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The Right to Unrestricted Birth Support: Dismantling Hospital Labor & Delivery Pandemic Restrictions

Updated: Oct 16, 2021

Introduction

On January 21, 2020, the first case of COVID-19 was identified in Snohomish, Washington. Now, nearly nineteen months later, worldwide cases of the virus have surpassed 200 million, with over four million deaths. The United States has reported more than 36 million cases and over 600,000 deaths. And while the Infection Fatality Rate (IFR) both nationally and worldwide has remained between 1% and 2%, drastic measures have been taken across the country in an effort to protect vulnerable populations as well as hopefully mitigate the spread of the virus. Some unintended consequences of these restrictions included (and continue to include) loss of employment, permanent business closures, virtual schooling for children, and inability for people to visit family members in assisted living facilities, nursing homes, and hospitals. Instances of depression and substance abuse have increased, and terminally-ill patients have died alone. The birth community has also been gravely affected by COVID-19 restrictions in the healthcare setting, with women being required in many instances to attend appointments unaccompanied and birth with minimal support of her choosing. In some cases, women had their babies with no support at all. To argue that there is no need to take precautions or develop policies to protect vulnerable populations and limit viral spread would be irresponsible. However, calling for moderation and compassion in specific and pivotal high-stress situations such as childbirth is both reasonable and necessary. And the issue of access to both trained and untrained continuous birth support is not only essential, but also potentially life-saving.

The Right to Receive Continuous Social, Emotional, and Physical Support from a Trained Professional

Developed by Childbirth Connection, The Rights of Childbearing Women is a statement of rights surrounding the prenatal, antenatal, and postpartum periods to which all women are entitled. Based on the most current scientific evidence and bearing in mind that many women are unaware that they have these rights, the statement aims to make this vital information readily available to all, noting that many of the routine maternity care practices are not only uncomfortable or painful, but that they carry with them a great deal of risk and, in some cases, little benefit or necessity to the low-risk mother. Additionally, the statement points out that some beneficial practices are disproportionately unavailable in hospital settings across the country.

Bearing this in mind, number fifteen on the list of these twenty rights reads: “Every woman has the right to receive continuous social, emotional, and physical support during labor and birth from a caregiver who has been trained in labor support.” The key in this discussion is the bolded, italicized section, because it specifically illustrates how the current pandemic restrictions in hospitals deprive birthing mothers of this right. Prior to the COVID-19 outbreak, it was not uncommon to see hospital policies allowing each laboring patient to have up to FIVE support persons of her choice in addition to the hospital birth team. While some hospitals have moved from allowing a single support person to two, many hospitals have returned to their earlier pandemic policies allowing only one. And with the seemingly-endless emergence of furthermore virulent strains such as the Delta variant, this single support person of the mother’s choosing is now being required in many instances to show proof of vaccination or a negative COVID-19 test before being permitted to accompany her to labor and delivery. Furthermore, in many hospital COVID policies a doula (see “caregiver trained in labor support”) counts as the mother’s one support person. So, if the mother has the right to continuous support from a trained caregiver, does this not place her in a position of having to choose between her partner (often the baby’s father or other parent, and who likely wants to be present) or other untrained support person (i.e., mother, father, sister, brother, friend, etc.) and having the undeniable and demonstrable benefits of a doula? Not to mention the immense pressure that this places on the sole support person if they are not a doula or trained labor companion. Some fathers, partners, family members, or friends are more than willing to jump in and help, but this enthusiasm and love for the patient does not substitute for knowledge or experience. And, enthusiastic or not, who is there to support the support person when they need a break, need to sleep or eat, or above all, need help supporting the mother. Many partners are not able to fully and capably assist the woman in labor on their own, and it is unfair to both of them to expect as much.

Some would argue that this right is still being upheld under these pandemic restrictions because labor and delivery nurses are caregivers trained in labor support. But, again, this argument falls short of what women in labor deserve and what the right in question is asserting. I am a nurse, and like the majority of my colleagues, I can say without pretense or exaggeration that it is not only impossible to provide any patient not currently experiencing an immediately life-threatening emergency with continuous support, but doing so is not typically supported by hospital policy. In the present-day reality of quantity-driven compensation, where door-to-turnaround times are reported to government agencies such as CMS (Centers for Medicare & Medicaid Services) and directly affect the hospital’s reimbursement, providing each individual patient “continuous social, emotional, and physical support” is not in the plan of care. Nurses are regularly administering medications which typically require titration and documentation of dose and response at specific intervals. They are performing physical assessments, procedures such as IV placements, fetal monitor application, and urinary catheter insertions, regularly communicating with providers, caring for multiple other patients and their babies, and eventually changing shifts. Lack of continuous support does not occur because nurses don’t want to do it, but because the expectations of their job do not allow it.

