City Paper is not for tourists
The novel coronavirus pandemic has shut down the D.C. area and much of the rest of the world, and changed nearly every aspect of life. But labor and delivery cannot be shut down. Pregnant people and new parents still need everything they’ve always needed. Hospital labor and delivery units must operate, and babies still need milk and diapers. Living during a pandemic presents specific challenges, some foreseen and some unforeseen, to pregnancy, childbirth, and new parenthood. City Paper spoke to six people with their own perspectives on birth—a pregnant woman, a doula, two OB-GYNs, and two certified professional midwives—to learn how the pandemic has impacted maternal health locally.
Katie Shepherd has just a while longer to go. She’s in her seventh month of pregnancy and her first child is due sometime between the end of May and beginning of June.
She had planned to take birthing and newborn classes beginning in her third trimester, but they were all canceled.
“I run a little anxious in general, and the way I cope with it is by planning and really thinking things out,” she says. “Everything has been tossed in the air now.”
Shepherd works as a sex therapist and lives in Alexandria. She says she’s holding a lot of anxiety for other people as well as herself during this time. Staying glued to the news and obsessively reading every alarming story about pregnancy and childbirth, along with the sometimes vicious comments on those stories, can cause even more unease. “Every day there’s a new thing to be worried about and I can’t live like that,” she says.
She initially planned to deliver at Inova Alexandria Hospital, the hospital closest to her home and doctor’s office. As circumstances changed in late March, Shepherd began weighing whether to continue with a hospital birth or plan for a home birth.
“I have no idea what it feels like to give birth, so having the safety net of medication and different interventions was actually calming and grounding for me,” she says. “The hospital I’m going to be using is already only allowing one support person. At least my husband will be able to be there, but my doula is not allowed to come with me now.”
She might be able to bring in her doula via iPad, but the experience will be different. Guidelines are changing so swiftly that she can imagine a scenario in which even her husband won’t be able to come with her.
Support is a huge part of the birthing experience, she says, adding that the distress that can follow birth is much more likely to happen without support. “When you look at the history of childbirth in the United States, we’re not good on this stuff anyway, and the idea of … having a very primal experience like that completely alone sounds very potentially traumatizing.”
Shepherd also wonders what post-birth life will look like. She has family in the area, but a lot of them are older and some have chronic medical issues. Is it safe to let her mother come over and help with the baby? She has to protect both her child and her parents.
After speaking with City Paper late last month, Shepherd ultimately decided to proceed with a hospital birth and work with her doula remotely. There was “not really enough time to get my self-guided pain management together and get that secure midwife relationship that you would normally spend the entire pregnancy cultivating,” she says.
Doula and doula trainer Samantha Griffin is the owner of DC Metro Maternity, through which she specializes in birth support for local women of color, the vast majority of whom are black or brown.
She leads a six-person team and says the last week of February and first week of March were hectic for the group. “I went to several births, some of which I was not expecting to go to. We had so many people in labor at the same time,” she says.
In that time, the novel coronavirus had made its presence known stateside. “It came at the end of what felt like a baby storm,” she says.
In mid-March, local hospitals started to limit visitors and support people in labor and delivery units. “Then there were all these questions like ‘does the doula count as a visitor?’ We have contracts with people, and although we’re not medical personnel, we have professional relationships,” Griffin says. “A lot of the time the doctors and the midwives and the labor and delivery nurses are very used to working with us.”
Griffin encountered a new policy while watching a CDC webinar: If a birthing person tests positive for COVID-19 during labor, the new parent could be separated from their child. “That policy really stopped me in my tracks and made me think how seriously the health professionals must be taking this in order to talk about separating parent and child because that’s not really common practice,” she says.
DC Metro Maternity ultimately decided to make their services virtual. The sudden transition has been stressful for clients and hard for Griffin and her team. Some clients are single mothers by choice, and postpartum doula support fills a care gap for them. If it’s 3 a.m. and a single parent needs someone else to hold the baby, there’s no substitute for that so far.
