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How COVID-19 Could Permanently Impact Birth for Western Women

  • Writer: AgeOldeBirthing
    AgeOldeBirthing
  • Apr 12, 2020
  • 17 min read

And how it, and other deleterious effects of the disease, will decrease our birth-rate to dangerous levels



In the wake of COVID-19, and what most are dubbing ‘unprecedented times’, stand the approximate 160,000 US and UK women forecast to give birth within the next 30 days. What will birth look like for these women in a time where hand-shakes and hugs have been deemed too excessively risky to EVER return [1], and are expected to deliver, potentially sporting open wounds, in supposedly ‘overworked’ hospitals ‘crammed’ with ’highly infectious’ COVID patients? [2]


You guessed it- panicked.

And, yes, that statement itself deserves a trophy for the most understated statement to have ever been stated.


The CDC and NHS have contested that pregnant women are at ‘higher risk’ [3][4] for developing COVID-19 due to an inherent increased susceptibility to respiratory infections and a generally dampened immune system; thus, hospitals in the USA and UK have begun implementing new policies for birthing women to mitigate the risk of infection and becoming a vector for the pathogen. It just so happens (surprise surprise) that these policies are a blatant and dangerous violation of a woman’s right to medical autonomy, boasting such draconian measures as: forcing women to birth in complete isolation [5]; and mandating epidurals (strong pain relief known to include opioids and increase risk of caesarean) to ALL labouring mothers [6]. Not only will women now receive the privilege of transitioning into motherhood dosed into oblivion in a completely isolated, padded cell, but if they are even SUSPECTED of being infected, could get away without having to even TOUCH their child for weeks! [7] What a result!


Despite the fact that no currently available test for COVID has a particularly high accuracy rate [8], the CDC has mandated that all mothers who are confirmed or suspected of infection should be isolated from their infant, with exceptions considered on a case-by-case basis [9]. If hospitals do not have the capacity to completely isolate these mothers, the Board says that alternatives should be employed- namely: the use of barriers (curtains/ screens) to reduce contact, to employ the necessary means to keep the baby at least 6ft from the mother, and full PPE equipment provided given that the mother needs to handle her infant in the instance that no other “healthy family member” or “medical professional” can tend to it. [10] Translation: skin to skin contact is a mortal sin.


But wait- it doesn’t end there! Mothers who “choose” to breastfeed (as if nourishing an infant is a choice) should be encouraged to mechanically express her milk into a sanitized bottle for numerous nurses to feed the child, towering over them in full-body PPE like a giant blue tootsie roll. (I’m sure those babies will sleep like a dream.) In some instances, a mother may be allowed to feed her child at the breast; however, it necessitates a chesticle acid bath and agreement to an extensive blood contract. I mean, that’s essentially the same thing as ferociously sanitizing your breasts in a desperate attempt to provide food for your child and catch a possible glimpse, through a curtain, of their little toe… right?


There is, however, a light at the end of the tunnel for these mothers; once they test negative for COVID, they will be pardoned and allowed to move their (now perfected) mother-infant distancing routine to their household- at the approval of a medical professional, who can rightfully detain the infant if and when they deem it necessary. [11]


Scathing humour aside, the current medical situation for birthing women is absolutely, unimaginably diabolical and works in opposition to established research suggesting that the very inverse measures would produce the best outcomes in terms of prevention of infection of the mother and newborn.


First and foremost, the Cochrane review (2017) found that continuous labour support, provided by a husband and/or doula, resulted in a 39% reduction in caesarean rate [12]; this is significant because it could potentially reduce the exposure a woman has to infectious diseases by reducing the necessary hospital stay and surface area of open wound exposure. That is without mentioning the inherent risk that surgical procedures may provide to any patient during a pandemic outbreak. Not only did continuous support reduce caesarean rate, but also other interventions (like those mandated epidurals) which could extend the length of labour and increase the likelihood of invasive surgical procedures (such as episiotomy); it found a marked decrease in the use of all pain medications and augmentations, and an increase in vaginal births and short labours. Overall, it would be logical to assume that the potential risk posed by a support person attending a woman’s labour would be less incidental (especially with the use of PPE) than the risk posed to a woman, without support, contracting an infection due to the increase in labour length, intervention, augmentation, stay time and potential surgeries of various kinds.


