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Health , US

Coronavirus threatens an already strained maternal health system

by Eileen Guo March 26, 2020

This article was originally published in The New York Times

On Wednesday, March 18, 28-year-old Latoyha Young and her mother, Thomasina Hayten, rushed to Sutter Health Hospital in Sacramento, believing that Young was in labor. Hospital staff sent her home — she wasn’t far enough along.

Two days later, Young spent her expected due date searching stores in Sacramento for key items: baby wipes, diapers and hand sanitizer.

The mother-and-daughter pair, who are homeless, dependent on city transportation and have been staying temporarily with a relative, needed supplies before a shelter-in-place order that went into effect on Monday. They found wipes, but no diapers.

That evening, they returned to the hospital, but were sent home. Young was only two centimeters dilated, rather than the three inches that would indicate active labor.

Nothing seemed to be going right.

The plan had been for Young to be accompanied during childbirth by a community doula, funded by a grant through Sacramentos’s Black Child Legacy Campaign. But when Young’s doula, Joy Dean, drove them to another hospital — one of the few that accepts her Medi-Cal plan, California’s Medicaid program — the new limits on visitors permitted in labor and delivery departments in an attempt to contain the spread of Covid-19 meant that she was unable to accompany them inside.

“I’m not worried about the virus. I’m worried about going back and they’re not listening to me,” said Young, adding that if Dean had been with her, they might have treated her differently.

Giving birth in unprecedented circumstances

As the United States struggles to respond to the Covid-19 crisis, tens of thousands of women across the country are giving birth in unprecedented circumstances. Hospitals are shifting their prenatal and postpartum care to telemedicine, limiting or outright banning visitors, offering elective inductions to full-term mothers and converting labor and delivery wards to coronavirus units.

These changes are leaving health care providers, industry associations and patients reeling as they try to make informed decisions. “It’s changing day by day,” said Thorild Urdal, a nurse in the San Francisco Bay Area with almost 35 years of experience in labor and delivery.

Coronavirus is straining a U.S. health care system that, for years, has had the worst maternal mortality rate in the developed world. In 2007, 12.7 of every 100,000 women died during pregnancy, labor or within 42 days of giving birth, the measurement set by the World Health Organization. In 2018, that number had risen to 17.4 deaths per 100,000, according to data from the Centers for Disease Control and Prevention.

Health outcomes are even worse for women of color, especially black mothers, with C.D.C. data showing that in 2018, black mothers died at twice the rate of white mothers. Other studies suggest that the C.D.C.’s numbers are conservative, and that black mothers are dying at 3.3 times the rate of white mothers.

With this kind of maternal health baseline, many birth workers are concerned that efforts to contain the coronavirus pandemic will have unintended consequences on mothers and infants that will only become visible after the pandemic ends.

Meanwhile, hospitals are struggling to keep up.

Last week, the Permanente Medical Group, Kaiser Permanente’s Northern California network, which collectively delivers 45,000 babies a year, became the first major hospital group to offer induced labor to women at 39 weeks, which is considered a full-term pregnancy, or offer earlier dates for women with already-scheduled inductions. Typically, it is only offered for medical reasons at 39 weeks.

The network is intentionally “trying to get patients delivered before this pandemic gets worse, as long as they are past 39 weeks,” said Dr. Amanda Williams, the head of ob-gyn at Kaiser Permanente Oakland in California. That way, they can “get delivered and get back home before they get sick, their partner gets sick and staff gets constricted.”

“We cannot force anyone to have an induction,” Williams added, “but we can very strongly recommend it if this continues to get worse.”

For Jhoanna Galvez, a licensed midwife based in Los Angeles, induced labor is the last thing that she would recommend during a pandemic, “because it may actually increase time in the hospital,” she said, and “if you induce and you’re there for 72 hours, you’ve defeated the purpose.” (Studies consistently show that induced labor lengthens the birth process compared with non-induced labor.)

The American College of Obstetricians and Gynecologists has not yet issued guidelines on the matter, but a spokesperson said induction is “under discussion.”

