Midwives on the Frontlines of a Pandemic

Midwives on the Frontlines of a Pandemic

BY SUSAN STONE, DNSc, CNM, FACNM, FAAN

As we prepare to celebrate National Midwifery Week in the United States, it offers an opportunity to reflect on the last nine months and the effects of the international pandemic on childbearing women and on the practice of midwifery.

Midwifery as practiced by certified nurse-midwives and certified midwives encompasses a full range of primary health care services from adolescence to beyond menopause including maternity care services. Midwives work in many settings including clinics, hospitals, birthing centers, and homes. Midwives pride themselves on working in partnership with women and their families to provide holistic care that includes health promotion, disease prevention, and individualized wellness and counseling.

The term coronavirus or COVID-19 began to enter our consciousness in January of 2020, and by March 2020 we were deeply feeling the effects. Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as acute respiratory syndrome. COVID-19 is a new strain that has not been previously identified in humans. In the beginning of the pandemic, we were very much at a loss not understanding completely all the ways it could be transmitted, who would be affected, and how severe those effects would be. As many hospitals quickly became overloaded with very sick COVID-19 patients, maternity care providers including midwives were struggling to understand the best ways to assist and care for women giving birth. Over

2 Midwifery Week Special Issue | OCTOBER 2020

Over time we learned that pregnant women and their babies were not at the highest risk of contracting the disease. And yet, we also knew that they and their family members could be carriers of the virus.

time we learned that pregnant women and their babies were not at the highest risk of contracting the disease. And yet, we also knew that they and their family members could be carriers of the virus. Hospitals quickly instituted very strict visiting policies; some not allowing the pregnant woman to have any support persons

accompany her to the hospital but more often allowing one person to support her. As social distancing became the norm, midwives quickly realized that they needed to put some procedures in place that would allow the family to have as safe and satisfying an experience as possible.

In the prenatal period, midwives and obstetricians implemented telehealth visits for many of the low-risk women. Even though it seemed from the early data that pregnant women were not at increased risk of contracting or becoming ill with the COVID-19, we were unsure. We know for example that pregnant women are more susceptible to the flu and at higher risk for severe illness compared to women who are not pregnant. Therefore,

telehealth prenatal visits soon became the new normal. Many, if not most, midwifery services adopted visit schedules that included both telehealth visits and office visits. Office visits were primarily done for times when the women needed an additional procedure such as ultrasound and/or glucose testing. Higher risk women and women closer to the expected birth date were more likely to have office visits. Ginny Bowers, CNM, a Frontier Nursing University midwife alumnus, reported doing prenatal visits in the clinic parking lot to keep her patients as far from exposure as possible.

We soon learned women, especially low-risk women, were often very satisfied with telehealth visits. It provided

time to have a relaxed visit with the woman without the rushing around involved in traveling to an appointment. Midwives taught women how to weigh themselves, check their own blood pressure, and monitor the baby through kick counts. In terms of technology, the visits could be done either by computer, tablet, or by cell phone which most, but not all, women have access to.

Midwives and nurses also quickly rose to the challenge of developing and implementing virtual childbirth preparation classes. Women could attend classes from their homes. People who were not skilled Zoom users quickly became skilled.

In the intrapartum period, there was much distress. In many situations, women were

4 Midwifery Week Special Issue | OCTOBER 2020

As social distancing became the norm, midwives quickly realized that they needed to put some procedures in place that would allow the family to have as safe and satisfying an experience as possible.

being admitted to maternity units without being allowed to bring a support person including their partners or their doula. At the same time, nurses were stretched thin due to the acuity of care being provided in the rest of the hospital. Midwives were required to wear full Personal Protective Equipment while at the same time experiencing the inability to comply with the mandate due to shortages. Midwives stepped into the chaos and provided the needed health care and in many cases, became the woman’s primary support person as well. They committed to assuring women received the physical and emotional care

needed during this important life event.

