This article originally appeared on VICE US.
Kara is 39 and a half weeks pregnant—and suddenly she’s rethinking her entire birth plan.
She always planned on delivering her baby at the hospital, as she’d done with her previous two children. She loves her midwife, who collaborates with obstetricians at the hospital near her house in Montgomery County, Maryland. (Kara didn't want to use her last name because she discusses her health history.)
But then she learned that her doula wouldn’t be able to be with her during the birth, because the hospital would be limiting visitors to one support person during labor and delivery as a result of the coronavirus pandemic. Kara worried that her husband would be banned next. Around the country, hospitals are putting stringent guidelines in place for childbirth; in New York, several hospitals banned partners entirely. Midwives in New York sharply criticized the move, which they feared could lead to more parents giving birth at home against medical advice. New York Governor Andrew Cuomo overruled the ban via executive order, allowing one support person per birth. Hospitals in the San Francisco Bay Area are also limiting pregnant people to one support person.
Kara’s hospital is also asking parents in labor to wait outside until they’ve been screened for COVID-19, she said. Some doctors are recommending inductions, even before the parent’s due date, so they can deliver before hospitals are overwhelmed. And, under new guidelines from the U.S. Centers for Disease Control and Prevention, parents who test positive for the virus should be separated from their newborns at the hospital.
The news made Kara deeply uneasy.
“It's become a procedure, like, get in, get the baby out and get out,” she said. “And I understand why they have to do that, but it is nerve-wracking for me.”
And so, full-term, ready to pop at any moment, she started exploring other options.
Before the coronavirus pandemic, a little more than 1 percent of parents delivered their babies at home. But in the face of widespread limitations on hospital births, as well as fears of parents and newborns alike potentially contracting the virus, birth workers said they have seen a spike in interest in home birth. One birth worker in Delaware said she has seen a sevenfold increase in requests—including one from a woman in New Jersey, who said she wasn’t allowed to switch to a home-birth midwife because she was already full-term. And Google searches for home birth are the highest they've been in more than five years.
“There is a comfort, I think, to being in a hospital just in case something does go wrong,” Kara said. “But now with all the stuff that's in the hospital that could potentially go wrong… do the benefits outweigh the negatives?”
Kara decided to speak with a certified nurse midwife—just like the midwife who would have delivered her at the hospital, but one who does home births. If the midwife had any concerns about Kara’s medical history or switching providers at this late stage, she said, she would unquestionably continue with the hospital plan.
Although labor and delivery wards are usually separate from the emergency rooms and intensive care units where COVID-19 patients are treated, some parents are worried that other people could arrive in the labor and delivery ward with unknown cases—or that health workers could unknowingly have the virus and pass it on to parents or children.
But every parent VICE spoke to was more scared that their support people—partners, family members, and doulas—could be barred from the delivery room than they were about getting the virus. And they’re worried about developing complications after the birth in a time when some hospitals are discharging patients much earlier than usual, according to news reports and doulas who spoke with VICE.
“We've had a lot of families that are trying to change their options for birth support,” said Heather Delaney, owner and CEO of Maryland State Doulas.
Delaney said many families have been asking for doula support and advice—should they cancel their baby shower? Is there anyone who can help them take care of a baby during the postpartum period? And then the big question: Should I stick to my plans for a hospital birth?
Home birth isn’t the right choice for everyone. For people like Kara, with low-risk pregnancies, uneventful health histories, and previous births that went smoothly, it can be an option when attended by a certified midwife. But those with high-risk pregnancies need to deliver at the hospital. And if complications develop at home, birthing parents need to be transferred to medical care as quickly as possible—which could involve going through an emergency room full of possible COVID-19 patients.
Annalise Hume was 40 weeks when she decided to switch to a home birth. She lives in New Jersey, and she wasn’t able to find a midwife who could deliver in her own home because she was already full-term. Instead, she made plans to give birth at a friend’s home in Pennsylvania, attended by a certified midwife. But the morning after making all of these plans, her water broke—and she saw meconium, or stool, in the amniotic fluid. That put her and the baby in the high-risk category, so she quickly switched back to the hospital plan. Her baby arrived safely, and he’s now home with his parents.
“I know that's what, in this situation, needed to happen,” she said. “I'm not gonna play the what-if game because it just doesn't help.”
There are both benefits and risks to birthing at home, even with a certified midwife, according to the American College of Obstetricians and Gynecologists (ACOG). In a 2017 report, the ACOG Committee on Obstetric Practice highlighted the fact that high-quality data on home versus hospital birth is limited.
Some studies, though, show that planned home birth has fewer interventions, like induction and Caesarean section, as well as less tearing and a lower risk of the pregnant person developing a fatal infection, the ACOG committee found. But, compared to hospital birth, it comes with a “more than twofold increased risk of perinatal death”—one to two infant deaths per 1,000 births—and a “threefold increased risk of neonatal seizures or serious neurologic dysfunction”—about one per 2,000 births, they warned.
“Those are concerning numbers to me,” said Linda Genen, a neonatologist in New York.
“As a neonatologist, I've definitely seen when things don't go well in a home birth,” she said. When it comes to resuscitating a baby or providing other critical care, she said, “seconds matter.”
“Waiting and getting transported [to a hospital] could be devastating,” she said.
