The classic pregnancy book What to Expect When You’re Expecting lists a few common questions women ask themselves before their baby’s due date, including “Can I work until I deliver?” and “Will I know labor when I feel it?” (Answers: yes, and probably.) Some questions not covered in the book: “What if my obstetrician has been called away to care for covid-19 patients?”, “Should I have a home birth to avoid the hospital?” or “Can babies catch coronavirus?”
Though no one really knows the answers to these newer questions, pregnant women and their partners—not to mention obstetricians, doulas, midwives, and lactation consultants—are scrambling to figure out how to navigate birth despite the uncertainty. The potential impact of this healthcare crisis goes beyond the more obvious issue of contracting covid-19. Women in danger of losing their pregnancy or suffering complications as well as those with preexisting conditions might find their provider is too inundated with calls from other concerned patients to adequately help her understand her unique circumstances. Many of the women I spoke to who fit these descriptions said their doctors haven’t offered any specific advice for them or made an effort to be in greater contact. Pregnancy is difficult enough, but dealing with it as a pandemic rages in the background adds a new dimension of stress, which has been linked to multiple negative outcomes of pregnancy, and could potentially have long-lasting health ramifications for both mother and child.
Some pregnant women have considered changing their birth plans to avoid a hospital, both because infections notoriously linger there and they’re worried that our facilities will soon be as overburdened as China’s or Italy’s, where a surge of cases in the north has meant specialists have been pulled off their regular wards to focus on covid-19 patients. Jada Shapiro, childbirth educator and founder of boober, an app that connects parents to pre- and post-natal care, said that across her vast personal and professional networks, expecting couples are panicking. “People are definitely scared, they’re definitely asking, ‘are there any alternatives [to hospital-based care]?’” (To check on this, I called the Brooklyn Birthing Center, New York City’s only freestanding birthing center, and Director of Midwifery Trisha Williams confirmed they had seen an uptick in inquiries; homebirth midwives in New York, San Francisco, Los Angeles, and Seattle reported the same.) Shapiro hasn’t definitively told her clients to switch their plans: giving birth at home or in a birthing center means doing so without pain medication, and is usually an experience women prepare for months to endure. But she did publish a blog post suggesting that women plan to “birth in place” for longer than they originally anticipated and purchase a “just-in-case birth kit” (including sterile gloves, a bulb syringe, and a baby cap) so they’ll have necessities on hand if they can’t travel or be admitted to a hospital.
Michelle Gabriel-Caldwell, a doula and owner of Baby, Please Birth Services in New Jersey, has gone a step further and started actively recommending women fewer than 20 weeks pregnant strongly consider a home birth. She added that one of her four current clients is set on switching to a birth center, but her husband is less keen on the idea. But Dr. Tristan Bickman, an OB-GYN who delivers in the Los Angeles area, told me she doesn’t agree. “I do not recommend switching to home birth or a birthing center, not yet anyway,” she said. “Each hospital has their own set of guidelines that are evolving every day and, as of right now, it has been proven safer to remain in the hospital.”
Another woman weighing her options is Sara Mauskopf, the CEO and co-founder of Winnie, a platform that helps parents find childcare, who is 37 weeks pregnant with her third child. She started toying with the idea of switching from the small, local hospital near her house in San Francisco to a birthing center or a homebirth midwife last week. “It hit me that a hospital might become a less safe place to give birth,” she told me. Like many pregnant women I spoke with, she’s comforted by the research that suggests covid-19 can’t be passed to babies in utero (known as “vertical transmission”) but she isn’t thrilled by the prospect of contracting a potentially debilitating respiratory infection in her infant’s first days, especially with two toddlers already at home.
After doing research and making inquiries, though, Mauskopf decided to stick with her original plan. “I’m a little less excited that [the alternatives are] actually safer,” she said. The midwives wanted to squeeze a bunch of get-to-know-you visits into the next three weeks and the birthing center required at least a pre-labor visit: that’s a lot of human contact for someone practicing social distancing. Because she’s at term, Mauskopf considered inducing labor early, but she’d rather wait as long as possible out of concern that any disruption to the birthing process might increase the chances of the baby requiring a stay in the neonatal ICU. Her colleague Anne Halsall gave birth six weeks early last week, and was recently turned away from a San Francisco NICU by a nurse citing the “essential visitation” policy (many hospitals are limiting patients to a single visitor, but some hospitals in San Francisco are banning visitors completely, including for women in labor; Mauskopf is already planning for her husband to stay home). Halsall was eventually allowed to see her newborn, but when she had to leave to get food—the hospital’s café has closed down—she tweeted she was “scared shitless” they wouldn’t let her return.