Griffin is also a small business owner, and the doulas working with her are independent contractors. She’s figuring out virtual support, and helped a client deliver in late March, but the physical support is missing. Her work doesn’t translate as well over Zoom as some other jobs do.
“We’re not covered by any of the stimulus. Those of us who are self-employed or do contract work, we’re not included,” she says. “My heart hurts for making this difficult decision. Some people opted not to move forward and that’s a loss of not only my life’s work but definitely my livelihood for a few months.”
She wants people to reach out to and communicate with her and join virtual support groups. Griffin is now teaching childbirth education virtually, preparing birthing people and their partners and talking them through what’s happening at hospitals.
She’s paying close attention to this birthing cohort, whom she believes may need more postpartum care.
“I’m especially concerned about it because most of the clients we work with are families of color, and although they do choose to birth in hospitals, there often is a bit of uneasiness about the hospital in the first place,” she says. “Now, we’re sending them in without a layer of perceived safety. And it’s perceived safety that matters when we think about birth trauma.”
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Dr. Connie Bohon, an obstetric hospitalist at Sibley Memorial Hospital and a gynecologist in private practice on K Street NW, has always maintained that pregnancy should be “a happy time.” For her, “there is nothing better in the world than delivering a baby,” she says. “It is outrageously wonderful.” But right now, the fear can be insurmountable for new parents. The nature of care has changed and continues to do so by the hour.
“It’s the fear of the unknown,” she says. “Being the provider, I want to tell them science. It’s hard not to be reassuring. We’re all in the same boat, trying to do the best we can. But it’s hard. In fact, for a vaginal delivery, we have to wear a mask because of the possibility of exposure. We have to be concerned about the possibility of infection. It’s not the kind of thing that we like. It takes away the support aspect, the fun part.”
With the virus straining hospitals, Bohon says she’s tried to be as informative as she can with patients, “trying to hide that veneer of anxiety that everybody has.”
Bohon and her colleagues have tried to limit the number of providers in the office each day. They’re a seasoned crew and are in a different position than other hospital doctors. “Right now, they’re pulling people who may not have been part of the emergency team. In labor and delivery, we’re not doing that,” she says. “We know the needs that everybody has. That allows us to function more as a cohesive team.”
When a patient visits the office, the staff tries to do as much as they can—sonograms and blood draws, for example—during one appointment. They’ve also recognized that some visits don’t have to be done in person.
At Sibley, Bohon says, they have a negative pressure room and three operating rooms for labor and delivery; one is reserved for people under investigation for COVID-19 and COVID-19 positive patients. For now, she says she and her crew have enough protective equipment and the hospital has enough labor and delivery beds.
“But every day is a new day,” she says. “I have an N95 mask, so I hold on to it. I wear it when I’m in the hospital. If we’re concerned that we’re going to be around a patient for a long time, we wear a surgical mask on top of it. The concern is if you use it and you go from one patient to the next, you can transmit it.”
The biggest impact has been limiting the number of visitors a birthing person can have in labor and delivery: No more than one person is allowed and, for a patient having a c-section, no visitors are allowed in the operating room. “A lot of these decisions are really, really hard,” she says. “We did a c-section a week ago and the woman was by herself.”
Bohon is also fielding the many questions and concerns patients bring up.
“What do we do with a mom who comes in and she has a fever?” she asks. “We have to treat her as a PUI (a person under investigation without the diagnosis).”
And what about transmitting the virus to newborns? Some newborns have been infected, Bohon says, but as of early April, she doesn’t believe the virus can be transmitted during pregnancy or birth or that the disease passes in breast milk. The thought is—and Bohon notes that at this stage, everyone is just talking without hard scientific data, which is rapidly evolving—“that mom can pass it on to baby like anybody else, through droplets.” Breastfeeding can provide immune protection for babies and she says she’s doing everything she can to encourage it.