Secondly, there needs to be a drastic reconsideration of infant-mother separation with emphasis on the capacity for said interaction to boost the immune systems of both mother and child. It is well established (admitted by the WHO) that breastfeeding is the best immune support available for infants in its capacity to prevent infection and build the immune system. The Journal of the American Osteopathic Association (2006) specifically touted the benefits of breastmilk in preventing respiratory infection among infants [13]; it is known that breast milk provides an infant with all 5 forms of antibodies, including (in the highest proportion) secretory IgA which is present in the respiratory system of adults to fend off infection. Formula-fed babies have immense difficulty in fighting off respiratory infections until they can produce IgA on their own, which is not for many weeks (or potentially months) after birth. [14] Given that a mother’s breast milk adapts to provide proportionate amounts of immunoglobins to fight her infant’s infections, the mother becomes equally as protected as the infant since the immunoglobins are produced en masse in her own system before relaying to her baby. [15] And if that wasn’t enough to convince you, breastfeeding also decreases a mother’s likelihood of developing diabetes, heart disease and high blood pressure- all of which are associated with increased risk of infection from COVID-19.


The measures suggested by the CDC, and implemented by many maternity wards, dramatically decrease the likelihood of successful breastfeeding. Mother-infant separation, a lack of skin-to-skin contact, a lack of sight of the infant, lack of ability for the infant to immediately establish its latch and the inability to bond immediately after birth all pose an enormous threat to a woman’s milk supply. Stress and anxiety can also take a heavy toll on said supply- and there is no denying an abundance of that in current times. It is then extremely likely that the vast majority of separated infants will receive some amount of formula milk, especially given that as low as 20% of mothers “choose” to breastfeed, leaving up to 80% of infants all the more susceptible to potential infection [16] - add to that the number of infants whose mothers will ‘fail’ to produce due to the aforementioned reasons, and we could see numbers exceeding the 80-90 percentile range within hospitals. That, combined with the potential of tens of different nurses (and sources of infection) feeding a single infant over their multi-week hospital stay, necessitates that we question whether these new guidelines are actually supposed to encourage infection- because they certainly don’t seem as if they will achieve the opposite.


Surely, given all the established data, it would make the most sense for these institutions to actively work at providing safe home-birthing (or birth centre) opportunities for labouring women? It is undeniable that a woman labouring with support, in a comfortable environment and without unnecessarily forced interventions, will have better outcomes both in terms of her susceptibility to infection and birth outcomes for mother and baby. Surely, if social distancing truly is necessary to prevent infection, it makes the most sense to continue distancing and provide each woman access to a medical professional within their home, thus limiting their exposure to potential sources of infection to 1? Surely, with already overburdened hospitals, taking patients who can be treated out of the hospital and supporting them in a confined space (with the use of PPE) would benefit both mothers and hospitals?


I can already hear it- the unbridled belly cries of the pro-pharma classification: “You bigot, advocating for women’s health and medical freedoms when SO many women have no choice and HAVE to be treated at hospitals!! What about the victims?”


Aside from the ever-necessary novella-length tangent regarding innumerous preventative measures potentially employed to reduce the appreciating rate of high-risk pregnancies (most easily characterised by obese, diabetic and hypertensive mothers) that is calling my name, this is easily addressed with simple statistics. With approximately 8% [17] of all pregnancies classifying as high-risk at term, 92% of mothers are potential candidates for homebirth; this closely corresponds to the WHO admission that caesarean rates should rest at an approximate 10% (not the current >30% average).[18] If only 10% of all mothers (including a generous 2% for low-risk emergency caesareans) required surgery in the next 30 days, then ~16,000 mothers would need to be treated in hospitals (USA = 10,000, UK = 6,000). This is NOT an unmanageable number by any stretch, amounting to 13% of average total monthly caesareans in the US & UK in 2018. [19] Even if the number of transferred homebirth mothers pushed that caesarean rate to 20%, it would still be more than achievable. Surely it would be entirely conceivable that mobilised labour and delivery units could attend multiple homebirths per day (aided by the shorter labour duration of non-induced and emotionally supported mothers) with elected surgeons to complete surgical delivery in hospitals for the minority who require them? Surely it makes sense for effective treatment of the overwhelming majority of low-risk mothers to take precedence in a global pandemic where mitigating infection appears to be the top priority? Instead, draconian policies are enforced upon ALL labouring women due to an unnaturally and unnecessarily inflated rate of surgical and intervention assisted births creating the illusion that homebirth (or birth-centre birth) is a fantasy for a minority of women.


Do you see where I am going with this? No Manchurian policy is going to protect women and babies from infection any more than adequately addressing the already abhorrent state of the birth industry; and, in this situation, bringing birth home may just remedy both conundrums.


Despite mine, and many others’, enthusiasm in advocating for a paradigm shift in this current state, it is evident that both the privatised US and socialised UK medical systems have other ideas.


