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A Pregnant Epidemiologist & Some Other Chick

People, this week has been tough. The reality of the long haul is settling in, the weather the first half of the week was crap, and my kids haven’t started online classes at their school yet. I’m bewildered by the people (both in-office and on the streets) who consider our most vulnerable citizens expendable, and I just wish everyone would freeze for three weeks in their places so we could move on from this sooner. Like red light, green light, and no one moves until green light is declared, once we are well again. Until then, RED LIGHT everyone. Just stop, please. Aside from that, I have a daughter whose world is a horse named Aria, and last night we all decided that her scheduled trips to the barn to exercise Aria (our ONLY time leaving our home), was simply not safe or justifiable anymore even with six feet, Clorox, etc. The right call but just another heartbreak. (I know, I know, first world problems.) I spend hours with birth doula clients on the phone trying to reinvent or re-imagine birth plans in light of shifting hospital policies, and my heart hurts when we hang up. I have several friends who are sick with Covid-19, and in the midst of all of this, I am scrambling to get all of our planned Baby Botanica classes online for April, which is a big ole learning curve super soon after just learning the ropes of a new physical space several months ago.  

Getting personal, I lost my parents at a young age, and, truthfully, what I feel like now feels akin to those months after that loss: grief. Not as devastating, not at all, but grief nonetheless. Many have compared this to the time after 9/11. Yes, that too. The suffering and isolation everywhere just feels like a gut-wrenching human reality at the moment, and shouldering that as a member of the human race feels intense. 

And then, I just have to inhale. Look around, see my kids, see my hubby, my pets, and exhale. Again and again, each time grateful my lungs still feel a-ok.

There is literally no significance to this photo. But if a four-year-old contemplating the oddness of a chick’s butt doesn’t cheer you up, I don’t know what will. Plus this pic provided an inspired blog title!

I thought of not writing a blog this week because I am not sure if people need a big dose of Eeyore or not. If you’re looking for solace and parenting wisdom or joy and humor, this may be the wrong blog for you this week (although, I did just share one of our most iconic family photos).  I promise, I’ll try to be sunnier or funnier next week. But, as I write this, the day is gray, and maybe some of you are good with a touch of gray as you read this. 

So back to the birth world, because in my orbit of birth-y people and professionals, this Covid-19 situation is a gigantic mess. As many of you know, throughout hospitals in NYC, people have been having babies without a partner, a doula, a loving mother, or dear friend by their side. This week, policies at many hospitals (in NYC and California, and elsewhere) have attempted to limit support people to ZERO in an attempt to keep hospital employees, as well as families, as healthy as possible. It’s awful, despite the amazing and stunning work of L & D nurses who still attended births. And, honestly, the birth community is up in arms over it. (Note: Please see here for NY Department of Health’s most recent advisory on this matter and here for an updated executive order from Governor Cuomo literally released right before we posted this on Saturday 3/28.)

I see both sides of this policy but in no way think limiting the number of visitors and support people for birthing people was an unjustifiably extreme or punitive measure, as much as I was devastated by it.  I think hospitals are in crisis and trying to mitigate risk however they can. Obviously the effects of this policy on families have been unfathomable, and we are all trying to empower expecting and new parents, educate them, give them options, and show them support however we can during these times. Anyways, while there is much to be done, debated, and said about people having babies without their beloveds by their side, for now, I am too deep in it to share either my understanding of or concern about this policy that is changing daily. I am still coming to terms with my own perspective and have thus invited someone with far more first-hand experience to share her perspective on hospital births – and pregnancy and breastfeeding – during Covid-19. 

Elizabeth Radin is a lecturer in epidemiology at Columbia University’s Mailman School of Public Health, whose 18 years of experience have spanned 20 countries and covered topics including social epidemiology, global health, HIV/AIDS, infectious disease, and maternal health. With a PhD from Oxford’s Department of Public Health, and now 32 weeks pregnant with her first child, Liz is both a valued doula client as well as an expert on epidemics and pandemics. I am so glad she agreed to share her perspective on this experience both professionally and personally.  A huge congratulations on her baby on the way and a warm welcome to Liz. 

(Oh, and a disclaimer, Liz & her husband, Seb, dropped by our house to drop off a car that had been borrowed. This was my first non-family interaction in a LONG time. But even with the six-plus feet between us for a brief visit in the open air, this felt – for all of us – like a stretch, like we were kind of cheating or something, and not in sync with the spirit of the precautions.  Oh, but how I eagerly await reuniting with friends and clients someday!)