Bohon is also asked how safe it is to be in the hospital. Home birth requests have surged since the public health crisis firmly took hold in the U.S. in March. She assures everyone asking that labor and delivery is a separate unit and still a safe place to be, and discourages last minute home births. “The vast majority of deliveries are perfectly safe, but if you are in the small percentage with a complication, we don’t know the stress on EMS, and time is not on your side—you need to get to a hospital immediately,” she says. “We’re being as safe as we can in labor and delivery. Our national organization has implored the surgeon general to say labor and delivery is not the ICU or emergency room.”
With so much palpable fright and anxiety, Bohon wants people to not act out of fear and irrationality, and to deliver their babies in the hospital if that’s what they had planned. For example, “you don’t want them to starve at home because they’re afraid of going to the grocery store,” she says.
What if you hardly have a grocery store to go to in the first place? Another huge concern in the District is how the pandemic will exacerbate the inequalities in Wards 7 and 8, like isolation, lack of social support, lack of postpartum care, limited transportation, and limited access to grocery stores, Bohon says. It’s important to make sure that those residents are getting the news.
To ease her own anxiety, Bohon has taken to running and restricting the time she spends consuming news. She wants to be updated and informed, but not overwhelmed. “I think it’s really important to get out in the sunshine.”
Mary’s Center outpatient OB-GYN and American College of Obstetricians and Gynecologists (ACOG) District IV junior fellow legislative chair Dr. Meghana Rao knows what it’s like to work with the underserved communities of D.C. She treats many patients who are uninsured, are covered by Medicaid, or are people of color. News for health care professionals is coming fast. “What I tell you today, in two days, it’ll probably be different,” she says.
The issues providers are encountering during the COVID-19 outbreak keep increasing.
“The biggest one is that we tend to see pregnant women very frequently in pregnancy, and so now we’re having to transition as much of our care as possible to telehealth,” she says. “You can imagine that with an underserved population there’s even more challenges. Just getting the supplies that they need in order to do their care at home, something as simple as having a scale or thermometer, those are things that we’re working on. And they’re not reimbursed by insurance companies so that makes it even more difficult.”
Rao’s team is trying to keep everyone as safe as possible by having patients do some prenatal and postpartum care at home but still come into the office if necessary. She’s doing two weeks of telehealth, followed by one week of in-person visits. Mary’s Center has combined its three D.C. clinic locations into its one location on Georgia Avenue NW for the time being.
Rao emphasizes the anxiety that she’s seeing in patients. “I can’t even begin to tell you how many patients I’ve referred to therapy just for anxiety around coronavirus,” she says. “When you’re already in a high-risk population, when you already have so many social stressors and financial stressors, to add one more thing on top of that is really rough.”
Numerous patients are dealing with food insecurity and many are diabetic. Lines at food banks get longer by the day, and pharmacies are selling out of basic necessities, from diapers to formula to medication.
As a care provider, Rao must balance supporting the patient during a difficult time and adhering to social and physical distancing to curb the spread of the virus. Plenty of people would like to have a doula or multiple family members with them when they deliver, but it’s just not possible right now, Rao says. While she feels safe in her workplace, she says many of her colleagues at other health facilities do not. She’s heard of people who change their clothes in the garage and shower before they will interact with their families.
She praises the clinic’s support staff, who she says has been incredible, but meeting patients’ needs remains difficult. She feels for them. “I think about how hard it is for us dealing with childcare—I have two young children—and then trying to put myself in the shoes of one of my patients who will be in the same situation but not have the same family support or financial resources or transportation … I can’t even imagine what they’re going through.”
The Mary’s Center staff now has to assess every decision even more carefully: Is this test necessary? Is there a better way to do this? How do we make sure the patient gets the best possible care while also keeping them safe? Inquiries about home births may be growing, but Rao says her high-risk patients wouldn’t necessarily be the safest population for that. They’re more likely to need access to a c-section and monitoring of parent and baby.
Rao talks to patients about their transportation every day. For some, the telehealth visits are more convenient, particularly if they had to commute for an hour to the clinic. But if a patient is coming by bus, providers have to think cautiously about what kind of exposure they might encounter on their way to the clinic. She also thinks about patients who don’t have internet access and can’t follow the quickly developing news about hospitals. “Day to day, you’re not really sure what the new guidelines are,” Rao says.
