There are about 300,000 births every month in the United States. That won’t change as Covid-19 continues its march across the country.
Health systems are doing the best they can under immensely difficult circumstances to treat very sick patients, stem the spread of the virus, and keep those on the front lines healthy. Health providers are balancing life-and-death decisions on many levels, from considering universal do-not-intubate or do-not-resuscitate orders for severely ill Covid-19 patients to rationing ventilator care.
As is always the case, the weaknesses in our strained health care infrastructure are disproportionately affecting the most vulnerable people, and that includes pregnant women.
Lessons from the first hardest-hit states show us how difficult it will be to strike the right balance between the needs of expectant parents and the needs of a health care system in the throes of an unprecedented fight. Several New York City health systems, for example, issued a rule that would have forced women in labor to go it alone without a partner, doula, or other support person. The New York State Department of Health and the governor quickly rescinded it after an outcry from patients.
Across the nation, expectant parents are worried, exploring options for birthing and often hearing different answers regarding where they can give birth and who can accompany them. Doulas, for example, advocate for women during birth and help them navigate the health care system. They, too are at risk for getting the virus, or spreading it, when protective equipment is in short supply.
These challenges will confront us for a while. What steps can we take in the short-term to make things better to promote maternal and infant health?
First, we should be prioritizing pregnant women for Covid-19 testing across the nation. In New York, the impetus for the decision to ban labor partners was tied to the fact that five of the seven pregnant women with confirmed Covid-19 were asymptomatic, so they weren’t tested. Testing pregnant women can allow hospitals to take immediate appropriate precautions during labor and give moms better information when exploring birthing options to choose from and when they take their babies home.
Second, we need to expand the ability of pregnant women to get care via telemedicine (video and/or phone) with an expanded perinatal care team involving midwives, doctors, and doulas. This does not solve the issue of where to give birth, but expanding the use of telemedicine would enable some pregnant women to stay home and participate in prenatal and postpartum visits via videoconference or the phone without coming into a clinic and putting themselves and their babies at risk of exposure to the virus. Telehealth should be covered by Medicaid, which finances nearly half of all births in the U.S.
Third, as health care capacity is stretched, we should be investing now in non-hospital sites of care, such as birthing centers, or repurposing ambulatory surgery centers for pregnant women at low risk of complications. Since connection to social services are strained during this pandemic, we also should foster and reimburse the integration of nonphysician providers like midwives and support persons like doulas who can help low-income women navigate the health care system and leverage local resources to connect to social needs like food and housing.
Fourth, we should permanently extend Medicaid’s postpartum coverage from 60 days to a full year. Women are at risk of getting sick or dying up to one year after pregnancy. Expanding coverage is critically important during the Covid-19 pandemic, when there is a real risk of health system capacity being overwhelmed and there is a need to follow-up with women after giving birth to address safety, anxiety, depression, and other medical concerns.
A crisis can sometimes lead to something better. This pandemic is stretching our public health and health care capacity in ways that most of us have never experienced. We must ensure it doesn’t harm those who are pregnant or their newborns. But rather than feeling defeated, we should see this as an opportunity to build the robust maternity system the U.S. sorely needs.
Laurie Zephyrin, M.D., is vice president of health care delivery system reform at The Commonwealth Fund.