Early on Sunday, March 22nd, Lauren Pelz got a text from a friend who’d heard that the NewYork-Presbyterian (N.Y.P.) hospital network had decided to bar partners from accompanying women in labor, due to concerns about the spread of COVID-19. It was the day before Pelz was scheduled to be induced to deliver her second child at N.Y.P. Lower Manhattan Hospital. She searched the hospital’s Web site and Twitter feed for news about the change in policy, but found nothing. She tried calling her obstetrician but couldn’t reach her. Hours later, her husband, Matthew, got through to someone on the hospital hotline, who confirmed that he would not be allowed to attend the birth of his daughter.
Pelz, a corporate event planner, spent the rest of the day crying. She considered cancelling the induction, which her doctor had recommended because she is thirty-nine and had some complications with her pregnancy, but she was also mindful that local hospitals were about to be inundated with coronavirus patients. “We just wanted to have the baby as quickly as possible and get back home safely,” she said. So, at 8 p.m. on Monday night, her husband brought her as far as the hospital lobby, hugged her tight, and told her not to worry. “You’ve got this. You’ve done this before,” he said. He watched as a security guard led his sobbing wife to the maternity ward, where she immediately received a mask. Once Pelz was settled in her room, a nurse swabbed her nose to test for COVID-19.
Through the night, Pelz was aware that the ward was short-staffed—several nurses were out sick. She tried to limit how often she asked for water or made other requests; for several hours, the hospital halted her drip of Pitocin, the medication used to induce her labor, because no staff were available to track her progress. All the while, Matthew was visible via FaceTime on an iPad at her bedside. Pelz found it difficult to breathe through her contractions under her mask; by late morning, after her COVID-19 test came back negative, she was permitted to remove it. Her obstetrician and a physician assistant coached her through ninety minutes of pushing, and Pelz delivered her daughter just before 1 p.m. on Tuesday. When the doctor put the baby on her chest, Pelz began crying again, overwhelmed by the bittersweet experience of greeting her daughter, Skylar Lucille, alone.
Pelz was one of the first women in the city to labor without a partner after both the N.Y.P. hospital network and the Mount Sinai Health System—which together see more than twenty-five hundred deliveries a year—announced the banning of all visitors for obstetric patients last Monday. Now it looks as if she may have been among the last. In the chaotic days following the N.Y.P. and Mount Sinai announcements, many expectant mothers began leaving town, seeking home births, or showing up in active labor at city hospitals, where partners were still allowed. But, on Saturday, Governor Andrew Cuomo caught many hospital officials off guard by issuing an executive order mandating that all maternity units allow women to have one asymptomatic partner during labor and delivery. All labor-and-delivery (L. & D.) units will have to screen visitors for COVID-19 symptoms and conduct temperature checks every twelve hours. Hospitals are asked to provide partners with masks from their dwindling supply.
“I’m elated,” Georges Sylvestre, an obstetrician who specializes in high-risk pregnancies at N.Y.P.-Weill Cornell Medicine in Manhattan, told me after Cuomo’s decree. Forcing women to labor alone seemed “harsh,” Sylvestre said, and many medical staff were uncomfortable with the rule. But he also understood his hospital’s position. The virus is both unpredictable and extremely contagious, he said, and the presence of even one extra person on the unit increases the risk of transmission, particularly as there is so little personal protective equipment (P.P.E.) to go around. “You don’t want to have the partner who gives a healthy newborn COVID, never mind the staff,” Sylvestre said.
In New York, the national epicenter of the COVID-19 pandemic, Governor Cuomo has asked for all elective surgery to be cancelled. Oncologists are deferring and revising cancer treatments, and fertility specialists have halted in-vitro-fertilization cycles. As the state’s coronavirus cases double every four days, health officials are working to limit the spread of infection and reduce other demands on hospital beds. But childbirth is not easily postponed, and the delivery of maternal health care amid this crisis differs considerably from hospital to hospital, and sometimes from hour to hour. “I’m at ease for now,” Sylvestre said, “but no one really knows what will happen next week.”
