Dueling Statistics: Is Out-of-Hospital Birth Safe?

Challenges and lessons learned birthing during the COVID-19 pandemic: A scoping review

Background and Aims

The impact of the COVID-19 pandemic on the healthcare system facilitated a change in policies to redress the consequences of increased demand and fear of disease transmission. Restrictive measures throughout the healthcare system limiting access to accompanying partners of birthing people in addition to fears of contracting COVID-19, an increasing number of birthing people chose to have an out-of-hospital birth. Out-of-hospital births are not prevalent in the United States. However, in recent years the percentage of out-of-hospital births has been steadily increasing. COVID-19 was a novel virus imposing a unique birthing situation for millions of women, complicated by lack of integration and varied policies in the U.S.

Methods

To better understand the challenges of birthing people during the pandemic a scoping review was conducted to explore the literature during the first wave of the pandemic related to out-of-hospital births. The approach for this review made use of the methodology manual published by the Joanna Briggs Institute for scoping reviews. All manner of publications (i.e. peer-reviewed published articles, grey articles, conference proceedings, webinars, editorials, and textbook chapters) were included in the review.

Results

Articles retrieved from the database search yielded sixty-three articles, after duplicate removal forty-six records were available for screening. Articles were further excluded using the PRISMA process, yielding thirty-one remaining records. From the thirty-one records twelve themes emerged, which were collapsed into four meta-themes.

Conclusion

These meta-themes focused on (a) advocacy, (b) homebirth infrastructure, (c) support networks, and (d) uncertainty during the pandemic. COVID-19 has accelerated this movement to birthing at home and thought must be given to how the healthcare system is going to support and integrate this mode of birthing.

Perinatal health care access, childbirth concerns, and birthing decision-making among pregnant people in California during COVID-19

Background

During public health emergencies, including the COVID-19 pandemic, access to adequate healthcare is crucial for providing for the health and wellbeing of families. Pregnant and postpartum people are a particularly vulnerable subgroup to consider when studying healthcare access. Not only are perinatal people likely at higher risk for illness, mortality, and morbidity from COVID-19 infection, they are also at higher risk for negative outcomes due to delayed or inadequate access to routine care.

Methods

We surveyed 820 pregnant people in California over two waves of the COVID-19 pandemic: (1) a ‘non-surge’ wave (June 2020, n = 433), and (2) during a ‘surge’ in cases (December 2020, n = 387) to describe current access to perinatal healthcare, as well as concerns and decision-making regarding childbirth, over time. We also examined whether existing structural vulnerabilities – including acute financial insecurity and racial/ethnic minoritization – are associated with access, concerns, and decision-making over these two waves.

Results

Pregnant Californians generally enjoyed more access to, and fewer concerns about, perinatal healthcare during the winter of 2020–2021, despite surging COVID-19 cases and hospitalizations, as compared to those surveyed during the COVID-19 ‘lull’ in the summer of 2020. However, across ‘surge’ and ‘non-surge’ pandemic circumstances, marginalized pregnant people continued to fare worse – especially those facing acute financial difficulty, and racially minoritized individuals identifying as Black or Indigenous.

Conclusions

It is important for clinicians, researchers, and policymakers to understand whether and how shifting community transmission and infection rates may impact access to perinatal healthcare. Targeting minoritized and financially insecure communities for increased upstream perinatal healthcare supports are promising avenues to blunt the negative impacts of the COVID-19 pandemic on pregnant people in California.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03942-y.

Understanding Recent Home-Birth Research: An Interview With Drs. Melissa Cheyney and Jonathan Snowden

In the past month, two new studies have been released-one in The New England Journal of Medicine (NEJM; Snowden et al., 2015) and the other in the Canadian Medical Association Journal (Hutton et al., 2015)-comparing out-of-hospital birth outcomes to hospital birth outcomes. These studies join a growing body of literature that consistently shows high rates of obstetric intervention in hospitals and also show low risk to neonates regardless of setting. However, the recent NEJM study found a small but statistically significant increase in risk for perinatal mortality for babies born out of hospital. Jeanette McCulloch of BirthSwell (http://www.birthswell.com) interviews Melissa Cheyney, PhD, CPM, LDM, medical anthropologist, chair of the Midwives Alliance Division of Research, and lead author on the largest study of outcomes for planned home births in the United States to date (Cheyney et al., 2014a), and Jonathan Snowden, PhD, epidemiologist and assistant professor in the Department of Obstetrics and Gynecology and School of Public Health at Oregon Health and Science University. Snowden is also the lead author of the recent NEJM study.