The Contradiction of Non-Emergent Gatherings and Labor & Birth Restrictions

Regardless of your left or right leanings on the political spectrum, it would be ridiculous at this point to assert that the restrictions put in place across the country to “stop the spread” of COVID-19 have been strictly adhered to by either side. Lawmakers call on the public to continue to do their part, sometimes at great personal and financial cost, while at the same time we see celebrities and politicians throwing holiday and birthday parties, attending political rallies, protests, and events, sometimes in clear violation of their own policies. Lollapalooza, a four-day music festival in Chicago’s Grant Park, drew an estimated 100,000 people daily, and South Dakota’s Sturgis Motorcycle Rally had an estimated half-million bike enthusiasts in attendance. We see people going to Disneyland, the Olympics, taking spring break vacations, gambling in Vegas, shopping in Walmart, dining out in restaurants, traveling on aircraft (arguably closer quarters than those in a delivery room), all with the only requirement being that they wear a mask indoors or while in close quarters, currently regardless of vaccination status. But in the midst of all this activism and celebration, laboring mothers are still left in many ways to fend for themselves, often attending prenatal appointments and ultrasounds alone, and in some places, even birthing alone. Mask or no mask. Vaccine or no vaccine. Not every prenatal appointment or birth has a happy ending, and there have been numerous stories of women who learned they had miscarried, that their baby would be stillborn, or who were informed of a disability or birth defect while they were alone in an exam room or hospital bed, sometimes only speaking to their support person over the phone. The disproportionate fight to for a multitude of other social freedoms bears a striking and gruesome contrast to what we should be fighting for: comprehensive and competent support for pregnant and birthing patients.

Protesting Racial Disparity While Pandemic Restrictions Further It

This is in no way intended to be a treatise on the risks and benefits of masks or vaccines, or on whether citizens should be allowed to move or demonstrate freely in any of the ways described above. In fact, it makes the opposite argument: that the current state of childbirth support urgently needs to be raised at least to the level of exercising other fundamental rights, such as those of free speech and assembly. The protests of the last year have been a deafening call to not simply reexamine systems which contribute to continued racial disparity, but to demolish them entirely in hopes of also dismantling the inherent injustice within. These demonstrations have resulted in change of varying degrees to systems such as criminal justice, education, and immigration, but the one place that seemingly remains overlooked is the medical system, particularly as it applies to women of color giving birth. Our nation is actively protesting racial inequity, and its continued presence in medicine is pervasive and well-documented today. So, doesn’t it follow that we should be actively seeking to dismantle those restrictions which uphold continued inequity where labor and birth are concerned? It isn’t enough that the United States has the highest overall maternal mortality rate of any developed country (17.4 pregnancy-related deaths per 100,000 live births, compared to 3.0 or less in The Netherlands, Norway, and New Zealand), but in this country, women of color die at a four-to-five times higher rate than white women. Specifically, black women with at least a college degree have a pregnancy-related mortality rate (PRMR) 5.2 times that of their white counterparts, with a staggering rate of 37.3 pregnancy-related deaths per 100,000 live births.

In 2019, a 13-state Maternal Mortality Review Committee (MMRC) determined that every pregnancy-related death it examined (including women of all races) was associated with many of the same contributing factors:

  • Decreased or lack of access to appropriate, high-quality care

  • Missed or delayed diagnoses

  • Lack of knowledge among patients and providers surrounding warning signs.

In summary, women are dying because of inadequate or non-existent care, devastating clinical errors, and knowledge deficits at all levels, from the patients up to and including the providers. What is even more disturbing is that the MMRC concluded that 60% of these deaths could have been prevented at multiple points during the patient’s care. And all of this data is pre-pandemic, when women were still “allowed” to have support people of their choice present at their births.

Trained labor support has been proven time and again to improve birth outcomes for both mother and baby, increasing the occurrence of spontaneous vaginal birth, decreasing labor duration, and reducing the incidence of cesarean birth, instrument-assisted delivery (forceps, vacuum), and analgesia administration. In essence, trained birth support leads to a decreased occurrence of the cascade of interventions that almost always results in surgical birth, and which can also contribute to maternal morbidity and mortality. Additionally, newborn five-minute Apgar scores are higher, suggesting babies born to mothers receiving continuous trained labor support tolerate birth better and adjust more easily to life outside the womb than those born to mothers who do not. So, if women of color in particular are 1) disproportionately disadvantaged by our nation’s maternity system as a baseline, and 2) are already at a significantly-increased risk of suffering adverse birth outcomes, including maternal and/or infant death, why are pandemic restrictions still in place that overtly deprive them of a resource that could arguably reduce this risk and possibly even save their lives? A doula’s main goals are supporting, advocating for, and empowering their pregnant client, safeguarding the process of informed consent, and helping the client verbalize her birth wishes to ensure her voice is heard. Every birth deserves the presence, expertise, and knowledge of someone filling this role.

