COVID-19’s Impact on Pregnancy and Childbirth Policies

April 22, 2020 | ASTHO Staff

As COVID-19 continues to spread throughout the United States, hospital systems are implementing heightened safety precautions to reduce risk of transmission, and obstetric wards are no exception. There is currently limited information on how COVID-19 affects pregnant people, resulting in a variety of restrictive safety measures and hospital protocols.

The Centers for Disease Control and Prevention (CDC) released inpatient obstetric healthcare setting guidelines which include: encouraging prioritized testing of pregnant women with suspected COVID-19 at admission or who develop symptoms during admission, separation of infants with suspected infection from healthy infants, and restrictions related to visitors and essential support persons in the delivery room. The American College of Obstetricians and Gynecologists (ACOG) provides additional clinical guidance for OB-GYNs, including for pregnant healthcare personnel.

While federal and national entities have issued guidance and recommendations, hospitals systems in the worst-hit areas have imposed stricter measures to prevent transmission, including highly restrictive visitation policies. Most notably, New York Gov. Andrew Cuomo and the New York State Health Department issued an Executive Order allowing one support person who does not have a fever to be in the delivery room. This was a reversal from the initial barring of all persons from the delivery room.

Many states have introduced bills to strengthen and increase access to these prenatal, delivery, and postpartum services, building a solid foundation of care for women who must navigate the healthcare system and make difficult decisions during public health emergencies. Although many hospital systems implement their own protocols, several states are also proposing and enacting legislation to address the growing concern around COVID-19 and the resulting healthcare decisions made during pregnancy, childbirth, and beyond.

Doula Reimbursement

The uncertainty and confusion around hospital policy changes related to COVID-19 has led to anxiety for many families. Allowing just one support person can present difficult decisions for some pregnant people, forcing them to choose between a spouse or external support such as a doula. A doula is a trained professional who provides continuous physical, emotional, and informational support during and shortly after childbirth. For women at-risk for adverse birth outcomes, doula care provides a positive birth experience and reduces the risk of maternal morbidity. Without an advocate in the room, adverse health outcomes are compounded for already high-risk populations, including black and Hispanic women. This is the case even if the doula joins via a telehealth platform.

Doula support during birth has been linked to lower c-section rates and fewer complications. Flexible Medicaid reimbursement policies that make doula services affordable, especially for vulnerable populations, may lead to improved maternal health outcomes. Last year, two states—Indiana and New Jersey—enacted legislation to provide reimbursement for care by doulas. Washington State also enacted WA SB 6168, which appropriated funds for the State Health Care Authority to reimburse for maternity services provided by doulas. The bill also instructed the Department of Health to develop methods for reimbursing doula services from the Centers for Medicare and Medicaid Services (CMS).

Home Birthing and Midwifery

As a result of COVID-19 uncertainty and restrictions, women are choosing to explore alternate options for hospital deliveries, such as giving birth at home with a midwife in order to limit exposure to the virus. Home births are only recommended for low-risk births, and some insurances do not cover this option. However, demand for homebirths is continuing to grow, and will likely increase with the COVID-19 pandemic—despite risk status and lack of workforce capacity.

In response to changes in birthing trends, several states are considering standardizing midwifery and home birth practices. Two states, prior to the spread of COVID-19, introduced legislation detailing protocols for midwives to establish a safe and accessible homebirth experience.

Illinois proposed HB 2249, also known as the “Home Birth Safety Act.” This bill sets provisions for midwives including application qualifications and administrative procedures (consulting, transfer and transport protocols) necessary to promote a collaborative and integrated maternity care delivery system and maximize patient safety and positive outcomes. North Carolina proposed HB 772, or the “Access Midwives Act,” to set limitations on what “certified midwife” means and what licensing expectations should be followed. This bill was proposed in response to the shortage of maternity care providers in the state and highlights how the practice of midwifery can expand workforce capacity.

Postpartum Health and Paid Family Leave

A few states are stressing the importance of postpartum health and wellness in the time of COVID-19. The postpartum and parenting period increases risk of isolation and loneliness, and stay at home mandates may exacerbate the incidence of postpartum depression. Given how crucial the postpartum time period—or fourth trimester—is for new parents, these state policies could provide important services for a population that urgently needs them. New Jersey introduced A 3913 that would expand the state’s definition of “family leave” to include times during a declared emergency when an employee or family member is subject to a quarantine directive or caring of a child due to a mandated school closures. Alabama proposed HJR 122 to expand Medicaid coverage for new mothers in response to the current COVID-19 pandemic.

Looking forward

As the pandemic evolves, state and territorial health departments should continue to consider:

• The impacts of COVID-19 on obstetric health care settings.
• Likely increases in home births.
• The need to expand maternity care provider capacity.
• The potential exacerbation of adverse health outcomes for already vulnerable populations.

Additionally, because of stay-at-home orders, clinical providers and public health professionals should anticipate a spike in birth rates in fall and winter 2020, which would further burden already overloaded hospital systems and social services.

Increasing flexibilities of licensure requirements and scope of practice for doulas and midwives should also be considered beyond the COVID-19 response. Expansion of Medicaid coverage during the postpartum period and for doula services provides healthcare support for populations that may not have had access to such services previously. As our understanding of the impact of COVID-19 on maternal and child health evolves, so must our public health and health policy response.