Mothers all over the country faced new hurdles when Covid-19 turned birth plans upside down: fathers not allowed to attend prenatal care visits, temporary closure of health clinics and OB/GYN offices, concerns over mother-to-baby transmission of the disease.
In rural America, it made the tough job of finding good maternity care that much tougher.
“It does come down to making a difficult situation prior to Covid-19 even worse for people giving birth in rural communities,” said Dr. Katy Kozhimannil, director of the Rural Health Research Center at the University of Minnesota.
Before Covid-19, rural mothers faced a unique slew of challenges connected to limited healthcare infrastructure, Kozhimannil said.
More than half of rural American counties don’t have hospitals with obstetric units. Women in rural areas are more likely to have underlying conditions that increase the risk of life-threatening complications during childbirth. A 2019 study by Kozhimannil found that rural women were nine percent more likely to suffer maternal morbidity or mortality than their urban counterparts.
Now, Covid-19 is exacerbating those issues.
Many rural mothers who previously only received sporadic prenatal care because their physician was far away are afraid of contracting the virus at the appointment and en route to it.
“You’re seeing patients who are afraid to access healthcare now,” said Certified Nurse Midwife (CNM) Lodz Joseph-Lemon of Albany, Georgia. “Whereas before you would borrow a car or you would get a ride… now you can’t.”
Since many rural people live in zero- or one- car households, a trip to the nearest OB/GYN sometimes means 30 to 45 minutes in the car with a neighbor who could potentially have Covid-19.
Although many rural maternal healthcare providers do offer telemedicine services, insufficient broadband infrastructure and the difficulty of recreating physical examinations virtually mean that this solution isn’t available to all rural moms.
“Not everyone has an iPhone or a computer, and even those who do, in some of these parts, you can’t get good reception,” said recently retired CNM Melissa Newell of Whitesburg, Kentucky. Newell’s former clinic, Mountain Comprehensive Health, has expanded its telehealth services for those who are able to use it.
Joseph-Lemon agrees that telemedicine cannot be, at least right now, the silver-bullet fix for maternal healthcare in the time of Covid-19.
“Everybody wants to talk about technology. But there’s an assumption that you have the technology to deliver care,” she said. The House of Representatives in Joseph-Lemon’s state of Georgia in March passed a bill intended to improve rural broadband access, but the bill has not yet been signed into law because the legislative session was suspended due to Covid-19.
Allison Stone, a school teacher from Lincolnton, North Carolina, was already in her second trimester when Covid-19 hit the U.S. She suffers from some pre-existing health conditions that qualify her pregnancy as high risk, which means that she was able to keep many of her prenatal care appointments that her friends with low-risk pregnancies had to cancel.
Yet Stone’s care has still been affected by the virus. At the beginning of the pandemic, her prenatal care physician told her she needed to undergo an EKG with a cardiologist due to her pre-existing condition. However, when she finally met with the cardiologist, it was a brief virtual appointment. “Obviously, we didn’t get the test done that was needed. You can’t do that over the phone,” Stone said. “He literally did a 15 minute video-chat with me, if it was even that long… It didn’t make sense to me that they referred me for a test, and then we didn’t have a face-to-face meeting so we could do it.”
Despite all these negatives, Joseph-Lemon has found a silver lining. She thinks that the pandemic has led women to seek out more agency over their births “because people want to feel safe at this critical time in their life.” She said whereas many women used to think of hospitals as the only viable option, now “they’re doing all this research and realizing they can go other places.”
One such “other place” for women to receive high quality medical care and support during pregnancy and birth is midwifery.
Despite decades of stigmatization and systematic disenfranchisement (especially across the southeastern U.S.), CNMs have been regaining popularity in recent years, and especially so amidst the Covid-19 crisis.
Frontier Nursing University, a premier midwifery and advanced nursing non-profit which focuses on training providers for rural and underserved communities, has stayed ahead of the curve by pushing out resources and guidelines on Covid-19-positive or possibly positive deliveries.
