 pandemic, Jennifer Scott, CNM, realized that she needed to take additional steps to keep her patients safe. As the pandemic rose in severity, Jennifer, whose primary patient base is a local Mennonite community in the Finger Lakes region of central New York, temporarily closed her clinic and began seeing patients in their homes.
The home visits were necessary, according to Scott, who had to rule out telehealth visits because her Mennonite patients don’t have computers or cell phones.
“We provided home visits because it is easier to isolate and wipe down our equipment between homes. This also prevented our clients from congregating in the waiting room. Many women will make appointments on the same day and share a ride. We are also only visited clients who were higher risk or near term. For example, we’ve spaced our four-week visits out to five weeks and are doing more phone calls.”
Jennifer is from the Finger Lakes region and, after working as a full-scope midwife in a community hospital for seven years, she joined other colleagues to open Community Midwives in 2019. She has retained admitting privileges at the hospital, though the Mennonite community prefers home births.
“The reasons are multifaceted,” Jennifer said, noting that she and her fellow nurse-midwife at Community Midwives attend six to 10 births per month in the community of approximately 600 families.
“Many are farmers, have large families and don’t drive cars. In order to have a hospital birth they would need someone to take care of the farm, watch the children and would have to hire a driver to take them to the hospital in labor, possibly in the middle of the night. The closest maternity hospital is 30 to 45 minutes by car. Some are put off by hospital costs and length of stay. Others like the comfort of their own home. They feel safer emotionally to give birth in their own surroundings.”
Making her patients feel safe became an additional challenge amid the COVID-19 pandemic. While the pandemic impacted this somewhat isolated community differently than other parts of the country, the fears were the same. The closing of schools and churches limited primary sources of socialization, entertainment, and information. Because the Mennonite community does not watch TV or listen to music, Jennifer shared news about the pandemic with the families she serves, printing off the latest information from the county and state health departments.
“Like everyone, they were worried for their families, stressed by the social restrictions and having to homeschool their children,” Jennifer said.
“The Mennonite community is very self reliant. They have stocks of canned and frozen produce from their own gardens and bake their own bread. They have fresh eggs and milk also. They may only go once a month to Walmart for other supplies so they are not as exposed to as many crowds.”
Jennifer, whose husband also battled the COVID-19 pandemic as a physician in a local hospital, said she hopes the pandemic inspires others to choose nursing and medicine, just as she was inspired by her experiences as a Frontier Nursing University (FNU) student.
“FNU taught me to grab my saddlebag, get on my horse and ride up that mountain,” Jennifer said.
“It taught me that my calling is to care for the underserved, the vulnerable families, without hesitation. I’ve always believed the education at FNU has prepared me for anything I encounter in the workplace. I remember Kitty Ernst giving a talk at Frontier Bound that I paraphrased as ‘We only educate the strongest, most resilient nurses’.”
A midwife–especially a Black midwife–can tilt the balance between life and death for African American infants and their mothers. Regardless of income and education level, childbirth for Black women is more dangerous than it is for White women. Even Serena Williams had a dangerous close call during her pregnancy, after doctors failed to heed her request for a CT scan and blood thinner medicine. Despite her history of blot clots, it was posited that “Williams’ pain medication must be making her confused.”
The Centers for Disease Control reports
that African American mothers die at three to four times the rate of White
women, and the mortality rate of Black infants is higher than that of any other
ethnic group in the US. Why? As AmericanProgress.org states in a 2019
policy blueprint, “Racism is part and parcel of being black in the United
States, and it compromises the health of African American women and their
infants… Put simply, structural racism compromises health.” According to Dr
David Williams, a pioneer in measuring the effects of racism on health, “We now
know that discrimination is linked to higher blood pressure, to high levels of
inflammation, to low infant birth weight…”
Enter the Midwife
One action that promises to change these dire
statistics is expansion of the midwifery movement, especially within the
African American community. Angela
Doyinsola Aina, interim director of the Black
Mamas Matter Alliance (BMMA) recently told an American Public Health
Association (APHA) conference, “We have to go beyond just talking about giving
people, especially low-income people, access to care…. We also need to ask
whether that care is high quality and culturally relevant.”
Where do Black midwives come into the picture? ProPublica
notes in a report
on how increasing the role of midwifery in the US could reduce maternal
complications and mother/infant mortality rates, “Many… [US] states
characterized by poor health outcomes and hostility to midwives also have large black populations, raising
the possibility that greater use of midwives could reduce racial disparities in
maternity care.” And Lamaze.org
suggests, “When Black families are cared for by Black health professionals,
like midwives, they are better heard, seen, respected, understood, and get
their needs met, which relates directly to health outcomes.”
One of the women at the forefront of the Black Midwives
movement is Jennie Joseph, founder of the Birth
Place in Winter Garden, FL. Joseph’s work as a provider of perinatal
services to underserved and uninsured women of color has already brought about
positive change in the CDC numbers. Trained in the UK, where half of all babies
are delivered by midwives, Jennie Joseph arrived in the US to find that in the
most affluent country in the world, owing to concerted opposition from doctors
and hospitals, midwives attend only 10% of all births. She also found that the
US has a much higher incidence of maternal and infant mortality
rates—particularly among minorities and the disenfranchised—than in countries
such as Canada, Sweden, and the UK, where midwives attend the majority of
Joseph’s “open access” clinic at the Birth Place provides pre-natal
and post-partum care for women regardless of their ability to pay and focuses
on minority and underserved women in the area. As Miriam Zoila Perez marveled
in the New
York Times, the Birth Place manages to beat the dire maternity figures for
women of color: “When you look into her statistics, you find something quite
rare: Almost all of her patients give birth to healthy, full-term babies… maybe
not surprising until you learn that the majority of them are low-income
African-Americans, Haitians and Latinas….”
Expanding the Midwives’ Movement
Another pioneering Black midwife is Shafia Monroe, who has long been one of
the major forces behind the Black midwives’ movement. Founder of the
International Center for Traditional Childbearing (which was re-formed in 2018
as the National Association to Advance Black Birth) and winner of a Lifetime
Achievement Award from the Human Rights in Childbirth Foundation, Monroe
started working with mothers and infants as a nurse’s aide in the postpartum
ward at Boston City Hospital at the age of 17. It was in 1991, when she
encountered difficulties in finding a midwife of color for her own pregnancy, that
Monroe founded her influential International Center for Traditional
Childbearing. Under the auspices of the ICTC, she became a pioneering figure in
the cause of Black midwifery. Monroe has worked tirelessly to reduce
mortalities linked to pregnancy and to increase the number of Black midwives
and doulas. To women who are interested in becoming midwives, Moore urges, “Join
an organization! There’s MANA (Midwives Alliance
of North America), ICTC, ACNM (American College of Nurse Midwives);
there’s so many organizations. Look into organizations that are familiar with
black reproductive issues, and our history.”
As the co-director of Black Mamas Matter Alliance (BMMA), Elizabeth Dawes Gay, says, “If even one more person just says they want to take up the cause, they want to become a doula, they want to become a midwife, they want to start an organization—to me that’s a success.”