COVID-19 is changing the American health care system for better or worse. Here, experts in maternal health care and childbirth break down what parts of pregnancy and delivery they expect to see permanently impacted by the pandemic we are currently facing. 

By Kelly Glass
April 10, 2020
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Credit: Illustration by Yeji Kim

As the threat of COVID-19 grows, it has also exposed some existing weaknesses in our health-care system—incomplete collection and dissemination of data, lack of universal health care, racial health disparities, focus on intervention rather than prevention, and access to testing. The coronavirus pandemic has also uncovered a larger societal attitude toward health care: the tendency to underreact to slow-growing, long-term health crises. 

We have been in a maternal health crisis. Year after year more women have died during and immediately after childbirth in America. Black and Native American/Alaska Native women have been disproportionately represented among the women who’ve lost their lives during labor. The novel coronavirus has followed a similar pattern, with the limited data available showing that Black people have died from the virus at a higher rate than white people. The rapid spread of COVID-19 and the consequences of this pandemic are changing norms in all areas of our lives, including current labor and delivery policies and practices in America. It’s also raised many questions regarding the future of childbirth and prenatal care once we’re on the other side of this. 

“I think this is a very good time to rethink the narrative of the story and not be forced into a position of coming up with a cookie-cutter template that’s going to solve everything,” says Kathryn Hall-Trujillo, founder of the Birthing Project USA and faculty member at the Charles R. Drew University of Medicine and Science. “It’s about expanding the conversation.” 

The uncertainties are many, but if there’s one thing we have learned for sure through this crisis, it’s that there is value in listening to the experts. Here are the conversations some of our nation’s experts are having about how maternal health care and childbirth in America could permanently change.

Routine Prenatal Checks Done From Home

Ezekiel J. Emanuel, M.D., professor of medical ethics and health policy in the Perelman School of Medicine and The Wharton School at University of Pennsylvania:

"We should really think about doing more of this prenatal care at home and postnatal care at home. One of the things we could think about is supplementing that with a nurse practitioner. Someone specialized in maternity care who could go out to the house on occasion. It's unclear to me why a mother needs to trek into the doctor's office all the time. Having a nurse practitioner who's skilled and can identify the core problems visiting the house may be more effective."

Katherine Mangu-Ward, a journalist who has reported on health care regulations

"When I first started going to the OB-GYN practice where I eventually gave birth to my two kids, I was delighted to discover that my doctor was willing to communicate via email. It seemed, at the time, like a huge breakthrough. In the decade since, almost every other profession has gone digital, but obstetricians have been slow to move online in their dealings with patients. This is in large part because they have been hamstrung by a web of patient privacy regulations and archaic rules about reimbursements, plus delayed availability of at-home testing tools. 

There are very few silver linings to the coronavirus pandemic—especially for pregnant women who must be feeling especially vulnerable and terrified—but one of them is that the U.S. government has relaxed restrictions in many of these areas to make it easier for people to get care from their homes. While this is meant to be a temporary measure to allow telemedicine under unusual constrained circumstances, the fact is that even before COVID-19 many expectant mothers already had good reasons to want to avoid crowded waiting rooms, peeing in a cup in an unfamiliar restroom, or waiting around for blood draws. And while there will always be reasons for in-person medicine, including, of course, birth itself, there are plenty of routine checks that could be done with the aid of video chat and at-home testing, if only some of the new rules are made permanent."

Planned Out-Of-Hospital Births on The Rise

Barbara Belcore-Walkden, CPM, LM, chair of the legislative committee for the Illinois Council of Certified Professional Midwives:

"Right now, hospitals are implementing strict policies limiting who can attend a hospital birth. Laboring people are being asked not to bring family members and doulas. Some hospitals are even restricting the co-parent from being in the delivery room. Home birth midwives all over the country are being inundated with phone calls from families who are changing their birth plans to avoid hospital restrictions as well as to limit possible exposure to COVID-19. Many of these families never even considered home birth until the pandemic hit. Home birth is quickly becoming more and more mainstream. Families are signing petitions to open up their options in and out of the hospital as well. The number of birth rights advocates is skyrocketing, and this is likely to result in major improvements in perception of out of hospital birth."

