As Maryland largely remains under a state of emergency due to the COVID-19 pandemic, women are scrambling to access reproductive and obstetric care. And the prominence of the virus in hospitals and other health care facilities is changing the way medical professionals reach their patients.
Dr. Raegan McDonald-Mosley, Planned Parenthood of Maryland’s chief medical officer, said that the pandemic has brought about a number of dramatic changes for the organization’s clinics.
Known for its integration of family and caregivers during the treatment process, Planned Parenthood’s Maryland branch has been encouraging patients to stay away from the organization’s facilities unless absolutely necessary and has transitioned a series of its services to digital platforms.
McDonald-Mosely said that the clinics have pivoted to telehealth services for those seeking care during the pandemic, including providing birth control prescriptions for pills, patches and contraceptive vaginal rings, remote pregnancy testing and options counseling, gender-affirming services and pre-exposure prophylaxis care.
“Anything that we can safely provide — and provide a good quality patient experience using telehealth services — we are,” said Mcdonald-Mosley.
While family planning clinics try their best to continue serving their patient population, a series of executive orders put in place by Gov. Lawrence J. Hogan Jr. (R) slowed their ability to maintain certain practices.
In mid-March Hogan issued an executive order temporarily halting elective and non-essential medical procedures, leaving many to question if that was a veiled ban on abortions in the state.
McDonald-Mosely said that, with the order, Planned Parenthood of Maryland was tasked with discerning which of its services were “urgent and life-threatening,” leaving it up to the discretion of individual care providers to determine if abortion services were necessary on a patient-by-patient basis.
While providers at Planned Parenthood are “grateful” that the order has been lifted and they can continue to provide reproductive health services to patients statewide, they are cautiously rolling out their offerings of in-person care services to prevent the spread of COVID-19.
Maryland Matters spoke with McDonald-Mosley over the phone last week, when she revealed that the clinics were just re-establishing IUD and implant contraception services — nearly two weeks after Hogan lifted the order.
“And then we have a plan to add back additional services over time, once we sort of see the impact week-by-week of adding back those services,” she said.
Though employing telemedicine is not Planned Parenthood’s norm, McDonald-Mosely said that she can see telehealth continuing to take root in their offerings even after the pandemic has subsided.
“Absolutely. I mean, I think, you know, nothing in our community — in our society’s are going to go back to the quote-unquote normal or whatever that was beforehand and certainly the medical community and Planned Parenthood of Maryland, are not excluded from that,” she said.
The clinic isn’t alone in its move to virtual reproductive care.
Dr. Sarah Crimmins, medical director of the Obstetrics Care Unit at the University of Maryland Medical Center, said that her hospital has made the shift to telehealth services as well, pushing for expectant mothers to come in for procedures that can’t be done virtually, like testing and ultrasounds, while otherwise fully taking advantage of telemedical services.
Further, she explained that all patients reporting to doctors’ offices are to be masked, visitors are discouraged from attending appointments, and “critical conversations” with family and other support are being done over platforms like Zoom.
“You know, the first and foremost priority that we’ve always had and always will have is a healthy mom and a healthy baby,” Crimmins said.
Some reproductive rights advocates and medical experts think the shift to telemedicine is here to stay.
“Definitely the telehealth is going to continue,” said Del. Ariana B. Kelly (D-Montgomery).
During the truncated 2020 legislative session, lawmakers passed legislation expanding telehealth availability in the state. Kelly called this “very controversial,” noting that some doctors and insurance providers were “not yet supportive of eliminating barriers.”
“Now that we have gone through this I think the doctors, along with the nurses, and pretty much everyone who’s providing obstetric care has invested a lot of energy and resources into figuring out how to make telehealth work, and now they’re much more supportive of utilizing that moving forward for all sorts of different health care,” she said
Antenatal care isn’t the only shifting piece in the birth industry. Labor and delivery units are restructuring how they protect mothers and babies from the ever-present threat of COVID-19, too.