“There’s a lot of stuff that can be elective and be postponed, but pregnancy can’t,” she adds. “We’re tracking our pregnant patients who also have COVID-19 very closely.”
In early March, before the virus outbreak shut most everything down, ACOG was lobbying on the Hill for support to reduce maternal mortality and advocating for expanding access to postpartum Medicaid coverage and increasing research on women’s health, Rao says.
“I do worry about how this pandemic may have impacted all of that,” she says. “It’s even more urgent. In some states, they’re using this as an opportunity to shut down access for abortion care.”
And yet, amid all the muck, there are lovely things happening too, she says: So many people, like George Washington University medical students, are volunteering to help with childcare for essential personnel. Community partners are donating items via Amazon that Mary’s Center patients need.
Aza Nedhari provides care as a certified professional midwife, working with people seeking home births. She’s also the executive director of Mamatoto Village, a nonprofit organization on 47th Street NE that provides accessible perinatal and postpartum support and primarily serves black women who live in Wards 7 and 8.
Some of her clients have been laid off in the wake of the pandemic and are concerned about social benefits and access to food.
“Food security is a huge issue right now because—especially for our clients, which are the majority of our clients, who live east of the river—there’s three grocery stores for both of the wards and they’re not easily walkable,” she says. “With public transportation significantly reduced, people are having a difficult time getting to those places to be able to get groceries. And then when they get there to get the groceries, there’s nothing that’s left hardly, especially for our clients using WIC and food stamps because people are also purchasing the WIC items.”
There are many challenges in many dimensions, she says. Several potential clients have inquired about home births, but some of them can’t afford to pay several thousand dollars for those services.
“Even though the certified professional midwives bill did pass, and the mayor did sign that bill, it’s not active yet—even though I petitioned for the mayor, along with 100 other people who signed the petition, to try to get them to activate the CPM bill now so people who are eligible could have access to out-of-hospital births. But that’s just not currently available.”
The law would give the midwives licensure to practice right now and moms who use Medicaid would be able to get reimbursement, Nedhari says.
The petition, dated March 31, 2020, reads: “We are writing to request emergency action to increase accessibility for District families seeking care from a Certified Professional Midwife (CPM) during the COVID-19 crisis. The Certified Professional Midwife Act of 2019, which was passed unanimously by the Council on March 3rd, 2020, is currently under your review. Pending your signature and approval by Congress, the law is to come into effect on October 1, 2020.” It goes on to say that COVID-19 has already claimed thousands of lives in the U.S., “while continuing to threaten the health of pregnant people and their babies. The District must immediately grant licensure to Certified Professional Midwives to practice within their full scope without waiting for appropriations.”
Last week, she planned to again reach out to the mayor and the mayor’s office to address the status of the bill and find a consensus around trying to activate it.
As of April 9, Nedhari says they’ve only had one client test positive. The thread of worries goes far beyond the illness itself. Clients who already had pre-existing mental health issues feel their troubles are being exacerbated by this crisis. They’re also not getting the in-person care that they’re used to. Mamatoto Village shut its office on March 16 and suspended in-person visits.
“We have several clients who have nobody,” she says. “While we’re continuing to do telehealth visits at the regular interval, that in-person support is not there and it’s sorely needed. They’re feeling the impact, we’re feeling the impact because our staff wants to show up and be there, but the situation doesn’t necessarily make that possible right now.”
In her own midwifery work, she’s heard from people who’ve reported having prenatal appointments canceled and were unable to get them rescheduled in a reasonable amount of time or weren’t able to reschedule them at all. Some people have called because providers recommended inducing labor and they worried there would be an overutilization of intervention to move people in and out quickly through the birthing process.
There has been a rise in people seeking out-of-hospital births, Nedhari says, to the point that “the home birth midwives in the DMV area, we’re all on one group together and we have this spreadsheet of who’s available, who has space. Most people are booked up until August at this point. I’m waiting for the next wave to happen, especially with the increasing COVID-19 cases for pregnant women—there’s a surge I think we’re about to see. We are almost at capacity, so the conversation we’ve been having is do we need to set up an ancillary birth center space where we can meet the demand that’s there.”
