In the midst of the coronavirus pandemic, more pregnant women are now seeking births outside of the hospital, at home and in freestanding birth centers, in an effort to minimize virus transmission and to free up valuable hospital personnel for COVID-19 care. On its surface, it may seem the sensible choice; however, there are other risks women should consider.
Those already planning a home birth should understand that they are not guaranteed protection despite their and their midwife’s strict precautions. By the very nature of their work, midwives have exposure to other families (with possible asymptomatic transmission and infection). In the event a home birth requires transportation to the nearest hospital, there is a heightened risk of infection associated with emergency transport. And the shortage of personal protection equipment has affected all care providers both in and out of the hospital.
Since Massachusetts is a state with only two freestanding birth centers, families who want to avoid the hospital setting have only the alternative of home birth, with home birth midwives as their attendants. Many studies have demonstrated the relative safety of home birth when compared with hospital birth in integrated systems such as Canada, where home birth midwives are incorporated into the health care system and transfer arrangements to the hospital are clearly established. This is not the case in most parts of the United States and it is one reason why prominent organizations like the League of Women Voters, ACLU Massachusetts, the Union of Minority Neighborhoods, Mass NOW, NARAL ProChoice Massachusetts, Our Bodies Ourselves, and the Women’s Bar Association support the midwifery bill being considered by the Massachusetts Legislature.
With the COVID-19 crisis, we urge that all credentialed Massachusetts home birth midwives be included in the emergency planning for maternity care and that the state move quickly to ensure that certified professional midwives be licensed to care for women who seek their services. These midwives, who meet international standards for training, could be swiftly trained in Centers for Disease Control and Prevention and Massachusetts Department of Public Health coronavirus screening algorithms and prevention strategies (if they aren’t already) and thus be of assistance to hospital-based providers who are likely to be overwhelmed in the very near future with symptomatic patients.
A 2018 study showed that states integrating credentialed midwives had better health outcomes, including fewer neonatal deaths, fewer preterm births, fewer cesarean births, and higher breastfeeding rates. In addition, the National Academies of Science Engineering and Medicine’s recent “Birth Settings in America” report called for greater integration and utilization of midwives across all settings as a strategy for reducing inequities and increasing access to high-quality maternity care. With the pandemic at hand, the services of CPMs are even more important and would allow more options for low-risk pregnant women and their babies.
The American Congress of Obstetricians and Gynecologist recently recommended the following: “Additionally, if not already doing so, facilities are encouraged to find innovative ways to collaborate with family physicians, midwives who are certified by the American Midwifery Certification Board (or its predecessor organizations) or whose education and licensure meet the International Confederation of Midwives Global Standards for Midwifery Education, and other obstetric care professionals.”
There will probably be future public health crises like this one, and we urge that public resources be allocated for the establishment of freestanding birth centers, so that women will have more options for out-of-hospital births. A national survey of women who had just given birth in a hospital found that 25 percent of them wanted to give birth in a birth center separate from a hospital in the future. The recent federally funded Strong Start study demonstrated clearly that birth centers have better outcomes than hospitals for women experiencing normal pregnancies — and at a lower cost to the system. It is time for Massachusetts to ensure such birth centers in communities across the state.
For now, we must at least make home birth as safe as possible for women who seek this option during the coronavirus epidemic. Then, hospitals could move swiftly to adopt transfer protocols that have been established and successfully applied in hospitals in other states. We can also support the training of more community midwives, as they will be key in preparing for the future and better supporting the childbearing families in our state.
Dr. Lucy M. Candib is professor emerita in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Judy Norsigian is board chair of Our Bodies Ourselves. Dr. Marcie Richardson is assistant professor of Obstetrics, Gynecology and Reproductive Biology at Harvard University and a part-time clinician.