Everything You Need to Know About Pregnancy and Birth in the Age of COVID-19
A few minutes before I spoke with Caitlin Fiss, M.D., an OB-GYN and a clinical instructor of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai last week, she asked to move our interview up by a half hour.
After our call, she had to drive two hours round trip to pick up 10 protective N95 masks from a friend.
"At the beginning of the pandemic in New York City, we were given a single mask," she tells me. "These masks are intended to be used per patient. We've been given a little baggie to carry around our mask in."
But if you're pregnant or have just delivered, you likely feel like you're on the front lines too. After all, as elective surgeries get canceled and doctors urge people to consider telemedicine for mild issues, labor and delivery go on.
This new "normal" of birth in the United States is—well—new. It's changing day to day. And depending on your personal circumstances and where you are, it looks a little bit different. But what we do know is this: Visitors are being restricted from hospitals. Support people are being limited. Women are being discharged early after delivery. Quarantines are isolating families. And you're likely wondering, how could this be happening? "I think, initially, what people are feeling is shock," says Catherine Birndorf, M.D., a reproductive psychiatrist and co-founder of The Motherhood Center of New York.
Here, new mothers, pregnant women, and doctors provide a glimpse into the truths beyond that shock—what birthing in a pandemic looks like, plus ways to prepare in unprecedented times.
The Ins and Outs of Labor and Delivery During the Pandemic
Check the rules for labor and delivery, visitor policies, or what to expect from your next prenatal appointment, and then you might as well check again—hospitals are changing their policies that frequently.
The most noteworthy example of this, of course, is that for six days, women at some New York hospitals birthed alone. After 30 health care workers were inadvertently exposed to mothers who unknowingly had COVID-19, two major hospital groups banned support people during labor and delivery, a mandate that devastated pregnant women, prompted a social media campaign (#IDeserveBirthSupport), a Change.org petition that more than 600,000 people signed, and ultimately culminated in an executive order requiring all hospitals in New York to allow a support partner.
Nicole Westphal, a 34-year-old from Long Island, gave birth on March 26 at Mount Sinai South Nassau during the ban. On the morning of her scheduled cesarean section for their second child, her husband, Greg, 33, dropped her off at the hospital. "It was a heavy and dreadful feeling in what should have been an appropriately nervous but exciting moment," she says.
There was a single security guard at a podium wearing a mask when they arrived. "I felt like I was in a biohazard movie," Greg says.
As hospitals set labor and delivery regulations around COVID-19, they rely on consultations with colleagues around the country and guidance from The American College of Obstetricians and Gynecologists (ACOG), Regan Theiler, M.D., Ph.D., chair of obstetrics at the Mayo Clinic, explains to me.
A few weeks ago, ACOG released both practice advisory guidelines and frequently asked questions to address labor and delivery during COVID-19. Recommendations include having COVID-19 positive or symptomatic patients wear masks, having all attending medical staff in personal protective equipment (PPE), and a consideration to screen patients and visitors.
But admittedly, many decisions—specifically around visitor policies and PPE—are being made at the local level, Dr. Theiler says. And as you can guess, rules vary: Some women at some hospitals are being asked to wear masks. Some hospitals (including Mount Sinai) are testing laboring women and screening support partners for COVID-19 upon arrival. Others are not. Most hospitals are banning visitors. At some hospitals, COVID-19 threatens supplies. Other doctors don't believe they've seen the worst yet. "In these uncertain times health care workers have had to band together and have had to coalesce as a team because we are facing shortages," says Dr. Fiss.
To this extent, safety has to come first. "Every obstetrician in every hospital in the country wants a woman to have a great birth experience, but never ever at the cost of safety," explains Dr. Theiler. "A healthy mom and a healthy baby is always the number one goal. Safety is not an assumption we can make during a pandemic. So that's where our focus is."
For the Westphals, Greg was present via FaceTime for the birth of their son. "You can imagine a million things going wrong during childbirth and you can have nightmares about it, but you never think that one of the things that could disrupt your moment is service cutting out," he says.
A health care worker herself, Westphal says she's grateful: She had a healthy baby, a smooth enough procedure, this wasn't her first birth, the hospital staff was incredibly supportive, and she understands why support people were temporarily banned.
But the experience wasn't easy. "I don't want anyone to go through what we went through ever—especially if you're a first-time mom, a younger mom, or a mom who's not in a safe place." Without Greg there for support postpartum, she didn't want to take as many painkillers because she knew she had to take care of the baby herself and she didn't want to feel "loopy.'" While she knows she could have relied on hospital staff for snacks at 4 a.m. or to grab her phone charger, it didn't feel as comfortable as having a loved one there.
