The coronavirus (COVID-19) pandemic is impacting the delivery of prenatal care and obstetric services.
Hindered by a paucity of data, clinical leaders are doing the best they can to adapt policies in ways that reduce the risk of virus transmission between pregnant women, their immediate contacts, and patients and healthcare providers within the healthcare system.
Based on a New England Journal of Medicine study demonstrating that 88% of COVID-19 positive obstetric patients late in pregnancy had no symptoms on presentation, some obstetric providers, including some of us, are treating all women as presumed positive until tested. Many hospitals are reducing the number of support people allowed to attend prenatal visits and the delivery—typically the partner alone is allowed—because of uncertainty about community prevalence.
Early series data on mom-fetus and mom-baby transmission are mostly reassuring.
However, out of an abundance of caution, the American Academy of Pediatrics recommends separating COVID-19 positive mothers from their newborns.
Anecdotally, pregnant women are making healthcare decisions influenced by fear that they will contract COVID-19 within a healthcare setting and concern that their support people will be prevented from accompanying them to both ambulatory and inpatient obstetric visits. Patients fear having to choose between their doula and their partner, and certain communities that have long-standing experiences of feeling "policed" regarding family visitors see this as one more insult.
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There is no national pregnancy-related COVID-19 surveillance system, and every jurisdiction is different, so practitioners are relying on word of mouth from their colleagues to learn best practices and understand how other institutions are addressing these challenges.
We wanted to understand how prenatal care and inpatient obstetric care had changed since the COVID-19 pandemic hit the United States, and how women perceive their pregnancy experience, their prenatal care, their birth plan and their care options. So, each weekend, we are sending a survey to women who use the Ovia Pregnancy mobile application.
Over the past four weekends, a total of 7,971 women in the U.S. have completed the survey, a completion rate of 72%. Among respondents, 83% reported being pregnant and 14% were 0-8 weeks postpartum.
Birth plans and delivery
About 3% of respondents reported that they plan to deliver at home, compared to 1% prior to the COVID-19 pandemic (additionally, 24.5% reported that they had begun considering home birth as an option).
Prior to the pandemic, 59.2% planned to have family members and/or a doula at the delivery in addition to the partner (nearly universal). Now, only 14.4% planned to have a non-partner attendant physically present at delivery. The number of women who were planning to teleconference support people into their delivery before the pandemic was just 0.4% and increased to 2%.
Among postpartum women surveyed, 35% reported having to wear a mask during delivery, 32% were discharged early, but only 6% reported delivering in a different location than planned, and 14% reported being tested for COVID-19 when presenting for delivery.
Care modification
At least 30% of prenatal and postpartum visits are now either modified, canceled or rescheduled.
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Among visits that were modified, 36% were conducted by phone, and 37% were conducted by video. Talk about resourcefulness: women reported being asked to report their own measurements or vital signs in 44% of remote visits, with 90% of respondents reporting at least some successful at-home measurements (picture home blood-pressure cuffs, measuring tapes used to measure the height of the uterus, you get the picture). About half (48%) of respondents with a remote visit felt that they received the same amount or more information and care than in a traditional visit. In general, privacy concerns (4%) and logistical concerns, such as finding a quiet space (11%), were not an impediment to virtual prenatal and postpartum care, even though only 10% reported using telehealth prior to the COVID-19 pandemic.
Concerns and insecurities
Top reported concerns among pregnant respondents related to the COVID-19 pandemic include the risk to personal health or their newborn’s health (68%), the fear that support people will be unable to attend delivery (68%), the risk of contracting COVID-19 during a prenatal or obstetric appointment (36%), that support people will become sick with COVID-19 (31%), and financial or job security (27%).
The top concern among postpartum respondents was that their baby would become ill (73%), followed by concern about childcare access (40%), postpartum depression (33%), and access to well-child (27%) and postpartum (24%) visits.
A total of 14% of respondents were deemed to be food insecure. This in comparison to the pre-pandemic average 11% of U.S. households typically reporting food insecurity.
Remarkably, when we measured maternal stress using a standard metric (the PSS-4), average scores didn’t differ markedly from benchmark data collected in easier times.
It is also interesting that, since late April when we began surveying, modifications to obstetric practices haven’t changed very much. Doctors and patients adapted quickly and have kept things relatively stable for a month. It’s reassuring to note that patient concerns have declined, in general, over the past month as we have all begun to adapt.
Like all Americans, pregnant and postpartum women are fearful that they, their children, and their loved ones will become sick with COVID-19. To the extent that healthcare providers can mitigate these concerns, provide resources to reduce risk and exposure, and plan for unprecedented levels of postpartum depression in the coming weeks and months, their patients will be better served.
We are also concerned that scared patients will consider potentially unsafe home births, a topic that warrants the attention of healthcare providers.
Healthcare systems have an opportunity to adapt workflows and visitor policies, and particularly to leverage conferencing technology, to safely support women through childbirth at this challenging time.
Support for freestanding birth centers that could, appropriately managed, provide a welcoming alternative to in-hospital obstetric services could be considered. Lastly, a fresh look at policies governing home births, surveillance systems for pregnant women, and payment structures for remote prenatal care and doula support are warranted.
Adam Wolfberg, M.D., is an obstetrician and the chief medical officer at Ovia Health. Neel Shah, M.D., is an assistant professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and director of the Delivery Decisions Initiative at Ariadne Labs. Rahul Gupta, M.D., is the chief medical officer for March of Dimes.