by Nina Martin, ProPublica
ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.
Over the next three months, nearly a million women in the United States will give birth to nearly a million babies — a huge influx of mostly healthy, highly vulnerable patients into a hospital system that’s about to come under unprecedented strain. Pregnant women, not surprisingly, are anxious. Those in their third trimester, looking to deliver during an epidemic, are close to frantic.
It’s hard to stay calm when reliable information is as scarce as N95 masks and prenatal providers are so busy revamping their procedures they’re struggling to respond to patients’ most basic queries. I spent the past few days gathering the latest information about the coronavirus and pregnancy, reaching out to doctors, nurses, midwives and doulas I’ve come to know while covering maternal mortality and health as part of ProPublica’s “Lost Mothers” project. Below you’ll find their answers to your most urgent questions (though you should always consult with your doctor about your own situation).
Spoiler alert: If you’re currently pregnant, the birthing experience you expected pre-COVID-19 is likely to be very different from the one you actually get. Your postpartum period will be even more isolated and stressful than it otherwise would have been. Obstetric providers are having to reinvent maternity care in real time to protect you and your baby as well as themselves.
For expectant mothers and their loved ones, the key to staying sane is to be as ready as possible for what lies ahead, including the likelihood that your best-laid plans will fly out the window. “In labor, you have to know that things can change at any moment — you have to be flexible,” said Rina Ríos, a childbirth educator and doula trainer in New York City. “You can always have your wish list — you might get all of it, you might get none of it. What’s happening now [with COVID-19] is the same but a little more extreme.”
Am I at greater risk for the coronavirus while I’m pregnant?
The good news, said Christina Han, a high-risk pregnancy specialist who teaches at the University of California, Los Angeles, medical school: “There’s no evidence that pregnant women are any more susceptible to COVID than the average healthy adult is.” That said, there’s not a lot of data on this — just under three dozen reported cases from China, plus anecdotal reports from other global hot spots that U.S. doctors are monitoring via tools like WhatsApp. (A registry to track U.S. cases has just launched.)
The bad news: Based on long experience with other respiratory illnesses, including influenza and SARS, the Centers for Disease Control and Prevention warns that contracting the coronavirus while pregnant could make you more vulnerable to severe respiratory problems, such as pneumonia, than other infected women in their childbearing years (this is because pregnant women already have increased heart rates, diminished lung capacity and what one doctor called “distracted immune systems”). There also may be a higher risk of miscarriage and premature delivery, saidDr. Romeo Galang, an OB-GYN on the CDC’s COVID-19 emergency response team. So far, there have been no reports of COVID-19-related maternal deaths.
What does the coronavirus mean for my baby?
More good news: The virus hasn’t been detected in amniotic fluid, cord blood, placenta tissue or breast milk, so apparently there’s no “vertical transmission” (you won’t give it to your fetus). This is in contrast to another recent virus that made mothers and public health officials sick with worry: “With Zika, we knew there was transmission and we started seeing birth defects right away,” said Houston OB-GYN Rakhi Dimino, who oversees labor and delivery hospitalists in several states. There’s been at least one report of COVID-19 in a newborn in the U.K., suggesting babies get it the same way as everyone else — through respiratory droplets, including potentially from an infected mom. Until this week, officials had been reporting that cases in kids were rare and relatively mild. But an ominous new study of 2,100 children with confirmed or suspected COVID in China found that 6% became severely or critically ill; the majority of the sickest kids were under age 5, and about a third of those were under age 1.
How should I protect myself if I’m pregnant?
This advice is the same as for everyone else, only more so. “Maximize your immune system and avoid any situation where you would be at higher risk for being infected,” said Amy VanBlaricom, vice president for clinical operations at the Ob Hospitalist Group, overseeing labor and delivery units at several Seattle-area hospitals that have been at the center of the COVID-19 outbreak there. “So avoid large crowds, avoid sick people. Wash your hands.” (Here’s more advice along those lines from the just-launched fertility-oriented JubelHealth site.) If you haven’t gotten your flu shot already, it’s not too late, VanBlaricom said: “It’s important for pregnant women or women who anticipate getting pregnant to do everything possible to maximize their immune systems.” The flu vaccine is safe in pregnancy and while breastfeeding, she adds, and as a bonus, “that immunity does pass to the baby.”
