Five ways COVID-19 might reshape maternal health
For years, Illinois Democratic Rep. Lauren Underwood has had a close eye on maternal health, rooted in the experience of grieving a close friend who died three weeks after giving birth to a baby girl.
Since the former nurse arrived in Congress, addressing maternal health disparities has been one of her cornerstone issues. Underwood flipped a Republican seat in 2018, and narrowly held off GOP challenger Jim Oberweis in November. The National Republican Congressional Committee in February identified Underwood on a list of "vulnerable" Democrats the organization plans to target ahead of the 2022 election.
Underwood said the COVID-19 pandemic, with its stark spotlight on disparities and the ways women often encounter impossible choices, has reframed discussion for legislators. Before, she said, when outlining disparities such as Black women being much more likely to die from pregnancy-related causes, she found that for some fellow lawmakers it was an unfamiliar topic.
But now that the nation has seen headlines about pregnant women's exclusions from trials and increased risk of severe illness should they contract COVID-19, people are more familiar with what's at stake.
"It's gone from people being in like disbelief," she said, "to what are we going to do about this?"
Underwood is hopeful increased awareness might pave the way for the multiple bills she has under her Black Maternal Health Momnibus Act of 2021 legislation.
"We needed to solve these problems years ago, but now we have an opportunity to do it," she said. "I think that people are ready to take action."
After already reshaping what we know about health, from telehealth options to rethinking how one's work might impact them, how might what we learned during the pandemic reshape maternal health?
Here are five things that might change.
Addressing health disparities. Experts have long known that some groups are more vulnerable during pregnancy and the postpartum period. In Illinois, Black women are six times more likely to die from a pregnancy-related condition. COVID-19 has only highlighted the disparities that women face while pregnant; of the COVID-19 pregnancy cases reported in Illinois, Black and Latina women made up over 70%.
After a year of health headlines, Underwood noted, "People are much more familiar with the concept of disparities, much more familiar with the concept of equity."
In an effort to address health disparities during the pandemic, officials have tried unique ways to reach at-risk communities, from allowing residents in harder-hit ZIP codes to get vaccinated early to creating bilingual awareness campaigns to address language barriers.
Meanwhile, telehealth allows doctors to reach more patients, but also has its limits. Jessica Davenport-Williams, co-founder of Black Girls Break Bread, a Chicago group supporting social/emotional wellness for black women and girls, has long monitored challenges for pregnant women and new moms in Chicago. The disparities in care extend to a digital divide, she said. Not everyone has a computer or wifi. The pandemic did bring creative solutions, like giving women blood pressure monitors at home.
"Telehealth is great, but that doesn't always work for pregnancy," she said. "Because you have to be weighed for every visit. You have to check your blood pressure. And when you're dealing with high-risk patients, things can change in the matter of a visit."
More birthing options. COVID-19 created stress for women planning prenatal visits or childbirth at hospitals: fear of pandemic germs, and worry that they might be separated from their babies in the wake of a positive virus test. There is also uncertainty around whether a partner would be allowed to be in the room. All of these things contributed to women considering home births or other options.
Davenport-Williams noticed more interest in home births. "Many have been afraid to even attend prenatal visits or go to the hospital to deliver," she said. "There's more movement around freestanding birth centers. I see that as something that's changing." In the last year, advocates have sounded alarms as the already limited places to give birth on the South and West Sides continued to diminish. In the wake of this, midwives are hoping to open a birthing center on the South Side.
Medicaid expansion. Advocates have long said expanding Medicaid care for new mothers would help both moms and babies. In Illinois, officials had sought to expand the time that women are covered under Medicaid from 60 days to one year postpartum, noting "alarming" statistics in Illinois, including that women with Medicaid coverage at delivery were five times more likely to die from a pregnancy-related cause than women with private insurance. Calling for an extension, Underwood had previously called extending Medicaid "the single best thing we can do to save moms' lives and tackle the glaring disparities."
In March, new legislation made the extension permanent, at least for new moms, who could now be covered under Medicaid for 12 months after chidlbirth. The American College of Obstetricians and Gynecologists lauded the legislation extending postpartum Medicaid, calling it "critical."
Teletherapy. One thing Dr. Karen Horst expects to stick around after the pandemic? Therapy from home. Considering it a gamechanger, Horst, an assistant professor of obstetrics and gynecology at Baylor College of Medicine and staff psychiatrist at Texas Children's Hospital, said she is "kind of shocked we didn't come to this earlier"—letting harried moms and pregnant women do therapy from home. "It's way better for moms, for new moms, for women at the end of their pregnancy, to not have to come in person to a mental health appointment," she said. Although some patients will prefer to be in person or need in-person care, "I'd say like 99 % of our moms are happy with doing mental health visits over telehealth," she said.
At Kids Above All, a Chicago group supporting kids and their families, communication director Andrew Dohan said they saw a significant uptick in relationship issues between partners, and between parents and children. "Family schedules were upended, and power dynamics within families all shifted," he said. "Mothers also struggled with social isolation and diminished time to themselves." Virtual therapy may have helped people feel comfortable seeking help; he said they saw more families accessing services.
More research for pregnancy. The initial exclusion of pregnant women from vaccine trials and subsequent lack of data for informed decisions, put women in a challenging position, Underwood said.
"They're looking at information and having to make tough medical decisions, and quite frankly our country has not necessarily served them well, because (pregnant) folks were not part of the trials," she said.
This lack of trial data for pregnant women highlighted how often women are not included in research, and the high-profile exclusion might expand the ways researchers include pregnant women in future.
The American College of Obstetricians and Gynecologists noted that in general, more women have been included in research trials, but "knowledge gaps remain because of a continued lack of inclusion of women, especially those who are pregnant, in premarketing research trials."
Previously, according to ACOG, arguments were made to exclude women because of possible harm to a fetus or to women who might become pregnant. The group added, "However, the risk of such harm can be minimized and, in itself, does not always justify the exclusion of women from research. Exclusion of women from medical research trials will only perpetuate the paucity of applicable data and the suboptimal practice of applying male-derived research results to women's health."
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