To the editor:
The COVID‐19 pandemic has drastically strained the American healthcare system.
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Crowded hospitals, overworked staff and a lack of medical equipment have implications
for those needing medical care unrelated to COVID‐19, including pregnant women. However,
few studies have examined the impact of the pandemic on maternity care. What little
work has been done has predominantly focused on treatment of pregnant women suffering
from COVID‐19
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and the risk of virus transmission from mother to baby.
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It remains unclear how the pandemic has influenced maternal care choices, in particular
how women have altered their birth plans. Data on common birth plan changes are needed
to help providers better understand factors shaping care decisions, information that
can be used to address patient concerns and tailor care recommendations. Here, we
use an online convenience survey to assess how American women's birth plans (eg intended
labour support and delivery location) have changed in response to the COVID‐19 pandemic.
The COVID‐19 And Reproductive Effects (CARE) study was posted on social media platforms
(Facebook, Twitter) and distributed via email to contacts working in maternity care
and public health. Pregnant women over the age of 18 and living in the United States
were invited to participate in a survey assessing how the pandemic was impacting their
medical care and birth plans. The data presented here were collected between 16 and
20 April 2020.
In addition to providing basic demographic data, gestational week and intended delivery
facility, participants were asked whether ‘any aspect of your birth plan changed due
to COVID‐19’ (yes/no). If they answered yes, they were then asked why and how their
plans changed. These analyses were limited to participants who completed the entire
survey (n = 1400). A subset of this sample also answered an open‐ended question describing
the specific changes to their birth plans (n = 592); these qualitative responses were
assessed for common patterns.
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This study received ethical approval from Dartmouth College (STUDY00032045).
The average participant age was 31.4 years old. The majority of participants were
married/in domestic partnerships (94.5%), White (85.9%), had completed at least a
bachelor's degree (77.3%), were employed full‐time (61.1%) and reported having not
experienced any COVID‐19‐like symptoms (89.4%). Most participants planned on giving
birth in a hospital (94.8% in hospital, 2.9% in free‐standing birth centres, 2.3%
at home).
Overall, 45.2% of respondents reported changing some aspect of their birth plans because
of COVID‐19, due in part to their own concerns (53.9% of respondents), their partner's
concerns (21.9%), the concerns of friends or family members (13.8%) and comments from
medical providers (60.8%). The prevalence of women changing their birth plans varied
by trimester. Approximately 28.6% of women in their first trimester (36/126) reported
changing their plans due to COVID‐19, compared to 37.0% of women in their second trimester
(228/617 women) and 56.2% of women in their third trimester (369/657 women).
Commonly provided COVID‐related birth plan changes—from a subset of 592 respondents—are
outlined in Table 1. These changes largely fell into three categories: (i) modifying
an existing hospital birth plan (ie shortening the hospital stay, altered pain management
strategies and accommodating new policies like wearing a mask while labouring); (ii)
changing birth locations and/or providers (ie opting for an out of hospital birth,
forced provider/location change because pandemic has limited availability, selecting
hospital birth because of fear complications); and (iii) other COVID‐related concerns
(ie having fewer support people at birth, visitors not permitted following birth,
care disrupted because moved in response to shelter‐in‐place orders).
Table 1
Commonly reported reasons for birth plan changes (eg changes in birth location, labour
and delivery preferences) provided by a subset of the sample (n = 592)
Remaining at same hospital with altered birth plan
Changing birth locations due to the pandemic
Other COVID‐related concerns
Planning to shorten my hospital stay and reduce risk of exposure by scheduling a C‐section,
planning an induction, labouring at home as long as possible before transferring to
hospital to deliver, and/or reducing post‐delivery recovery time (n = 62)
No longer plan for hospital birth because I worry about being separated from my newborn,
having to labour alone, and/or I fear COVID‐19 exposure (n = 81)
Will have fewer people present to support me during delivery (and they will not be
allowed to leave and return) because of delivery room restrictions and/or I fear that
they have been exposed to the virus (n = 367)
Will have to accommodate new hospital protective policies during delivery (eg masks
on labouring mothers and restricted movement during labour) (n = 46)
The pandemic has restricted provider availability and/or deliveries at local birth
centres no longer allowed (n = 25)
Loved ones can no longer travel to visit after the birth and/or my partner may have
to care for our other children and not be able to support me in labour (n = 186)
Altered pain management strategy (eg nitrous oxide no longer offered, worried to get
epidural because of exposure risk, or can no longer have a water birth) (n = 42)
Now prefer hospital birth over home birth in case things go wrong: do not want to
suffer complications because unknowingly have virus or have trouble getting admitted
because hospital at capacity (n = 8)
Left COVID‐19 epicentre and/or temporarily moved in with family to shelter‐in‐place
and now have to find a new provider (n = 8)
Note
The number of responses for each COVID‐related reason is noted, respondents sometimes
listed more than one factor impacting their birth decisions.
John Wiley & Sons, Ltd
This article is being made freely available through PubMed Central as part of the
COVID-19 public health emergency response. It can be used for unrestricted research
re-use and analysis in any form or by any means with acknowledgement of the original
source, for the duration of the public health emergency.
Many participants planned to remain with their current provider, but were preparing
for a very different birth experience with fewer support persons during labour (n = 367/592)
and no visitors to meet their baby or care for their other children during delivery
(n = 186/592). Some women worried they might have to labour alone if childcare could
not be arranged and their partner had to watch their other children instead of attending
the birth. Several women reported opting to no longer give birth in a hospital due
to restrictions on who would be allowed in the delivery room, the possibility of forced
separation from their newborn and fear of virus exposure (n = 81/592).
Pregnant American women face a variety of care‐related challenges related to COVID‐19,
and our results demonstrate that this has led to altered birth plans. Yet, the reasons
behind the changes appear to be individual‐dependent. While several participants reported
that they now preferred an out of hospital birth because they feared COVID‐19 exposure,
a handful of women reported choosing a hospital instead of a home birth because they
feared suffering COVID‐related complications during delivery if they were unknowing
carriers, or because they worried they would not be admitted to an overcrowded hospital
should they need to transfer.
Notably, the women in this sample exhibited a much higher preference for out of hospital
births than the national average before the COVID‐19 pandemic (5.4% vs. 1.6%, respectively).
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While this may be due in part to the demographic characteristics of the sample, this
percentage is also comparatively high among women in the sample who had previously
given birth. Specifically, of the 667 women in the sample who had previously given
birth, 3.1% reported an out of hospital delivery for at least one of their previous
births, but 5.1% of these same women now reported they planned for an out of hospital
delivery. This, combined with the qualitative data reported here, suggests that part
of this increase in out of hospital births is likely attributable to the COVID‐19
pandemic.
It is important to note that due to the use of convenience sampling these data are
not representative of the whole US population. Additional work is needed using more
diverse samples to identify additional issues influencing maternal care decisions.
The diverse factors influencing maternal birth plan choices highlighted here may serve
as reference providers can use to explore the specific concerns of each patient, ultimately
leading to more productive provider‐patient conversations about the maternal care
and delivery options available to best address any given situation.
CONFLICT OF INTEREST
The authors declare that they have no competing interests.