Separately, the college noted that while pregnant women are not more susceptible to Covid-19 than the general population, symptoms of the disease like upper respiratory infection and high fever can affect infant health.

And while early studies from Wuhan, China, suggest the virus does not transmit vertically (for example, during delivery), for mothers who test positive, or are presumed positive, U.S. hospitals may separate them from their infants for a 14-day quarantine period — whether in a separate room or by a barrier in the same room.

Hospital systems shuttering labor and delivery wards

Complicating matters, some hospital systems are shuttering labor and delivery wards entirely to keep beds clear for coronavirus patients.

In San Francisco, the California Pacific Medical Center network of hospitals converted one of its two labor and delivery units into a Covid-19 unit. Women in labor (with no symptoms of coronavirus) are now sent to another hospital in the network. This change, however, has not been publicly announced.

Urdal, the Bay Area nurse, said that while consolidating birth centers in the face of a pandemic “sounds good in theory,” in practice it doesn’t work well because when women are in labor, “the vast majority simply show up. And it’s not in any way prudent to move a woman in active labor.”

And then there’s the visitors dilemma.

NewYork-Presbyterian Hospital and other city hospitals have banned all visitors from labor and delivery wards in an attempt to stop the spread of coronavirus from asymptomatic carriers. And at hospitals which allow just one visitor, mothers are facing the almost impossible choice of who to have by their side: a partner or a doula. Studies have shown that the presence of doulas improve both mother and infant health outcomes, regardless of race.

“Oftentimes people are seeking support because they’re already emotionally, financially vulnerable,” said Galvez, the Los Angeles-based midwife. “So already they’re saying, ‘I need support for this incredibly vulnerable thing, and that’s not going to be available.’”

Smita Nadia Hussein, a mother of two, gave birth on March 17 in Morristown, N.J., accompanied by just her husband, rather than her support network of mother, sister and doula. “I didn’t feel like it was unfair of the hospital. I thought it was unfair of the universe,” she said, adding, “It sucks, it really sucks.”

The issue of support doesn’t end in the delivery room: Casey Hogle, a first-time mother who delivered at Massachusetts General Hospital in Boston on March 14, said that while delivery went smoothly, being at home highlighted other challenges. “The biggest impact is a social impact,” she shared, her voice wavering. “Both of our moms are probably not going to see the baby for quite some time now.”

That social support is especially important for people who have already been marginalized by the U.S. health care system.

Williams, of Kaiser Permanente Oakland, acknowledged that her hospital’s policies and the disproportionate effect that they have on women of color and at-risk people are adding countless layers of stress in an already uncertain time.

“The marginalized just become more marginalized when there is stress on the system,” she said. But, she added, “These are extraordinary times, and we’ve had to take extraordinary measures.”

Kathryn Hall-Trujillo, founder of Birthing Project USA, which focuses on improving black maternal health outcomes, added that many people already distrust the health care system, which they see as racially biased. “We have spent a lot of time convincing black women their link to survival in the health care system is their doula,” Hall-Trujillo said. Now they don’t even have that.

Instead, women like Latoyha Young are doing their best to navigate the health care system — and a city under virtual lockdown — by themselves.

As of Thursday, Young was still waiting to go into active labor, and still has not found diapers. When the time comes to push, Thomasina Hayten refuses to leave her daughter’s side, regardless of hospital policies. She doesn’t want her daughter to give birth alone.

“If they [want to] cite me for it, they can cite me,” Hayten said. “Because she’s not going to do this herself.”

The crisis has led some mothers to consider giving birth at home instead of at the hospital, where over 98 percent of all American births still take place.

Galvez has received five to eight new inquiries per day from mothers with due dates in the next two weeks who are interested in home births, a huge increase from her usual three clients per month.

But Dr. Taraneh Shirazian, president and founder of Saving Mothers, a nonprofit focused on maternal health globally, and an ob-gyn at NYU-Langone Medical Center, stresses that hospital births are still the safest option, given both the high risks of complications in labor, as well as the additional logistical challenges that a pandemic presents.

“When any system is under stress, it’s going to slow the process,” she explained, so it’s best to be in the hospital already, where you can get access to care quickly.

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