Coronavirus COVID-19 | Evidence Based Birth® Resource Page
A SPECIAL MESSAGE FROM DR. REBECCA DEKKER
Founder and CEO of Evidence Based Birth®
It’s Rebecca, here. I know this is an uncertain time and many are feeling a range of emotions. Our goal remains the same: to provide you with friendly, accessible, evidence based information so that you can make informed decisions
During a global pandemic, our goal is more important than ever.
At Evidence Based Birth®, we are continually monitoring the situation and our research team is examining the best available resources. We will keep this page updated with relevant information for both pregnant parents and birth professionals.
Wishing you calm and a sense of peace,
VIRTUAL DOULA SUPPORT FOR BIRTHING FAMILIES DURING COVID-19
Evidence Based Birth® has created a Virtual Doula Directory, populated by our Professional Members and Instructors. We know that birthing during a pandemic can be fraught with uncertainty, confusion, and even anxiety. We believe now, more than ever, birthing families will benefit from the support of a doula. Knowing many hospitals are restricting visitor access, the birth world has responded by increased virtual support options. We have collected some of the best of the best options for you!
What is a Virtual Doula?
A Virtual Doula provides education, comforting affirmations, and reassuring support throughout pregnancy, birth and the postpartum transition. You will be supported in a similar way as a traditional in-person doula, except services will be conducted virtually.
What does it look like to be supported by a Virtual Doula?
Virtual Doulas will likely meet for your prenatal consultations via video chat, and will still be available to answer any questions via phone, text, or email. For your birth, a virtual doula will likely use a video meeting platform and provide you with comfort measures and laboring techniques that you previously rehearsed and discussed. How virtual doula support is conducted varies from doula to doula – be sure to ask in your interview what the doula’s support package looks like!
Why would I hire a Virtual Doula?
Navigating birth during this unprecedented pandemic, having a virtual doula on your team for support is a great option for when a doula is not able to attend your birth in person.
What kinds of interview questions should I ask?
You should ask the same interview questions you would ask during a normal doula interview – including, and especially, what the virtual doula’s backup options are.
VIRTUAL CHILDBIRTH EDUCATION FOR BIRTHING FAMILIES DURING COVID-19
Evidence Based Birth® has moved its pioneering Childbirth Class completely online, taught by our Evidence Based Birth® Instructors. The best way to get enrolled in our completely online Childbirth Class is to contact your local Instructor.
The Evidence on COVID-19
Webinar Replay | Monday, March 23rd 2020
Official Public Health and Relevant Organizations
Parent and Birth Worker Advocacy
Evidence Based Birth® Communications & Resources
Research update from Monday, March 23 at 9PM
SARS-CoV-2 is the 7th coronavirus known to infect humans (Mullins et al. 2020)
- 4 human coronaviruses cause the common cold
- 3 human coronaviruses cause more severe, acute illnesses; MERS-CoV causes Middle East Respiratory Syndrome (MERS), SARS-CoV causes severe acute respiratory syndrome (SARS), and SARS-CoV-2 causes COVID-19
The main way the virus spreads is person-to-person. This virus can be isolated from respiratory secretions and feces. A new study found that the virus is also stable on surfaces for up to several days. The study was conducted by scientists from the National Institutes of Health, CDC, UCLA and Princeton University and was published March 17 in The New England Journal of Medicine (van Doremalen et al. 2020).
- SARS-CoV-2 was detectable in aerosols for up to three hours, up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and stainless steel.
- The results suggest that people may acquire the virus through the air and after touching contaminated objects.
A new study from Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, confirms that the median incubation period of the new virus is around 5 days, meaning that about half of the people who contract SARS-CoV-2 will start showing symptoms at that point in time.
- The study was published in the Annals of Internal Medicine on March 10. There were 181 confirmed cases with identifiable exposure and symptom onset windows to estimate the incubation period of COVID-19. The median incubation period was estimated to be 5.1 days (95% CI, 4.5 to 5.8 days), and 97.5% of those who develop symptoms will do so within 11.5 days (CI, 8.2 to 15.6 days) of infection.
How long are you contagious? A retrospective review of adult patients in China with lab-confirmed COVID-19 found the median length of viral shedding was 20 days in survivors. The longest observed duration of viral shedding was 37 days (Fei Zhou et al. 2020).
To date, no evidence of parent-to-baby transmission during pregnancy has been published. Samples of breastmilk, cord blood, placenta, and amniotic fluid from infected pregnant people have all been negative.
- An infected newborn could have acquired the infection from health care workers or the infected mother immediately after birth, not necessarily during the womb or during birth.
