Giving birth during COVID-19

Where should a person give birth in a pandemic? Home, hospital, hotel? A glimpse of the emerging debate.

The day I gave birth to my younger daughter was the day that the first case of SARS was identified in Toronto. I've always felt lucky that we'd planned to have her at home. SARS was a scary time. Hospitals felt dangerous. Friends giving birth there couldn't have visitors. Breastfeeding clinics were shut down.

All that pales given the reality now, of course. 

But of all the people facing stark choices these days, it's the ones soon to deliver babies that I think about the most.  

Birthing in the time of COVID-19

As hospitals cancel elective procedures, many of us have begun to worry about all the non-elective events that take place in hospitals — like the births of babies. 

And many of us have wondered: should low-risk births be moved out of hospitals? If so, where could they take place? Should we ramp up home births? Should we set up temporary birthing centres in novel places? Or should we do the opposite: create larger maternity units in select hospitals so that more women can be cared for by fewer attendants? 

It turns out there's not a lot of agreement in these troubled times. 

Home births

Many women who had not seriously considered home birth before have begun to consider it now. It feels logical: birthing mothers want to stay away from overcrowded and infectious hospitals. A midwife writing in The Conversation underscores the virtues of home birth during a crisis.

But despite the uptick in interest, home births in many places are being restricted or even halted. The Guardian reported on the weekend, for instance, that in the UK, almost a third of midwives surveyed said that they had stopped doing home births. The CBC reported Monday that there would be no home births in the province of Nova Scotia during the pandemic.  

Among the concerns are whether there will be enough midwives available, whether midwives are at increased risk of contracting the virus during home births, and whether women who need emergency transport to hospital would be able to get it.

Twitter gives us glimpses of the debate:

@Gracewife: Home births are being stopped but if hospitalisation increases COVID-19 in maternity patients then the policy will increase demand on staff and risk more lives. Needs expert analysis and modelling. 

@Clairewest87: Homebirths are still going ahead in the area I work in and hopefully will continue that way! More women than ever are considering homebirth as they've closed the FMU [fetal medicine unit] in our trust. I really hope we can continue as we are now 

@Ali_R0ssi: My understanding is that the main issue is not the home birth provision as such but the unprecedented ambulance services activity levels. It is heartbreaking, but many Midwives are worried that in case of emergency they may not be able to transfer patients in a timely manner

@susan_bewley: Bad reasoning to make hosp matters worse. What about the 'army' of volunteers bringing together some 'rapid home birth transfer' vehicles - better than nothing and unlikely to be used but will provide the physical & psychological safety mothers & MWs need

@Gracewife: There are many women planning unassisted births. While most will be fine it is that 1 per cent that really worries me. I think the Trusts are underestimating this.

Hotels 

Early on in the crisis, I wondered if shuttered fertility clinics could be repurposed as safe birthing centres away from hospitals — perhaps they have some of the right hardware, I mused, and fertility doctors could even lend a hand. The folks I asked seemed skeptical, though, pointing out that clinics (in Ontario, at least) don't have the licensing required for emergency C-section anaesthesia.

But it turns out that in the Netherlands, midwives have moved many births out of hospitals and into hotels. Many other births will take place as planned at home.

@birthhumanright: Innovative models of care in the Netherlands - moving births into hotels, midwives only working with pregnant families, freeing hospitals for people who need obstetric medical care, for #COVID19 or other reasons.

@FrankaCadee: Dutch @De_KNOV #midwives come to taks during #covid19! 

#Women have choice to birth either in security of hotel made into birthing centre or own homes supported by their #midwife, freeing hospitals for women needing obstetric medical care.  the right care in the right place!

Hospitals 

In much of the world, hospitals are the most common place to give birth. And for women needing complex surgical interventions or babies needing neonatal intensive care, they are essential. 

In a time of pandemic, with health practitioners scarce, delivering in hospitals might also allow stretched medical staff to handle a larger caseload.  

But COVID-19 has been rewriting some of the rules around hospital birth. Some hospitals in New York, for instance, banned partners or companions from being with a woman in labour. Though the New York governor later overruled that, it caused huge anxiety.

In some places, mothers and newborns have been separated after birth.

@SassyE: a hospital in NYC new policy today is to take your baby from you right after birth until they get your covid test results back. Theres no rapid testing so that means 8-10 hours from your newborn. And before you ask, there's no evidence to back up this policy.

The World Health Organization (WHO) is clear that it does not support separation of mother and child — even if the mother has confirmed COVID-19. Mothers with COVID-19, they advise, should keep the baby close and breastfeed if they choose to. "Close contact and early, exclusive breastfeeding helps a baby to thrive," the WHO writes. "A woman with COVID-19 should be supported to breastfeed safely, hold her newborn skin-to-skin, and share a room with her baby."

All women have the right to a safe and positive childbirth experience, writes the WHO, whether or not they have COVID-19. The key principles, they remind us, are: clear communication by maternity staff, birth position of choice, companion of choice, pain relief, and, above all, respect and dignity.

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First-hand accounts:

"What it’s like to have a baby during the coronavirus pandemic." Vox. 18 Mar, 2020.

"I'm nine months pregnant, and I'm bringing my baby into a world I no longer understand. I have to remain hopeful anyway." Insider. 20 Mar, 2020.

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Links

"NHS trusts begin suspending home births due to coronavirus." Guardian. 27 Mar, 2020.

"Midwife shortage doubles as NHS staff diverted to tend Covid-19 patients."Guardian. 29 Mar, 2020. 

"Some hospitals are asking birth partners to stay home during coronavirus pandemic." mother.ly. 24 Mar, 2020. 

'The babies keep coming': What the coronavirus pandemic means for people giving birth." Vox.  25 Mar, 2020. 

"New coronavirus leaves pregnant women with wrenching choices—but little data to guide them." Science. 27 Mar, 2020.

"They Didn’t Have Coronavirus Symptoms Until After They Gave Birth. Then They Tested Positive." Propublica. 27 Mar, 2020.

"The babies were delivered. No one realized the mothers had the virus." New York Times. 27 Mar, 2020. 

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Registries

International Covid-19 and Pregnancy Registry (Covi-Preg)

Pregnancy Coronavirus Outcomes Registry

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Contact me at alison.motluk@gmail.com

Follow me @AlisonMotluk and @HeyReprotech 

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