Current Resources for Evidence-Based Practice, May 2020.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.

Marit L. Bovbjerg, PhD, MS

Place of Birth During a Pandemic

In February 2020, the National Academy of Medicine (formerly the Institute of Medicine) released a consensus report entitled, “Birth Settings in America: Outcomes, Quality, Access, and Choice” (National Academies of Sciences, Engineering, and Medicine, 2020). The take home messages from this report are that (a) planned community and planned hospital births can be safe depending on pregnancy characteristics; provider experience; and easy, seamless availability of higher-level care should it be required; (b) no birth location is risk-free; and (c) any effort to increase maternal choice around birth place in the United States must explicitly consider and address the pervasive racial and ethnic disparities experienced by women of color in the current maternity care system.

As a long-time community birth researcher, I eagerly anticipated the publication of this report. As soon as it was released, I spent the next several evenings poring over the document, reading related literature on ethics and choice, and planning this May 2020 column. I had a pretty solid outline for a column in which I would have delved into the global safety literature and then explored the idea of informed consent in maternity care. I would have explored the idea of choice and what it means in terms of planned place of birth, specifically within our unique, U.S. health care system.

That was almost exactly one month ago. My, how times have changed.

I sit here now on March 19, and nothing is the same. By the time you read this column in another 6 weeks, I cannot begin to speculate about what our lives will look like—what your lives, as health care providers, will look like. (Thank you, so much, for doing what you do.) As an epidemiologist, I have spent the past two weeks answering questions from my friends and family; no doubt this will continue as we are bombarded by daily news—some true, much of it not—about the novel coronavirus. My children are out of school at least through the end of April, and my university has announced that all classes for spring quarter will be held online only. Hopefully these and other social distancing measures will allow our health care system to keep up with the sudden increased demand for critical care. Perhaps by early May, when this is published, we will be beginning to return to our normal lives. As I write, China is just beginning to relax some of their mandatory social isolation measures following several days of no observed community-transmitted cases. Hopefully, this is where the United States will be in 6 weeks. Although, of course, it is entirely possible that China will be forced to return to mandatory social distancing in the meantime and that we would be wise to follow suit.

Given this global pandemic backdrop, the question of planned community birth suddenly becomes much more salient. Thus far, it seems that pregnant women and children are not at high risk of severe disease given SARS-CoV-2 infection (so few data are available that I cannot provide citations). However, like so many other things about our current situation, we just don’t yet know. What we do know is that even under best case scenarios, in the next few weeks our hospitals will likely exceed their capacities, and our health care workforce will shrink as physicians and nurses become infected themselves. Hopefully, the excess demand is not too high. Regardless, as a pregnant woman, would you want to have your baby in a hospital in which most other patients have COVID-19? In which the medical staff are stretched even more thin than normal? In which there might not even be a bed for you? Unfortunately, most women who are due to give birth in the next several weeks will not have a choice.

Perhaps it is time that we as a nation embrace the idea of planned community birth. This change cannot happen overnight. We currently do not have nearly enough midwives, most U.S. women are not socialized to accept community birth as a viable option, most midwives are not comfortable with community birth, and most local health care systems are not set up to allow seamless transfer of care when indicated. But imagine if our maternity care system looked more like the one in the Netherlands, where planned home birth is considered a viable option for most women, midwives are comfortable in both settings, and transfers into and out of obstetric care when indicated are seamless (Amelink-Verburg & Buitendijk, 2010). Surge capacity in the midst of greatly increased demand secondary to a pandemic would still be an issue, but I cannot help but think that maternal and child outcomes over the next several weeks would be better if women in labor were able to safely stay away from our overwhelmed hospitals.

Acknowledgment

The author acknowledges Sabrina Pillai, MPH, for assistance with the literature searches for this column.