Johns Hopkins University has a great resource for the latest COVID-19 figures (confirmed cases, deaths, recovered) here.
Instead of large studies, we only have the details from individual reported cases at this point. Researchers are grouping these cases together to analyze the data. Mullins et al. in the U.K. published a “Rapid Review” of COVID-19 in pregnancy and birth.
- So far, there is no evidence that pregnant people are at greater risk of infection or severe illness with COVID-19 (they are only considered a ‘vulnerable group’ as precaution).
- They reviewed reports from China on 32 infected pregnant women and 30 babies (one set of twins and three ongoing pregnancies).
- There have been no reported maternal deaths.
- 7/32 mothers (22%) were asymptomatic
- 2/32 (6%) were admitted to the ICU, 1 with severe pneumonia
- 27 mothers had Cesareans, 2 had vaginal births. We don’t know why the Cesarean rate was so high among these mothers.
- Women gave birth within 13 days of onset of illness. The authors mention that fetal growth is unlikely to be affected in this time period.
- There was one stillbirth that occurred to a mother who presented at 34 weeks with a fever and sore throat; her condition worsened to severe pneumonia; she required ICU and life support (extracorporeal membrane oxygenation or ECMO). She had a stillbirth by Cesarean. (Yangli Liu)
- The one newborn death occurred when a baby died after being born at 34 weeks. The baby was admitted to ICU 30 minutes after birth with respiratory difficulties. The baby developed shock, multiple organ failure, and died at 8 days postpartum. (Zhu)
- This is not enough evidence to know if COVID-19 infection increased the risk of harm to babies. However, the high number of preterm births is concerning; it could mean tremendous pressure on newborn health services if the infection is widespread. With these case reports of preterm birth in women with COVID-19, it is unclear whether the preterm births were always because of medical intervention by Cesarean, or whether some were spontaneous preterm labors that resulted in Cesareans. Cesareans were predominantly for maternal indications related to the viral infection, although there was evidence of fetal distress in at least 7 reports (Mullins et al.) and prelabour PROM, in at least one report (Zhu et al.).
- We don’t have any data on outcomes with COVID-19 infection in the 1st trimester.
To get evidence on which treatments are most effective, WHO and its partners are organizing a large international study, called the Solidarity Trial, to compare different treatments. They announced the trial on Friday, March 20. It will be a global megatrial of the four most promising coronavirus treatments. Click here.
We recommend you watch the Royal College of Obstetricians and Gynecologists (RCOG) practice guidance on COVID-19 because they are updating it very often. The most current (fourth) version is here.
Lauer, S. A., Grantz, K. H., Bi, Q., et al. (2020). The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 [Epub ahead of print 10 March 2020]. Click here.
Mullins, E., Evans, D., Viner, R. M., et al. (2020). Coronavirus in pregnancy and delivery: rapid review [published online ahead of print, 2020 Mar 17]. Ultrasound Obstet Gynecol. Click here.
Schwartz, D. A. (2020). An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes [published online ahead of print, 2020 Mar 17]. Arch Pathol Lab Med. Click here.
van Doremalen N, Bushmaker T, Morris DH, et al. (2020). Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 [published online ahead of print, 2020 Mar 17]. N Engl J Med. Click here.
Zhou F, Yu T, Du R, et al. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published online ahead of print, 2020 Mar 11] [published correction appears in Lancet. 2020 Mar 12;:]. Lancet;S0140-6736(20)30566-3. Click here.
Research Update from Monday, March 16 at 1:57pm
Last Friday, we sent out an email with the latest research evidence on COVID-19 and pregnancy. Our research team plans to send out updates on this topic every Monday, starting today.
We also created a COVID-19 resource & pregnancy page that will include links to the most important websites, archives of our newsletters, and any other info we think you might find useful (such as resources for doulas who are encountering visitor bans). You can access that page here.
Research Update from Monday, March 16:
- According to the World Health Organization’s (WHO) most recent situation report here, there are now over 153,000 confirmed cases and 5,735 deaths globally
- The WHO published interim guidance on March 13, 2020, here.
- There is little research on the clinical presentation of COVID-19 in pregnant women and children
- There have been a few cases of infants with COVID-19 and they experienced mild illness
- So far, there is no evidence of mother-to-baby transmission, and when researchers tested women who were infected, the samples of amniotic fluid, cord blood, vaginal discharge, newborn throat swabs, and breast milk have all been negative.
