Emma Clark, CNM, MSN, MHS; Senior Maternal Health Advisor, USAID Contractor, GHSI-III
Shortly after the World Health Organization (WHO) declared the COVID-19 pandemic, home birth practices in the United States saw increased interest from pregnant people looking to avoid hospitals. But this wasn’t just a U.S. phenomenon: Pregnant people all over the world were suddenly forced to make decisions, often with very little information, about where to give birth safely without increasing their risk of COVID-19 infection. Further, they had to do so while navigating restrictive new policies at hospitals and, frequently, reduced access to facilities due to transportation disruptions or curfews.
Potential to reduce years of progress
In places where access to—or trust in—health facilities was already weak, the problem was even worse. Previous experience with the Ebola epidemic in West Africa and statistical modeling exercises in the early days of the pandemic suggested that birthing people would avoid facilities (and in turn lifesaving care), and rates of maternal mortality would rise. Among other data, modeling using the Lives Saved Tool (LiST) showed an 8.3-38.5% increase in maternal deaths per month across the 118 low- and middle-income (LMIC) countries included in their analysis, depending on the severity and duration of the pandemic. The Ebola experience also suggested that it can take years for facility deliveries to return to pre-epidemic/pandemic levels.
Unfortunately, the COVID-19 pandemic came at a time when more birthing people than ever were able to receive quality care with a skilled birth attendant in facilities (see graph below). In 2019, almost 80 million women gave birth at health institutions globally, three times the number of institutional births in 2000 (Countdown to 2030). Falling maternal mortality rates in LMICs reflected this improved access to care. In many countries, community birth with a traditional birth attendant was actively discouraged or even made illegal. Countries also discouraged people from giving birth unassisted or with only a family member assisting. A growing evidence base drove these policies with data showing the improved safety of facility delivery. Persistent resource constraints for maternal and newborn health services, including human resources for health, further encouraged the shift to facilities.
But pandemic times are not normal times. The indirect risks posed by the COVID-19 pandemic— including reduced access to and quality of services for pregnant people and newborns due to logistics (e.g., lockdowns, reduced income) and psychosocial reasons (e.g., fear of facilities, family pressure)—have led to quantifiable reductions in institutional birth and increases in maternal and newborn mortality.
Opportunities to reconsider evidence
The evidence supporting most current policies and guidelines around where and with whom people can most safely give birth can safely give birth was gathered in a pre-COVID-19 pandemic context . While existing evidence can provide suggestions about how interventions should be structured, it should not be used to dismiss viable alternative options such as community birth with a traditional birth attendant, particularly if what data exists suggests these are occurring regardless. Simply continuing to promote facility birth as usual is insufficient in both the immediate and long run.
Hard-line policies pushing facility birth ignore the daily choices and challenges people face; in addition, concerns that it is “unethical” to put in place policies or support interventions perceived as harmful or inferior overlook what is actually happening. Countries have the unique opportunity—and challenge—of moving beyond the classic pro-facility birth paradigm to consider their country’s context and circumstances and at least temporarily make choices that better meet maternal and newborn health needs.
While situations are fluid and rapidly evolving and ongoing data collection and continuous learning and adaptation are essential, five options for ensuring safe, respectful, and acceptable care for birthing people within and beyond facilities include:
- Maintaining and promoting full intrapartum services and facilities exclusively/primarily
- Maintaining full intrapartum services in alternative spaces
- Supporting skilled birth attendants to provide community birth, as an alternative to having skilled birth attendants work exclusively in facilities
- Expanding the use of traditional birth attendants
- Providing information and commodities to make unassisted or family assisted community birth safer
Ultimately, we suggest governments embrace a “harm reduction model” that pivots maternal health strategies to use every channel available to provide essential maternal and newborn health care and reduce the immediate risk of harm and preventable death. While there is no one right answer, the goal is to do whatever is necessary to reduce immediate risk and minimize risk to future service quality and delivery.
If you’d like to learn more about when and why these options are most viable and effective, overall priorities for action to save maternal and newborn lives, and the effect of the COVID-19 pandemic on facility birth globally, join the “COVID 19: Impact and Implications for Facility Birth” session at the upcoming ACNM 66th Annual Meeting, held virtually May 23-25, 2021.
The contents of this article are the responsibility of the authors/organizations and do not reflect the views of the U.S. Agency for International Development (USAID) or the United States Government.
Emma Clark is a Senior Maternal Health Advisor at the United States Agency for International Development. She is faculty in Georgetown University’s midwifery program and maintains full-scope practice at a Federally Qualified Health Center (FQHC). She previously worked in humanitarian response in countries including Iraq, Haiti, Somalia, and South Sudan. She is chair of the Reproductive Health Supplies Coalition’s Maternal Health Supplies Caucus and ACNM’s Division of Global Engagement Networking Committee.