In the age of coronavirus, some medical needs can be postponed. Childbirth isn’t one of them. Oakland midwives, doulas and obstetricians are reimagining how they work with and support pregnant women during this crisis, and the challenges are immense.
Reproductive health workers are swapping in-person visits for virtual appointments and navigating equipment shortages and new hospital rules that can make childbirth lonelier and riskier.
More mothers are discharging early from the hospital against medical advice, and in some cases, they don’t show up at all, opting to give birth at home rather than risk COVID-19 exposure at the hospital.
Lactation consultants and doulas have started offering late-night breastfeeding video consults to help new mothers struggling with the dual isolation of the postpartum period and quarantine.
Some practitioners say hospitals haven’t fully thought through the realities of giving birth in the midst of this crisis, and how pregnant women will be impacted by new emergency measures.
“The community and individuals are stepping up, but health systems are not acknowledging that they can’t think about anything beyond COVID-19,” said TaNefer Camara, a lactation consultant at Highland Hospital who is currently pregnant herself, expecting her fourth child. “It’s sad that our health systems are so dysfunctional that one disease can shut down all other care.”
We spoke with a number of local health care providers and pregnant women to understand what it’s like to be expecting in Oakland right now, how local hospitals and support workers are adjusting, and what resources are out there to help ensure a safe and healthy pregnancy in an extremely challenging time.
Swapping in-person visits for virtual care
Kaiser Permanente Hospital, a major East Bay delivery center, has canceled in-person classes that help new parents prepare for labor and delivery, breastfeeding and life with a newborn.
“We signed up for all the classes at Kaiser, and every single one was canceled,” said Emily Ahsoon Wightman, a teacher at Urban Montessori Charter School who is set to deliver in May. “For each cancellation, I got an email and a phone call. So it was another nail in the coffin: ‘Oh, there goes breastfeeding, there goes the newborn care.’”
Dr. Amanda Williams, physician maternity director of Kaiser Permanente East Bay, said prenatal and breastfeeding videos are available online. Some prenatal appointments, such as scheduled ultrasounds, still happen in person. Kaiser has offered telemedicine for many years, but it has become more important since the COVID-19 pandemic began. “We customize the plan for combining in-person and virtual visits based on the status of the individual pregnancy, with shared decision making between the prenatal care provider and the patient,” said Williams.
Ahsoon Wightman said she’s checked out the videos online, but so far, she hasn’t found them as useful as an in-person class or a lesson with a doula. “They kind of look like a PowerPoint presentation that they’re talking over,” she said.
Telemedicine certainly has advantages. Health workers don’t need to don personal protective equipment to talk to patients by phone, conserving valuable resources for those on the frontlines of the COVID-19 response. It also protects the patient from unnecessary exposure to the virus.
Patients who visit Oakland’s public Highland Hospital, many of whom have lower incomes and rely on MediCal insurance, often struggle with the time and money it takes to get to and from doctor appointments. The shift to more phone appointments has alleviated some of that burden, said Simone Lance, a midwife at Highland.
Some local midwives and doulas have also transitioned from in-person support to virtual support. Linda Jones, a co-founder of Black Women Birthing Justice, has worked as a pregnancy and postpartum doula for 30 years. She’s offering prenatal, labor, and postnatal support through phone and video calls. Whether or not a video call is permitted during labor depends largely upon the physician’s preference and hospital policy.
“I feel for the women who are pregnant during this,” Jones said. “I tell people it’s like they’re having to grieve what they’ve lost. They’ve been planning birth to look a certain way, and now it’s not anything like they imagined.”
Who’s allowed in the delivery room?
New rules about who can accompany women in the delivery room can compound the anxiety. In an effort to combat the spread of COVID-19, only one visitor is allowed in the delivery room at Kaiser Oakland and Highland Hospital. A pregnant woman who may have been counting on several people supporting her through labor—a partner, friends or relatives, a doula—must now pick only one.
“The visitor policy has been a really heartbreaking adaptation,” said Lance, a certified nurse-midwife at Highland.
Highland Hospital and Kaiser have differing policies if a woman in labor, or her support partner, comes into the hospital with COVID-19-like symptoms such as a fever or a dry cough.
“As doulas, our superskill is that we adapt well to changes and we keep calm in times that might seem stressful for a lot of people,” said Katelyn Gonzalez, a Hayward-based doula with many Oakland clients who is also pregnant, and due in July. Research has shown that women who have good support during labor can experience lower rates of C-sections and better birth outcomes than those who give birth alone.