It almost goes without saying that, if possible, pregnant women should avoid going to work in medical and other settings where they are at higher risk of becoming infected. The CDC’s Galang noted during a conference call last week, “Facilities may want to at least consider limited exposure of pregnant personnel. … This can be especially important in higher-risk procedures that generate [respiratory droplets].” But in reality, some understaffed, under-resourced hospitals and medical offices have been slow to put such a policy in place. (If you know of one, my colleagues and I want to hear from you.)
Providers have been scrambling to create telemedicine and virtual options to protect their staffs as well as their patients. Your group prenatal care and childbirth classes have already been pushed onto YouTube, Zoom and Skype. Communicating with your care team is more important than ever; if you haven’t signed up for your provider’s patient-portal system, now’s the time. (While you’re there, download or screenshot all of your medical records, and make sure you stay up to date after every appointment or call; print out copies and keep digital versions on all your devices, as well as photos of all your medication labels and anything else you want your caregivers to know.)
Expect many of your basic prenatal check-ins to take place by phone or FaceTime, as well as visits that almost always used to happen in a doctor’s office with a box of Kleenex handy, such as genetic counseling. Because you’ll need to do more self-monitoring, your home pharmacy should ideally include a blood pressure machine and urine test strips (both essential to screen for pregnancy-induced hypertension, aka preeclampsia, the most common life-threatening complication of pregnancy). Talk to your provider about how frequently you should be using them and what to look out for.
Appointments that do take place in person are likely to be shorter and feel more perfunctory. You should plan to do without the friend or partner you’ve counted on to be your advocate or hold your hand, so keep a running list of all your questions and concerns and consult them at visit and call. Midwife Jennie Joseph’s The Birth Place clinic, 30 minutes from Orlando, Florida, is famous for its enveloping environment and its impressive outcomes for low-income women of color (those most at risk for maternal and neonatal complications). But Joseph has had to ban walk-ins, spread out appointments and require temperature screens for all visitors. “Normally, we’re all about including the children,” she said, but now, “no kids, sorry.”
Can I just skip some of my prenatal visits?
Here’s the truth about prenatal care in the U.S.: There isn’t a lot of good scientific evidence about how much monitoring a healthy expectant woman needs or the best way for her to get it. The silver lining is that you and your providers have more leeway than you might realize to adjust — reduce — your care schedule without endangering you or your baby, which frees up resources for moms-to-be who need heightened vigilance.
Pre-pandemic, the typical American mother-to-be could look forward to 10 to 13 prenatal appointments and multiple ultrasounds. These days, for low-risk women, “If you’re early in pregnancy, maybe instead of seeing you every four weeks, we’ll see you every six weeks,” said Judette Louis, chair of the OB-GYN department at the University of South Florida and president of the Society for Maternal-Fetal Medicine. Even women in their ninth month, who are often counseled to see their OB-GYN every week, may be able to cut back on in-person appointments. Similarly, it turns out that, contrary to what you may have read in your pregnancy books, most sonograms are not necessary for most low-risk women. The most important ones for any patient occur in the late first trimester (11 to 13 1/2 weeks) to screen for fetal and genetic anomalies and an anatomy scan in mid-pregnancy (18 to 22 weeks).
It’s different for women with complicated pregnancies. But much depends on a patient’s risk profile: Someone who’s labeled high risk just because she’s 36 is not in the same category as someone with high blood pressure, diabetes, asthma or twins. Though some high-risk appointments (like diet consultations) can be virtual, many will have to be in person, so make sure all the members of your team are working together to minimize your office time and exposures. “The worst-case scenario would be for higher-risk women to stop prenatal care without a conversation with their doctor,” said maternal-fetal specialist Cynthia Gyamfi-Bannerman, who co-directs Columbia University Medical Center’s Preterm Birth Prevention Center.
Women at high risk of complications will also need more frequent ultrasound monitoring. But Brian Iriye, a Las Vegas high-risk specialist and SMFM past president, warns women against relying on unaccredited ultrasound centers as a way of avoiding potential COVID-19 infection in the hospital or doctor’s office. “They might not be cleaning their equipment in the [right] way. The equipment might not be upgraded. Their people don’t have to go through the same standard of training.” (Here’s how to find out if a center is accredited.)
For more details about what higher-risk women can expect, here’s a just-published expert review and guidance from maternal-fetal specialists in the U.S. and Italy. Here are the American College of Obstetricians and Gynecologists’ clinical guidelines for COVID-19 and instructions for accessing the SMFM’s COVID-19-education library at no cost.
