How Is the Pandemic Changing Perinatal Health Care?
Nearly overnight, the coronavirus pandemic transformed health 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.
of all rural U.S. hospitals ended labor and delivery services between 2011 and 2018.
Source: The Chartis Group, "Tracking the Decline of OB Access."
of U.S. rural hospitals were identified as “vulnerable to closure” in February of 2020.
Source: The Chartis Group, “Understanding the Performance of the Rural Health Safety Net.”
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
Prior to the pandemic, pregnant and birthing people in marginalized groups were already at higher risk of complications and death, as explored in Nursing@Georgetown’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.
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.”
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.”
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.
of women are affected by perinatal depression.
Source: National Institute of Mental Health, “Perinatal Depression.”
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.” Accessed August 24, 2020.
“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?”
Intimate Partner Violence (IPV) May Increase
women have experienced and reported contact sexual violence, physical violence, or stalking by an intimate partner in their lifetime.
women have experienced psychological aggression by an intimate partner in their lifetime.
Source: CDC, “Preventing Intimate Partner Violence.”
The coronavirus pandemic has devastated many families economically, cut them off from community support, and created uncertainty and panic. IPV could dramatically increase because of these conditions, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) report, “Intimate Partner Violence and Child Abuse Considerations During COVID-19” (PDF, 328 KB).At the same time, stay-at-home orders to prevent the spread of COVID-19 limit the ability to flee or file a protective order.
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 in 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: Nursing@Georgetown, the online Women’s Health Nurse Practitioner program from the Georgetown University School of Nursing & Health Studies