Crimmins said that her hospital has transitioned from multiple hospital room visitors down to just one supporter. Some mothers can’t have any birthing support from family members or partners at all.
Melissa Fleming, American College of Nurse-Midwives Maryland affiliate president, has noticed changes in the way that mothers are allowed to prepare themselves for labor once they’ve arrived at the hospital: Right now, women aren’t able to walk unit halls to distract themselves or consult their doulas or family members in person.
Additionally, their one chosen support person, once in the delivery room, cannot go back out — an edict Fleming described as “really intense.”
“When they’re trying to go through the birth, sometimes it’s nice to be able to step out for a moment to catch your breath, so that you can be a strong support for your partner, but you know having to stay in the room with their partners … and trying to explain that, you know, we really don’t want you to go in and out, possibly be exposed,” she said.
Initially, Fleming feared that the mounting amounts of personal protective equipment required for birth workers would get in the way of how she interacted with mothers in labor. Luckily, she said, she hasn’t noticed much difference.
The midwife explained that she and other providers find themselves going the extra mile to ensure that protective measures don’t get in the way, often asking each other if they can tell that they’re “smiling with [their] eyes” while a mask covers their mouths.
She said that a lot of the time even laboring mothers are masked themselves.
“If anything, it just makes me feel like I need to be even more empathetic and close to them to assure them because them seeing everyone in PPE, you know also already being maybe concerned or fearful because they are feeling things in their body they don’t normally feel, you know, it almost makes you even feel like you have to reach out for them more and say, ‘You’re going to be OK.’”
‘There’s not a huge risk of prenatal transmission’
Precautions don’t lift once the birthing process is through.
Fleming said that she has seen birthing teams ask new mothers to try to leave the hospital within 24-hours post-delivery to reduce the amount of time their infants are in a high-risk environment.
Crimmins said that her hospital is recommending that new parents isolate as much as possible for the protection of themselves and their babies.
“It probably means a lot of new parents are staying home more than they might have before. And that’s probably the safest way to keep both mom and baby healthy,” she said.
Crimmins said that COVID-19 isn’t the only virus that altered birthing practice, pointing to the HIV crisis of the 1980s and 90s when the medical community began to screen for mother-to-baby viral transmission.
She told Maryland Matters in a phone interview last week that “from what we understand for coronavirus, there’s not a huge risk of perinatal transmission,” adding that evidence does not show that pregnant individuals are more susceptible to fall victim to COVID-19 and that her hospital is doing its best to test prior to delivery.
“So, as most people know at this point the coronavirus can be an asymptomatic thing that somebody carries around and doesn’t know they’re positive,” Crimmins said. “And so we’ve been universally, or, as best we can, testing moms when they arrive for delivery so that they can prepare for delivery and prepare for the postnatal period with their baby, knowing they’re positive or negative.”
Fleming said that, while there aren’t enough studies to know the true impact of COVID-19 on pregnant women, medical professionals are trying to make informed decisions based on data they have surrounding other respiratory diseases.
High maternal death rates are an issue the state has grappled with for years.
“Maybe 10 years ago we were more focused on the infant deaths,” said Kelly. “And the last couple [of] years, we have really homed in on these huge disparities, particularly with African American mothers.”
According to the Maryland Maternal Mortality Review 2018 Annual Report, from 2012 to 2016, Maryland experienced an average of 23 maternal deaths for every 100,000 live births — 19% below the national average and a welcome change. From 2007 to 2011 Maryland’s maternal mortality rate was 120% above the national average.
But disparities in maternal health remain.
During the same time periods, black women in the state had a higher rate of maternal mortality than white women by between 275% from 2007 to 2011, increasing to 372% from 2012 to 2016.
Kelly said that this is “not just a blip,” noting that black communities are also being harder-hit by the pandemic than white parts of the state.
“We have these existing health disparities that are then profoundly exacerbated by the COVID crisis, and we’re seeing that,” she explained.
“I think we’re going to see an increased investment in focusing on really how to get at the underlying reasons for those disparities, which are both differences in, in health … but also increases in discrimination in health care settings.”