In the US, many medical insurance providers will not cover homebirths or birth centre births- there have been cases of providers relinquishing that rule in recent weeks, however it is still disallowed for many women. With the average homebirth midwife costing $5000 out of pocket, the likelihood of women switching care is extremely unlikely given that 16 million [20] (and counting) Americans have filed for unemployment due to widespread business shutdowns, with no clear indication of the return of financial stability.

In the UK, the NHS (paid for by the people’s taxes) have banned homebirths attended by an NHS registered midwife [21] despite a surge in demand due to the pandemic. Furthermore, many hospitals cannot guarantee ambulance back-up should a mother require emergency hospitalization, which dramatically increases the chances of fatality. Once again, private midwives are an expense that most cannot afford in unstable financial times.


So what does this mean? It means that the majority of labouring women are now faced with 2 options:


  1. Birth in a hospital, under the potential threat of all the aforementioned policies and fear of deadly infection;

  2. Birth unassisted at home.


As an advocate for planned unassisted homebirths, I am not here to stand on my soapbox and tout the ‘dangers’ of birth without the presence of a medical professional; however, I AM concerned that the rising levels of fear, anxiety and nonsensical hospital policies are forcing women to birth unassisted without education, and, in many cases, with little to no planning. An unplanned, unassisted home birth could be a disaster waiting to happen, given that the majority of women know so little about pregnancy and birth that they could not tell you the role of the cervix, let alone how to manage a post-partum haemorrhage. Education is absolutely essential in ensuring a positive birth outcome, despite the common belief that women’s intuitions are enough to guide her- we are so far from our natural state, and so enshrined in inaccurate societal perceptions of birth, that intuition alone will simply not cut it. Some birth workers, like myself, have sought to provide free (or very affordable) information and support regarding planning an unassisted homebirth, however our reach is limited, and it is grossly naïve to expect either US or UK medical systems to release any information (after all, where is the profit in that in comparison to mandated epidurals and a potentially inflated caesarean rate?) This leaves a considerable percentage of near-term mothers indescribably vulnerable, teetering on the edge of what is perceived to be a potentially life-threatening decision either way.


(My free Freebirth 101 information packet)


Alternatively, choosing to birth in a hospital is an option which is becoming increasingly undesirable. With many birth workers already noting a marked increase in clients opting for ELECTIVE induction and caesarean section in response to mounting fear, it is wise to predict that the potential extra burden on both systems could well lead to additional policies, such as the mandatory epidural dictate, to increase efficiency and turnaround times. Ironically, many say that opting for induction or caesarean was an attempt to curb the likelihood of birthing in a hospital under stricter provisions or at the height of infection, all the while placing themselves and their children at a potential higher risk due to a lack of education, information and support offered to them by providers.


Many will be questioning why these new measures and policies warranted me writing such a droning monologue- after all, isn’t it simply a necessity for the duration of this pandemic? Surely this can’t have lasting impacts on the rights and freedoms of birthing women?


I’m not so sure.


Officials have already touted an estimated minimum duration of 18 months [22]- and that is IF a vaccine is approved for release at the end of that time-frame; it has the potential to last for longer given that the proposed vaccine is a new kind which has never before been fully tested. Even with the advent of a vaccine, there is no promise that the threat of this pandemic will decline; it is already predicted that yearly occurrences of COVID-19 will present, just as the cold and flu season does. [23] With a touted R0 value much higher than the flu, it is not a stretch to say that hospitals may become overburdened and strained every year from here-on-out unless a great effort is made to build more and more facilities (and with a threatened economic crisis, how likely is that looking?) The focus within hospital facilities, for at least the next 18 months, will be on mitigating the spread of infectious disease; beyond that point, it is illogical to assume that these new policies will be revoked and invoked repeatedly per annum at the dawn of a new outbreak- that is to say, they will more likely be made permanent. This, alongside the fear of increased potentiality for new pandemics arising more often [24], points to this moment as being a defining paradigm shift in the care of pregnant and labouring women (accelerating at breakneck speed towards complete remission of medical autonomy.)


Not only do I fear for the autonomy of women birthing in a medical facility, but also the reputation and subsequent legality of homebirth. A rise in intervention-laden hospital births will proportionately lead to an increased interest in alternative birthing modalities; namely homebirth (assisted or unassisted). Normally I would praise this fervently, however the unlikely provision of educational material and lack of professional assistance leaves the reputation of homebirth an easy target; with many women taking birth into their own hands completely unaware of the potential threats and how to handle them, the potential for fatality is increased. With an increase in negative outcomes, one can expect harsh restrictions to be placed upon expecting mothers’ rights to birth at home. Many states already have restrictive rules on home birthing, and the lawful status of unassisted birth is a hot topic of debate; although it is classified as legal in both the US and UK, it comes with an increased likelihood of CPS/SS (child’s services) involvement and is generally considered to be unsafe, irresponsible and undeserving of lawful status by the majority. What could make it easier for its legality to be questioned than a rise in negative birth outcomes?