Liz & her husband, Sebastian Abbot, enjoying some nice non-social distancing.

Liz, I suppose my first question is really a reiteration or explanation of information already out there, but still important: can a pregnant person infected with Covid-19 transmit the disease to a baby in utero, in childbirth, or while breastfeeding? And if not, why are we hearing of a few (rare!) cases of infected neonates?

We really don’t know yet whether Covid-19 can be transmitted in utero, during childbirth or through breastfeeding.  We have only a handful of cases of Covid-19-positive mothers who have given birth that we can study and we simply don’t have enough data points to draw firm conclusions.

As of now, no evidence of Covid-19 transmission during pregnancy, childbirth or breastfeeding has been presented in the peer-reviewed literature — that is to say, among the studies that have been rigorously examined and approved by impartial experts for publication in academic or medical journals.  Some studies have reported on very small numbers of Covid-19-positive mothers, the most widely cited being this data on 6 women in Wuhan China. So far, all infants reported in these studies have tested negative for Covid-19, and the virus has not been found in cord blood, amniotic fluid or breastmilk. Maybe this means the virus isn’t transmitted from mother to infant, or maybe it means we just haven’t documented a case where it is transmitted yet.

As you say, there have been rare reports in the media of newborns testing positive for Covid-19, perhaps most notably this case in the UK. It’s possible these are cases of transmission during pregnancy or birth, or it’s possible there is another explanation, such as laboratory error.  I find these concerning but inconclusive. 

As an epidemiologist, I know that based on the data available, I can neither confirm nor rule out the possibility of Covid-19 transmission during pregnancy, birth or breastfeeding. As a pregnant woman, I am hopeful that the lack of evidence so far will turn out to mean the virus is difficult or impossible to transmit from mother to child but I am wary and watching this space closely.

In the meantime, I strongly encourage every pregnant woman to discuss potential Covid-19 related risks with her care provider. I’m not an MD, so the above is a summary of the evidence, not medical advice, and this is a very rapidly evolving situation.  

Liz, thanks so much. Interestingly, between the time I wrote that question this morning (3/26) and now, I have read that we may not be able to rule out vertical transmission (but had previously heard otherwise). Like you said, quickly evolving info… In any case, I know it’s one thing to research this as an epidemiologist, and another to assess these risks as a pregnant person! So thank you for being both personally invested and also scientifically objective.

What other information do we have about breastfeeding at this point? My sense is that breastfeeding’s immunological benefits are more desirable than ever. Any research suggesting otherwise if someone is infected? Precautions to be taken? And do we know if a neonate or baby can acquire immunity to Covid-19 via breast milk?

Similarly, with breastfeeding, we have no evidence that Covid-19 is transmitted through breast milk, though we can’t conclusively rule it out either. Interestingly, our public health and clinical organizations, namely CDC and ACOG, are not recommending against breastfeeding for Covid-19 positive mothers. I imagine this is in part because of the potential immunological benefits you mention. There is rightfully a hesitation to discourage feeding with breast milk without some evidence of transmission risk.

It is important to note that, whether or not Covid-19 can be transmitted through breast milk, data from China indicate that children of all ages can be infected with Covid-19, and that children under 12 months face a comparatively high risk of severe disease.  A study of over 2000 pediatric patients with Covid-19  reported that 10.6% of those under one year old became severe or critical cases. 

In light of this no doubt, both CDC and ACOG recommend measures to ensure Covid-19 positive mothers don’t transmit the virus to infants through respiratory droplets WHILE breastfeeding. They recommend women with confirmed or suspected Covid-19 and their clinicians work together to ensure infection prevention when breastfeeding or expressing breast milk with a pump. They also recommend considering having an uninfected caregiver feed expressed breast milk to the child. The goal here is to allow the infant to benefit from the nutritional and immunological benefits of breastfeeding while minimizing the risk of transmission through known pathways during breastfeeding. 

Oh, that’s so interesting. I feel pretty up-to-date on the research about breastfeeding, and I did not realize feeding with expressed milk was a current recommendation for an infected person. This truly breaks my heart for breastfeeding parents, particularly people who are brand new to breastfeeding.  But it does make sense in terms of exposure via droplet versus actual risk of transmission through birth milk.

A couple of breastfeeding follow-up questions and a whole slew of questions about hospital testing in general: if someone is breastfeeding, and does not know if they have been infected, should they take any preventative precautions just in case they are infected but asymptomatic? Both in hospitals and at home? And would a previously or currently exposed breastfeeding parent share their acquired Covid-19 antibodies with the baby via breast milk, thereby making contact or exposure safe for the baby.

