Wide-awake in the middle of the night, Angela Magno, eight months pregnant and diabetic, found that only one thing could take her mind off the coronavirus pandemic. With a bottle of Pine-Sol and a bucket of hot water, she repeatedly cleaned her home: wiping baseboards and handrails, washing walls and mopping floors.
As if being pregnant weren’t enough all by itself to make you nervous, covid-19 has raised a brood of scary new questions. Experts acknowledge there are still enough unknowns about the virus and its impact on pregnancy to keep expectant mothers – and their doctors – up at night.
“We are operating in a data-free zone,” said Yalda Afshar, an obstetrician and gynecologist at UCLA Health in Los Angeles. “People are appropriately scared because when we can’t counsel them with good evidence-backed data the unknowns are very intimidating.”
U.S. doctors have been relying to date on small studies from China and hypotheses based on experience with other illnesses to inform their guidance to patients, Afshar said. But she and her multidisciplinary team of colleagues hope to change that in a hurry, as they compile a new national registry of pregnant women and new mothers who have tested positive or are being evaluated for covid-19.
They plan to follow the women and their babies for up to one year, culling data about symptoms and outcomes.
The response to their call for participants has been “incredibly humbling,” Afshar said. Within three weeks of their launch, about 1,000 women have signed up for the Pregnancy Coronavirus Outcomes Registry (PRIORITY), coordinated through UCLA and the University of California, San Francisco (UCSF).
Normally, this kind of project can take a year or more to start providing data, Afshar said, but her team intends to start announcing findings this spring to help doctors coping with the void.
While awaiting more certainty, researchers and front-line obstetricians have been advising patients as best they can and adapting policies as new evidence emerges. Several paused to respond to some of the most frequent questions they are hearing from worried pregnant women.
What can I do to protect myself and my baby while I’m pregnant?
Major national health organizations advise that pregnant women take the same precautions as everyone else. The American College of Obstetricians and Gynecologists (ACOG) says you should:
Avoid anyone who is sick.
Stay home as much as possible.
Stay at least six feet away from other people.
Frequently wash your hands with soap and water, for at least 20 seconds.
If you cannot wash, use a hand sanitizer containing at least 60% alcohol.
Avoid touching your eyes, nose and mouth.
As of April 3, the Centers for Disease Control and Prevention (CDC) has been advising that everyone, including pregnant women, also cover their nose and mouth in public with a cloth face mask.
In New York, Silvana Vergara, who is 22 weeks pregnant, said she and her husband took every precaution – working from home, avoiding public transportation and wearing gloves and masks – yet both still caught the virus. Coughing “24/7” and short of breath, she said she called the emergency room at her hospital but was informed that they didn’t have any tests. It was only after she made a second call to the same hospital’s maternity ward that she was told to come in, was tested and was also reassured. “I just want everyone to know how contagious this is and how unprepared our medical system is,” she said.
While pregnant women have no special tools to fight the virus, they may reap extra benefits from being more vigilant, since doing so also protects them from influenza and other contagious diseases.
“The quarantine is kind of working out for me,” said Sharon Devendorf, a Dallas marketing consultant who is 37 weeks pregnant. Disappointed that she had to host her 42 baby shower guests on Zoom instead of in person, Devendorf said she was also grateful for having to shelter at home earlier than planned, thus avoiding co-workers who might be ill, adding: “As it was, I was worried about every little cough or sneeze.”
Does being pregnant put me at more risk of complications from covid-19?
There’s some encouraging news on this front. Pregnant women are unlikely to suffer more severe effects than anyone else from covid-19, according to an April 9 study in the American Journal of Obstetrics & Gynecology MFM. The report involves the largest U.S. sample of its kind to date, with researchers having observed 43 pregnant women diagnosed with covid-19 at two New York hospitals. The breakdown of the severity of the cases closely resembled the pattern for patients who are not pregnant, with 86% of cases being mild and only 14% severe or critical.
Still, that’s no reason to throw away the masks, particularly since other research suggests that pregnant women hospitalized for severe or critical cases of respiratory illnesses including covid-19 infection may be at greater risk of pregnancy complications. A new meta-analysis combining a variety of studies of the severe acute respiratory syndrome (SARS), the Middle East respiratory syndrome (MERS), and different types of coronavirus infections among pregnant women suggested that in severe cases, most of which included pneumonia, these illnesses can cause greater risks of pre-term births, preclampsia, C-sections and perinatal death.
What should I do if I get covid-19 while pregnant?
Once again, major U.S. health organizations offer no separate guidance for pregnant women other than to stay in close touch with their doctors. The CDC guidelines for anyone infected with the virus say you should:
Stay home except to get essential medical care.