The impact of COVID-19 on pregnant women and infants is not yet well known, which helps explain the conflict and confusion. The initial news had been reassuring: research from China showed that pregnant women who tested positive for the virus did not transmit it to their babies, and all had good outcomes. But the study included a mere nine women, all of whom had only mild symptoms. A more recent study, of forty-one pregnant women with COVID-19, found that they had a higher risk of miscarriage, preterm birth, and preëclampsia (along with a higher rate of C-section), particularly if they had been hospitalized for pneumonia. “I’ve never been so dependent on such shaky data to make what are fundamentally life-or-death decisions,” Neel Shah, an assistant obstetrics professor at Harvard, told me.
The messages new mothers are receiving are therefore jumbled. Hyein DeGannes, a thirty-six-year-old Mandarin teacher at a Brooklyn charter school, is another woman whose delivery date fell in the week between the private hospital ban on birth partners and Governor Cuomo’s reversal. She gave birth to her daughter, Keanu, on March 25th, at Mount Sinai West, while her husband, Randy, stayed at home with their older child. The next morning, the COVID-19 test DeGannes had taken when she was admitted came back positive, and she and her daughter were moved to a quarantine room with another sick mother, where visits from nurses were infrequent. She received contradictory instructions about how to care for Keanu, who tested negative. A doctor told her to pump and dump her breast milk for two weeks and give her daughter formula in the meantime. A doula friend said she should go ahead and breastfeed, but with a mask on.
N.Y.P.’s decision to ban partners was informed by two cases involving women who arrived at an N.Y.P. hospital with no coronavirus symptoms; after giving birth, both showed severe signs of COVID-19 and needed days in intensive-care units. What alarmed the hospital was not only the speed at which the women’s health deteriorated but also that they went untested until they developed symptoms. Before their diagnoses, they came into contact with an estimated total of at least thirty health-care workers, all of whom lacked P.P.E.
“Having partner support is essential for labor,” Jesse Pournaras, a doula who launched a Change.org petition protesting the ban on partners, said. (The petition received more than 613,000 signatures before she closed it on Saturday.) She pointed to studies showing that women who deliver without a companion are at greater risk of complications during and after birth. But not all obstetrics staff are delighted by the reversal of the policy. “We have too many health-care workers sick in hospitals, and quite a few on ventilators,” Sascha James-Conterelli, the president of the New York State Association of Licensed Midwives, said. Many providers are “scared to death,” she said, especially if they live with older or immunocompromised people; eight nurses and four obstetricians in the Mount Sinai system are infected, and one postpartum nurse recently died from COVID-19. James-Conterelli told me that she has been hearing too many stories of fathers lying about their symptoms so they can witness their child’s birth, and not every hospital has the staff to keep checking the temperatures of non-patients. One L. & D. nurse at Maimonides, a private hospital in Borough Park, recently posted on Facebook that some partners are still being sent away if couples arrive during the night shift, when hospitals tend to be particularly short-staffed. A compromise that some city hospitals are striking, James-Conterelli said, is to bar partners from labor—which is often long and unpredictable—but call them in for the birth itself.
“Everyone’s risking their lives on a daily basis,” one private-practice obstetrician for Mount Sinai told me (on condition of anonymity, because the system’s providers are not authorized to speak to the press). Childbirth may be uniquely dangerous to providers because it is an intimate and hands-on process over a long stretch of time, involving bodily fluids and fecal matter. The grunting and heavy breathing of labor can also aerosolize the virus if the mother is a carrier. “There are a lot of Facebook groups where we look at the data and protocols of other countries,” the obstetrician added, “and they’re taking a hundred times more steps than we’ve been taking.” She noted that China protected some of its health-care workers by putting them in full hazmat suits with N95 masks; in the U.S., workers are rationing lesser surgical masks and struggle to get tested even with serious symptoms. She recently asked her brother if he would take care of her children if she died.
