As hospitals feel the strain of COVID-19 patients, expectant parents are altering birth plans. Many who once considered hospitals to be the best choice to give birth are now scrambling to find midwives to attend a home birth.

Why are women choosing homebirth now?

Many states and communities are restricting access to birth partners during hospital births. Expectant mothers worry they may be placing their baby’s or their own health at risk by delivering in a hospital treating COVID-19 patients. Doctors are canceling prenatal appointments. Limited medical supplies and hospital staff may create an unsafe environment for birth, as well as put an extra strain on hospital resources. The resurgence of home birth as a safe, practical method of childbirth is due to a variety of reasons.

Oregon licensed midwife Amanda Moore explains:

Many women are now choosing homebirth over clinical or hospital settings due to the risk of exposure of the CV19. Women are learning that staying at home with a skilled practitioner in an out of hospital setting is safer where their own biodome and immunity is strong in their own safe, environment.

Midwives are trying very hard to accommodate these women and families to ensure they have options outside of the hospital with midwifery care.

The challenge is many homebirth midwives have a capacity per month and work independently; limiting availability to help these women who seek our services.

In addition, Homebirth midwives can only accommodate low risk pregnancies. 

We are doing our best to give the individualized midwifery care and hope that more women will know that homebirth is a safe and alternative option… not even in a health pandemic.

Choosing homebirth during CV19 allows the hospitals to serve critical patients, lowers demand on PPE, keep Mom and baby healthy in their own homes and limits exposures to disease. 

Homebirth is appropriate for low risk, healthy women.

Amanda Moore, CPM, LDM

One mother’s story

Rachael Kimball is expecting a baby during these strange times of stay-at-home orders and non-essential businesses closing. Her first child, who is almost five-years-old, was born in a hospital.

Prior to the Coronavirus Pandemic, Rachael was planning another hospital birth. When asked why she decided to switch from hospital birth to a home birth now, she replied:

Well to be honest I always wanted a home/natural birth but was too afraid. People always shamed it in a passive way, and I just thought it would be too hard or too much. 

So I went the typical route, as all of this started to come up I became really concerned about hospital policy and protocol. When at my 30 week appointment my husband and daughter couldn’t come watch the ultrasound, then my ob told me Riverbend would not allow my daughter into L&D with me and that there were other restrictions on support people, I lost trust in the process. I cried all the way out of the office. I didn’t trust the encouragement of induction, c sections, separating mother and baby, etc…so all that ushered me to confront my wishes for a home/natural birth, and I am so relieved that I did.

Rachael Kimball

Rachael is not alone. As if the fear of contracting COVID-19 were not enough, the restrictions and changes made to hospital and doctor’s policies are causing women to alter their birth plans. Furthermore, many doctors are encouraging induced labors in order to birth prior to peak COVID strains on hospitals or under a controlled schedule.

Expectant parents around the world are experiencing the same anxiety. According to “Coronavirus Pandemic and Worries during Pregnancy; a Letter to Editor” from researchers at the Midwifery and Reproductive Health Research Center at Shahid Beheshti University of Medical Sciences in Tehran, Iran:

Coronavirus (COVID-19) is a new respiratory disease that is spreading widely throughout the world(1). There is no valid information available on pregnant women and their complications. But given previous epidemics (SARS and MERS), as well as mental and physical changes during pregnancy (2), pregnant women are more likely to be affected by the virus.

On the other hand, the Coronavirus epidemic has created stress and anxiety for pregnant women in different parts of the world. Concern and stress in pregnancy are associated with side effects such as preeclampsia, depression, increased nausea and vomiting during pregnancy, preterm labor, low birth weight, and low APGAR score (3–7). 

In the Coronavirus pandemic, pregnant women cited the following reasons for their concerns:

– Many pregnant women have had a birth plan before the pandemic, but are currently worried about how their families (mothers) will be present, given the urban and quarantine constraints; moreover, even if there is no inter-urban restriction, they may be worried about their families being infected during transportation.

– Many pregnant women do not go to visit their physicians due to concerns that they may be exposed to the Coronavirus in the hospital environment or on the way to the hospital and may be post-term. Or on the contrary, due to stress and worry they want an early termination and elective cesarean section.

– Many pregnant mothers are employed and constantly use sodium hypochlorite and alcohol detergents to control and prevent the virus, which can lead to poisoning. Some other pregnant mothers might become highly stressed and anxious, and overuse these detergents.