Rolling Back Restrictions in the Hospital Setting

What would it look like if we were to remove the current restrictions placed on birth support in our nation’s hospitals? What would we replace them with, and what guidance and recommendations could be implemented? One possibility would be to allow an increased number of support people to attend the birth, such as the two we are currently seeing in some facilities, but with a trained labor support person such as a doula not counting as one of those two. Instead, we could encourage hospital birthing facilities to work with area doulas, finding ways to allow them to function as an independent provider with limited facility privileges as outlined in their scope of practice. Or better yet, utilize a widely-accepted scope of practice, such as DONA International’s for example, to develop a facility-specific policy for visiting doulas. Hospital performance improvement committees and risk management departments could spearhead the development of visiting provider or outside contractor agreements, similar to those seen with device representatives present and functioning in operating rooms across the country, which would allow trained labor support people to attend their clients’ births.

Like many high-risk units (ICU, OR, Pediatrics, NICU, Newborn Nursery, etc.), labor and delivery departments are secured units. Another possibility is to develop policies governing untrained support persons and visitors, such as family and friends, outlining where they are required to remain during their stay and make them specific to the pandemic. If the facility wishes to limit their movement to within the patient’s room only, they can. If they must wear a mask and socially-distance while walking with the patient in the halls, that can be specified. And requiring visitors to wear a mask while in a hospital setting is not an unreasonable request given the at-risk populations located there. Hospitals can tailor policies to meet both reasonable safety and infection control guidelines while also meeting the physical, social, and emotional needs of their pregnant patients. Most labor and delivery units have their own small kitchens with food provided by the hospital’s Food Services department; increase the amount of food available to the patient and support people to discourage them from going to the cafeteria or out in town to eat. The rise in food available on the units will be offset by the decreased utilization of the cafeteria’s common space. Even if the cost to the facility proves to be higher, it will always be exponentially lower than the cost of a pregnancy-related adverse event or death.

Organic Response to the COVID-19 Hospital Restrictions by Pregnant Patients

In 2019, home births accounted for approximately 1% of the total births in the United States. This is about half of the United Kingdom’s 2% home birth rate, while it is significantly lower than that of The Netherlands’ 25%. And while ninety-nine percent of birth in the US occurs in the hospital or an accredited birth center, there has been a steady increase in the incidence of home birth over the last two decades. Many recent studies have also demonstrated that, for low-risk mothers, planned home birth is as safe, or possibly safer, than hospital birth. The CDC’s most recent data demonstrates the following regarding “out-of-hospital births” (i.e., home births, birth center births, and births occurring in any location that is not a hospital) in the United States:

  • Out-of-hospital births generally had a lower risk profile than hospital births

  • The risk profile of out-of-hospital births declined from 2004 to 2012

  • In 2021 (most recent data reported), the incidence of out-of-hospital birth reached its highest level since 1975

Given that this data only represents births occurring up to 2012, much of the data available regarding the same births during 2020 is still anecdotal. Many home birth providers report a stark increase in home birth interest coinciding with the spread of COVID-19 and the resultant restrictive hospital policies. One midwife noted that, pre-pandemic, she would receive new patient inquiries at a rate of about six to twelve per week. Once the pandemic began to spread, she began receiving the same number of inquiries in a single day.

Without much data available at the time of this writing, it can be surmised that the rising interest in home birth correlates to women’s desires to retain control over their birth space, their birth team, and ultimately their birth experience, and they recognize that the hospital is not currently fulfilling those desires. In fact, the current restrictions harken back to a time fifty years or more in the past when women like my grandmother routinely labored and birthed with only medical professionals present, when fathers and partners waited hours or days to meet their child, and when then separation of mothers and newborns was routine. We have spent decades fighting to change this outdated and often inhumane culture of birth. Let’s not allow our current practices to backslide into an era we have worked so hard to escape.

Conclusions

Perhaps it took a pandemic to open our eyes to the current status of birth in the United States. Not just its status as it exists in the shadow of COVID-19, but as it has existed up to this point. Women have begun to realize in greater numbers that they have rights with regards to their birthing experience, that they don’t want to make concessions when it comes to such a transformative moment in their lives, and that maybe they have already been making concessions for far too long. The increased interest in out-of-hospital birth, and particularly home birth, hopefully represents a shift in the way birth is being viewed by those who are at its center. One that frames birth as a natural event requiring intervention and medical management on a much smaller scale than has been practiced to this day. In order to maintain, protect, and even advance the sacred moment that is birth, we must urge facilities as well as local and state governments to exercise rationality when recommending and disseminating polices that could induce more harm than good. Finding balance in the wake of this pandemic between caution and humanity will not only sustain the rights of childbearing women as they have been recognized for more than two decades, but it will surely improve birth outcomes and save lives.

Sources (in order of utilization):

US Ranks Worst in Maternal Care, Mortality Compared With 10 Other Developed Nations: https://www.ajmc.com/view/us-ranks-worst-in-maternal-care-mortality-compared-with-10-other-developed-nations

National Center for Health Statistics, Maternal Mortality: https://www.cdc.gov/nchs/maternal-mortality/index.htm

Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths: https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html

Trends in Out-of-Hospital Births in the United States, 1990-2012: https://www.cdc.gov/nchs/products/databriefs/db144.htm


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