Pregnant women become accustomed to frequent doctor’s appointments, especially in the third trimester, but the coronavirus outbreak has abruptly forced them and their health-care providers into new routines. In mid-March, most private hospitals introduced telemedicine visits for routine prenatal checkups: some expectant mothers receive cuffs for monitoring their blood pressure, and women with diabetes get glucometers or dipsticks to test the blood-sugar levels in their urine. Pregnant women still come in for a handful of “milestone” visits for blood work and anatomy scans, but other visits are considered on a case-by-case basis.
The city’s public hospitals have been slower than better-funded private consortiums to adapt to the shifting demands of the pandemic. One junior midwife at a city hospital in the Bronx told me (on condition of anonymity, because she was not authorized to speak to the media) that she and her colleagues have been trying to conduct prenatal and postpartum appointments over the phone or WhatsApp calls and texts. “The population we take care of, half the time, when I’m calling them with a prescription, their phones are disconnected,” she told me. The conditions are especially daunting for women with complicated pregnancies. “Everyone is on high alert already, so people’s threshold for anything that is not normal is so low,” she said. “I can see this spiralling into more C-sections.”
According to this midwife, unless a delivering mother is a known or suspected carrier of COVID-19, masks are not required for either patients or staff—a stark contrast with most private hospitals, where masks and testing are mandatory for patients. Proper N95 masks are exceedingly rare, and staff are expected to use a single surgical mask for a week. “Right now, providers are seen as bodies, not as vectors who are possibly spreading the virus and putting their health at risk while going back and forth to their families,” she said.
A director of midwifery service at a city hospital told me last week that she was taken aback when she read that Columbia University Irving Medical Center, in Manhattan, tests all pregnant women admitted to deliver for COVID-19, regardless of symptoms. At her own and other city facilities, staff members often have to “fight to get themselves a test or to get a patient a test,” she said. “Issues with access have never been more pronounced.” Her patients tend to be black and Latinx and suffer many of the health problems exacerbated by poverty, such as diabetes and preëclampsia. Because the hospital is not testing asymptomatic staff or patients, they have no way of isolating those who could be shedding the virus. After hearing of some instances at the hospitals where fathers presented symptoms during labor, she has concluded that allowing birthing partners puts more people at an unacceptable risk. “It impedes our ability to practice when we have to police partners—it’s not fair to us,” she said. Already, five midwives and two doctors on her team have been out sick. She herself woke up feeling feverish on March 17th and got tested, after strenuous pleading, at a CityMD. Last Friday, her tenth day of self-quarantine, she learned that she had contracted COVID-19.
Many expectant mothers are understandably wary of hospitals right now, owing to contagion fears and a lingering uncertainty around birth partners. But their alternatives are limited. The city has some twenty home-birth midwives, who typically handle around one per cent of the city’s births: all of them low-risk and rarely covered by insurance. Given the sprawl of the city and the uncertain timing of a woman’s labor, few midwives take more than five clients in a month, and most practices are already full.
Trinisha Williams, the director of midwifery of the Brooklyn Birthing Center, told me that, before the crisis began cresting, only sixteen women were expected to deliver at the center in March. Between March 23rd and 25th, she received more than a hundred and fifty inquiries, mostly from women in their third trimesters. Kimm Sun, a certified home-birth nurse-midwife also based in Brooklyn, had been getting more requests in a day than she usually receives all year; her small practice has had to hire someone simply to field all the calls. “I can’t listen to them anymore, because they are so distressing,” Sun said. “Many of them are literally in the middle of a panic attack when they are calling.” Tanya Wills, a certified home-birth nurse-midwife with offices in Brooklyn and on the Upper West Side, says she and her partner had to put on an automated away message, because they are not interviewing prospective clients right now. “It’s just heartbreaking to tell people over and over again we don’t have room.”
Home-birth midwives are self-quarantining between births, pooling their masks and gloves, and advising their clients to stay as isolated as possible. Those I spoke to said they worried that taking on new mothers could put their existing clients at risk, either by complicating their already busy schedules or by exposing them to COVID-19. In response to the deluge, the NYC Homebirth Collective put out a statement warning that fear and panic are not good reasons to choose a home birth; women who began their pregnancies believing a hospital was best for them, the statement said, should probably stick with their original birth plan.
