Perspective: The Uncertainty of the Coronavirus is Weighing on Pregnant Women. How Are Providers Adapting to Address Their Concerns?

The coronavirus pandemic has brought increased anxiety to women welcoming a new baby into the world.

The coronavirus pandemic has imposed a collective sense of worry about the future on all of us, and has raised many questions we may never have asked before. When will our world return to normal? What new precautions do we need to adjust to making? How will this pandemic impact our ability to access safe healthcare services if we need them? How will we thrive without the in-person support we lean on when things get difficult?

For pregnant women who will soon be welcoming a new baby into the world, these questions, and many more, feel especially weighty, and contribute to feelings of uncertainty. Some providers are moving quickly to adapt to this new dynamic.

Lack of Information about Covid-19 Contributes to Uncertainty
Because this coronavirus is a novel disease, there is currently very little conclusive information about the risks, birth implications, and contingencies to plan for. The American College of Obstetricians and Gynecologists (ACOG) acknowledges that “at this time, very little is known about COVID-19, particularly related to its effect on pregnant women and infants, and there currently are no recommendations specific to pregnant women regarding the evaluation or management of COVID-19.” The CDC recently conducted a public webinar, and in it, reported that no perinatal transmission of the virus has been observed, and that testing has not detected the virus in cord blood, amniotic fluid, breast milk, or neonatal throat swabs. There have been isolated reports of infants testing positive, but it is believed that in these cases, the virus may have been transmitted after birth by a mother or other family member.

One clear message that surfaced for the two pregnant moms who are featured in this story is the weight of uncertainty. Ann, a pregnant mother of two, who is due with her third child in early June, said that she is hearing different messages from her obstetrician than she is from her pediatrician. This, combined with the rapidly shifting burden on healthcare facilities and providers, and rising infection rates, leaves her with more questions than answers.

Dr. Ligia Giese, an OB who works for Permanente medical group in northern California, shared similar observations about uncertainty due to the lack of available information about the virus and its effects on pregnancy, as well as its potential impacts on the post-partum period. For her pregnant patients who are deemed “essential” and must continue to work outside the home, she must try to provide recommendations about what is and is not safe, but has very little information and guidance on which to base those recommendations. She works hard to determine what providers can say with confidence, and what “we don’t really know, so our best guess is...” Dr. Giese notes that this can create a lot of anxiety not just among patients, but also for the people taking care of them. “How do we really know that what we’re saying is correct?” She and her colleagues must weigh the question of whether a COVID-positive mom will need to be separated from her infant, and how this would impact breastfeeding and bonding. They must try to understand what they can of the available scientific evidence, weighed with its impacts upon the deeply intimate new mother-child relationship.

Expectant Mothers Are Examining Their Options Closely, with More Considering Home Birth
Ann says that she has become interested in birth-only hospitals, and is planning to discuss this possibility with her OB. Because there are no birth-centers in Washington, DC, where she resides, this would mean travelling to Virginia to give birth. She also said that although she does not want to have a home birth, she is suddenly wondering if that might be safer than giving birth in a hospital, where she worries about exposure, whether a bed will even be available, or if she should give up her space in the hospital for someone who may need it more.

Adina, a Michigan mom expecting her second child any day, said that her midwives told her that they could refer her to someone if she was interested in a home birth, but that this feels like too much of a change to make now, given the nearness of her due date.

Evidence of a shift toward considering home births in the US is building, particularly in areas of the US where COVID-19 spread early and quickly. News stories from New York and Washington State indicate that certified midwives and other providers who support home births have been inundated with calls from pregnant mothers who are reconsidering their original decision to give birth in hospitals, and exploring the possibility of instead birthing their children at home. Dr. Giese noted that two home birth midwives she knows are receiving a great number of calls from pregnant women wanting to change from in-hospital to home birth. Like many questions that have arisen as a result of the coronavirus pandemic, whether or not to give birth in a hospital is a complex issue.

Adina, the Michigan mom, is also having to rethink her birth plan – she has recently received word that the doula team she engaged to support her birth is likely to be barred from attending. She is also adjusting to the fact that her three year old daughter will be unable to visit in the hospital, and is scrambling to find someone to care for her daughter at home so that her husband can attend the birth. She is also concerned about the lack of post-partum support she is likely to get, as her family and friends, lactation consultants, and other in-person support services will be unable to visit due to social distancing.

Ann and Adina both expressed similar concerns about the possibility of actually contracting the virus, and having to potentially be separated from their newborns, or trying to care for their children while being ill.

Providers Are Responding by Transitioning to Telemedicine
Dr. Giese provided some insight on how the coronavirus is impacting her practice, including working quickly to rethink how they can use phone, email, and video as they transition toward maximizing the telemedicine infrastructure they already had in place. She highlighted that traditionally, prenatal care is intensive and in-person, particularly at the end of pregnancy, when patients tend to take hospital tours and attend birth and parenting classes, as well as increase their regular prenatal visits. She and her colleagues are now developing ways to support online prenatal education and hospital tours.

Dr. Giese also said that transitioning to remote care has meant patients often have to see different providers depending upon who is available, which can be particularly difficult for some of their more complex patients, for whom continuity of care may be especially important.

How Providers Can Help Pregnant Women Navigate the Uncertainty
Dr. Maria Lapinski, who runs the Health Risk and Communication Center at Michigan State University, stresses that patients often come to their providers bearing a sense of uncertainty and seeking guidance. She notes several factors that may help providers support their pregnant patients:

• Maintain a patient-centered focus: Listen to the patient, and begin the conversation by asking about her concerns and questions. Start with a good understanding of each patient and her individual perspective. Be thoughtful about the language you use, and avoid over-complicated medical jargon, with the goal of coming to a shared understanding and plan.
• Provide simple, clear messages: Give patients clear, simple guidance, and discuss what they “must do, should do, and could do” to help them understand the varying weight and importance of their health behavior decisions. Providing clear, simple information can help provide a patient in a high anxiety scenario with something to focus on to help reduce her risks.
• Acknowledge uncertainty: The risk communication literature has shown that expressing uncertainty does not damage a provider’s credibility: if a physician or midwife says “I don’t know, but I will try to find out...” it is unlikely to have a negative impact on the patient’s perception of the provider and their ability to do their job.
• Avoid over-reassurance: Especially in cases like the impact and risk of coronavirus on pregnant women and infants, it is important not to err on the side of downplaying the seriousness of the situation in an attempt to reassure patients. Instead, work with them to come up with a targeted plan to address uncertainty.

Dr. Giese shared that on the positive side, pregnant patients on the whole are already taking great care of their health. They are a highly motivated population who are committed to following recommendations to help ensure the health of their babies and themselves. She reminds her patients to try to avoid too much social media exposure, so as not to be inundated by potentially unreliable information, and instead to try to stay focused on the birth experience for its own sake. She believes that after the pandemic has ended, there will be many lasting benefits borne out of the lessons obstetric practitioners have learned about using telemedicine to care for patients: “With all of [us] getting more used to using these technologies for more than just information gathering, but really using [them] for human interactions, we’ll figure out how to use this to our advantage in healthcare.”

To learn how Altarum can improve maternal and child health outcomes in your community, contact Tara Fowler, director of Altarum's Center for Healthy Women and Children.