By Louise P. King and Neel Shah
Among pregnant people and those who love them, the past few weeks have been especially confusing and anxiety-provoking.
As the new epicenter of the COVID-19 pandemic, New York City hospitals temporarily restricted pregnant people from having a birth partner present during labor, a move that stoked international outcry and a vocal community response. Following a Change.org petition that rapidly amassed more than 600,000 protesting signatures, Governor Cuomo responded with an executive order, stating via a spokesperson, “[i]n no hospital in New York will a woman be forced to be alone when she gives birth. Not now, not ever.”
Both of us are obstetrician/gynecologists who have dedicated our careers to supporting the reproductive health and rights of those we are entrusted to care for. We are trained in health law policy and bioethics. And while we support the strong show of support for laboring women and their rights, we believe the Governor’s decision to mandate all New York hospitals allow birth partners — irrespective of the local case rate of COVID-19 or hospital capacity to test for infection or protect health care workers — is uninformed and unethical.
My favorite thing about being an obstetrician is watching families meet their baby for the first time
Doulas are among my greatest professional mentors
I’ve published evidence on how labor support improves safety and dignity
…and I worry this policy may be ill-considered https://t.co/Ofj1LuNW5W
— neel_shah (@neel_shah) March 28, 2020
Hospitals did not come to this decision lightly. It was not driven by a business case or public relations opportunity — in fact, as the public reaction and Governor’s intervention indicate, quite the opposite. Rather, it was a wrenching decision to keep patients, hospital staff, and communities safe under extraordinary circumstances that have turned medical centers into war zones with mass casualties.
At the time when the executive order was issued, New York City’s Mount Sinai Hospital had over a dozen members of their labor and delivery staff under quarantine, infected by COVID-19 and unable to work. New York Presbyterian-Columbia University Medical Center has seen multiple previously asymptomatic laboring patients acutely decompensate and require intensive care due to the grave effects of COVID-19. Due to well-documented delays from the Trump administration in securing supplies, neither facility had adequate personal protective equipment. And both were still weeks away from experiencing the peak of expected cases.
Notably, the executive order requires hospitals to mitigate risk by screening for COVID symptoms: “Hospital staff must screen the support person for symptoms of COVID-19 (e.g., fever, cough, or shortness of breath), conduct a temperature check prior to entering the clinical area, and every twelve hours thereafter, and screen for potential exposures to individuals testing positive for COVID-19.” This is in keeping with recommendations from the World Health Organization.
However, given the indolent nature of this virus, at least one in four infected people do not have symptoms at initial presentation. In some cases, this asymptomatic incubation period may last weeks. The screening described above could easily miss these cases and lead to further spread of infection. In fact, the large number of asymptomatic carriers is one of the main rationales behind social distancing and statewide lock-downs across the country. Even with widespread testing, the false negative rate is high enough that cases could be missed.
Importantly, most labor and delivery providers are not wearing N95 masks, although ACOG has recently called for a change. Our labor and delivery providers may be at unique risk of infection due to the multiple sources of exposure — not just air and droplets, but fluids and surfaces. One goal of the original policy banning support partners was to decrease that risk in New York where they are experiencing a surge. One postpartum nurse has already died. If the surge continues as projected, many labor and delivery providers will be infected and more may die.
In addition, there are risks to newborns and to mothers that we don’t fully understand. At first we thought vertical transmission was unlikely. Now we believe it is possible, and one infected 6-week-old-infant has died. Although an individual and her partner might be able to assess these risks and determine that they would still prefer to take them on, this does not account for the risk to other women and to providers on the labor floor.
By singling out pregnant people, the Governor’s executive order also seemingly fails to recognize the wider array of necessary triaging decisions that are already being made. Surgeries are being labeled “nonessential” and getting delayed, cancer patients are being deprioritized for treatments. All people requiring health care are affected. Just as there are heartbreaking stories of people birthing alone, there are heartbreaking stories of people dying alone. Sadly, hospitals are not in the position of choosing between good options. They are instead tasked with choosing the least bad option for the most people. Overriding this principle based on political pressure rather than scientific realities is unjust.
The intention of these drastic measures is to buy all of us the time we need to decrease the number of people who are severely infected at once, and ensure hospitals have adequate supplies of tests, protective equipment, and life-saving treatments. All of these measures could have been in place months ago. It was the failure of public leaders to make difficult decisions soon enough that led to the dire conditions that New York City is currently experiencing. As we write this from Boston, we are approximately 10 days behind New York City. It is likely that in the days ahead, other hospitals across the country will need to make difficult decisions as well.
Managing a global pandemic is the ultimate collective action problem. Faced as we are now with absurd shortages of necessary supplies, equipment, and testing, we must ethically ration. We are rationing not only masks and protective gear, but also our most precious resource, our trained and talented health care workers themselves.
Allowing hospitals to make difficult decisions when deemed temporarily necessary does not represent a failure to recognize the individual suffering faced by women giving birth without their partner of choice. We are grateful for this sacrifice, as we are grateful to the providers who continue to put their own well-being at risk to provide the best care they can. With empathy for these sacrifices, and bravery to do what is necessary, we will get through this together.
Louise P. King MD, JD is an affiliate faculty member at the Petrie-Flom Center, assistant professor at Harvard Medical School and director of reproductive bioethics at the Harvard Center for Bioethics
Neel Shah, MD, MPP is an affiliate faculty member at the Petrie-Flom Center, assistant professor at Harvard Medical School, and Director of the Delivery Decisions Initiative at Ariadne Labs.