I’m an OB/GYN physician. I don’t blame women for considering home birth in light of COVID19.
By: Dr. Nicole Calloway Rankins
Tags: Birth, Covid 19, Home Birth, Coronavirus, Pregnancy

Due to coronavirus, pregnant women in the United States have been exploring home birth in record numbers. I don’t blame them. Even before the pandemic, US hospitals have been problematic places to give birth. Things are only amplified as a result of the pandemic.

So what’s wrong with US hospital birth?

For one, hospitals intervene too much during labor and birth. Women typically desire a birth that is free of unnecessary interventions. Many women desire a birth that is as physiologically natural as possible. Yet, interventions are common in hospital birth. Many interventions, such as continuous electronic fetal monitoring and routine artificial rupture of membranes, lack evidence of benefit particularly in low risk women.

Women also experience mistreatment at alarming rates in hospital birth. A recent study found that 28% of women reported mistreatment during hospital birth. Mistreatment meant loss of autonomy; being shouted at, scolded, or threatened; or being ignored, refused, or receiving no response to requests for help.

And then there’s the culture of hospital birth. US hospital birth is rooted in women not having control over what happens to them during labor and birth. For decades hospital birth was characterized by women having little or no say in their experience. We’ve made advances, but remnants of this culture remain. Think use of “allow” or “permit” to describe things like eating during labor or the use of intravenous fluids in labor.

The culture also includes physical control. Stories of women getting an episiotomy without consent or having their membranes stripped without consent are not rare. I personally know physicians who’ve done both. I myself have been guilty of not asking explicit permission before a vaginal exam. I’ve never forced an exam. But I’m embarrassed that almost 15 years into this, it only occurred to me a few years ago that I should explicitly ask “is it ok for me to check your cervix?” It’s just not a routine part of hospital birth culture.

Now take a problematic hospital birth system and add a pandemic on top of it.

A necessary component of slowing the spread of coronavirus is limiting hospital visitors. This means many women are faced with not having the support persons they want during birth. Having support persons (of their choosing) helps women feel safer during birth. Support persons can act as a buffer against mistreatment and serve as an advocate. When restrictions on support persons were introduced, hospitals didn’t provide advice on how things might adapt, for example using virtual support. This left women frightened and very unsure of what to expect.

Another concern is the safety of giving birth in the hospital. It’s estimated that 20% of those infected with coronavirus are healthcare workers. There have been numerous reports of hospitals not having enough PPE (personal protective equipment). So naturally women are concerned about walking into the hospital healthy but then catching coronavirus while there.

And finally, for moms who are positive for coronavirus, there’s the real possibility of being separated from their baby after birth. There’s no right answer about whether coronavirus positive women should be separated from their babies. There’s not much evidence on the topic so it should be a case-by-case decision. But there have been reports of it not being presented as a choice. Moms and babies are just being separated, another source of intense distress.

Put this all together and no wonder women are considering home birth.

I want to be clear that home birth is not the answer to giving birth during the coronavirus pandemic. Up to 30% of women attempting home birth will need transfer to the hospital. The type of integrated care that’s necessary for prompt transfer and continuation of care after transfer is not common in the United States. Right now overburdened ambulances with prolonged response times may result in a dangerous loss of time for care. This could be especially problematic for a newborn baby.

Also home birth is only appropriate for low risk women — single baby, head down, between 37 to 41 weeks, no medical problems, no pregnancy problems, no prior cesarean birth, and ideally had a prior vaginal delivery. And even for appropriate candidates, it’s challenging to find a qualified provider, and it’s a significant out of pocket cost. Home birth is generally not covered by insurance and can cost anywhere from $3000-$8000.

So if home birth isn’t the answer, what can pregnant women do? Here’s my advice.

Ask the hospital where you plan to give birth if the staff and patients are using appropriate PPE. One institution found that 32% of pregnant women on their labor and delivery unit were asymptomatic carriers. With these high rates, all providers, patients, and visitors should wear masks to reduce the possibility of transmission. If the hospital is not providing patients and visitors with PPE, then bring your own masks.

Ask the hospital what their policy is on separating coronavirus positive moms from their babies. Both separation and keeping mom and baby together are reasonable options. On April 4th the CDC revised its guidelines to say that the decision to separate mom and baby should be on a case-by-case basis using a shared decision making approach. The World Health Organization recommends that babies can remain with their coronavirus positive moms with appropriate precautions. Breastfeeding and skin to skin contact are still encouraged.

Ask to go home as soon as it’s safe for you and your baby to do so. The less time you stay in the hospital, the less time you’re exposed.

If you need support beyond one person, consider virtual support. Many doulas have adapted their services to provide virtual support. Or you can arrange virtual support via video chat or by telephone with whomever you choose. Don’t forget chargers, long cords, and a stand for your device.

Invest in quality childbirth education. There are online options available. The vast majority of labor and birth is still the same even during a pandemic. Educating yourself is more important now than ever so you’re knowledgeable and prepared about what to expect, and empowered to advocate for yourself during your birth. Understanding labor will also allow you to stay home longer so you can reduce the time you’re at the hospital.

And finally, do your best to control the things you can control, don’t get consumed by the things you can’t control, be as prepared as you can, continue to wash your hands and practice social distancing. It’s what we all have to do to get through this.