The COVID-19 pandemic is stressing every aspect of our society and revealing glaring deficiencies in the policies and systems needed to help everyone thrive, including guaranteed sick leave, affordable housing, support for gig and part-time workers, justice for undocumented immigrants, and reduction in poverty and income inequality. Nowhere are those deficiencies more obvious than in our health care system.
Lack of universal health insurance has left over 50 million inadequately insured people worrying about how to pay for necessary care. Underinvestment in public health has undermined our preparation for confronting inevitable pandemics. Consideration of health care as a profit-generating commodity rather than a public good has diverted resources from primary care to high-tech specialties. Consolidation of health care systems for the sake of profit has occurred at the expense of community health, particularly the health of communities of color and indigenous peoples.
COVID-19 is making these shortcomings painfully obvious, especially for mothers and babies. Once again, deficiencies in our care of women and children have been overlooked in our crisis management decisions even though the SARS-CoV-2 virus poses significant risks to pregnant women and their children. Although data are limited, it appears that transmission of SARS-CoV-2 to the fetus during pregnancy and through breast milk is not the major concern. The greater risk is from the changes in the overall health care system in response to the surge in demand for hospital care.
Some hospitals are converting their labor and delivery rooms and reassigning staff to care for COVID-19 patients. Major health care systems are encouraging women to induce labor early at 39 weeks or earlier with the hope of delivering before hospital situations worsen. Hospitals are limiting who can attend births, leaving women without a support person in the room, raising concerns about the short and long-term physical and emotional health of mothers and babies.
The current COVID-19 pandemic crisis underscores the need to reassess the structure and functioning of many of our systems, particularly our health care system. That reassessment should start with our care of pregnant women and their infants. Implementing changes now could help with the immediate effort to deal with COVID-19 while setting a course for a more rational health care system in the future.
Alternatives, from birth centers to telehealth
Evidence-based alternatives to providing care that protects the health of mothers and babies have been tested and shown to be safe and effective. Based on these studies we should immediately establish hospital-linked but non-hospital-based labor and delivery units, expand the capacity of accredited free-standing birth centers, and develop guidelines to allow for safe home births. Combined with that should be expansion of the use of licensed and/or certified midwives, allowing them to practice to the full extent of their training. Expanding the use of telehealth would also enhance high quality out-of-hospital prenatal, postpartum and newborn care. We have normalized hospital-based deliveries as the safest approach to birthing when experience and data show that there are alternative approaches that can be just as safe and often with better outcomes.
Along with physicians and midwives, the care team for pregnant women and their babies should include doulas, community health workers, and public health nurses. These professionals could provide education and support that would allow for more services to be provided in community settings.
Financing changes needed
Changes in financing health care will be necessary to allow this to happen. Adopting a financing mechanism for universal health care would be the most logical approach. Short of that, changes that could be implemented quickly are permitting states to continue eligibility for women following a Medicaid financed birth and expanding the financing for home visiting for postpartum women and their infants for a year after delivery. Providing professional liability insurance for this expanded and reconfigured perinatal work team would also be necessary.
Even before the arrival of COVID-19, infant and maternal mortality rates in the United States were higher than those of other wealthy countries. The COVID-19 pandemic could worsen the situation. There is an urgency to changing our approach to caring for pregnant women and their babies. The current crisis provides an opportunity to make those changes. Doing so could immediately free up health care resources to address individuals with COVID-19 while saving the lives of mothers and babies now and into the future.
Edward P. Ehlinger, M.D., MSPH, is a former Minnesota commissioner of health and past president of the Association of State and Territorial Health Officials. He also directed the Maternal and Child Health Program at the Minneapolis Health Department and is an adjunct professor in Maternal and Child Health at the University of Minnesota’s School of Public Health.
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