Avoid public transportation.
Consult with your health-care team by phone before going to the office.
Get care right away if you feel worse.
Separate yourself from other people in your home.
Wear a face mask whenever you are with other people.
If I do get the virus while pregnant, will I give it to my baby?
Mother-to-child transmission of coronavirus during pregnancy is unlikely, according to the CDC. The virus has not been detected in amniotic fluid, and none of the babies in the recent New York study tested positive immediately after birth.
Doctors had worried about reports that some babies in China had tested positive for the virus shortly after birth, yet it is still unclear when those babies became ill, said Neil Silverman, an expert on obstetric infectious diseases at the David Geffen School of Medicine at UCLA. In this case, experience with other illnesses is promising.
“As a respiratory disease, the coronavirus is different than HIV and hepatitis B, both of which carry risks of high levels of virus in the mother’s bloodstream that can pass the infection from the mother to the baby,” Silverman said. He added that a “big takeaway” from the latest information is that “there is no evidence of direct fetal infection or birth defect due to this virus.”
Should I see my doctor less often while I’m pregnant?
Delivering babies is still considered an essential service – but yes, experts say that as long as you and your future offspring are in good health, you can and should – for the time being at least – skip several of the conventional once-a-month in-person appointments, keeping in touch with your doctor instead by phone and online. This will minimize your risk of catching the virus.
“During the covid-19 pandemic, we’re advising women with low-risk pregnancies to come in at about 12, 20, 28 and 36 weeks,” said Vincenzo Berghella, director of the Maternal-Fetal Medicine division at Thomas Jefferson University in Philadelphia and editor in chief of the American Journal of Obstetrics & Gynecology MFM.
“Pretty much every one of our obstetrical provider colleagues has dramatically decreased the amount of in-person prenatal care visits,” Berghella said.
Afshar, at UCLA, said many doctors’ offices throughout the country have come up with new protocols to protect expectant mothers’ health.
“We ask women to come by themselves to the prenatal visits, and we check their temperatures when they arrive,” she said. “We also space out visits and let them wait in their cars until we call them in, so they don’t have to wait in the waiting rooms.”
For pregnant women without access to a primary health-care provider, Planned Parenthood, which offers prenatal care up to but not including delivery, recently announced it is expanding telehealth services to all 50 states.
Wouldn’t it be safer to give birth at home?
No, warns the ACOG, which notably is not an indifferent party. Even when not amid a pandemic, the safest place to give birth is in a hospital or hospital-based birth center or accredited free-standing birth center, where professionals and appropriate technology are available in case anything goes awry, the organization says.
International studies have found that home births with professional midwives can be just as safe as hospital births for women with low-risk pregnancies – meaning, among other things, no high blood pressure, diabetes, or previous C-sections. Still, those conditions often don’t apply to the estimated one-fourth of all home births that are unplanned.
Research promoted by the ACOG has found that giving birth at home is linked to a twofold risk of perinatal death and threefold increased risk of neonatal seizures or “serious neurological dysfunction.”
Other research suggests that many women who plan to give birth at home still end up in the hospital. One meta-analysis found that between roughly 10 and 32% of women attempting home births are hospitalized due to reasons including postpartum bleeding and fetal distress. What’s more, giving birth at home can be more painful, without top-of-the-line anesthesia, and may be more expensive because insurance plans may not cover it.
The total number of U.S. home births is still small – just about 35,000 per year, or less than 1%, but it has been rising in recent years. The pandemic could offer an additional boost, as advocates argue that home births could help protect low-risk mothers and babies and relieve the stress on hospitals crowded with covid-19 patients. ACOG advises that any women considering giving birth at home should first talk to their OB/GYN about the risks and benefits.
What about a C-section?
Not unless it’s medically justified, says the World Health Organization. And testing positive for covid-19 isn’t by itself a justification.
Silverman said a C-section might be unavoidable for a pregnant woman who was so severely ill that she required mechanical ventilation. But offering a C-section to try to minimize the chance of an infection was not a good idea, he said, adding that it often required a longer hospital stay for the mother.
Should I consider induced labor?
ACOG guidelines say that women can be induced artificially, with hormones or other treatment, for nonmedical reasons after 39 weeks, one week short of a normal term. This question might arise for women who live far away from a hospital – or who want to have their babies and leave before an expected surge of women testing positive for the virus. But the ACOG warns that inductions carry risks that include infecting the mother and fetus, rupturing the uterus and making a C-section more likely.