The guidance above pertains to mothers with confirmed Covid-19 infection and those who are symptomatic (with fever, cough and/or shortness of breath) and under investigation for suspected Covid-19 by their clinician. I can’t find any guidance as of now specifically for women who are asymptomatic, and in the absence of specific guidance, the standard recommendations on breastfeeding prevail. I can definitely say that this is something I’ll be discussing with my team of care providers in order to understand the latest guidance and any personal risks I should consider when the time comes for me to make decisions about how to breastfeed. I think that’s an approach we can strongly recommend to all women. 

In terms of whether breastfeeding can help to protect babies from Covid-19 through maternal antibodies, we can be hopeful that breastfeeding confers some protection, as it does for a number of other infectious diseases, but we don’t know yet. In fact, just yesterday researchers at UC San Diego announced they are starting a study to answer this very question of whether breast milk can protect infants from Covid-19. While we are awaiting better evidence on this topic, I think it is worth prioritizing breastfeeding, subject to the guidance above, in the hope that it is protective, while also remaining extremely attentive to infection prevention. It would be risky at this point to assume that a breastfed baby is partially or fully protected from Covid-19 and reduce infection control efforts.

OK, so a super important topic to keep revisiting. Thank you for helping explain these nuanced elements of the whole breastfeeding picture.

In terms of actually assessing maternal infection, how do we know (and how quickly do we know) if birthing people are Covid-19 positive? If someone comes to the hospital in labor, is the current protocol to be tested across the board? Can you walk us through hospital protocols in general right now based on WHO and CDC guidelines for birthing people, partners, and neonates? 

The only way to know if someone is Covid-19 positive is if they receive one of the tests specifically approved for Covid-19. Some hospitals, including several in the New York City area,  have announced they are testing all women in labor for Covid-19 regardless of symptoms. Other hospitals in the US are not doing this. I haven’t seen a blanket recommendation on testing of all women in labor from WHO or CDC. In general, CDC’s guidance on the management of Covid-19 prevention and control during inpatient obstetric care is framed as “Interim Considerations”. It highlights overall issues to consider such as limiting germs from entering the facility and isolating confirmed or suspected Covid-19 cases, but it doesn’t set expansive guidelines for things like who should be tested and how many visitors or support persons should be allowed in facilities.  

The more concrete recommendations are really the purview of state and local authorities. On this front, we have seen some extraordinary actions in New York this weekend. First New York State clarified that one support person should be allowed for every laboring woman (here). This was a requirement for public hospitals and a recommendation for private ones. As of Saturday evening (3/28) there are reports that Governor Cuomo will release an executive order requiring all hospitals to comply (here). 

 As this situation highlights, we see rules and guidelines changing day to day and even hour to hour. Like many pregnant women, I am scrambling to figure out what the actual policies are and separate truth from rumor as this crisis evolves. My best source for this has been the types of official government statements referenced above as well as hospital websites, and communications directly from hospitals and clinical practices. Online communities and word of mouth have sometimes provided advanced warning, but in other cases, they’ve been misinformed or inaccurate.

Yup, we are all adjusting to info in real time, and having to be vigilant about hearsay versus actually updated protocols. I’d love to hear your reflections on some of these guidelines both as an epidemiologist and as someone who planned to deliver in a hospital.

As someone who planned to deliver and may still wind up delivering in a hospital, I am heartbroken and scared that my doula, not to mention my husband, may not be present for the birth of my child.  I am worried that despite my best efforts at social distancing, I could test positive for Covid-19 while in labor which could change my plans for breastfeeding and limit the contact it is safe for me to have with my newborn. No question about it, we pregnant people are faced with some very upsetting possibilities that seemed unimaginable just a few weeks ago. 

I truly can’t imagine. As a doula, as your doula, the thought of you and others going through birth alone feels like a terrible alternate reality – but here we are. I do understand that hospitals are being confronted with truly extreme and unprecedented circumstances, and they’re trying to create policies with very little time to weigh all the risks, options, and consequences, particularly in these hardest hit places. All of that said, can you share your perspective on the issue of support people being limited or prohibited from births – understanding that even as we have this dialogue, the policies are rapidly shifting. (For example, this JUST in that Cuomo made a statement that an executive order is going into effect today whereby all NY hospitals MUST allow one support person in the delivery room, making this question perhaps dated.)