– Some mothers are worried about their fetal or their neonate being born. Also, some mothers worry about postpartum such as breastfeeding, and neonatal care (postpartum vaccination, screening).

Archives of Academic Emergency Medicine

The challenges for clients and midwives switching care models

As many doctors and OBs switch to virtual prenatal visits, midwives are still doing physical exams and tests. Their clients are getting personal attention necessary to calm their fears surrounding not only their approaching labor and delivery but the changing and evolving world around them. Midwives not only provide physical assistance but emotional support, as well, but this comes at a risk for midwives taking on new clients during the COVID-19 pandemic.

Just like most parts of the economy forced to shut down, doctors are also experiencing economic loss as their offices are closed. According to Moore, many are limiting costs by not following the typical protocol for prenatal visits, such as extending the length between each consult. One of her clients even reported her doctor would not conduct prenatal visits after 30 weeks of gestation. Frustrated over lack of care, expectant parents are switching to midwifery.

When expectant parents change birth plans near in the second or third trimester from OB to midwife care, there can be challenges. As Amanda Moore, CPM, LDM explains, “Women who did not choose home birth, to begin with, have a very different foundation and view of birth…This could be a concern for midwives to take on late transfers.”

Rachael is 35 weeks pregnant and considered a late transfer. Most midwives will allow home birth delivery at 36 weeks, as the lungs are fully developed but may encourage their clients to go to the emergency room.

Racheal made her choice at 33 weeks to seek out a midwife and has since had two prenatal appointments with her midwife Amanda Moore.

Midwives and their clients build a trusting and educational relationship through extensive prenatal care. Midwifery prenatal appointments last for 30-40 minutes on average, are often in your home, and do not have the rushed sense of a brief medical appointment. When expectant parents move from the conventional medical model to the midwifery one later in the pregnancy term, they have missed this opportunity for relationship building.

Certified midwife Amanda Moore explains, “Honestly, there is a liability for the midwives taking on women who were not committed from the beginning. A huge part of midwifery is a working relationship through prenatal care. Building trust and educating them takes time and we are doing the best we can!”

PPE shortages affecting midwifery care

Like many other healthcare workers, midwives are finding it difficult to obtain personal protective equipment (PPE).

I asked Amanda Moore, CPM, LDM a few questions regarding PPE:

ECP: Would you say it is more difficult for midwives to get PPE?

Moore: Yes, we don’t have masks. We made masks with 3M filtration. N95 and cleaning supplies for health care are out of stock or on rations. I ordered anti-hemorrhagic and IV fluids, and other various medical supplies to have on stock to ensure my practice has basic necessities to serve my clients.

ECP: Were these necessary supplies back-ordered?

Moore: Everything is on rations…even through medical suppliers. I’m having my patients order their birth kits early to ensure they have their needs met.

ECP: Are your clients finding the birth kits unavailable or are they experiencing delayed shipping or shortages?

Moore: Unavailable or back-ordered supplies: N95 masks, PPE, alcohol, alcohol wipes/pads for injections, Hibiclens and other cleaning soaps for medical tools and equipment, gloves!! The birth kit supplier shipper is charging more for shipping.

Some states are making it midwifery care easier during the pandemic to reduce strains on hospitals

On April 1, 2020, the state of Oregon issued a temporary administrative order for the Oregon Health Plan effective until September 27, 2020. According to Moore, this order “adjusted the parameters for inclusion in their prior authorization processes making midwifery care more accessible.”

The Division needs to amend this rule to support appropriate response during an outbreak or epidemic of an infectious disease. This amended rule provides alternate criteria for coverage During the state of emergency under governor Kate Brown’s executive order 20-03, to improve access to care, reduce exposure to COVID-19 and potentially reduce hospital utilization. The amended rule authorizes the Division to operationalize revised coverage criteria for planned out of hospital birth services based on a draft coverage guidance under development by the Health Evidence Review Commission.

Across the United States, midwives are experiencing a demand for their services. The American College of Nurse-Midwives has asked President Trump to “temporarily lift the restrictive licensure requirements that limit access to the midwifery workforce” in response to COVID-19.

During the Influenza Pandemic of 1918, a majority of babies were born at home. During the Coronavirus Pandemic of 2020, expectant parents are seeking home birth due to restrictive hospital policies, fears contracting the virus, virtual or non-existent prenatal care by OBs, and strained hospital resources. The shift from hospital to home birth may be difficult for all parties involved, but midwives in the United States are stepping up to provide essential care and services during this crisis.