And a friendly PSA from your harried OB-GYN provider: Please resist the temptation to slip that bottle of hand sanitizer or unopened roll of toilet paper into your bag. Your provider can’t protect you or other patients if she can’t protect herself.
I’m not pregnant yet, but I’ve been trying. Can I at least continue with my fertility treatments?
That depends on where you are in the process. On March 17, the American Society of Reproductive Medicine recommended that fertility clinics and doctors suspend all new treatment cycles during the COVID-19 crisis, including in vitro fertilization, intrauterine inseminations and egg freezing. Providers should “strongly consider cancelation of all embryo transfers whether fresh or frozen,” the society said. It also urged IVF clinics to do what other providers are doing: suspend elective surgeries and nonurgent diagnostic procedures, minimize in-person interactions and increase their use of telehealth.
Under the guidelines, however, patients who are currently “in-cycle” or who require urgent egg stimulation — for example, because they’re about to undergo chemotherapy or radiation for cancer that could leave them infertile — could continue their fertility treatments. “We also understand our patients’ time-sensitive aspirations to achieve pregnancy,” the ASRM stated, “and so we will regularly reassess these recommendations with a hope to resume initiation of comprehensive fertility care as soon as possible.” In the meantime, you should check with your provider as soon as possible to see how the new guidelines could affect you and your family.
What should I do if I develop coronavirus symptoms while I’m pregnant?
“Don’t stay quiet about it,” Seattle doctor VanBlaricom urged. “If there is a potential exposure or suspicious symptoms, if you would fit into a category that you should be tested, reach out to your personal physician and see if you should have that testing done.” Call ahead so the team can take extra precautions; they might ask you to stay home if your symptoms are mild, or they might direct you to the hospital.
If you’re not already wearing a mask when you arrive (hint, hint), be sure to ask for one, especially if you have any respiratory symptoms. Expect your provider to put you in an isolation room (in a pinch, this might be a repurposed restroom) and test you for other respiratory bugs and possibly COVID-19 (assuming you meet your local public health criteria and tests are available). If your symptoms are mild, you’ll probably be sent home to wait for results, with instructions to self-quarantine and treat yourself as if you have the flu. You may even be sent home if you test positive and symptoms are mild, the high-risk pregnancy specialist Han said. But it’s important to stay vigilant. If you start having any trouble breathing, get on the phone to your OB-GYN immediately and go where you’re told, probably the ER. You and your baby will be closely monitored in hospital until you’re out of the danger zone or you deliver.
Whether you test positive for COVID or are still only a “person under investigation,” when you go into labor, you’re likely to be placed in a negative pressure room (one whose ventilation system is sealed off from the rest of the facility), attended by a limited number of providers wearing (hopefully) the full complement of personal protective equipment. In the reported cases from China, almost all the women who delivered after testing positive had cesarean sections, but the C-section rate in that country is generally higher than in the U.S.; here, the type of delivery will likely depend on your symptoms, your doctor and your medical facility. In VanBlaricom’s hospitals, “the indications for C-section would remain the same whether or not you were COVID-19-positive,” she said.
For many new moms with suspected or positive COVID-19, the real hardship will be what happens after the baby arrives. The CDC has recommended that mother and newborn be segregated for at least 14 days, either in a separate isolation room or, if that’s not possible, by a curtain in her room that keeps the baby at least 6 feet away. (If the COVID-19 test comes back negative, the separation order will end.) Because the virus doesn’t seem to be transmitted through milk, breastfeeding is possible — though the mother will have to be well-scrubbed and heavily masked (some hospitals may urge her to pump). Until she recovers, she may be asked to designate a close relative to handle the bulk of newborn care like bathing, diapering and skin-to-skin cuddling.
How is COVID-19 likely to affect my labor and delivery experience if I don’t have the coronavirus?
Robust debates have been happening in OB-GYN circles about whether women who’ve reached their 39th week should be scheduled for induction before their due date to control the timing and, if possible, avoid the looming shortage of hospital beds. But that doesn’t mean you’ll be forced to deliver before you want or pushed into an non-emergency C-section just because your labor is going slowly, Han said. Letting a woman go into labor naturally instead of inducing her electively reduces the amount of time she’ll spend in the hospital. So does facilitating a vaginal birth rather than resorting to unnecessary surgery. At Han’s hospital, “we are trying for vaginal delivery whenever possible because it will get them home earlier.” For moms and hospitals alike, she said, “a few extra hours in labor is worth the downstream benefits.”