As an epidemiologist who has spent many years working with health systems, I support measures to limit the number of visitors and support people allowed in hospitals as we stare down the very real threat of hundreds of thousands or even millions of deaths from Covid-19. Every additional person who enters a hospital in an area with widespread transmission faces an increased risk of Covid-19 infection. Of equal or greater concern is that every additional person who enters a hospital risks exposing other patients and healthcare workers to Covid-19 infection. In hospital systems like New York Presbyterian with over 2,000 births per month, having every laboring woman bring two support people means rolling the dice on infection risk an additional 4,000 times every four weeks. In a pandemic epicenter like New York City, we don’t need advanced statistics to know those are dangerous odds. 

Additionally, from an ethical standpoint, my thoughts turn to healthcare providers who are putting their health and wellbeing on the line to continue providing care, sometimes in the absence of personal protective equipment. They deserve our maximum possible effort to limit their risk of infection. Additionally, the more healthcare professionals fall ill or face quarantine, the more quality of care could suffer, endangering future patients.  If we don’t protect our health workforce today, we risk seeing mortality rise dramatically from all conditions, not just Covid-19. By contributing to infection control when I deliver in May, I am supporting a woman who delivers in June to receive adequate care. 

This is not to say that limiting support persons has no impact on birth outcomes. We have good evidence that the presence of support persons, particularly doulas, is associated with a lower risk of obstetric intervention, c-section delivery and possibly even postpartum depression. Unfortunately, we are now in the position of choosing lesser evils. In places like New York City, the collective risk of infection, severe complications and death from Covid-19 outweighs the benefits of supported labor and delivery for many pregnant women. 

Tragically, like school closings and the economic effects of social distancing, an infection control policy that limits birth support is likely to have the worst impact on the most vulnerable people in our society. In particular, we know that black, American Indian and Alaskan Native women face the highest risk of maternal mortality in the United States and arguably stand to gain the most from having a support person by their side. Within the requirements of infection control, we urgently need to find strategies that mitigate the greatest harms to those who are likely to be worst affected. Innovative approaches and practical leadership on this point will be a tremendous contribution from the birth support community. 

Liz, I am in awe of your ability to see all sides of this while you are smack in the middle of it.

To wrap things up, what do you suggest for people in NYC, and elsewhere, who are due in April, May & June. Either clinically or emotionally, what is the one bit of advice or even offering of support you’d like to share?

I think my strongest suggestion is to work with your care team to figure out what is best for your unique situation– clinically, logistically, financially and emotionally– really from all angles. As my doula, Jeni has really been the centerpiece and the driving force in this process for me. She has been invaluable in helping my husband and me understand the current status of obstetric care at various facilities and consider what that may look like by the time I’m due. She has laid out alternative options for us and guided us through the pros and cons from all angles. She’s provided us with links to additional resources, from introductions to other care providers to the wide range of virtual classes and online resources available through Baby Botanica.  While respecting infection control policies, Jeni has been able to provide all of this counseling remotely or, as our photo shows, from a very safe distance!  I certainly hope Jeni will be able to attend my birth as planned, but even if regulations at the time prevent that, having her as our doula has already been absolutely critical to navigating this challenging time. We are in a vastly better position now than we would have been without Jeni. 

In terms of an offering of support,  I can only share my personal experience which is that negotiating a crisis has brought me clarity and focus on what is truly important. For me, the past week has been an exercise in sorting my many hopes and preferences about my birth experience from my one and only essential goal: safely delivering a healthy baby however possible. Many of my preferences and expectations for pregnancy and birth are not likely to pan out, at best they are uncertain. But I take comfort in knowing that I can and I will bring this baby into the world safely and that is all I really need to focus on for now.

However our birth story plays out, we will wind up on the other side of this with a healthy child and a hell of a tale to tell her about the circumstances under which she was born. I hope it will serve as a lesson in the importance of science, the power of acting in the common interest and the necessity of summoning resilience when life veers wildly off the expected path. But it might just be one of those old family stories that parents repeat as they glide towards eccentricity and old age. As long as my daughter is here and safe and healthy, that’s what matters most to me.  

Well, I’m tearing up a bit, both humbled by the incredibly kind words about me, as well as by the extraordinary focus and strength being summoned by Liz and so many expecting families out there. Thank you for the warmth as well as the inspiring resilience, Liz. Your daughter is lucky indeed.

Everyone, please know, I am here. We are here. Doulas serve many roles, and right now, one of our most effective roles is that of counselor. Reach out to any of us for support, guidance, love, and experience. 

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