National Advocates for Pregnant Women
The coronavirus pandemic, and our country’s lack of preparedness for it, give us an opportunity to make important observations and learn (or relearn) key lessons. Foundational issues including severe income inequality, lack of a national health care system, and corporatization of public goods and services are being exposed during this pandemic. Also exposed are the Trump Administration’s totally inadequate, often misleading and counterproductive responses to the coronavirus that have put all of us at risk.
For example, as Dr. Anne-Marie Slaughter explained in a New York Times op-ed, South Korea mobilized health care companies to make coronavirus tests in late January, when the country had only four cases. Soon, 10,000 Koreans a day were being tested, and now new infections are dropping. The first cases in the United States were identified in January, too, and yet we still don’t have enough tests.
People providing health care, including doctors and nurses are also facing the coronavirus without enough protective gear. In many places, a shortage of personal protective equipment, something that could have been anticipated by the federal government, means that medical staff have to reuse masks and do without key protective measures. Governors, mayors and public health officials have been begging President Trump to address shortages in medical equipment. On March 18, Trump signed an executive order invoking the Defense Production Act, a law that authorizes the President to compel U.S companies to produce equipment necessary to protect national security. But the President has refused to require production so that private companies can profit, forcing states, counties, and localities to fend for themselves and to compete among each other for scarce protective gear and medical equipment.
This is the context in which some hospitals are limiting or prohibiting visitors for all patients, including those in Intensive Care Units, those who are dying, and those who are giving birth. Some hospitals have announced that only one person will be allowed to be with a pregnant patient in labor. Women giving birth at two leading New York City hospital networks (with over a dozen hospitals) have been told that they must labor without anyone - spouses, partners or doulas. This has prompted an online petition and particular concern about the impact of such prohibitions on Black maternal health.
Certainly, among the legitimate reasons for the prohibition on visitors is protecting the health of medical staff – a group at particularly high risk for contracting the virus.That risk undoubtedly could have been significantly reduced if testing had started earlier, if there were enough tests for everyone, and if there was enough protective gear for medical staff, patients, and visitors. Lack of planning and Trump’s refusal to use his power to ensure production and coordinated distribution of medical supplies leaves hospital staff, pregnant patients and their support people at grave risk.
We could also have been prepared by policies supporting births outside of hospitals and training in homebirth skills.
In 2006, in the aftermath of Hurricane Katrina, the White Ribbon Alliance for Safe Motherhood recognized the critical importance of “homebirth skills” in times of disaster, when hospitals may be unavailable, inaccessible, or overwhelmed with casualties.
In a 2010 editorial in the Journal of Perinatal EducationI, Elizabeth Mitchell Armstrong, PhD, MPH, similarly recognized the value of homebirth and the need for homebirth skills in light of experiences with infectious diseases. As she explained:
"[S]entinel events of the last decade underscore the downsides of routinely bringing new life into the world in settings otherwise dedicated to the care of the sick, where the risks of infection necessarily run high. During the SARS epidemic in Toronto in 2003, several hospitals closed their maternity wards to contain the infection (at least one hospital quarantined five newborns and their mothers for 10 days), and area midwives reported an uptick in interest in home birth among pregnant women as they came to appreciate the risks of giving birth in hospital settings. Fears about the H1N1 virus [in 2010] have served the same purpose; indeed, many hospitals have banned all visitors under 18 years old and severely restricted adult visitors out of concerns about H1N1. For many families, hospital restrictions on visitation have delayed the joyous first meeting of newborn and older siblings and other extended family members. The SARS and H1N1 events remind us that hospitals ought properly to be the preserves of the sick and the individuals who care for them."
The current coronavirus pandemic calls on us, as Dr. Armstrong suggested in 2010, “to rethink how and where birth takes place—in particular whether it really makes sense for all babies to be born in high-technology, intervention-intensive hospital settings.”
The lack of integration of midwives into our healthcare system; lack of continuity among the providers caring for pregnant people prenatally, during birth and during the postpartum period; inadequate use of low-tech methods during delivery; and lack of capacity to meet the needs of healthy people during childbirth outside of hospitals, are all problems that could have been addressed before the pandemic.
