Meshawn Tarver, MPH, HBCE, CHC, Doula, Senior Program Manager for Maternal and Child Health
Lisa Richardson, PhD, Chief Impact Officer, Institute of Women & Ethnic Studies

The COVID-19 pandemic shifted the dynamics of U.S. health care as we know it. Hospitals were forced to change policies and procedures, adjust staffing, and delay scheduled surgeries. Amid widespread uncertainty, public anxiety, and stay-at-home orders, hospital admissions in the United States fell dramatically. As noted in Health Affairs (September 2020), while emergency rooms and critical care units for coronavirus patients were stretched to the limit, many other patients, including those with acute medical illness, did not seek hospital care out of fear of contagion or concerns about hospitals being overrun with COVID-19. These fears were heightened among patients in need of maternity and obstetric care. For families who decided on birthing at a facility, the new COVID-19 protocols also turned out to be unsettling. For example, the new protocols specified that:

• A birthing person’s partner was prevented from attending prenatal or ultrasound appointments, and the birthing person was restricted to having only one person—including a doula—during labor and delivery. 
• All visitors were prohibited during the postpartum period. 

“That was one of the main reasons that pushed me to have a home birth,” said a mother living in New Orleans in a discussion about the shifting hospital policies related to COVID-19. “It felt like [with] every [new] appointment, [I was told about] a new policy change and I didn’t feel comfortable with that. One moment I was told that I could have one support person, then I was told that I may be alone. I just did not want to chance it.”

Launching into Studies on COVID-19 Potential Effects on Pregnancy 

The Centers for Disease Control and Prevention (CDC), the American Hospital Association, the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and immunologists have worked tirelessly to learn more about COVID-19 and its potential impact on pregnancy, birthing, and postpartum care. In June 2020, the CDC reported that pregnancy may increase a person’s risk of severe illness from COVID-19 after a study showed that pregnant women were significantly more likely to be hospitalized, admitted to the intensive care unit, and receive mechanical ventilation than non-pregnant women. In New York, Governor Andrew Cuomo convened a taskforce to address the effect of COVID-19 on pregnancy and determine best approaches to provide mothers with safe alternatives to hospitalization, when appropriate. The New York COVID-19 Maternity Taskforce’s recommendations included testing all pregnant women for the virus and designating doulas as an essential member of the care team. However, as the studies were underway, and with concerns about increased risk of exposure to COVID-19 in hospitals, some families decided to opt out of an in-hospital birth and looked for alternatives such as birthing at a freestanding birth center or at home with a midwife.

The Evolving Story of Midwives

There are approximately 12,200 midwives in the United States, and during this period of intensified interest in out-of-hospital birth, practitioners have reported that the home birth community has become deluged. Midwives around the country have reported an astronomical increase in inquiries from expecting families considering home birth. One midwife from New York who typically sees 40 patients per year said at one point in the early spring of 2020 she was receiving almost 40 calls a day to inquire about home birth. Michelle Drew, a Certified Nurse Midwife and historian, points out that renewed interest in home births and midwifery care has deep roots in our culture. Birthing at home was the norm until the early 20th century. Drew asserts:

• During that time, 90 percent of midwives were Black women, and 10 percent were ethnic immigrants. Physicians still weren’t attending births because it was not considered important.

This situation changed when the American public hospital system developed in the 1900s, and midwives were eclipsed by a narrative that framed physician-assisted deliveries in hospitals as the highest standard of birthing care.

Freestanding Birth Centers

According to the American Association of Birth Centers, more than 384 birth centers are located in the United States in 37 states. A freestanding birth center provides prenatal, labor and delivery, and postpartum support to families who are usually receiving midwifery care. In general, a birth center is not in a hospital setting and provides care to women with low-risk pregnancies in a home-like environment. Access can be extremely limited in some areas, and states vary in how they regulate and accredit their facilities. 

Who Can Perform Birthing Services and for Whom?

Although three types of midwives can perform birthing services—a Certified Nurse Midwife (CNM), a Certified Professional Midwife (CPM), and a Certified Midwife or Licensed Midwife —some states only permit a CPM to provide care in a home environment. CNMs are available nationwide, but in some cases, they are limited to seeing patients either in a hospital setting or birth center setting under the supervision of, or in collaboration with, a physician.

In a time of such uncertainty, civil unrest, and a global pandemic, families choosing a safe, calm, and healthy alternative to maternity care should be welcomed to do so; it is their choice. Doula and midwifery care both have been documented to demonstrate improved birth and breastfeeding outcomes. Home births are a viable option for many women, and they can ensure the safe birth of a baby and the appropriate care for a mom. The midwifery care model is clear that candidates for home birth must be low-risk pregnancies. High-risk pregnancies are most appropriately served in a hospital under the care of a trained obstetrician. Families who choose home births need a strong support system to provide much needed emotional support and must ensure the midwifery team is aware of any potential signs of distress. If complications arise at any time during a home birth, the family must transfer care to a hospital maternity team. The detailed midwifery intake process focuses on identifying who are the best candidates; vetting has kept the transfer to hospital rates to less than 1 percent for birth center births.

Conclusion

As maternal and child health professionals, our primary goal is to improve maternal and child health outcomes, and that includes reducing trauma to birthing families. In that spirit, our job is to: 

• Ensure the community is made aware of and educated on all birthing options available to them. 
• Encourage and ensure that all health care providers provide respectful maternity care.
• Advocate for policies that support all birthing options for families.

Resources

American Association of Birth Centers. National Birth Center Study II. https://www.birthcenters.org/page/NBCSII#about. Accessed January 5, 2021

MacDorman, M. F., & Declercq, E. (2019). Trends and state variations in out‐of‐hospital births in the United States, 2004–2017. Birth, 46 (2)279–288.