At the same time, many hospitals are setting strict limits on the number of non-providers who can attend the birth — usually just one or two people, often with no exceptions for skilled birth workers whom women were counting on to help them through the long hours of pain and pushing. “Increasingly, a mom has to decide, ‘Do I want my doula or my husband, my doula or my sister?’” said Melissa Harley, a Florida childbirth educator and president of the doula organization DONA International. “I totally understand how hospitals need to limit extra people now, but doulas are not ‘visitors.’ We’re an important part of the care team, providing emotional support that also relieves the nursing staff a little bit.” As the COVID-19 crisis worsens, she said, their value will only grow: “The health care system’s going to be really stretched.”
Hospitals are also restricting the movements of those visitors — no coming and going, not even to grab a bite to eat or take a break if labor is prolonged. Some doulas are being barred unless they can prove they’re certified. Harley spoke with a doula in Seattle who recently assisted at a 31-hour labor and couldn’t call backup. “We’re telling people to bring extra food and clothes, because once they enter that birthing room, they may not be able to leave.” One option birth attendants are already starting to adopt: in-person support through the early stages of labor, then Skype or Google Hangout when clients move to the hospital. (Here’s a toolkit for doulas that pregnant women might find reassuring, too.)
The limits on visitors after delivery are even tougher; in many hospitals, there’s a near-total ban. In some hospitals, even doulas are sent packing an hour after the baby is born.
And don’t be surprised if postpartum hospital care, including breastfeeding support, feels more rushed than it did in the pre-COVID-19 era (when it was already far from adequate). As one high-risk doctor acknowledged, “Everything will be designed so everyone can go home as soon as possible.”
Giving birth at home suddenly seems a lot more tempting. What should I consider before deciding to go the natural route?
In the past couple of weeks, home-birth midwives like Amber Berry, who delivers babies in the Houston area, have seen a surge in interest among women terrified of catching COVID-19. “I just got a call from a woman who’s 39 weeks pregnant, due in five days.” The woman had all her medical records and was willing to commit, so Berry agreed to take her on as a last-minute client. But when other worried moms-to-be came calling, the midwife passed. “They were looking for a backup plan in case the hospital was full” — not the type of scenario many in the birth community find appealing.
The decision to deliver at home or in a freestanding birthing center, supported by midwives instead of MDs, is not for the half-hearted. There are safety issues that stem from inconsistent training of midwives, inadequate oversight and, in many parts of the U.S., poor integration into the medical system (this is important if, for example, it’s necessary to transfer a mother or newborn to the hospital because of an emergency like a hemorrhage or breathing problems). There’s the reality of what an unmedicated birth entails: many hours of intense pain, with minimal interventions to speed the process along. There’s the cost: In many areas, out-of-hospital births aren’t covered by insurance.
What’s more, only low-risk moms-to-be who’ve had completely uncomplicated pregnancies are candidates to make the switch. That rules out women with high blood pressure, chronic or gestational diabetes, preexisting conditions such as epilepsy or hepatitis B, and in many places, women who’ve had a prior C-section or who are pregnant with twins. “The list of women I can’t accept is really, really long,” Berry said.
One of the biggest issues with changing providers in mid- or late pregnancy is that it short-circuits the process that is one of midwifery’s hallmarks. “In [this] model of care, it is very important for us to take the time to develop a trusting relationship with our clients,” said Wendy Gordon, who delivers babies at a birthing center in Seattle and heads the midwifery department at Bastyr University. This typically involves spending much more time together than moms-to-be ever spend with their OB-GYNs — as long as an hour per prenatal appointment. A good relationship is critical if, for example, problems arise during labor: “If we say, ‘It’s time to go to the hospital,’ the client has to trust us enough to say, ‘OK.’”
Home births might help mothers-to-be avoid the risks of hospital exposure to COVID-19 — but they can expose midwives to people and environments that put them at greater risk. The coronavirus is forcing the same types of changes to their practices as hospitals, doctors and nurses, including less one-on-one care. If a midwife gets exposed to the coronavirus, she’s likely to be out of commission for weeks — and her clients could be left scrambling at a time when “it needs to be all hands on deck,” Gordon said.
But even if you don’t want to birth from home, it might not be a bad idea to at least plan for the possibility in case you don’t have any choice. Thesebrief guides for how to “birth in place” in an emergency, from the American College of Nurse-Midwives, are useful and even calming (be sure to check out the list of supplies to have on hand).