Genen also pointed out that hospital nurses can offer some support in the absence of a partner or doula. “You really do have a lot of support by the actual health care staff who understand even more how scary this can be,” she said. When she gave birth to both of her children, Genen said, the nurses were the ones telling her when to breathe and when to push, while her husband stood by the bedside. “I don't begrudge him—it was more about the experience—but it really was my nurses who were the ones who helped me through the process,” she said.
But the parents VICE spoke with were nervous that nurses would only check in every half an hour or so during labor, and that health workers may be even busier than usual because of the virus.
Many of them consider the support of their partners and doulas just as important as the medical check-ins. Kara said having her husband there is an important part of her psychological support, “because a lot of childbirth is mental,” she said. And for her, doulas are “worth their weight in gold,” she said, comparing them to an offensive coordinator in a football game.
Erica Gardner was 36 weeks along when she heard the news that some local hospitals in the Washington, D.C., area were only allowing one support person; she worried that soon they would ban all visitors.
“Without a husband or partner, without a doula, you really are in the room alone,” Gardner said. “Except on the 30-minute marks when the nurse comes to check, and then when you're ready to push [and the midwife or obstetrician comes in]. I just don't think I could handle being alone during labor like that.”
Her parents, who are at high risk for COVID-19, realized that they weren’t able to travel across several states to help watch their two-year-old grandson during and after the delivery. Faced with no childcare and diminishing labor support, Erica and her husband decided to switch to home birth.
She’s worried about changing the plan so late in the game. “The choice is kind of the best of the worst two choices,” she said. She loves her provider at the hospital. But, she said, this was the only way they could keep everyone together—her husband, her son, her doula, and the new midwife.
Not everyone is totally changing their birth plan; others are just tweaking it a little. Vered Asta’s pregnancy is high-risk, because she developed HELLP Syndrome, a life-threatening complication, with her first, so she knew home birth wasn’t in the cards for her.
Instead, the Maryland resident is planning for her doula to offer virtual support through Zoom video conferencing. And she’s also hoping to get as much postpartum support as possible. At hospitals, she said, “they're trying to get women in and out, which I have mixed feelings about.”
“Of course there's less exposure to germs if you get out quickly,” she said. “But because I developed HELLP syndrome six hours [after my first birth], it's also a little bit scary to think that I could be heading home and then something could happen.”
Her parents have already joined her family at home in self-quarantine to help support them after the delivery.
For her clients with later births—as far off as September—Delaney compares the birth planning process to packing sandbags for an imminent hurricane. Clients are asking what they should do if their providers’ offices and their local hospitals are hit hard by the pandemic in coming months. Some hospitals in California are already closing their labor and delivery units in order to free up more room for COVID-19 patients.
Those planning to deliver at hospitals that might later convert to COVID-only care would benefit from having physical copies of their records in the event of a transfer, Delaney said. “No matter when you're due, get a copy of your health records.” For those switching to home birth, certified midwives aren’t able to care for patients without knowing their health history, she added.
However, there simply aren’t enough certified midwives with experience assisting home births to meet the growing demand. Some midwives in the D.C. area are forming impromptu cooperatives to support each other, acting as backups during prenatal visits and labor. “Home birth midwives cannot take the same influx as a hospital,” Delaney said.
She worries about parents who become fixated on home birth, even when they’re not able to find a certified midwife to assist them. Completely unassisted birth, or “free birth,” can have devastating outcomes.
“Free birth is something that does terrify the bejesus out of me,” Delaney said. She’s had potential clients ask about it recently, and she immediately steers them toward hospitals or home-birth midwives.
“When you're not trained, you don't know what to look for—it could tragically turn,” she said.
For years, the United States has had the worst maternal mortality rate in the developed world—and it is even worse for families of color. Some health workers are concerned that this pandemic will only make these outcomes worse.
It could also spur lasting changes to the way Americans give birth. For instance, patients and doulas told VICE that some insurance plans are now completely or mostly covering home births, which they rarely did before.
Ann Grauer, former president of Doulas of North America (DONA), said this pandemic is revealing longstanding weaknesses in hospitals, where workers are already stretched thin and delivery wards were already frequently near capacity.
“They have been operating on a shoestring for a very long time,” Grauer said. “And the only reason it hasn't completely crashed and burned is we didn't have anything massive happen.”
Now, the coronavirus is making her seriously question the role hospitals should play in low-risk births. “I have really come to believe that we made a massive mistake by allowing birth to take place primarily in a hospital. And this virus, this pandemic, is showing us why that is a problem,” she said.
“If the vast majority of our births took place even in a hospital-related birthing center, and then [we] brought them into hospital if there was a medical need, we wouldn't be running into this,” she said, talking about both the need to limit visitors and the possible spread of the coronavirus within hospitals.
Genen, the neonatologist, also brought up the idea of birthing centers linked to hospitals. “You have a home birth setting, and you're right there and there are people who can quickly tend to you and the baby—wonderful,” she said.
“I am a huge fan of midwives and doulas, but I would love to see them practicing in partnership with experienced OBs in a hospital setting, so that everything is there for the just-in-case episode.”
According to one study, integrating midwives into the health system has the best outcomes for both parents and babies. The more open hospitals are to working with midwives, the better.
In the meantime, however, parents are faced with difficult decisions in light of the rapidly spreading virus.
A day after our interview, Kara sent me a message: She had decided to do a home birth with a certified nurse midwife. “I feel very comfortable with the standard of care,” she wrote, “and the birth experience I'm looking for.”