Radical shifts in the way reproductive care is provided-and how women experience it-have occurred during the COVID-19 pandemic. Few aspects of access to prenatal and birth care, contraception, and abortion access have been unaffected, particularly as new research becomes available and novel practices are implemented. The crisis is reshaping reproductive care in ways that could have a long-lasting impact.
TELEHEALTH PRENATAL CARE
Information about pregnancy and coronavirus infections was scarce early in the COVID-19 pandemic. A systematic review and meta-analysis in the American Journal of Obstetrics and Gynecology MFM has since suggested an association between women who have COVID-19 and higher rates of preeclampsia, preterm birth, and perinatal death. The Centers for Disease Control and Prevention (CDC) now warns that pregnant women may be more susceptible to severe illness, and reports published recently in JAMA and JAMA Pediatrics say the virus may be transmitted to the fetus during pregnancy. A recent study conducted by researchers in Philadelphia (available as a medRxiv preprint) found that pregnant Black and Latino women had a five times greater risk of exposure to COVID-19 compared with white women, supporting reports that communities of color are disproportionately affected.
To reduce pregnant women's exposure to the virus, many prenatal visits are now conducted using telehealth. In-person visits may occur every eight to 10 weeks for low-risk patients, with virtual visits occurring in the interim. Screening and assessments are combined during on-site appointments, and pregnant women report information such as blood pressure and weight during telehealth visits.
The increased self-monitoring required by telehealth can be empowering, some women and providers say. Moreover, anecdotal reports suggest attendance at virtual prenatal appointments and birth classes is better than it is for in-person appointments, perhaps because of the removal of barriers such as taking off time from work, making childcare arrangements, and paying for transportation. Telehealth enables providers to offer additional assistance during the immediate postpartum period, when new parenting and breastfeeding issues may arise, and virtual visits can ensure more pregnant women receive prenatal care in rural or remote areas. Still, there are concerns that unequal access to technology and digital literacy skills could worsen existing health inequities.
BIRTH SETTING AND SUPPORT
Demand for the services of home birth midwives has greatly increased during the COVID-19 pandemic, particularly in areas experiencing virus outbreaks. During the surge in cases in New York City, for instance, women turned to home birth to reduce exposure to the virus and ensure the level of support they wanted, says nurse midwife Helena Grant, CNM, director of midwifery at Woodhull Hospital in Brooklyn. "These were people who had never even thought of midwifery care before. That's how important support is to women," she says, adding that many said they'd have their baby at home or leave the state.
The crisis has led many hospitals around the country to allow only one outside support person, such as a partner, spouse, or doula, to accompany women during labor and birth. In late March, two private New York health care systems took this a step further, banning all outside support because of concerns about patient safety. There was also concern about the accuracy of screening for COVID-19 symptoms, the lack of personal protective equipment, and the risk of infection to the already strained health care workforce. Within a week, however, a petition opposing the restriction had garnered more than 600,000 signatures, and Governor Andrew Cuomo ordered all facilities to allow one support person to be present during labor and birth.
The decision was in keeping with guidance from the New York State Department of Health, which says that "one support person [is] essential to patient care throughout labor, delivery, and the immediate postpartum period," and the American College of Obstetricians and Gynecologists, which notes birth support is associated with improved maternal outcomes. Support during labor and birth is thus vital in the context of the current U.S. maternal health crisis, in which women die from pregnancy-related complications at higher rates than in similarly developed countries. Women of color especially are at an increased risk for death-Black women have a three to four times higher risk than white women according to the CDC-and face structural racism and bias when accessing health services.
Yet, options that offer the potential for additional birth support during COVID-19, such as home birth or temporarily moving to less affected areas, require resources that not all pregnant women have. Home birth midwives generally don't take insurance, and many women can't simply relocate. As a member of the New York State COVID-19 Maternity Task Force, Grant was involved in providing recommendations to the governor to ensure improved access to maternity care during the pandemic, including the development of more birthing site options. "I hope a lot of midwifery-led birthing centers will open," she says, "and I hope they open in hospitals, because that's an option to integrate midwifery care into obstetrics services."
CONTRACEPTION AND ABORTION ACCESS
Access to contraception has been difficult at times during the pandemic, notes Mariarosa Cutillo, chief of strategic partnerships at the United Nations Population Fund, who spoke during a July online event, "The Power of Choice: Ensuring Access to Family Planning in the COVID-19 Era." Women have had less access to their preferred contraceptive methods, she explains, owing to the unavailability of products or the providers who supply them. This has been a problem for women who choose long-acting contraception, which requires a provider's intervention. Problems with the global contraceptive supply chain were at their worst in the beginning of the crisis, Cutillo says. However, many women are still not seeing their providers, she points out, because of office closures, virus fears, and confusion about available services.
"Childbirth and love don't stop for pandemics, but often that's the first part of the health system that's being asked to shut down and not considered essential," observes Roopa Dhatt, MD, a primary care physician and the executive director of Women in Global Health, who also spoke at the event. "There has been a universal experience in a lack of care. It doesn't matter if you're in a high-income country or low-income country. Women have been denied health care."
In the United States, many women have been denied access to abortion care, particularly during the early days of the COVID-19 pandemic. As each state declared a public health emergency, the Kaiser Family Foundation has reported that 12 states classified surgical abortion as an elective, nonessential procedure, effectively banning it. Most of these suspensions are no longer in effect or have been blocked by court order, but abortion is still effectively inaccessible in Arkansas. By contrast, some barriers to medication abortion have been removed as the crisis persists. As reported in the June issue of Contraception, researchers have developed a no-contact protocol that utilizes telehealth for evaluation and follow-up, in recognition that the crisis can prevent timely access to in-person care. Medication abortion typically requires two visits to a health facility, where an ultrasound, a pelvic exam, or laboratory tests may occur, but international research supports the safety and efficacy of no-test protocols. Additionally, in July a federal judge ruled that in-person visits represent a "substantial obstacle" during the national public health emergency and abortion medication can instead be delivered to patients.
REIMAGINING THE FUTURE OF CARE
Women make up the vast majority of the global health workforce, but relatively few have been in decision-making roles during the pandemic, Dhatt points out, citing a recent review of 90 countries by Women in Global Health that revealed women made up only 12% of roles on national COVID-19 response teams. As health care systems are rebuilt after the crisis, Dhatt says, it's essential to consider women and their reproductive health needs in the design process. "Health systems have been designed by men for men," she notes. "If we operate in gender-blind ways, we're not going to be creating systems that work for everybody."
Monica McLemore, PhD, MPH, RN, FAAN, an associate professor in the Department of Family Health Care Nursing at the University of California, San Francisco, says she's concerned people are focused on returning to pre-COVID-19 conditions and not envisioning what can be done differently in the future. "The first thing we could easily do is support [nurse] Lauren Underwood and pass the Momnibus," she says, referring to the Black Maternal Health Momnibus Act of 2020, which Underwood (D-IL) introduced in the House of Representatives in March to comprehensively address racial and ethnic disparities in maternal health outcomes. "If we center the people of greatest need," McLemore notes, "care will improve for everyone."-Corinne McSpedon, senior editor