Problems with capacity at many hospitals may now undercut the safety of home births, which always include the possibility of an emergency transfer. “The safety of a home birth isn’t dependent on home versus hospital, or a midwife versus an O.B. It’s really about how those systems come together and coördinate. And it’s a really hard time for that to happen,” Shah said.
Several doulas told me they worried that visitor bans would especially hurt women of color—black mothers are more than three times more likely to die of childbirth-related causes than white mothers. A recent study also found that black and Latina mothers in New York City are more at risk than white women to suffer serious complications while giving birth, even when they deliver in the same hospitals and have similar insurance. “It’s already a challenge for black women to have autonomy over their bodies and births in hospitals,” said Regina M. Conceiçaõ, a doula and the founder of A Passion for New Beginnings, a doula team in New York. When she helps women of color with their births, she notices that she has to work especially hard to push back against doctors and nurses who insist on an I.V. or a catheter when her clients don’t want it. “When you add COVID-19 and you take away the support of people who are meant to advocate for you—that’s where I’m concerned.”
Given that many maternal deaths take place in the postpartum period, doulas and other health-care providers are nervous that the pandemic will compound the isolation of already vulnerable women, who are now less likely to see a doctor if something feels off. “It’s a time when you’re already not getting much sleep, and now you can’t have family or community members come to help at all,” Shah said. Complicating matters further, poorer women tend to lack the funds to make stockpiles of essential supplies, such as diapers, wipes, and baby formula, all of which have been harder to find since the outbreak.
Despite changes in hospital policies, doulas are wary of offering anything more than virtual help, not least because they lack the necessary P.P.E. “All I can do is support someone via Zoom. It’s very stressful, but I would feel awful if I brought something into someone’s home,” Annette Perel, a doula and lactation counsellor, said. Some of Perel’s colleagues are getting demands for refunds from clients who expected a more hands-on experience. “Some of my friends don’t know when they’ll be able to make a living as a doula again,” she said.
Terry Richmond, a labor doula and childbirth educator, said that even under optimal conditions, helping mothers virtually is challenging. Via FaceTime on an iPad, she supported a client she has worked with before, but she sensed that her looming video presence made the nurses uncomfortable. “When I’m in the room, I’m usually able to build a warm rapport and show that we’re working together,” she said. “It was much harder to win their trust when they thought I was just watching them.” By offering a spare set of reassuring hands, Richmond is usually able to do things that might otherwise fall to nurses. “But my options are basically to say, ‘Nurse, can you please do this?’ It’s a lot more work for them.”
L. & D. units around the city are grappling with staff shortages, with some colleagues out sick and others redeployed to the emergency room. Health-care students and retirees are getting letters from Cuomo asking them to pitch in. Even still, nurses at a variety of hospitals began volunteering last week to give extra support to mothers who were laboring alone. “I’ve had nurses reach out to me saying, ‘We see these women are stressed. Do you have a training program we can take to support them?’ ” Chanel Porchia-Albert, the founder of Ancient Song Doula Services, an organization that offers doula training and full-spectrum doula services for mostly poor women of color, said. She now offers an online “crash course” to give nurses the tools they need to help laboring women, and hospitals around the country are asking for special training programs for their own staff.
The medical staff who do continue to show up every day are under no illusions about their own safety. “All of us are running out of P.P.E.,” Eugenia Montesinos, a midwife at a public hospital and a co-chair of NYC Midwives, said. Her hospital has not offered guidance for how workers should protect themselves while commuting, but she tries to wear a mask on the three trains she takes to get from her home in Brooklyn to her job in East Harlem. She is sixty-three, and, though she suffers from rheumatoid arthritis, she is sewing her own masks and making more for her colleagues. “If we get exposed,” she asked, “who’s going to deliver all the moms?”
David Keefe, the chair of the ob-gyn department at N.Y.U. Langone Medical Center, said that he has seen a number of patients reduced to tears at the sight of all the doctors and nurses who are still coming in every day to make sure the city’s babies are born safely. “I feel very fortunate,” he said, “to be in a profession where the way we deal with anxiety is to worry about other people.”
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