- Some reports of PROM (premature rupture of membranes), fetal distress, and preterm birth have been reported when mothers became infected in the third trimester
- The mode of birth should be individualized and Cesarean used only when it is medically justified
- Standard infant feeding guidelines should be followed with appropriate precautions for infection prevention and control. These standard guidelines include initiating breastfeeding within 1 hour of birth and continuing to exclusively breastfeed for 6 months, continuing breastfeeding up to 2 years or beyond. Infected mothers who are breastfeeding or practicing skin-to-skin should wear a medical mask, perform careful hand hygiene, and clean and disinfect all surfaces. Infected mothers should still be provided with breastfeeding support. If complications prevent the infected parent from breastfeeding, they should be encouraged and supported to express milk for the infant for someone else to feed to the baby or to maintain milk supply. There should be no promotion of breastmilk substitutes (formula) or pacifiers.
- “Mothers and infants should be enabled to remain together and practice skin-to-skin contact, kangaroo mother care and to remain together and to practice rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.”
- The Centers for Disease Control and Prevention (CDC) in the Unites States (U.S.) publishes situation summaries here
- The CDC has a pregnancy/breastfeeding and COVID-19 page here
- ACOG Practice Guidelines: The American Congress of Obstetricians and Gynecologists published a practice advisory on March 13, 2020.
- ACOG has worked with the Society for Maternal Fetal Medicine to develop an algorithm that can be used to assess and manage pregnant women with suspected COVID-19.
- They encourage care providers to read and familiarize themselves with the complete list of recommendations from the CDC about inpatient obstetric facilities (see below).
- ACOG refers to the CDC guidance on breastfeeding and COVID-19 infection. They state, “Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.”
- CDC Interim Guidance on Inpatient Obstetric Healthcare
- The CDC has released interim guidance on caring for pregnant women with suspected or confirmed COVID-19 in the inpatient hospital setting.
- In contrast to the WHO, the CDC recommends separation of a newborn from a mother with confirmed or suspected COVID-19: “To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.”
- The guidance goes on to say, “If colocation (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19.”
- UpToDate® guidance for clinicians here.
- There is very little info regarding COVID-19 during pregnancy
- Mother-to-baby transmission during pregnancy or birth has not been identified
- There have been at least two newborn cases documented
- Pregnant people are more susceptible to infectious diseases due to immune suppression during pregnancy
- Other respiratory infections—(SARS)-CoV, (MERS)-CoV, and influenza—have been shown to develop into more severe disease in pregnant people
- Out of 18 pregnant women with confirmed or suspected infection, there was no laboratory evidence of transmitting the virus to the newborn
New research on PubMed: A retrospective study reviewed the clinical and CT imaging features of 59 people in China with COVID-19. This group included 14 non-pregnant adults with lab-confirmed infection, 16 pregnant women with lab-confirmed infection, 25 pregnant women with clinically diagnosed infection, and 4 children with lab-confirmed infection (Liu et al.)
- All of the pregnant women had mild illness. None were admitted to ICU and none of the babies had abnormalities or evidence of mother-to-baby transmission.
- Compared with the non-pregnant adults, the pregnant women (both lab-confirmed and clinically diagnosed) had atypical clinical features, making early detection difficult. It was more common for pregnant people to have an initial normal temperature—only 36% to 44% had a fever. This means that fever may not be as useful of a screening tool with pregnant people.
- It was also more common for the pregnant people with infection to have leukocytosis (increase in white blood cells) and elevated neutrophil ratio (a marker of inflammation) compared to the non-pregnant people with infection.
For other research updates that we sent out last week, view our COVID-19 resource page here.
Rebecca Dekker, PhD, RN
Founder, Evidence Based Birth®
'Here's the Evidence on COVID-19 + an upcoming Relaxation session' Newsletter from Fri, Mar 13, 5:29 PM
At Evidence Based Birth®, we are continually monitoring the situation and our research team is examining the best available resources. Here is what we can share with you today:
> The latest evidence on COVID-19 and pregnancy:
- Here is the CDC’s FAQ about pregnancy and coronavirus disease. You’ll notice that a lot of the answers start with “We do not know…” It is an unfortunate reality that very little research has been published on pregnancy, birth, and COVID-19. Due to the emerging nature of the situation, I anticipate more research will arise in the coming weeks.
- The International Society of Ultrasound in Obstetrics & Gynecology issued new guidance for birth professionals on March 11, 2020 (Poon et al. 2020). This is the most recent professional guidance we were able to find today. For patients, their main recommendations were to:
- Avoid close contact with others, i.e. avoid gatherings where a distance of 1 meter between individuals can not be maintained
- Frequent hand washing or hand sanitizer (with 70% alcohol concentration)
- Seek medical attention when experiencing symptoms such as fever and cough (but call first before going in; see if telehealth is an option)
- Check out their article for detailed info about health care provider protection, suggestions on care for infected mothers and their babies, and more. They state that there is no evidence on the safety of mother-infant separation if the mother is infected. “If the mother is severely or critically ill, separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production. Precautions should be taken for the cleaning of the breast pumps. If the patient is asymptomatic or mildly affected, breastfeeding and [rooming-in] can be considered…Since the main concern is that the virus may be transmitted by respiratory droplets rather than breastmilk, breastfeeding mothers should ensure to wash their hands and wear a three-ply surgical mask before touching the baby.”