"The hardest thing is that I wasn't able to hold her hand, stroke her cheek, and whisper, hey, it's going to be OK. You're doing great, I love you," Greg tells me. "It's a pretty intimate moment, and you're having it on FaceTime with a dozen or so people in the room. One of the moments I'll always remember is the nurse stroking her cheek. That meant a lot to me, but it was tough not to be that person."
Forty-eight hours after her C-section, Greg picked Nicole and their son up.
Charlotte Savino, 33, who delivered a daughter on March 22 at Mount Sinai West, left the hospital 24 hours later.
"Many of the reasons we keep moms for another 24 hours are things we can address—albeit maybe not quite as well—in the outpatient setting," says Dr. Theiler, referring to lactation and normal discomforts of the postpartum time period. "We feel that getting these moms home given the pandemic status and the increasing number of sick people in the hospital is the safest thing to do."
Savino says leaving early was "a mixed bag." Her daughter only passed her auditory test on one side (it can take several days to get a good reading), she got a "cursory, though helpful, tutorial" from lactation consultants, and the first night home was tough. "My body was still in shock. I would have liked another night with nursing staff to allow me to rest and heal," she says. "That said, it was scary to be in a hospital, wondering each time a new person came into the room whether they were a carrier, or if they were reusing PPE."
Experts tell me that hospitals are trying new ways to support moms postpartum—phone calls to make sure breastfeeding is going OK, telemedicine, online screening for postpartum depression.
Westphal and Savino note they haven't received any such follow-up care. Savino says she canceled a postpartum doula, ate the cost, and has relied on videoconferencing consultations that she set up on her own instead. "Selfishly, not having our doula here has been the hardest part because breastfeeding is so emotional and lactation consultants can be so hands-on." Both sets of grandparents also canceled their plans to meet the baby.
"We're sending people home and telling them, 'stay in; no, the grandparents can't come over; and no, you can't go back to a normal work situation.' We've never seen a situation exactly like this before," says Dr. Theiler.
Some people are getting creative once they get home. Maggie Mundwiller, who gave birth to her second baby, Mylo, on March 18 in St. Louis, Missouri, has been having family members meet him from a distance. "We were inspired by senior living communities, where my husband and I work, and the residents who visit their families through windows," she says. "We have seen lots of joyful tears, had songs sung, shots taken, smiles, and just lots of life. Everyone understands the importance of social distancing and appreciates our special way to meet Mylo."
Other women are wondering if they should pivot their plan, researching the possibility of a home birth instead. It's something Nicolette Rath, a 32-year-old nurse who lives just outside of Philadelphia and is due May 21 with her first baby, looked into. She ultimately found it to be too expensive.
To that point, doctors point back at safety. "A hospital or a center that's equipped to take care of complications of pregnancy is the safest place to have a baby and the reason for that today is no less true than it was several months ago or a year ago," explains Toni Golen, M.D., medical director of labor, delivery, and postpartum at Beth Israel Deaconess Medical Center in Boston. "Most childbirth complications both for the person who is giving birth as well as for the baby are unanticipated. Access to the ability to escalate to a higher level of care when needed is critical."
Ultimately, fluid and fast-changing rules and regulations surrounding labor and delivery are frustrating. But they're also necessary. Amidst them, it's important to speak up if you have questions or concerns. "You have to advocate for yourself now in a way you never did," says Dr. Birndorf. If you won't be able to have visitors in the hospital, who will be your point person? If you're discharged early, what kind of follow-up care can you count on?
As for staying up to date, get in touch with your health care team if you have questions. "The best thing a patient expecting to be in labor can do is check in with their provider, physician, obstetrician, or midwife who can tell them what the policies are at that moment in that hospital," reminds Dr. Golen.
How Prenatal Visits Have Changed Amidst COVID-19
Even if labor and delivery are still months away, the COVID-19 pandemic has likely already impacted your prenatal care. Today some OB-GYN offices are asking patients to take their own blood pressure or weigh themselves at home for virtual prenatal appointments (a move suggested by ACOG in the right cases) or are asking patients to have tests taken at clinics away from the hospital. Offices are spacing out appointments to do away with a traditional waiting room experience.
"Offices haven't closed," reminds Dr. Golen. "We've changed the way that we provide care."