For many people anticipating birth during this crisis, this is their first direct experience with the limitations of hospital-based births and our maternity care system. Yet, many of the issues raised in the Change.org petition about why support for pregnant women is needed in hospital births point to long standing systemic problems with giving birth in settings designed for people who are sick, and where birthing care is provided by people who are trained primarily in surgery rather than in the midwifery model of care.
In this moment, some people will be able to transfer from planned hospital births to birth at home or at freestanding birth centers that are capable of accommodating social distancing. Many if not most people, however, will not want to or know how to. In addition, they might find that their insurance won’t cover out of hospital births, or that they are unable to transfer care because there are simply not enough birth centers or homebirth providers.
Indeed, the human rights of people during pregnancy and birth are regularly violated in the United States and all over the world. The United Nations finally recognized this problem in a report to the General Assembly last year, and a survey of pregnant people in the United States found that one in six experience mistreatment during childbirth. The report to the U.N. identified as key problems the lack of governmental response and legal remedies for human right violations relating to pregnancy and childbirth.
People facing the exclusion of partners and support people at their births during this pandemic may wonder what legal recourse they have. Unfortunately, the law does not yet provide useful mechanisms for addressing or resolving this issue or any related to rights violations during labor and birth. For example, litigation during the 1970s tried to establish the right of fathers to be at births. Hospital policies at that time regularly excluded fathers from the delivery room. These cases, however, were not successful and a right to be with a partner and attend the birth was never recognized by the legal system. Importantly, those policies have changed not because of laws but because of consumer advocacy, public pressure, and changing norms. The Affordable Care Act has a provision that requires equality in visitation policies, but it does not require hospitals to allow any visitors. As we are seeing in the midst of this pandemic, hospital policies limiting visitors are being applied across the board, not just to doulas or pregnant people.
Nevertheless, there are many dedicated birth professionals in every community doing everything they can to make sure pregnant people have the information they need to take care of and support themselves during this time.
We recommend individuals look for local childbirth educators, doulas, lactation support providers, midwives and doctors offering digital support, information and resources during this challenging time.
We recommend States take steps to lift restrictions inhibiting home births and birth centers births as part of emergency executive orders:
● Remove barriers for midwives to practice autonomously and attend out-of-hospital births.
● Recognize and treat midwives as health care providers, with access to the resources, exemptions, provisional licensure, and special orders for pandemic response.
● Change scope of practice laws so that midwives can practice in all states and territories without fear of arrest.
● Provide all practicing midwives with information, equipment, and resources regarding pandemic risks and response to promote the safety of the workforce and the public.
● Reimburse for midwifery care at 100% of the rate of physicians for the same service, whether from insurance or Medicaid.
● Remove barriers to opening freestanding birth centers to increase capacity.
● Fast-track student midwives with provisional licenses when they are close to completing their credentials.
● Preserve hospital personnel and beds for pandemic response by encouraging hospitals and hospital-based providers to refer low-risk births to out-of-hospital midwifery care.
● Require hospitals to meet best practice transfer protocols to ensure a safe and efficient interface with out-of-hospital birth providers when a laboring patient is in need of a higher level of care.
We hope this pandemic and the federal government’s failure to protect us will motivate people to fight for national policies that prepare for and protect the health of all. Fortunately, we work alongside many wonderful advocates and groups working on these issues.
Here Are Some of Those Groups:
Academy of Perinatal Harm Reduction
A Mother’s Choice
Ancient Song Doula Services
Birthmark Doula Collective
Birth Rights Bar Association
Black Mamas Matter Alliance
Center for Optimal Living
Citizens for Midwifery
Every Mother Counts
Groundswell Birth Justice Fund
Harm Reduction Coalition
Harm Reduction Therapy
Health Care for America Now
International Cesarean Awareness Network
Michigan Prison Doula Initiative
National Association for the Advancement of Black Birth
National Birth Equity Collaborative
National Black Doulas Association
National Partnership for Women and Families
National Perinatal Association
National Perinatal Task Force
Rise Up Midwife
We Rise! Leadership Collective Minnesota
White Ribbon Alliance
Find More Information:
To find a doula try searching “Your State + doula + association”
For a List of Organizations Doing Birth Justice Work Consider Looking at the List of Past and Present Grantees of Groundswell’s Birth Justice Fund:
For more information please contact:
Shawn Steiner | 917.497.3037 | SCS@AdvocatesforPregnantWomen.org