In response to the increasingly strict visitation policies at hospitals and people’s newfound aversion to being in close quarters, Gabriel-Caldwell and Shapiro have been rushing to move all their services online, launching virtual childbirth classes, lactation consultancies and mental health consultations. Doulas have even started Skyping with their clients during labor. On Sunday afternoon, Shapiro hosted a webinar with Dr. Jaqueline Worth, an obstetrician at Village Obstetrics in Manhattan and co-author of The New Rules of Pregnancy, and Dr. Julie Capiola, a pediatrician and lactation consultant with Premier Pediatrics in Brooklyn, to talk through these issues and more. Shapiro hadn’t even marketed the event until that morning, but more than 500 people registered even though the meeting was capped at 100 attendees.
The class covered many things I’d already considered, but a number that had never even crossed my mind. Like, how can you cut down on prenatal appointments? By monitoring yourself with a home blood pressure cuff, urine drip sticks, and a scale. How should you breastfeed if you have covid-19? Pump your milk, and have an uninfected person bottle feed (if you are well, you might still consider wearing a mask while nursing). How can you limit the infant’s pediatric appointments in the early months? You should still go in for the required vaccines, but consider buying a scale to monitor the baby’s weight at home to skip other visits (with your doctor’s help, so you don’t drive yourself insane). Both doctors were clear that everyone is operating on little information or conjecture—much of what they are recommending with respect to breastfeeding comes from research done on SARS and MERS—and the advice could change every day.
Of course, many pregnant women don’t have the option of avoiding their doctors’ offices, either because their physicians haven’t provided the same guidance as Dr. Worth has, or because they’re high-risk and need to have more frequent ultrasounds, or they’re on Medicaid and can’t afford to pursue alternative childbirth (birthing centers and home birth midwives are often not covered by insurance). To safeguard these patients, some obstetricians are putting out statements detailing their office’s new disinfecting policies—from stocking up on extra hand sanitizer to removing periodicals from waiting rooms—and advising patients with non-urgent appointments like yearly pap smears to delay. Though hospitals are constantly sanitizing, there is still a risk of in-hospital transmission, though many doctors think it’s low.
“We see transmission of other respiratory issues like flu or rhinovirus within hospitals,” said Benjamin Goldman-Israelow, who studies virology at Yale-New Haven Hospital. “That being said, the amount of vigilance that’s going on right now is at an all-time high.” Uncertainty over individual hospital policies has led some women to fear they’ll be separated from their newborn if they present with symptoms of coronavirus. The Centers for Disease Control and Prevention’s guidelines recommend that new mothers infected with Covid-19 be “temporarily separated” from their infants. They add, however, that the “risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team.”
When I spoke to Dr. Worth after the webinar, she said she felt sure that in New York City, anyway, the hospitals would continue to accept women in labor. “I believe that our city government will build ten ICUs in a parking lot before they kick out all the other patients.” That’s good news for high-risk patients who don’t have another option. Sandra Rose, 35, from Brooklyn, is due with twins on May 24, but is scheduled to undergo a C-section on May 10, at Mount Sinai hospital in Manhattan, where New York City’s first coronavirus case was diagnosed. She’s currently a patient at an obstetrics practice specializing in high-risk births—multiple pregnancies are often high-risk due to increased chance of prematurity, low birth weight and respiratory complications, among other possible issues—which she said has only given her the standard advice to wash her hands and stay home if she was feeling ill. Like many pregnant women I spoke to, it isn’t the prospect that she’ll get coronavirus and pass it along to her babies in utero that scares her, but the idea of spending three days after birth in a hospital, especially if her twins come unexpectedly early. “I would imagine that newborns with very new lungs...,” she said, stopping short. “You would think that a respiratory disease would be pretty detrimental.”
Talitha Phillips, the CEO of Claris Health, which offers affordable sexual health services in underserved communities in Los Angeles, said she’s particularly concerned about black women, who have disproportionately high rates of infant and maternal mortality and are often suspicious of healthcare providers because they’ve been condescended to in the past or experienced iatrogenic trauma. “Efforts to combat these rates include increased group-based prenatal care, doula support for labor and postpartum, and other community-support efforts. The current healthcare crisis creates barriers to these services and may isolate this population even further,” Phillips noted.
Rose is trying to remain sanguine about the situation. She’s glad that Mount Sinai, like many hospitals across the country, has instituted a policy limiting visitors, and having the procedure on the calendar already gives her a sense of control over the situation. She follows the news, but doesn’t dwell on the horrors: the newborn in London who tested positive for the virus, the pregnant women in Wuhan under quarantine who have to rely on volunteer drivers to attend medical appointments, the dire prognosis for America’s hospitals if we can’t “flatten the curve” immediately.
“I can’t let my mind run with this,” she said. “Come hell or high water, they gotta come out.” Dr. Worth echoed Rose’s optimism: “We will deliver babies. We will help each other. We will be safe. I’m confident of that.”
Kelsey Osgood is the author of How to Disappear Completely: On Modern Anorexia. Her essay on premature birth will be published in the collection What We Weren’t Expecting, out in fall 2020.