ACNM Town Hall recap: Perspectives on home and birth center birth during the COVID-19 pandemic

Bathing beauties!

Happy Monday (although it’s almost Tuesday in the lower 48). Alas, when you work the night shift the days tend to blur together. We did a lot of sleeping, playing outside and social distancing this weekend – hope your weekend was filled with the same!

Today we have another webinar recap! The American College of Midwives hosted another webinar on March 30, 2020 on home and birth center considerations in the pandemic.

The panel was well put together and they discussed a variety of topic. My recap is below as well as a little commentary.

If you’re thinking about watching it on your own time, the webinar was about 90 minutes long and I thought it was a good use of my time! I liked each panel member’s point of view and the considerations each person brought to the discussion!

Here’s the recap:

Martha Jackson from BirthCare & Women’s Health, Ltd. (Washington D.C.) spoke first on specific things their practice was doing to prepare for the pandemic.

Mrs. Jackson said 70% of the births are home births and 30% of births are at birth center.

Precautions her practice have taken included:

  • Social distancing (the goal is to limit face to face contact)
  • Screening both clients and staff (check temperatures, assess for signs/symptoms of COVID-19, or recent travel)
  • BYOP – bring your own pen!
  • Wipe surfaces hourly…using a 10% bleach solution
  • Appointments for gynecology or primary care are postponed; OB visits are completed by telehealth
  • Avoid clients waiting in the lobby
  • Meetings moving to Zoom platform when possible (both for patients and for staff)
  • Detailed exam room cleanings (wipe surfaces and door handles after every visit)
  • Using masks for all patient care and other PPE (personal protective equipment) as appropriate

In regards to home birth practices, Mrs. Jackson discussed the following precautions:

  • Encourage family to have clean surface for midwife’s supplies
  • Ensure that there is a clean surface on floor for birth bag
  • Limit number of family and friends present (and also screen for infection)
  • Wipe down all equipment with disinfectant before replacing in birth bag
  • Water births have continued as before
  • Nitrous oxide is still in use (no evidence was found to support to stop use)
  • Midwife protection (making efforts to change clothes before entering own house, using precautions, etc.)

And some thoughts from Mrs. Jackson on how to support our own immune systems. (She also spoke on how midwives often struggle most with these things….I thought this was so true!)

  • Rest
  • Decrease stress
  • Exercise
  • Good nutrition
  • Hand washing
  • Social distance
  • Don’t share computers
  • Supplements as recommend bu Aviva Romm
    • Zinc 30mg/day
    • Vitamin D 4000IU/day
    • Vitamin C 1000mg/day

Amy Johnson-Grass (from Health Foundations Birth Center and Women’s Care Clinic) spoke next on care modifications during COVID-19 at her birth center; late transfer agreements; hospital transfer considerations; and birth center/hospital collaboration:

  • Prenatal visit schedule adjusted based on World Health Organization guidelines
    • Prenatal education videos recorded for patients to view prior to in-person visits
    • Center asked patients to obtain a blood pressure cuff to use at home
  • Algorithms have been essential for triaging patients (this has helped give guidance to staff and to patients)
  • Drive-up care tent set up for simple labs/screenings
  • Individual COVID-19 screenings occur for all in-person prenatal visits and birth
  • Limits placed on extra visitors in clinic and at births (currently the center allows the partner and a doula at the birth)
  • Late transfer agreement set up to accommodate influx of patients…patients must:
    • Complete a tour of the facility (virtual/in-person)
    • Produce full records of their OB care
    • A “mid-pregnancy” ultrasound
    • If transfer after 28 weeks, must have diabetes screening completed
    • If transfer after 36 weeks, must have GBS swab completed
    • Encouraged to have a professional doula
  • Of note, Midwives in Minnesota cannot accompany hospital transfers unless they are providing direct care (cord prolapse, bimanual compression) – have to consider your own state regulations
  • In regards to birth center and hospital collaboration:
    • Start conversations with local hospitals and provider now
    • Birth centers must understand their capacity and capability (example: if birth centers accept patients from the hospital, what does that look like?
    • Establish a process of communication
  • “Pop-up” Birth Centers
    • Guidelines are being developed to guide communities on this type of birth center (keep your ear open as these guidelines come to fruition)
  • Resources for Freestanding Birth Centers

Saraswathi Vedam spoke next from Birth Place Lab. She commented on the birds eye view of COVID-19 and maternal health.

  • There is a global scarcity of childbearing care providers.
  • The evidence is continuing to evolve…there is no local consensus on containment.
  • We cannot forget that there are human rights in childbirth that include the rights of equity, respect and equity. There is no reason not to give high quality care.
  • Quality care consists of:
    • Evidence-based care
    • Effective communication
    • Respect and preservation of dignity
    • Emotional support
    • Competent, motivated personnel
  • Specialists and scientists recommend separation of well people from sick.
  • Midwives are perfectly poised to help triage and care for the community that they are in just by the nature of their training and expertise.
  • The International Confederation of Midwives published a statement on March 29, 2020.
Source
Source
  • Global strategy hinges on having a global conversation with individuals that are experts in their area (clinical expertise, operational expertise, strategic expertise).