Just when I need help the most, I’m supposed to be practicing social distancing. My baby’s grandparents were going to be my postpartum support team, but they’re too vulnerable to travel. How am I supposed to cope?
There’s no easy answer or solution, just one incredibly difficult challenge piled on another. Chances are you’re already doing the basics: connecting with other new parents on social media, FaceTiming like crazy, buying as much as you can online. All the usual trite advice — Get more sleep! Make time for yourself! — seems even more out-of-touch in the context of an unfolding pandemic. And as the news grows more dire by the day, the sense of helplessness and despair may only get worse.
If you haven’t had the baby yet, you still have time to figure out ways to deal with some of the massive disruptions ahead. Two major priorities: putting together a new, largely virtual village to keep an eye on you if your Plan A support team is stuck in another state, and understanding the health care basics, like your pediatrician’s telemedicine options for newborn visits and what your insurance will and won’t cover. Karen Hays, a certified nurse-midwife and expert in midwifery disaster preparedness and response in Seattle-King County, said now is not the time to be shy with your neighbors. “If people know there’s a new baby on the block and new parents in need, I think they really want to help.”
Nor is it the time to worry about the effects of antidepressants and anti-anxiety meds on your fetus or breastfeeding infant. The consensus among doctors and researchers is that your spiraling mental health is far more dangerous — for your baby and the rest of your family, not to mention for you — than Prozac or Zoloft in your amniotic fluid or milk. (Here are a couple of useful articles on the topic, and an advocacy group with many more great resources.) If you’re suffering, don’t hesitate to reach out to your provider about the possibility of medication. But pills alone aren’t ideal and probably not enough, cautioned Catherine Monk, a perinatal psychologist at Columbia University who specializes in mood disorders in pregnant and new mothers. “Too many people, especially women, are too readily given a pill without being given tools for managing anxiety. There is evidence to suggest that when some women ultimately choose to go off the medication, they haven’t really gained any ability to manage their anxiety. They’ve just been dampening it down.”
Of course, affording professional help to manage perinatal mood issues was hard enough during the Old Normal; now — even with the growth of “telepsyche” services — it may be impossible. Monk recommends some relatively easy (and zero-cost) tools from the cognitive behavioral therapy arsenal that researchers have shown to be effective.
A key strategy, she said, is to recognize that when you’re feeling anxious and depressed, you’re seeing the world through soot-covered glasses: a dark mood makes bad news seem even worse. A small way to cut through the gloom and doom, at least for a little while, she said, is to force yourself to take a mental microbreak: “Say, ‘Just for 30 seconds, I am going to observe what I smell, what I see, what I taste, what I touch.’ It’s hard to do for 30 seconds. But even practicing that, closing one’s eyes and maybe just feeling the material on your pants or the couch you’re sitting on, and getting good at this, is a useful strategy that can really help.” (These additional CBT techniques might help, too.)
The other big concern for postpartum women is their physical health. “We know a lot of maternal mortality and [severe complications] are directly and indirectly caused by social isolation,” said Neel Shah, an OB-GYN and assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. “In a period of social and physical distancing, it exacerbates that challenge ever more.” Postpartum women were “already a vulnerable population at baseline,” he said, “and they’re about to get much more vulnerable.”
And just not to the coronavirus. More than ever, the onus will be on you and your village to be vigilant about post-birth symptoms, such as headaches, breathing difficulties, fever and swelling, which could be signs of potentially deadly problems like postpartum preeclampsia, infection, blood clots or heart problems. This crib sheet of warning signs to watch out for, created by nurses who specialize in maternal and neonatal health, is a true lifesaver. You’ll also want to bookmark this helpful website by the 4th Trimester Project. And remember, “You need to be a little bit of a squeaky wheel,” Hays said. “A lot of people aren’t calling their providers because they don’t want to bother them. The flip side is the providers think everything’s fine out there when it’s really not.”
One more thing: It’s critical not to skip your regular postpartum follow-up visit, Han said, even if you have to do it online. More urgent needs, like an incision or a breast infection, can be monitored via FaceTime or Zoom, too. It may not be the option women or providers would choose, but it’s the one they’re going to have to work with until something better comes along. We all have to get used to the idea that when it comes to maternal care, Han said, “it’s a whole new world.”
Republished with permission.