Cleo’s co-founder Chitra Akileswaran, MD, MBA offers her thoughts on the implications of policies excluding partners from the labor room.
Around the world, pregnant families have questions about whether support people will be allowed during labor considering COVID-19. Hospital policies are in flux, and we’re seeing everything from “business as usual” to total bans on even partners in the birth room. Expecting parents are understandably upset, and there has been significant backlash against the most restrictive policies. Below, Cleo’s co-founder Chitra Akileswaran, MD, MBA offers her thoughts on the implications of policies excluding partners from the labor room.
Labor rooms are unique settings that attempt, at once, to create a calm, soothing environment for a normal process to occur while making room for the worst-case scenario. Pastel wallpaper juxtaposes against ICU-style monitors that keep minute-to-minute tabs on the health of moms and babies. Birthing tubs sit within bathrooms that have been sterilized to regulatory standards. And within nearly every labor room I’ve seen, a chair (or two) converts to a bed, assuming that a partner or support person will be living and breathing next to that birthing parent through day and night.
In light of COVID-19, several prominent health systems have issued policies to not permit a laboring person to have a single support person with them. This not only places an undue burden on the person in labor, but also on their care team and the healthcare system. As the responsibilities of healthcare professionals increase, especially in the midst of a pandemic, I will certainly be looking increasingly to a birthing person’s doula, partner, or support person to be another spokesperson for that patient. I cannot tell you the number of times a support person has come out of a room to say that someone is feeling an urge to push, is nauseous, or even just that a machine is beeping.
Frankly, without bringing support people with them, most birthing folks simply won’t get the support they need. The reality of traditional hospital birth is that you may see me, your obstetrician, for a few minutes throughout the entirety of the process and no more. Physicians are attending to many other patients and handling high specialization tasks (e.g. surgery). While the labor nurse is often at the bedside, caring for someone in labor, they are also responsible for the medical aspects of their care — monitoring parent and baby, administering medications and IV solutions, charting and reporting on progress, and communicating with the care team. Ninety percent of their energy is on activities other than emotional well-being. Nurses aren’t even in the room all the time during labor. The somber image of a person laboring by themselves could be the reality for many.
There are few childbirth interventions proven to help people have a vaginal birth, avoid unnecessary interventions, and feel positive about their birth. Continuous birth support — having a person with you who is focused on supporting you emotionally and physically throughout labor and birth — is one of the evidence-based ways to achieve these outcomes. As a result of dismissing this evidence in the name of public health, I believe we will be trading one theoretical short-term gain for a longer-term loss: increased birth-related interventions including unnecessary cesarean births.
Without the support of a trusted person by your side, I can imagine we will see more use of epidurals to cope with the stress of labor, more need for medical interventions in labor (labor tends to go awry when birthing people are under stress), and ultimately, more cesareans, which all use up more resources than is required. Cesareans in particular mean more extensive care teams (Anesthesia, operating room staff); the use of operating rooms, which will then have to be sanitized; more personal protective equipment by this larger care team (masks, gloves, gowns, eye protection, soap); as well as all of the tools required for surgery. On the other end of this, families will face longer postpartum recovery both in the hospital and at home, with likely less social support.
We cannot afford this myopic, non-data driven policy at a time when we are trying to conserve as many healthcare resources as possible.
This policy could lead to more birth-related trauma, postpartum depression, and anxiety. One of the critical functions that a support person plays during labor and birth is being the eyes and ears as well as advocate of a birthing person. Birth can be a challenging and sometimes even traumatic event, at times activating past memories related to a lack of control or violence against one’s body. The reality is that the vast majority of women have experienced some sort of violation of their bodily autonomy: in the US, more than 80% of women have experienced sexual harassment and 1 in 5 women have been sexually assaulted in their lifetimes. Having someone who is willing to advocate for you during a process that is deeply vulnerable is critical to feeling empowered throughout it.
I also am concerned about the impact on informed consent. Support partners often play the role of asking questions and representing the birthing person to ensure their wishes are being followed. Without someone there who can think straight and isn’t experiencing the physical intensity of labor, it is very difficult to imagine that birthing people will feel they were able to weigh pros and cons of decisions before they are made. Obstetrics is an inherently litigious field in the United States, and many legal actions taken by families are explained by a lack of shared decision-making that must occur during the uncertain course of labor and birth. Without a support person in the room, it is unclear whether obstetricians and care teams will feel comfortable communicating the most personalized, safest recommendations to a birthing person, rather than simply taking a defensive approach.
Taking this one step further, one could frame a lack of personal support during childbirth as an anti-women, misogynistic step backwards. We used to isolate and sedate birthing women up until the 1970s in this country, as part of a paternalistic sentiment that women couldn’t “handle” the emotional and physical difficulties of childbirth. While we require families to do their part for the greater public’s health, we still must hold what is sacred to us as human beings. Acknowledging that the beginning of life is as much a spiritual, emotional, communal, and fundamentally human event as much as it is a medical one is not something that the healthcare establishment has traditionally been very good at. Policies such as this one surface this tension, and reinforce distrust in our healthcare system.
Cleo has heard from several concerned families in the past week asking for guidance about when and whether to switch to a home birth in response to the fear that their birth preferences won’t be honored under hospital policies and out of fear that they and their newborn will be exposed to COVID-19. In non-US settings, there is sound evidence supporting home birth as a safe option for low-risk pregnancies. But in many cities in the US, where home birth is not an integrated choice within our healthcare system, it should be a thoughtful, intentional decision made in collaboration with an experienced home birth provider. Going this route means actively seeking care outside of our current model of birth, which assumes you may need interventions including pain medications and other medications to help move labor along. You likely belong in a hospital if you subscribe to this idea and do not want to face the possibility of transferring to a hospital in order to receive anesthesia or urgent interventions.
The institution of home birth is built upon a trusted relationship between a birthing person and their midwife; a trust that is built over time and forms the foundation for understanding the benefits and risks. Not only is it important to vet the varied qualifications of home birth midwives, but also form that relationship with them to weather the challenges of birth as a team. That trust allows you to take on the very intense reality of a home birth knowing that you have what it takes to come out on the other side (and you absolutely do!). What we see now is more of a scramble of sorts to access homebirth midwives and create this as a “backup” plan. However, home birth should not be treated as a “Plan B” in the event that your hospital gets full, is under quarantine, or can’t accommodate you.
While visitor restrictions in theory make sense in response to this overwhelming and growing pandemic, let’s also not forget that healthcare facilities represent more than just the sick. They represent the joyful beginnings of life, the reflective ends of life, and a wide range of fundamentally human experiences in between. Health system leaders, in doing their best to curb COVID-19 transmission among their staff, patients, and larger community, must also consider an optimistic view: that their hospitals will outlast this virus, and must continue to hold space for those things which we consider paramount. Ensuring the safest, most dignified beginning for each and every new family is one of them.
Chitra Akileswaran, MD, MBA is a physician and entrepreneur. She is the Co-founder of Cleo and serves as Chief medical Officer. Dr. Akileswaran is a Board Certified Obstetrician Gynecologist and is currently a Strategy and Operations Lead at Highland Hospital within Alameda Health System, a Level 1 Trauma Center in Oakland, California. She holds a Lecturer appointment at Harvard Medical School. She previously worked Kyruus, Inc. and McKinsey & Company. She received her undergraduate degree from Brown University, an MD from Harvard Medical School, and an MBA from Harvard Business School. She lives in San Francisco with her husband and son.
Cleo aims to give the most accurate information about COVID-19, but details and recommendations about this pandemic may have changed since this story was published. For the latest information, please check out resources from the WHO, CDC, and local public health departments.