It shouldn't take a global pandemic to change the way our country supports women, but since it did, let's hope these changes stick.
As the coronavirus transforms the world as we know it, in recent weeks expectant and new moms have been particularly affected—and left in the lurch. Some have seen prenatal appointments rescheduled, others are afraid to go.
Mothers in New York were, for a time, forced to birth alone. New moms find themselves without the postpartum support they planned for and expected and postpartum group gatherings have been canceled or moved online.
Coronavirus has lifted some telehealth restrictions
Yet as our efforts to contain COVID-19 are reshaping public life, we are also seeing decades of healthcare policies relax overnight, bringing with them dramatic changes to the business of birth and postpartum care. For the sake of moms everywhere, I hope some of these stick around well beyond the current timetables.
While the experience of birth and new motherhood is personal, support—from specialists and communities alike—improves outcomes and overall experiences. Lactation consultants can improve women's breastfeeding outcomes, pelvic floor therapists can help moms recover from pregnancy and birth physically and therapists can help treat postpartum depression, making a huge impact on maternal mental health. But millions of women in the United States do not have access to such providers.
Yet suddenly, in response to the urgent need to shelter in place, Medicaid, the Department of Health and Human Services and major private insurers relaxed policies that have long been barriers to prenatal and postpartum care (and care in general). Many providers are now able to practice virtually across state lines in accordance with their licensing; HIPAA enforcement has been relaxed to facilitate email, phone and video consults for professionals new to offering them; and Medicaid and insurance companies are quickly approving new telehealth reimbursement categories including physical therapy and mental health.
I believe that many elements of these changes should be made permanent, while we also need to do more to ensure that these care providers are adequately compensated for their services and time, no matter the medium.
Though virtual visits are not always perfect substitutes for in-person care, maternal care providers are often a lifeline that can make or break the transition to new motherhood. In recent weeks, through my work as a founder of a maternal care startup, I have received countless messages from new moms seeking help with breastfeeding, anxiety and lack of sleep or simply seeking validation that they are not alone. More than one new mom has described her experience as "hanging on by a thread."
I didn't give birth in the midst of a pandemic, and the transition to motherhood was still challenging. It's challenging no matter what. And it was my doula, who had been present at the birth and who came to our home after I gave birth, who helped me through it—reminding me and making it possible for me to care for myself as well as I cared for my son.
She was the one who suggested I seek support from a lactation consultant, urged me to make time for pelvic floor physical therapy (and find one that was child-friendly, so I could bring my son) and made sure I was able to focus on my mental health as I navigated an identity shift that took me by surprise.
I don't know what I would have done without her.
But my experience is not an anomaly. Becoming a mother has a profound impact on women, as does the act of giving birth.
Most new moms are:
- Sleep deprived (which does its own number on relationships and mental health)
- Recovering from injuries sustained from childbirth
- Struggling with breastfeeding (which does not, it turns out, come naturally to all of us)
- Experiencing pelvic floor issues
- Wrestling with identity change
- Contending with realities that don't match up with how we pictured things
- Dealing with varying levels and degrees of postpartum anxiety (PPA) and/or depression (PPD)
Addressing the maternal mental health care challenges in our country
PPD affects 1 in 7 new mothers, according to the American Psychological Association, and symptoms can last up to a year postpartum. Yet less than 25% of the women who screen positive for PPD receive follow-up care, for reasons that range from the stigma around mental health issues to their providers not knowing where to refer them. Many therapists have reported a spike in virtual visits during the coronavirus outbreak, which is a promising indication that people, including new mothers, are seeking the help they need.
Coronavirus concerns only exacerbate these challenges. Yet long before COVID-19, we were in the midst of a maternal health crisis and the United States has had clear gaps when it comes to actually delivering on adequate maternal care due to racial, socioeconomic and other disparities. The March of Dimes coined the term "maternity care desert" to refer to the thousands of U.S. counties that lack obstetric care hospitals or providers, leaving millions of women driving long distances to seek care or else are found in the hands of general practitioners with limited experience.
Millions more women have limited access to appropriate preventive, prenatal and postpartum care in states with too few providers per birth who specialize in pelvic floor physical therapy or lactation consulting, for example. And many women simply struggle to attend appointments out of the home—that's why giving women the opportunity to have telehealth consultations with such providers is a necessity.
The changing landscape of doulas
In some ways, doulas have been disproportionately affected by the shifting landscape, as so much of their work is typically done hands-on and in-person. But the value of doula support—whether remote or not—cannot be overstated in improving outcomes for mothers.
Many doulas are approaching this crisis by embracing tools that can enable them to be present virtually for their clients. Though care from doulas is not traditionally covered by insurance (except in a few states where there are massive gaps in terms of the reimbursement offered for their time and labor) this embrace of satellite doula support is creative and welcome, and may eventually help to expand the adoption of doula services everywhere.
Pelvic floor and breastfeeding support can even be done virtually
Meanwhile, millions of mothers experience pelvic floor issues after birth and beyond, which are often best resolved by pelvic floor physical therapists. But several states have no such providers at all. Their work can be challenging to replicate virtually, but manual therapy is not necessarily required in order to be helpful. Many providers have techniques to support moms from afar, including exercise programs, teaching and observing scar mobilization.
In a recent study, 60% of mothers reported that they did not breastfeed for as long as they intended to, for a variety of reasons—issues with latching, concerns about infant nutrition and weight, worries about medications, unsupportive work policies and lack of parental leave. Support for such issues comes largely from lactation consultants, but there are only about 10 lactation consultants for every 1,000 live births in the United States—which means demand vastly outweighs supply.
In recent weeks, lactation consultants have been pivoting to do virtual consults, but some who have only ever done home visits have said it seems new moms aren't fully aware of their options here. And although the Affordable Care Act mandated coverage of breastfeeding support and supplies, in practice, actually receiving such benefits remains notoriously challenging. We have more work to do here across the board, including facilitating virtual support.
Getting support should not be dependent on where a person lives or if and how often they are able they are to leave their homes. Motherhood is a physiological transformation and it is clear that women who have better support before, during and after birth, do better. The fact that many women are now able to access those providers virtually will have a lasting impact.
If it is possible to have something good come from this time period, which will disproportionately impact our most vulnerable, let it be this.