Pre-COVID-19, Colleen L., a 32-year-old due April 13 in Boston, was attending prenatal appointments with her husband. Now, she's going alone. She wears a mask for appointments. Rath just had her first prenatal telehealth appointment.
"Over a six-minute call, they basically just asked if the baby's moving, if I'm having any painful contractions, if I found a pediatrician, and if I had any other concerns," says Rath. She also weighed herself for her records and was asked to check her blood pressure, but she did not have a blood pressure cuff handy. Rath's next appointment, at 36 weeks, won't be until the end of the April. By then, it will be over a month since her last in-person visit.
"Health care innovation is not rapid," says Dr. Theiler. It takes a revolutionary event to change traditions, she says. "I think we're in one of those revolutionary moments in medicine. We are asking every day, 'what is essential and what is comfortable?'"
Dr. Theiler adds: "Why do we do 13 prenatal visits for a routine, normal pregnancy? Because we always have, and ACOG says that because we always have, we probably should. There's really not a lot more to it than that."
Moving forward, prenatal care might look like four to six prenatal visits in-person for a healthy person paired with virtual support, home blood pressure monitoring, or off-site ultrasounds, she says. "Maybe the way we've been doing it is comfortable for physicians but not what women needed all along. I think this is the moment to ask that question."
How COVID-19 Impacts the Physical and Mental Health of Moms-To-Be
Policy changes, flux guidelines, and prenatal appointments aside, if you're pregnant or postpartum right now, you likely have a lot of questions about how this pandemic could impact your health and your baby's health.
And in short, the answer is: That's hard to say. The data is limited—and that's why so many extra precautions are in place. "We're always going to err on the cautious side because we know that we don't have the full body of information and we want to look back and make sure that we've taken appropriate precautions," says Dr. Golen.
Right now, the World Health Organization (WHO) notes that there's no evidence that pregnant women are at a higher risk of severe illness than the rest of the population. The Centers for Disease Control and Prevention (CDC) says that "we do not currently know if pregnant women have a greater chance of getting sick from COVID-19 than the general public nor whether they are more likely to have serious illness as a result." ACOG says that "pregnant women are known to be at greater risk of severe morbidity and mortality from other respiratory infections such as influenza and SARS-CoV. As such, pregnant women should be considered an at-risk population for COVID-19."
It's always important to take necessary precautions—avoiding people who are sick, hand-washing, social distancing, reporting possible symptoms (fever, cough, or difficulty breathing). But Dr. Theiler offers some reassurance. "The data we have really shows that for healthy, young women with normal pregnancies, this virus is not more dangerous than it is for other healthy people," she says. "If you are an exposed or infected pregnant woman with an otherwise normal pregnancy, we think this is unlikely to be a damaging event for you or your baby."
Yet, anxiety and worry are pervasive. "The list of my concerns grows daily," says Colleen. "What if we have to shelter in place and I can't get diapers? What if I have COVID-19 and don't know it and give it to my baby? The news is a perpetual fear machine (see my freezer for proof), and with no end in sight, my list of questions grows longer by the day."
Rath is worried about the possibility of having to breastfeed with a mask on or potentially having her baby placed in quarantine if she tested positive. "I feel as though my heart is breaking hourly," she says. "I feel robbed."
In response to an uptick in such anxieties, The Motherhood Center has started hosting online webinars to talk about how to manage anxiety during pregnancy in the time of COVID-19. "Mentally, the way to prepare is to remember that you can hold two things that are diametrically opposed and see them as both/and," says Dr. Birndorf. (It's not, "this stinks, and I'm not going to be able to do it." It's, "this stinks and this is the new reality which I will work to accept.") "Both things are true," she says.
She also encourages women to take advantage of technology. Many doulas offer digital postpartum care, family members can be FaceTimed in. "It's not as good as being there for real. You can't feel them in person. But it is a reasonable alternative—the best alternative—at this moment in time."
And don't discount the power of voice and video. "Hearing someone's voice, especially the voice of someone you know and trust, is still really valuable," says Dr. Theiler.
For others, thinking about the greater good is helping them acclimate. "The way I got myself through this global crisis was remembering that there are sacrifices everybody has to make, whether it's family members getting sick, losing a job, or not being able to go on vacation," says Greg of missing his son's birth. "I saw this as our challenge."
As Dr. Fiss tells me before hanging up to go pick up her masks: "We have to be in the mindset of, 'this is for all of us. We're all in this together.'"
Read more of Parents.com's maternal health investigation here.