Making Women’s Access to Health Care and Insurance a Priority

Kathryn Hall-Trujillo, founder of the Birthing Project USA and faculty member at the Charles R. Drew University of Medicine and Science:

"The glaring thing is that a woman only becomes important enough to have designated health care when she’s pregnant. But what we know is that the most important factor in pregnancy is not what happens when you’re pregnant, but what happens to you before you’re pregnant. So looking at the pregnancy story does not begin at the point of your pregnancy. We should start thinking about education and prevention long before we start thinking about intervention. We need to start looking at providing support to women over a lifetime."

Labor Will Be Less High-Tech and More Personal

Dr. Emanuel:

"We often in America associate high-tech with better and safer. There are many high-tech interventions in pregnancy that there's no evidence that they actually make a difference and are better for the mother or the child. Fetal heart monitoring is one of those with no evidence of better outcomes, but we do it. Making it less high-tech and more personal may be much better. It's the kind of thing we really need to look at. Just because we have a tradition of doing things one way does not mean that way is better—because almost all of that kind of stuff has never been evaluated."

Mobile Health Services for Women in Rural Settings

Diana W. Bianchi, M.D., director of Eunice Kennedy Shriver National Institute of Child Health and Human Development:

"The increased use of telehealth and mobile health services can potentially be adopted for women in rural settings, in urban maternity deserts, in communities with limited health care support, and for women with physical disabilities who encounter difficulties getting to appointments. The successful increased use of online education and conference services will provide new opportunities for education and counseling of pregnant women. The NIH is developing a research agenda in response to COVID-19. We are particularly focused on medical, behavioral, and social issues that are being encountered by pregnant women, children, and people with intellectual and physical disabilities."

Technology Can Create a Bridge to Access If We Address Existing Inequalities

Mary-Ann Etiebet, M.D., executive director of Merck for Mothers:

"One of the key drivers for improving maternal care is getting access to quality care, and challenges to accessing care have been further exacerbated by a crisis like COVID-19. Technology and digital engagement platforms can create a bridge to essential services at a time like this, creating virtual spaces and communities for providing information, care, and support.  

However, we need to make sure that the deployment and scale-up of such innovations do not worsen inequities and inequalities in access patterns. The social determinants of health—the economic, language, cultural, or location factors—that limit access to facility-based health services can also limit access to telehealth-based services. We need to ensure that digital solutions consider if a woman has access to the internet or a phone or computer that supports it in the first place. We also need to ensure that these solutions are deployed in a way that can be leveraged for broader health and social impacts and contribute to creating inclusivity and resiliency in health systems for the long-term. Once we deploy these new technologies, and if they are meeting the needs of women and making it easier to access quality services, they will be here to stay."

Increased Access to Diverse Maternal Health Care Providers

Nastassia K. Davis, DNP, RN, IBCLC, founding executive director of the Perinatal Health Equity Foundation:

"New partnerships and relationships have been formed, which will hopefully turn to long-standing relationships. A big one is that many states have given advanced practice nurses (APN) like nurse practitioners and midwives full practice autonomy. Prior to COVID-19, bills to support autonomous practice in New Jersey were shot down. Removing this barrier has the potential for more Black APNs to enter into private practice to improve access to high-quality care to Black women. Hopefully, this is a change that will continue past the pandemic."

Dr. Etiebet:

"The majority of the current focus is on how to make sure care delivery within health care facilities stays safe. However, women received a significant portion of necessary care and support services in their communities from essential members of their care teams like community health care workers, peers, coaches, advocates, and doulas. We need to ensure that these frontline health care workers and those encounters are also protected so that they can effectively and safely augment facility-based care."

Patient Advocacy and the Demand for Informed Consent

Belcore-Walkden:

"The demand for informed consent is likely to change policies for the better in hospitals across the country long-term. Birthing families are speaking up in a way they never have before, recognizing that birthing alone in a room with strangers is not going to improve outcomes. Even hospital providers are encouraging their patients to look into other options. The increase in home birth inquiries is pushing states that do not license certified professional midwives to consider and implement emergency licensing to meet states’ needs."

Parents.com investigates the nation’s maternal health crisis and what can be done to lower the risk for thousands of expecting mothers. Read more here.

 

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