At Kaiser, a person with symptoms gets tested, according to Lisa Cowan, director of regional services for maternal and child health. If they are COVID-19-positive, have symptoms, or have been exposed, hospital health workers will don protective equipment, mask the mother and her companion, and manage the labor as they would for any other patient.
Highland Hospital’s current policy is to separate the mother from her support person if either the mother or support person screen positive for COVID-19. In that situation, the mother would be tested for COVID-19 and separated from her support person. It usually takes about 24 hours to get the COVID-19 test results back.
“I understand that desperate times call for desperate measures, but I think we need to acknowledge the risk we’re taking by not allowing a woman to have continuous labor support,” said Lance. “It doesn’t have to be a doula, but I do think the potential risk of having a woman birth alone needs to be acknowledged. It’s more than just sad or a pity—it has a potential negative impact.”
Postpartum social distancing
Usually, mothers will stay in the hospital for at least 24 hours after a vaginal delivery, said Serena Meyer, nurse and lactation consultant at Kaiser. During that time, nurses will monitor the baby for jaundice and other potential problems, and lactation consultants will help establish breastfeeding and keep an eye out for dehydration, tongue ties, or other feeding problems.
Meyer is the founder of the Bay Area Breastfeeding Support Group, a Facebook group for related professionals. She said that since the COVID-19 pandemic, she’s seen more people discharging quickly from the hospital, against medical advice, than she has ever seen at any other point in her career.
“I’ve never seen so many people try to have their baby and bounce up off the floor so fast. They’re just headed out the door, and I don’t know what they’re heading out the door to,” said Meyer. “We can’t stop them, but we are scared for them.”
Normally, lactation consultants with a private practice would offer in-home visits after birth, but due to COVID-19 concerns, Meyer shut-down her private practice entirely, while Camara moved hers to virtual visits only.
There are also a growing number of online support groups. Camara runs the Midnight Milk Club, a Facebook group that provides nighttime breastfeeding support for new moms. Since the COVID-19 pandemic, she’s been contacted by panicked mothers who are seeing the supply of formula, diapers and other essential baby-care items dwindling in stores. To help answer new questions and manage stress, she has increased the number of group calls to twice a week.
“I don’t feel that there is enough being done to really support pregnant women at this time, in terms of just the increase in anxiety and depression around having a baby and being confined to the home and not being able to have visitors,” said Camara, who is due in August.
“Will we see an increase in preterm birth because of the stress that women are under? How is this affecting my baby? How is this affecting me emotionally in the long term?”
Hospital, or home birth?
Wary of new rules and aware that local hospitals are also treating COVID-19 patients, some pregnant women are now completely rethinking their birth plans.
Mason Cornelius, a licensed midwife at Nova Midwifery in Oakland, said that East Bay midwives have recently received an increase in requests from women who want to switch from a hospital birth to a home birth. Sometimes these calls come as soon as two or three weeks before the due date.
“They’re worried that they are going to arrive in labor, and that the hospitals will change policy and they will have to birth alone,” said Cornelius. “They don’t feel safe there without an advocate.”
Reproductive health experts worry some mothers will be caught in the middle: too afraid to go to the hospital, but unable to afford a midwife or a doula to assist with a safe home birth. This is most likely to affect women who already face other disparities in the healthcare system. Black women are more likely to die in childbirth than any other population, and black babies are more likely to be born preterm or face other adverse outcomes, which makes giving birth without the support of a doctor or midwife that much riskier.
“I am fearful that we’re going to lose Black women that will do this,” said Linda Jones of Black Women Birthing Justice. “We need to have alternatives.”
The American College of Obstetrics and Gynecology generally cautions against home births, particularly for women with complicated pregnancies and those who are considered high-risk. Some of the factors that might make a pregnancy high-risk, or more likely to deliver preterm, include pre-existing medical conditions such as high blood pressure, diabetes, obesity or past preterm births, according to the National Institutes for Health.
Camara, the lactation consultant at Highland, has always had healthy pregnancies and opted for home births. Currently pregnant herself, she will be giving birth to her fourth child at her home in Oakland. Now that her prenatal appointments are all virtual, Camara is self-monitoring her pregnancy by measuring her belly, tracking her blood pressure, and staying vigilant about her physical health and safety.
“I’ve just had more anxiety. My heart rate has been elevated because of these things I haven’t really struggled with before,” said Camara. “I’ve already had healthy pregnancies and natural births, and I want things to go good with this baby as well.”