- A review article was published in the American Journal of Obstetrics and Gynecology on February 24 (Rasmussen et al. 2020). This article compares and contrasts the effects of SARS, MERS, and COVID-19 on pregnant women. They summarize the result from several small studies from China in which pregnant women with COVID-19 were followed. In one study with 9 pregnancies, 6 had intrauterine fetal distress, 7 gave birth by Cesarean , and 6 infants were born preterm. The symptoms in these women were similar to non-pregnant patients: fever, cough, muscle aches, sore throat, and fatigue.
- A case report was just published March 12 [online ahead of print] that reports the first case of COVID-19 infection in a newborn whose mother was also diagnosed with COVID-19 in China (Wang et al. 2020). The researchers are not sure how the baby caught the virus, since the baby was separated from its mother at birth and there were zero traces of the virus in breastmilk, cord blood, and the placenta. We don’t know if the virus can be transmitted through the placenta before birth. Fortunately, in this case, the illness was mild in both the mother and baby, and the baby’s prognosis was good.
- Dr. Aviva Romm, an MD specializing in integrative medicine, has posted some interesting articles on her website about pregnancy and COVID-19.
> Doula support in hospitals in light of the COVID-19 situation
Around the world, hospital visitation policies are becoming quite restrictive. It’s important to remember that doulas and partners are not visitors, rather, they are members of the health care team and their presence is critical to having safe birth outcomes. However, I know that parents are becoming anxious about the possibility of their doulas being turned away from the hospital (and doulas are worried, too!). As far as resources go…
- Birth Monopoly has an excellent article on this subject… I highly recommend absorbing the info there!
- EBB Instructor Jolynne Polichette posted a letter template for care providers to sign about doula support
- The American Association of Women’s Health and Obstetric and Neonatal Nurses has issued a statement on this subject.
We’ve heard from countless doulas, nurses, childbirth educators, expecting parents, and others that their anxiety is running high! With school and event closings, jobs being disrupted, the fear of infection, preparing to give birth or to support birthers in hospital settings, there is plenty to worry about. With that being said, I think it’s important to calm down our nervous systems and practice some intentional relaxation. I can personally attest that even though I am generally a calm person, today I felt my heart rate going up and fight/flight hormones kicking in at times. This means it’s time for me to do some deep abdominal breathing and mental relaxation techniques!
Given that many of us are in need of some anxiety-reducing techniques, I am going to lead a public relaxation session sometime this weekend. I will read a relaxation and deep breathing script for professionals, and I will also read a relaxation script for expecting parents. These sessions will take place on Instagram Live and Facebook Live. I will send out an email about 30 minutes before I go live. You’ll have to forgive me for not knowing the exact time… I will need to work it around my kids’ schedule.
> Online education
I know that childbirth education programs are being cancelled at hospitals in many places around the world. Fortunately, our EBB Childbirth Class was already 80% online, and we took steps this week to create a fully online class that EBB Instructors can use– it will be rolled out this weekend where it is needed.
So, if you’re looking for a comprehensive class that includes an emphasis on self-advocacy methods, comfort measures for labor, and evidence based care, you can check out our Events page to find an EBB Instructor near you. If social distancing is appropriate in your geographic area, then the class can be offered online. If the registration page doesn’t state whether or not the class will be offered online, feel free to email the individual Instructor to find out which method will be offered (80% online or 100% online). This is a brand new option, so registration pages might not reflect the change in method!
For those of you who don’t have a local Instructor in your geographic area, we’re hoping to have an online option open for registration in the next few weeks. This full online class will be taught by our EBB Instructors who work at EBB Headquarters. We know that people who don’t live near an Instructor have really been wanting this option, and we’re working on getting it up and running as quickly as possible!
We are also working on getting all of our other EBB Instructor Professional and Parent events and workshops online, wherever social distancing is appropriate or required.
Thanks for being part of our community, and I’ll be in touch as soon as I know what time I can lead the relaxation session! It will be recorded for those of you who can’t make it.
Rebecca Dekker, PhD, RN
Founder, Evidence Based Birth®
Author, Babies Are Not Pizzas: They’re Born, Not Delivered