How COVID-19 continues to impact birthing practices

March 5, 2022

Courtesy Kyaira White

(NEW YORK) — As many states relax COVID-19 protocols, birthing practices continue to be impacted by the virus nearly two years after the World Health Organization declared it a global pandemic.

Kyaira White is set to give birth for a second time during the pandemic, with her baby due in late spring.

“I was hoping things would be over,” White, of Ellenwood, Georgia, told ABC News. “I’m just not looking forward to having to have a C-section and have your mask on.”

As a first-time mom, White didn’t know what to expect when she gave birth to her son last year.

“Everything was so new to me,” she said.

Weeks after recovering from COVID-19, she tested positive for the virus upon admission on what she said turned out to be a faulty batch of rapid tests. She said she wasn’t able to see her son in the neonatal intensive care unit for several days until it was sorted out.

“The hospital kind of was just giving me the runaround because they knew I didn’t know anything,” she said.

Much has been learned about the virus in the past two years, particularly around the risk of infection for newborns following delivery, allowing medical associations to update their guidance. However, COVID-19 continues to complicate families’ plans, oftentimes limiting who can be at the hospital and, if a parent tests positive before the delivery, restricting visits to NICUs.

Some hospitals also may still lag on standards of care when it comes to keeping otherwise healthy COVID-positive mothers and their newborns together, which can help foster bonding and breastfeeding, by instead separating them, according to Dr. Lori Feldman-Winter, a professor of pediatrics at the Cooper Medical School of Rowan University and the chair of the American Academy of Pediatrics’ Section on Breastfeeding.

“We understand how to care for mothers and babies during the pandemic, even when mothers present with positive PCRs for COVID,” Feldman-Winter told ABC News. For instance, immediate skin-to-skin contact was something “we weren’t sure about early in the pandemic,” but which the AAP currently recommends, she said.

Varying practices across hospitals means pregnant women should be prepared to advocate for themselves, and that hospitals might need to improve their care practices, according to Feldman-Winter.

“It is shocking, actually, how long it takes to get policies from the AAP into practice,” she said.

Where the latest guidance stands

AAP’s clinical guidance on care for infants born to a mother with a confirmed or suspected case of COVID-19 has remained largely unchanged since May 2021. The organization says that mothers and infants can room-in safely, as long as the mother is well enough.

“The evidence to date suggests that the risk of the newborn acquiring infection during the birth hospitalization is low when precautions are consistently taken to protect newborns from maternal infectious respiratory secretions,” the AAP said.

The Centers for Disease Control and Prevention also note that the latest evidence “suggests that the chance of a newborn getting COVID-19 from their birth parent is low, especially when the parent takes steps (such as wearing a mask and washing hands) to prevent spread before and during care of the newborn.” It advises birth parents to talk to their health care provider about the the “risks and benefits” of rooming-in and shares precautions to take in the hospital. “Having your newborn stay in the room with you has the benefit of making breastfeeding easier, and it helps with parent-newborn bonding,” it says.

The American College of Obstetricians and Gynecologists also advises that COVID-positive mothers and their infants “should ideally room-in according to usual facility policy,” due to the benefits of early and close contact, including “increased success with breastfeeding, facilitation of mother-infant bonding, and promotion of family-centered care.”

“Decision-making around rooming-in or separation should be free of any coercion, and facilities should implement policies that protect an individual’s informed decision,” it says.

The guidance deviates when an infant is in the NICU, where there typically is separation following a positive test, Gail Bagwell, president of the National Association of Neonatal Nurses, told ABC News.

“We cannot risk having moms in the NICU that are COVID-positive because the other babies are immunocompromised,” Bagwell said. “That said, our goal is to not separate moms from their babies. It’s a balancing act between the trauma that the baby could experience from not being with its mother to keeping every other child in that NICU safe.”

In practice

Early on in the pandemic, when much wasn’t known about the virus, COVID-positive mothers would often be separated from their newborns in the hospital. That started to shift in summer 2020 with updated CDC guidance that emphasized the mother’s autonomy in the decision, according to Dr. Melissa Bartick, an assistant professor of medicine at Harvard Medical School who studies breastfeeding.

“Unfortunately, a lot of hospitals had this separation policy, and they never changed that policy,” explained Bartick, who said she continues to hear reports of COVID-positive mothers and their infants being separated.

How long hospitals require COVID-positive parents to isolate before being able to visit the NICU may also vary from 10 to 14 days, Bagwell said.

It’s difficult to assess nationally what hospitals’ policies are currently when it comes to COVID-positive mothers due to a lack of tracking. The CDC’s national survey of Maternity Practices in Infant Nutrition and Care does look at room-in policies, though the 2020 survey did not address COVID-19 specifically, Feldman-Winter said.

“It would be useful to have a survey of exactly what hospitals are doing now with respect to infected mothers and infants, and … if they are separating, why they’re still separating,” Bartick said. “That would be useful to know because that should not be a standard of care right now.”

Hospital policies may be impacted by COVID-19 transmission in the area, their interpretations of CDC guidance and their risk tolerance, Bagwell said.

“Some people have lower tolerance for risk and other people have a higher tolerance for risk,” she said.

Whether a hospital is designated as a baby-friendly facility, meaning it has practices that optimize mother-baby bonding, could also impact room-in policies, according to Becky Mannel, clinical assistant professor at the University of Oklahoma Health Sciences Center and director of the Oklahoma Breastfeeding Resource Center.

“Most hospitals, especially if they were hospitals who were really already trying to follow best practice and keep moms and babies together … I would think that most hospitals are back to doing that,” she said. “We still have hospitals that didn’t have that as routine practice, so it’d be really easy for them to use COVID as an excuse to continue doing what they want to do.”

New moms may also be put in a tough spot trying to decide what to do if they test positive for COVID-19, Mannel said.

“If they’re actually not giving you really all of the current recommendations, have you made an informed choice at a time that you’re extremely vulnerable?” she said.

Kimarie Bugg, president of the Atlanta-based breastfeeding advocacy group Reaching Our Sisters Everywhere, said some moms may be able to advocate for themselves, while others might not have enough information.

“They say, ‘OK, fine, I’ll do whatever you say,'” she told ABC News. “It’s inconsistent.”

With her second baby due later this spring, White is optimistic she will have a smoother experience. She hopes she’ll be able to have her mother, in addition to her husband, with her for support — unlike last year, when she was only able to have one support person.

“Some things are definitely changing, but since COVID it’s been really different and painful. People aren’t even able to get into the hospital at all,” Bugg said. “So many grandmothers I know are sitting in the parking lot while their daughter’s in the hospital because they cannot go in.”

Where guidance goes from here

As more is learned about the virus, that could continue to impact guidance and policies, Bagwell said.

“It depends on what we find out,” she said. “As we learn more about this disease, as it goes from the very pandemic type of state that we’re in now to more endemic, like seasonal flu, I would predict that things would again change more.”

For instance, she said, during certain times of year NICU visitors are limited to just parents due to the flu.

The designs of NICUs — often open bays with multiple infants in the same area — also could have an impact on protocols. Even before COVID-19, there was a push for more family centered care in NICUs, such as private rooms with beds, Bagwell said.

“The newer NICUs that are being built are incorporating more of the single-patient room design into their NICU design,” Bagwell said. “Parents are caregivers and they’re the ones that take the babies home, so we want them there 24/7 if possible.”

The behavior of future variants could also impact guidance, Feldman-Winter said.

“It’s always ‘to be continued,'” she said. “That’s why we call the guidance ‘interim guidance,’ which we look at monthly, really, to see if we need to update or reaffirm.”