Most maternity units adopted a policy of testing for COVID-19 of every woman as she was admitted for labor. Many persons who are positive for COVID-19 are asymptomatic; therefore, some women were very surprised to learn the test was positive. This precipitated isolation and according to CDC Guidelines, separation of mothers and babies after the birth. Women could refuse to be separated from their baby, but were put in the unconscionable decision of trying to do the best for their baby under such difficult conditions. Midwives along with the rest of the health care team worked tirelessly to assure that women received not only excellent physical care but emotional care as well.

This entire situation soon resulted in an increased demand for out of hospital birth. Midwives who were operating either home birth practices or free-standing birthing centers began to respond to the growing demand. Birthing

Centers operated by midwives reported hiring additional midwives and increasing the number of birthing rooms in an effort to meet women’s desire to remain out of the hospital. A group of midwives from the American Association of Birth Centers and the Commission for the Accreditation of Birth Centers developed Guidelines for Auxiliary Maternity Units. The goal was to provide guidance to health care systems and others seeking to move low-risk maternity care out of the hospital. A group of midwives from New York City used these guidelines to develop a brand new free-standing birthing center.

As COVID-19 has continued to spread across our country, the disproportionate effect on racial and ethnic minorities has become glaringly apparent.

According to the CDC, as of June 12, 2020, age-adjusted hospitalization rates for COVID-19 are highest among non-Hispanic American Indian or Alaska Native and non- Hispanic black persons, followed by Hispanic or Latino persons. Black and Native Americans have a rate of five times that of non-Hispanic white persons.

Why are people of color at higher risk? We see the same health disparities in many if not most health indicators. Midwives have been fighting a battle against maternal mortality which similarly shows much higher risk in people of color compared to white people. First, to be clear, there is no evidence that people of color have any biological factors that make them more susceptible to disease. Long-standing

We soon learned women, especially low-risk women, were often very satisfied with telehealth visits. It provided time to have a relaxed visit with the woman without the rushing around involved in traveling to an appointment.

www.minoritynurse.com www.dailynurse.com www.springerpub.com 5

Midwives and nurses also quickly rose to the challenge of developing and implementing virtual childbirth preparation classes.

systemic health and social inequities have put some members of racial and ethnic minority groups at increased risk of getting COVID-19 or experiencing severe illness, regardless of age, according to the CDC. Systemic racism affecting people of color in the United States results in these health disparities. Crowded living conditions, employment in an area of essential service (not allowing social distancing), lack of access to health care, lack of health insurance, financial challenges, and racism are some examples of obstacles to health. The stress

of dealing with daily racial discrimination should not be underestimated; it has been linked to underlying conditions and can increase the risk of severe illness.

Midwives have committed as a profession to eliminating health disparities. In 2018, the members of the American College of Nurse- Midwives adopted a Racism and Racial Bias position statement committing to a series of actions designed to eliminate race-based disparities. Examples of these include increasing the racial and ethnic diversity of the

profession, addressing their own implicit bias through education and introspection, and increasing the education in midwifery programs about racism and race-based disparities. Ultimately, midwives committed to provide nonjudgmental, culturally sensitive care to all people while working simultaneously to identify and implement ways to reduce the effect of racism on the health outcomes for their patients of color.

Midwives are fully engaged in the struggle of the COVID- 19 pandemic. We realize that a major goal of having any impact is to address the racial disparities. To do this, midwives are at the frontlines providing compassionate supportive care as well as doing simple but important education such as urging people to

wear masks in public to protect not only themselves but the people providing service every day. Midwives are also in the background lobbying for unfettered access to health care, and increased funding for education for midwives of color. COVID-19 has been a glaring reminder of not only the effects of a pandemic but once again brought to full exposure the weaknesses in our health care system. It will take the entire health system working together to make change. Midwives are an essential part of that team.

Susan Stone, DNSc, CNM,FACNM, FAAN, is the presidentof Frontier Nursing University.

6 Midwifery Week Special Issue | OCTOBER 2020