Newell, an alumna of Frontier Nursing University, mentioned that one such recommendation included midwives performing temperature, blood pressure, and fetal doppler or fetoscope checks for women in their cars. She also said her former clinic is still taking patients in the office, but with social distancing measures, limited capacity, and mandatory temperature checks in place.
Joseph-Lemon explained that midwives are trained to handle birthing situations when things go wrong; importantly they know how to call in backup for a situation that gets out of hand. “Everyone’s like, ‘What if something happens?’ My friends, that is pregnancy,” she said. “That’s what midwives do: try to keep you in the window of normal. And when you’re not in that window, we know when it’s time to co-manage, when it’s time to transfer a patient to a doctor’s care.”
As a board member for the Foundation of the Advancement of Haitian Midwives and a practicing midwife for rural Americans, Joseph-Lemon is glad to see that the conditions of the pandemic are pushing mothers to realize that they can have safe and normal births outside of a hospital setting. She, like many other midwives believe that promoting midwifery is a major key to resolving rural America’s long-term maternal healthcare problems.
However, Joseph-Lemon cautions that not all rural populations are benefitting from this realization equally. The virus is taking a disproportionate toll on Black people across the board, but especially in Georgia. Joseph-Lemon said racial disparities in access to care are ever present.
“If you’re black or brown or native, especially Alaskan Native, the maternal mortality rates are still higher there.” In reference to midwifery, she says, “If you’re white and rich, you can still get access to the care that you need and want.”
Joseph-Lemon believes there are several systematic changes that would need to occur in order for midwifery to be more accessible for people of all socioeconomic, geographic, and racial backgrounds both during and after the pandemic. These include better insurance reimbursement for midwives and extending coverage past six weeks postpartum, case management that reaches out to new patients in rural areas, and legalizing the independent practice of midwifery in every state.
Midwives are not alone in their quest to improve rural maternal healthcare. The growth in utilization of doulas across the country in recent years has made these people, whose role is to support women throughout the birthing process, a vital component of the maternal healthcare response to Covid-19.
A non-profit organization in Apex, North Carolina called “Birth Beginnings Doula Volunteer Services” started up in November of 2019, just a short time before Covid-19 hit. The organization’s mission is to provide high-quality and accessible doula care to all women, especially those in rural and low-income settings, free of charge. In its first few months, Birth Beginnings recruited more than 20 doulas, training 17 of them in-house with a certified doula trainer.
With the pandemic shutting down in-person training, the nascent organization has switched to entirely remote training of its doulas. Additionally, Birth Beginnings is finding creative ways to serve its rural and low-income mothers through “virtual doulaing,” says Keegan Chit Khin, grant writer for the organization.
“Everything’s really had to change quite a bit. Instead of being able to be there in person with the mother to provide comfort and support, [the doula] has to switch and go through email, text, facetime, Skype, videocall, or Teams” says Khin.
Khin admits that virtual training and doulaing come with their own challenges and can never replace the “hands-on experience of being with the mother in that situation.” However, amidst differing preferences from doctors and families about how to minimize the risk of mothers and babies being infected, Birth Beginnings believes it’s the best solution right now.
Just as with other maternal healthcare staff across rural America, the psychological and physical well-being of the mother is the top priority of every doula in Birth Beginnings. “Because everything is so up in the air,” Khin says of the confusion and concern shrouding birth and Covid-19, “We don’t want to jump the gun. We don’t want to remove something beneficial, but [in-person doulaing] could be something harmful. We’re trying to find that balance.”
“Finding that balance” seems to be a common objective for healthcare professionals of every type during the pandemic. Come back tomorrow to read the second part of this series and see how rural end-of-life physicians are weighing the risks of coronavirus spread with the importance of physical human interaction in their work.
Tomorrow: Hospice care and the pandemic.
For more information on the Foundation for the Advancement of Haitian Midwives: http://www.fahminc.org/
For more information on the Birth Beginnings Doula Volunteering Service: https://www.bbvolunteerdoulas.org/