For many health-care providers who worked through the 2003 SARS epidemic, especially in epicentres, like Toronto, the COVID-19 pandemic is a reminder of the many lessons health-care providers learned at that time. Social distancing measures are the most effective way to “flatten the curve” and minimize the spread of the epidemic.
However, as a midwife working in Toronto for over 20 years, I can also speak about another important lesson learned during SARS that is often forgotten or overlooked: the importance of home birth and the role of midwives during an epidemic.
There is ample evidence from high-income countries like Canada, the United States and the United Kingdom to demonstrate the safety of home births for healthy people who have a trained midwife. In fact, research shows that home birth may even be beneficial in terms of rates of unnecessary interventions, complications and associated cost to the system.
The evidence is so compelling that in 2014, U.K.’s NICE, the National Institute for Health and Care Excellence — the main body responsible for setting guidelines for health care in the U.K. — recommended home births for all low-risk healthy pregnant people. Since the selection criteria for home birth is vitally important to safety, being a low-risk pregnant person is an important factor. For people with high blood pressure, diabetes, preterm labour and other health issues, home birth would not be the safest option.
However, despite these recommendations, mainstream perception has not greatly changed regarding hospital as the preferred place of birth for the large majority. The reasons for this are numerous and complicated, and highly related to social norms, preferences and perceptions of risk.
I have seen many news articles, targeted campaigns, TV shows and even movies supporting home births. But in all my 20 years as a regulated midwife, nothing in my recollection came close to changing people’s minds about place of birth than SARS.
For midwives, this was not necessarily surprising, as we know the safety of a home birth. But it was one of the first times mainstream public perception was greatly altered.
Home births during a pandemic
During a pandemic, people quickly remember that hospitals are, and should be, for sick people; that is, those needing medical care. Ironically, however, in Canada and the U.S., health-care systems the No. 1 reason people are admitted to hospital is for childbirth.
During a pandemic it soon becomes apparent what a bad idea it is to have healthy women and newborns in the same places and spaces as those who are unwell, and increasingly so as more get infected.
Suddenly — our high tech, bells and whistles “for the normal” starts to seem like a really poor idea. In fact, research shows all those bells and whistles lead to more intervention — more episiotomies, more use of forceps and vacuum, and more severe vaginal tearing — with no better outcomes for either the pregnant woman or newborn.
As soon as that babe is here, it becomes even more apparent what a bad idea it is to have a vulnerable new human in a place with lots of sick people.
Home birth starts looking better every second.
I fully appreciate all the bells and whistles — when they are needed. But, like many of my colleagues, I personally prefer a home birth for low-risk births with a healthy uncomplicated pregnancy and normal labour. Not just because it can be very beautiful — quiet, intimate, family oriented — but also because it is actually safer for healthy people — at least during a pandemic.
Although I could talk about the great benefits of home births in general, I’m specifically advocating for home births, or out-of-hospital births, during a pandemic. So, as our health resources and hospital beds become more scarce, I hope we remember the importance of home birth.
Lessons from SARS
SARS was one of the rare times in my career that I had both obstetrical and pediatric colleagues openly supporting the idea of home births and encouraging people to stay out of hospital. At that time, we understood hospital care should be saved for those who were high risk. This was even more clear as the situation worsened during the SARS epidemic.
There were many other important lessons learned during SARS, particularly for Canadian midwifery — although there is almost no academic literature on this subject. However, I do have some anecdotal experience to share as a front-line care provider during that time.
If there is one essential service that we know must continue during a pandemic, it is the business of birthing.
Midwives are an important part of the health force that is often overlooked. Our speciality is low-risk normal birth: this is where we have the most expertise and where we can be most effective.
This is a time when other birth attendants — mainly obstetricians — will be called on for their clinical and surgical speciality skills to manage those pregnant people who have complications, have COVID-19 or are unwell for other reasons.
Midwives can be divided into those who work within the hospital setting and those that work outside within the community. This would help prevent movement in and out of people’s homes and health-care settings.
Midwives have a lot of crossover skills between nurses and physicians. We can stitch and prescribe, like a physician, but also start an IV and take blood, like a nurse. There are many things we can use our skills for beyond birthing.
Some midwives have more advanced skills such as being able to assist during surgery, perform bedside ultrasounds and conduct vacuum deliveries. These skills could be important as the health force declines.
Birth centres, or other out-of-hospital birth locations, should be considered and opened as places for low-risk people to give birth and for healthy newborns to stay.
Finally, the needs of those who are pregnant are often overlooked. Home birth has many potential benefits, but most importantly in a pandemic, we need healthy people to give birth with the best chances of staying healthy — which doesn’t always mean hospital.
Manavi Handa is an Associate Professor at the Midwifery Education Program at Ryerson University.