The midwives are also dealing with a crushing lack of personal protective equipment. Nedhari says CPMs don’t have access to PPE, and when they try to get their own, they’re blocked from even the small suppliers they’d normally order from as it’s all been purchased. Now, it’s difficult for her to get it because she has to order an exorbitant amount of supplies.
“They’re basically price-basing for hospital or government entities and if you have a small practice where you’re doing three to four births a month, you can’t afford to pay $6,000 or $7,000 for PPE,” she says. “There’s like 50 or 60 midwives in the DMV area, and even if all of us pitched in, it’s still way more than we would ever need to use. In normal situations, we wear gloves at a birth, but we don’t come to birth with all of this equipment on our physical person. We’ve always used gloves but I’ve never worn a mask or a face shield or any of the stuff that we’re having to do now—that is not normal. And it feels so abnormal being in people’s homes geared up.”
Despite the trials, Nedhari says she’s an optimist who always tries to find the silver lining. These days, resilience and joy have frequently come to mind. She’s found it by hugging her children and letting “the sun beat on her face.”
“Black people are resilient people,” she says. “This moment is a continuum of things we’ve had to overcome collectively. This situation, as many situations, impacts black and brown people the most. And it’s hard acknowledging the difficulty in seeing the statistics and how they’re playing out in our families and our communities. I’ve definitely known several people who’ve lost family members or whose family members are at risk for loss from COVID-19.”
It’s critical, she says, that we don’t marginalize or ignore one feeling over another.
“It’s important for us to feel all the range of emotions that come from this thing because it allows us to be more fully human in this moment.”
Sam Sewell runs Sage Midwifery, where she provides inclusive care to local families as a certified professional midwife based in Northern Virginia. With ever-changing guidelines, she has found that groups of midwives, both certified professional midwives and certified nurse midwives, have united to collaborate and share information.
Sewell says she and other midwives are acting as if they’re asymptomatic carriers of the virus to be more careful with their clients.
Currently, for clients that she will see in person, she calls and asks them to take their temperature the morning of their appointment. Sewell takes her own temperature several times each day. Then, assuming the clients have answered no to all virus screening questions and they’re afebrile, Sewell goes to their house, sits in her car in their driveway and calls or FaceTimes them. She does 80 percent of the visit that way.
“Midwives are very touchy feely,” she says. “We build a trusting relationship and that’s how we have really good outcomes. So it’s a very big change.”
Now that people are flocking to her to inquire about home births, she’s having to build these trusting relationships in just a few weeks. In late March, she got a call from a pregnant person who was due days later. Her typical capacity as a solo provider is four due dates per month. Recently, she’s had 10 interviews with prospective clients in two days. If a midwife gets sick, someone has to back them up. Since out-of-hospital providers are left out of the supply chain and are thus unable to fully protect themselves, she says the midwives have had to be crafty and creative with PPE. They’re using masks that people have sewn for them, and one of her friends, a student nurse midwife, got PPE from dentists, many of whom are out of work right now, and dropped it off at Sewell’s house.
“[It’s] your phone ringing off the hook, your email blowing up, all of these Zoom calls with other midwives and other providers, and then trying to come up with emergency practice guidelines to deal with the pandemic, notifying your clients of the way things are going to be and also telling them if you’re presumed positive or test positive for COVID-19, you are risked out of home birth and you have to go to the hospital. If anybody in your family is, you have to go to the hospital,” she says.
A big part of the midwife’s job is to counsel, Sewell says, and pregnant people have heavy hearts. “Their childbirth education classes have been canceled, their mommy groups have been canceled. Everybody’s scared.” At this moment, midwives are checking on clients and each other.
To push through fear, compassion is key for Sewell. She likes to remind people to not feel ashamed if they’re feeling extra tired and taking extra naps. “That is a natural response to trauma. We’re all being traumatized right now.”