Sunita Iyer, the Co-President of the Midwives Association of Washington State spoke on utilization of midwives in disasters, community transfers of care, and communicating guidelines:

  • Rural versus urban settings planning is a real concern. Planners have to take into account what is possible in rural areas outside of Seattle (or your local city). She spoke about a midwife student by the name of Emily Jones that is completing Masters work on midwives in the disaster setting (how cool is this?!). A lot her Masters work is being put to work on the front lines as we speak!
  • The concept of tiered planning – allow absorption of antenatal and postpartum care into midwifery care and take the burden off of the hospital setting. The idea is this: move from hospital based care to birth centers or home birth. As hospital capacity is breached, birth centers can absorb low risk pregnancies.
  • Communicate guidelines and make them publishable
    • Ms. Iyer gave the example of washingtonmidwives.org. She said the midwives use the website to communicate to each other and to their patients. The website answers the following questions:
      • As a whole, how are midwives adjusting their transfer of cares (when is too late or when is too soon?)
      • How do we keep midwives safe?
      • How do we sustain midwives?
      • How do we keep midwives safe in a shortage of PPE?
      • How much care can be by telemedicine and how much should be in person?
  • We must continue to work with hospital colleagues and transport colleagues. Midwives must continue to work with these allies in the event transfer is indicated. The strength of these relations is imperative to success. We also must assume this may be a bi-directional transfer (example: patients may transfer out of the hospital setting and not just to the hospital setting).
  • Ms. Iyer also spoke on these considerations:
    • If pregnancy care is transferred among a variety of providers – who and how do midwives get paid? Midwives should not have to forgo payment in exchange for risks to their physical or mental health.
  • Lastly, she emphasized that midwives must continue to show support for a woman’s right to have labor support.

Q+A portion:

  • Relationships was a common theme across the panel. The idea was that care may be transferred from and to a variety of settings. The details of these transfers are somewhat unknown but preparation is key.
  • There are AMCB guidelines that guide CM and CNMs; as we strive to take care of women, we must be safe and adhere the standards the profession has set forth. It’s important to ask these questions….
    • What are your clinic guidelines?
    • What are the community guidelines? Who are the community workers? Are you in contact with the programs across your communities? How are you networking and talking about midwives as the solution?
    • Have you reached out to your department of health and asked questions about reimbursements/payment?
  • Social responsibility is imperative at this time. The example provided was the CM/CPMs that asked the governor of New York if they could help with the shortage of birth providers. Governor Cuomo published an executive order for any type of midwives, licensed in any state, to come help in New York. This order also applies to almost any medically trained individual.
  • Mrs. Vedam spoke more on the United States and stated the country is struggling with a lack of coordination and a lack of proper infection control.
    • Recommendation: Review the PPE needed for every point of care. Don’t reinvent the wheel; just find the right guidance and follow it.

My thoughts on the webinar…

  • Amy Johnson-Grass spoke on a pandemic so prevalent in a community that a midwife may not being able to give a proper hand off provider to provider – in this instance she and her practice made a transfer sheet to serve as a hand off, or report, to another provider. This is a great idea. I very much hope it doesn’t come to that. She also spoke on how a doula is encouraged for late transfer into her practice. This is so important. For a woman that wasn’t preparing for home birth or a birth center birth, sometimes the thought of a doula falls by the wayside. Another consideration is that doulas cost money for their services. I worry that women that are transferring care late in their pregnancy don’t have the money to pay both a birth center and a doula.
  • Saraswathi Vedam thoughts on if you take away companionship were so spot on: you are at risk for intervention without labor support and this increases the risk that more providers may need to be involved. Both the patient and provider lose in the situation where labor support is either taken away or not provided.
  • Lastly, the group talked about a higher tolerance for patients that are declining tests. Should providers require a diagnostic test to rule out comorbidites that may increase a pregnant patient’s risk of COVID -19?
    • Should we not allow the option of unknown status of GBS?
    • How do we care for an influx of women that are seeking birth center or home birth care that are motivated by fear? (for this in particular – if the transfer is fear based, how does that affect a woman in birth?)
  • Don’t be a cowboy. This was an underlying theme but I think it deserves a comment. There are many, many guidelines that dictate midwifery care and maternity care. This is not the time to forgo those guidelines that have been strongholds of midwifery practice. We must learn to give pandemic care while holding strong to guidelines.

Whew! Again, a great webinar. I am loving the push from ACNM to communicate through this platform.

Curious about the other ACNM webinars? Check out the webinars themselves or the recaps:

Also – mark your calendar for April, 8th, 2020, 8:00pm EST – Midwives and Telehealth. As a provider at home who had done more telehealth than I ever thought possible, I am so curious as to the points the panel is going to make. As I plan on listening in, plan on a recap!

Are you a midwife on the front line? What struggles is your practice working through? How are your patients handling the precautions and screenings?

Hope everyone is well! Happy Monday.

Jamie

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