Doctors who have debated the question say elective induced labor at 39 weeks can be a safe option for healthy women, and many insurance plans will cover it.
Can I have a support person with me during my labor?
In the first panicked weeks of the pandemic, some hospitals barred all visitors from delivery rooms, infuriating many parents-to-be.
That harsh rule has since been overturned. Magno, who gave birth at the UCLA medical center, said her baby’s father could stay with her during the delivery, although he had to leave two hours later. Some variant of that limit is now standard practice for many hospitals, said Silverman at UCLA. Women are limited to just one support person, be it a spouse, relative, friend or doula, who will be given a mask and told to stay in the room for the duration – no pacing the corridors. In most cases, hospitals also will not allow postpartum visitors.
At UCLA and elsewhere, Afshar said hospitals are trying to soften the effect of their newly strict rules by having nurses spend more time with the expectant mothers and by discharging patients sooner than normal, providing they are stable.
How can I feel safe while giving birth in a hospital crowded with coronavirus patients?
Hospital directors throughout the country have been working overtime on this question, even while coping with the notorious shortages of diagnostic tests and personal protective equipment (PPE) for providers, Silverman said.
“For deliveries, we have always worn standard surgical masks, face shields and gloves,” he said. “What’s a little different now is that everyone in the hospital is wearing standard surgical masks.” At the UCLA hospital and many other facilities, expectant women enter the hospital through a door far away from the emergency entrance and are immediately given a mask to wear.
At Sibley Memorial Hospital in Washington, maternity patients enter through the front door, avoiding the emergency room, and they must then be buzzed through to the labor and delivery unit, said Constance Bohon, an obstetrician-gynecologist in the District. Bohon said all obstetric patients are masked until their covid-19 test results are available, typically within two to four hours. All providers and staff in labor and delivery units wear masks at all times, and both masks and face shields are used by anyone within six feet of the patient when she is in the active stage of labor.
Many U.S. hospitals now require that all incoming patients have their temperatures taken and symptoms screened at the door.
As tests for the virus become more available and in more common use at metropolitan hospitals, some doctors urge they should be standard practice everywhere.
“This is a hot topic among hospitals now,” said Char-Dong Hsu, chair of the Wayne State University Obstetrics and Gynecology Department in Detroit. Similarly to the population at large, as many as eight out of ten pregnant women who have covid-19 may be asymptomatic yet contagious, he noted, meaning they could pose an extra danger to other women and providers if they aren’t identified.
How will my delivery be different if I have the virus?
Typically, hospitals now have special isolation rooms for women in labor who have tested positive for covid-19, Silverman said. Some are equipped with “negative pressure,” meaning that the ventilation system is sealed off from the rest of the building.
Hospital policies vary throughout the country, but in some cases, due to the risk of infection for babies, new mothers testing positive for covid-19 may be separated from their newborns for up to two weeks, Silverman said, with the separation ending once the test comes back negative.
This too is controversial, given the many benefits of skin-to-skin contact between a mother and a newborn. The CDC says such separations should be made on a case-by-case basis, with input from both the mother and health-care providers. Factors that should be weighed include the likelihood of healthy breast-feeding and whether the newborn has tested positive (which would make separation unnecessary).
Should I breast-feed?
Yes, if you can, is the mainstream consensus. Breast milk is still the best source of nutrition for most infants, according to the CDC, and it helps protect against many illnesses. That initial close contact between mother and newborn also helps babies thrive.
If a mother has tested positive for covid-19, she doesn’t need to worry about infecting her baby with her milk because research suggests the virus doesn’t appear to be transmitted that way. But she will have to take special care during feedings, making sure she wears a mask and has washed her face and hands.
Many doctors are encouraging women to buy a breast pump, which is covered by most insurance plans, and it can be used if the mother tests positive for the virus and needs to limit contact. Expressing breast milk also helps establish breast-feeding and maintains your supply.
Besides deep-cleaning my house, what can I do with all this stress?
“Stress and anxiety in general is never good for anyone, and all of us are feeling it to varying degrees right now,” Silverman said. While stress doesn’t appear to increase complications such as hypertension, he said, he is encouraging his patients with histories of anxiety to consider counseling and advising them that the majority of anti-anxiety medications and antidepressants can be taken safely during pregnancy.
The ACOG website includes a breathing exercise for expectant mothers coping with stress: Breathe in for 4 seconds, hold for 7 seconds, and breathe out for 8 seconds. Repeat three times.
It’s something that may come in handy again over the next 20 or 30 years.
Ellison is the author, among other books, of The Mommy Brain: How Motherhood Makes You Smarter.”