Midwifery in the Time of COVID‐19

For many midwives, visualizing the care we provide during labor and birth likely conjures images of a caring professional face‐to‐face with a patient, holding a hand, rubbing a back, fostering the initial bonds of a new family. But since early 2020, the news has been filled with concerns about rampant coronavirus disease 2019 (COVID‐19) and images of health care providers in their personal protective equipment, or worse, makeshift pseudo‐protective gear. There are stories of births (and deaths) unattended by partners or family. Health care providers themselves have COVID‐19 and are quarantined from patients or even from their own families. Health care providers, including midwives, are dying, along with their patients. ¹ , ² How does one live the philosophy of midwifery, working in close and caring partnership with individual patients and pregnant families, giving of ourselves, in the midst of such a crisis? How do we protect the essence of midwifery care from 6 feet away, behind face shields and N95 masks? How do we manage our concerns for ourselves and our families?

I remember working as a midwife in New York City during the 1980s HIV‐AIDS crisis. In many places, midwives had been attending births without much in the way of protective equipment, as we had little compelling reason to worry about being close to our patients. We did not wear masks, had bare forearms above gloves (if we even managed to glove up), sat on the bed with parents and newborn, and soaked in the beauty of the birth. But as the HIV‐AIDS crisis ramped up, the need to protect against infection infiltrated our work in ways that changed our practices dramatically. Perinatal care providers were advised to use full face and body protection to approach a laboring patient. We were told to worry about any exposure to bodily fluids. I remember a defective glass blood vial shattering in my hand as I removed it from a centrifuge, cutting through the skin. As a result, I had to call the patient back in for HIV testing in order to follow recommendations for possible treatment for me. But the call terrified and traumatized the patient, worried that we thought she was HIV positive; our relationship was never the same. I can see still the faces of women who died of AIDS before we knew what was making them sick. And I remember the concern and fear that we could contract the infection ourselves despite all our precautions. Those experiences at times seemed so distant from my image of midwifery care that I wanted to grieve.

But midwives responded and midwifery care evolved. We found ways to be present for our patients in spite of the HIV‐AIDS crisis and all it entailed, including the need for universal precautions and the need to manage our own fears. In the process of responding to one crisis, we developed strength and resilience to face the next. And there have always been crises; HIV‐AIDS was never the only challenge. In this millennium alone, midwives providing care in war zones and camps for displaced persons and in areas affected by natural disasters have faced overwhelming odds and continued to care for their patients. Midwives have provided care in hotbeds of SARS, H1N1, MERS, Zika, Ebola, and other epidemics. Yet, and always, we have found ways to be with our patients and their families, despite the chaos in the world outside.

And here we are again. This COVID‐19 pandemic may dwarf what has happened before, in global reach and scope and mortality. What is happening in the world is staggering, but again, midwives are responding. Online midwifery forums and webinars are replete with discussions that are thinking ahead to how the emerging science around COVID‐19 can be merged with the art of midwifery care. ³ , ⁴ Yes, the realities of attending birth while managing families and staff and the rationing of personal protective equipment, not to mention one's personal concerns about becoming infected, are painfully visible. But we need such honest discussions to help find a way forward. Midwives are communicating innovative ideas for homemade disposable equipment and redesigned guidelines for call schedules, birth centers, and water births. We have moved to internet connections that allow for virtual visits; some midwives had already been exploring virtual support in early labor, and their work now has special relevance. ⁵ Colleagues are communicating ways we can foster resilience in ourselves. ⁶ Concerns raised about the need to avoid putting our most vulnerable patients at even higher risk reflect the best of midwifery. It seems that through it all, midwives continue to confront uncertainty and pain and fear with strength and compassion, to be with our colleagues, our patients, and our families.

The final chapter of the current COVID‐19 pandemic has yet to be written, and indeed may well be different as you read this from what was anticipated when it was written in April. There will no doubt be those among us who will have to grieve family or colleagues or patients, and those who will fall ill themselves; the rest of us will be there to support them. Even as the pandemic eases, the mental health aftermath for our frontline health care providers will continue. ⁷ But we should have no doubt that our profession is resilient. We will always find ways to honor our professional philosophy: to provide therapeutic human presence, in continuous and compassionate partnership, affirming the power and strength not only of our patients, but of ourselves. ⁸