But why does all of this even matter? Why can’t women suck it up and birth in hospitals under new, restrictive policies? Why is the legality of homebirth a necessity?


Because the medical autonomy and birth circumstance of labouring women directly impacts our fertility rate; and it is already below replacement level, with a potential ~20% decline in native population numbers per generation. [25]


In fact, a decline in fertility rate is well established to be a steady, predictable and direct consequence of sickness; the birth rate falls proportionately 9 months after seasonal flu outbreaks (which is standard globally) [26], and to even greater degrees in response to epidemic or pandemic occurrences. The best predictions we can fathom regarding the impact COVID-19 on our birth-rate is to analyse the effect of the SARS outbreak in Hong Kong (2003). The death toll of this outbreak was relatively low at approximately 700, yet there was a disproportionately extreme and lengthy drop in the fertility rate; Richmond et al (2017) (who analysed a cohort of pandemics and their effect on birth rate) found that “it is not really the number of deaths which is the main determinant [of impact on fertility rates], but rather the total number of persons who experience an adverse shock in their living conditions.” [27] These are called collateral survivors. When analysing the SARS outbreak, Richmond et al note that the main difference between it and other studied pandemics was the degree of shock spread by government-instituted responses; all schools shut for 1 month, public places were closed and inaccessible and finance companies were encouraged to work from home. The total death rate took approximately 10 months to normalize to the rate it was before the outbreak; the total birth rate never returned to its pre-outbreak numbers but took 17 months to stabilize at a significantly lower level. This was the effect of 1 month of school and public amenity closure, in comparison to a projected 18-month pandemic cycle with schools closed for at least 6 months in the US and no indication of a time-frame for all other disrupted facets of life to return to their pre-pandemic levels. If we compare the total deaths from COVID in the US and UK (29,936) [28] at 28x the magnitude of the SARS outbreak, and school closure time at least 6x the magnitude of the SARS outbreak, we can predict unprecedented deleterious effects on our joint fertility rates.


For those with a penchant for comparing COVID to the Spanish Flu, here’s one for you: The Institute for Family Studies stated that “whatever effect Spanish flu had on birth rates, COVID should have a similar but smaller effect. Because COVID is very infectious, but not extremely lethal, there will likely be a large number of collateral survivors, suggesting that births in the immediate wake of a COVID outbreak should fall considerably. If, on the other hand, 30% of the population is infected, and mortality is near the World Health Organization’s current estimates of 3.5%, effects could be larger: births 9 months from now could fall by half.” [29] And it only gets more and more chilling as TIFS state that Wuhan has “only very modest potential for mortality-replacement-style recoveries later on” [30] due to the effects of population-wide quarantines, economic disaster and a rise in divorce rates on the attitudes of collateral survivors. Whilst there is no current evidence that divorce rates are climbing in the US or UK, most states and the entirety of the UK have been placed under strict quarantine with the threat of potential economic disaster much like Wuhan. If we continue to follow in the footsteps of Wuhan, we are potentially faced with a situation whereby fertility rate is HALVED with very little likelihood of a return to pre-pandemic levels in any reasonable length of time; add to this the potentiality for the disease to reoccur annually, thus thwarting any attempted resurgences of births, and the entire situation looks quite bleak.


To make matters worse, this specific pandemic provokes numerous established factors already acting to reduce the birth rate on top of the initial setback demonstrated above. These are namely:


  • A dramatic change in economic activity- financial instability is currently rife, with 16 million unemployed, 78% living paycheck-to-paycheck [31] and 28% with absolutely no savings in the USA alone. [32] Considering that the conventional child-rearing route is touted to cost $250,000 per child, I don’t think we’ll be seeing a modern Brady Bunch-esque take back any time soon.

  • Redefining relationships- the average age at marriage rose from 26 to 39.1 in the last 50 years [33], with 59% married between 18-34 versus the current 29% [34]. This staggering discrepancy is supposedly due to 2 factors: economic instability, and an inability to “meet the right person”. The current state of COVID means that the potentiality for an individual to meet a viable spouse is ever-more slim, with social distancing and mandated quarantine drastically reducing the socialisation of the majority of the population. If said quarantine hypothetically lasts 18 months, marriage rates could fall incredulously low, with unknown lasting consequences on our ability to seek romance in person without fear of physical relations spreading disease. The impact this could have on birth rates is unimaginable.

