1. Kriebs, Jan M. MSN, CNM, FACNM

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A year ago, I sat at my desk writing this column. COVID-19 had just been shown to have jumped into the United States (US). No one knew whether it would flare and die out as SARS or MERS did, proving less dangerous than initially expected, or whether it would burn through the entire world, causing millions of illnesses, hundreds of thousands of deaths, and lasting injury to many survivors in the United States alone.


While everyone who has worked with infectious diseases at any level knows that there will be surprises, there was still a chance. A chance for containment; chance that the new virus would transmit poorly if everyone took precautions; a chance that it would not be too bad.


Well, a year has gone by. I rewrote that column in late March before it went to press. There were already 8000 deaths in the United States. In the months between writing and the time it reached publication, the first wave of COVID-19 had crested and the first 100 000 deaths were recorded. Now another, higher wave of illness and death has peaked, with more than half a million dead. As all viruses do, this one mutates, and some mutations carry increased risk. And the US healthcare system has been reminded that nothing replaces thoughtful planning and effective implementation, adaptability, and reliance on science for answers. The reminder has come because these things did not happen at the highest levels of our healthcare system and government.


I retired from clinical practice before this pandemic hit. Still, I can see in memory my H1N1 patient in 2009, 36 weeks pregnant, gasping for breath as she was transferred to the intensive care unit. I can still remember the hospital pandemic response discussions from that same relatively benign winter about where to care for the healthy pregnant women and what to do if more very premature infants had to be delivered than the hospital had ventilators. I honestly cannot imagine what my colleagues and friends in the "happy specialties" of perinatal nursing, midwifery, and obstetrics have experienced in this year of COVID-19. By the time anyone knew what was coming, it was too late to begin to plan. Even in low-risk hospital settings, everyone has had to be on high alert constantly. With apologies for the dour tone with which I have begun, I want to use this column to make 2 different, equally important points.


The first, which has become one of this year's lessons, is the importance of self-care and perhaps self-forgiveness. Increasingly, burnout, moral injury, and stress-related effects from this year are being reported. The health professions are at risk of long-term damage to both numbers and resilience of staff. This becomes a matter of advocacy on several levels. Self-advocacy is always important but is insufficient. At this time, every facility, every practice, ought to be taking steps to promote healthy habits and offer counseling where needed. It will be hard and perhaps impossible to provide the needed resources in the hardest hit units, but future need can be anticipated just as the need to debrief after a sentinel adverse event is recognized today. Clinical staff, heroes that you are, cannot survive on praise alone.


The other issue is perhaps more subtle; it is equally as critical. Hospital and system administrations must step up to evaluate and learn from what has happened. Did the frontline nurses get sufficient masks and gowns, or were they reserved for those with more important titles? Did the emergency department security guard and unit secretary get into the first vaccine group, or were these individuals shunted to a later date? Of course, every site is different-the stories out of one institution are not the reality of every place. Where was the human planning that made choices based on presumptions of value-did anyone ask? If not, I submit that there is an obligation to call out that error now, before the next challenge. It would be both false and dangerous to assume that the most egregious examples were the only ones.


In doing that, attention must be paid to the hierarchic traditions of the healthcare systems. There is a difference between a multidisciplinary team and one which is truly interprofessional. The first is any group that includes people from different professions or jobs within a system and in which each participant responds to the needs of his or her own role. The second requires that the skills and expertise of each member are equally valued in making decisions and looks at the overall process of care. In times of scarcity, stress, and unknown challenges, it is hard to give up the security of a professional silo. Doing so can improve the chance of a creative solution. With regard to childbirth, was there no way to provide labor support in the early days of the pandemic? Many hospitals forbade partners or doulas, even when risk mitigation might have been possible. How long was it before some hospitals encouraged breastfeeding in minimally asymptomatic COVID-19-positive mothers?


A side result of decisions such as these was the rapid increase in women seeking out-of-hospital births they had not previously considered. Make no mistake; community birth can be a satisfying and desirable choice-with effective screening and preparation. And many women have experienced safe, physiologic births that they would not have considered otherwise. That is one decision some women made. Others lived with our choices, and perhaps lost some trust that their care providers had their best interests at heart. Or, perhaps, they too were damaged by their experience of birth. My point is that the system failed women by failing to address their legitimate concerns about their own autonomy during childbirth. We failed them when we did not include their perspective in our planning.


It is probable that the true costs of COVID-19 to the US systems of healthcare will never be known. Nurses and midwives need to know that the cost paid collectively can be used as down payment on a more equitable future that maximizes quality of care and minimizes harm wherever possible. We need to plan for the next pandemic and ask-what needs to happen to be sure that we have the resources to problem solve in real time? How will we ensure equity? How will we care for each other? Or, will we forget what we have seen and might have learned in our relief that another pandemic has ended?


-Jan M. Kriebs, MSN, CNM, FACNM


Adjunct Professor


Midwifery Institute at Jefferson University


Philadelphia, Pennsylvania