  • Infertility- COVID-19 is known to bind to ACE2 receptors in the testes [35], with the possible consequence of long-term fertility issues. With approximately 14.2% of UK, and 10-15% of US [36], couples already classifying as infertile, this virus has the potential to propel infertility statistics into unchartered territory. This admission is all the more heartbreaking when we read that, according to the National Institute of Population and Social Security Research, almost 1/5th of all studied respondents stated that the reason they were childless was due to an inability to conceive. [37]


The simple fact is that for maintenance of a given population, the fertility rate needs to be at 2.1 children per woman. The current US rate is 1.88 and the UK rate is 1.87 [38] and those figures include children born to migrants. That doesn’t seem exceptionally low, you might retort; well, for comparison’s sake, China’s figure (who only recently renounced their 36-year 1 child policy for population control measures) is already at 1.63. Add to that the fact that both the US and UK rates are in decline, and there is already a stable case for arguing that this is a worrying issue.




It is even more worrying when one considers what a low fertility rate means in terms of a population’s susceptibility to disease; a low fertility rate increases the average age of a given population, and the heightened rate of elderly people is directly proportional to the rate of potentially immunocompromised or vulnerable individuals (particularly in the case of respiratory infections). It has now been established that the reason Italy was so fiercely hit by COVID-19 is because its average citizen is 45.5 [39] (the 5th highest in the world) as a result of their abhorrently low birth rate of 1.31 [40]; thus, with a larger elderly population, their death-rate seemed disproportionately high. The result is a population, already failing to maintain itself, vulnerable to severe population decline in the wake of infectious diseases.


Not only is a low fertility rate one RESULT of an infectious pandemic, but it is a suspected CAUSE of the degree of its spread and impact.


Contrariwise, when we look at the countries with the highest fertility rates, we see that the spread of infectious disease is greatly mitigated and subsequently the population is protected. Many African countries, including Niger (fertility rate 7) [41], Angola (fertility rate 5.6) [42] and Uganda (fertility rate 5.5) [43], have an average age of <16 [44]; these three countries combined have a third of the population of the USA, but a disproportionate 1385x [45] lower rate of confirmed cases, and an incredible 2229x [46] lower rate of death. The same trend can be observed to a lesser degree in India (fertility rate of 2.2) [47] where the average age is 26 [48]; their population is 4.1x that of the USA yet their confirmed case rate is 69x lower [49], and death rate 82x [50] lower.


In spite of the TV and Bill Gates constantly espousing the dire state of global overpopulation and the stress it causes on acquisition and consumption of resources, it seems that, in this instance, a high fertility rate could actually be protective in that it would decrease a given population’s requirement for medical resources by lowering the total rates of infection and death. The truth is that more babies equal a higher resistance to disease within a given population and subsequently is it essential that we protect women’s rights to medical autonomy in the birth industry. It is essential that we encourage mothers to continue to reproduce in spite of current fear and anxiety, and that we do so, to the best of our professional abilities, in a way which will educate and support them.


This is a necessary call for midwives, doulas and birth-workers in general to step up to the plate and defend the autonomy of birthing women in a situation which could permanently change the Western world’s attitude to birthing and motherhood; this is a sacred rite and is not up for debate.


Regardless of one’s personal beliefs regarding the genesis or nature of COVID-19, real-life policies are being altered and administered; thus, a real-life response is a necessity.


In the current mirage of fear, anxiety and unpredictability, we need only to look to the Bible for guidance; as is so eloquently expressed in Psalm 127:3-5:

“Behold, children are a heritage from the LORD, the fruit of the womb a reward. Like arrows in the hand of a warrior are the children of one's youth. Blessed is the man who fills his quiver with them! He shall not be put to shame when he speaks with his enemies in the gate.”


REFERENCES:

[19] Calculated by taking total annual births in US and UK (2018), then dividing by 12 to achieve a monthly figure.

[28] Numbers from Google COVID count at time of writing (12/04/2020)

[45] Calculated using Google COVID-19 statistics at time of writing (12/04/2019) (Sum of total confirmed cases divided by total confirmed cases in USA)

[46] Calculated using Google COVID-19 statistics at time of writing (12/04/2019) (Sum of total deaths divided by total deaths in USA)

[49] Calculated using Google COVID-19 statistics at time of writing (12/04/2019) (Sum of total confirmed cases divided by total confirmed cases in USA)

[50] Calculated using Google COVID-19 statistics at time of writing (12/04/2019) (Sum of total deaths divided by total deaths in USA)

 
 
 

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