The Covid-19 pandemic has undoubtedly demonstrated just how much power governments have in times of extremis. Even with a lockdown, however, there are some things they simply cannot stop: with childbirth being a prime example. To try and manage this in the safest way possible, some highly stringent protocols regarding birthing mothers have been discussed – the implementation of which will likely severely limit the ability of these women to have a positive birth experience. When the World Health Organisation (WHO) has indicated that reproductive rights must be respected even in the face of the virus, the question must be asked whether these are proportionate. To what extent pregnant women, themselves a vulnerable group, can be expected to bear the brunt of the pandemic is a decision that must necessarily be swift, yet considered. All the risks, not solely transmission of Covid-19, must be taken into account. The goal of this short piece, therefore, is to encourage discussion as to whether the correct balance is currently being struck. It is suggested that the potentially severe consequences of such measures may mean alternatives need to be considered.
Giving Birth During the Crisis
Current evidence does not indicate that pregnant women are more likely to suffer severe symptoms should they contract the virus. Other pertinent issues, such as whether it is vertically transmissible, remain unclear. At present, therefore, there appear to be two primary fears influencing the protocols that have been introduced regarding childbirth and Covid-19. A particularly pressing concern is that mothers or birthing partners who are asymptomatic may pass it onto doctors or other patients in the hospital at the time of the birth. It is with this in mind that an increasing number of maternity wards, in states including France, Germany, Portugal and the United Kingdom, are beginning to introduce measures trying to limit inter-personal contact. A critical example of this has been refusing to allow birthing partners, or any visits after the birth. The second fear is that the babies themselves catch it. In order to protect the infants, some have gone so far as to suggest a 14-day quarantine period before parents can be allowed contact with their baby after the birth – particularly if showing symptoms.
Even when guidelines and protocols are released centrally, in the face of general confusion it seems that the precautions are often hospital-specific and subject to fast and regular change. The potential severity of their consequences, however, cannot be overlooked. They merit consideration as a matter of reproductive justice.
Childbirth and Women’s Rights
The idea of ‘reproductive rights’ is traditionally associated with longstanding feminist causes: ensuring fair and universalised access to contraception, the right to choose to have an abortion. Only far more recently, however, has consideration been given to the rights of women in the context of childbirth itself. The phrase ‘labour of love’ is often conjured to describe the process. Though the agony it involves for women is well-known, birth is nonetheless often romanticised. It is assumed that mothers invariably reflect on it as a magical experience; the pain a distant memory. Increasingly, however, it is recognised that this is not always the case. Childbirth can be a highly stressful experience for women no matter how successful its outcome. Some even go on to develop symptoms of PTSD as a result of the experience. Such a negative experience naturally has significant psychological consequences for these women – which can also impact their ability to bond with the baby. For some time, therefore, the importance of autonomy in childbirth decisions has been emphasised. The idea of respectful maternity care is now a central one, promoting a positive birth experience and minimising the risk of harm as a result. Adequate information and consent are central to any medical procedure – and there is no reason that this ought not also be true of childbirth. It is vital that birthing mothers have their rights of physical integrity, privacy and self-determination respected.
Potential Impact of these Measures
Though the protocols referred to above may help prevent the spread of Covid-19, the countervailing problems they pose for these reproductive rights therefore cannot be overlooked. There is now widespread recognition, including from WHO themselves, that having a birth partner can be critical to ensuring a positive birth experience for women. Often the father of the child, they offer indispensable emotional support and reassurance during labour – as well as other benefits such as non-pharmaceutical pain relief through massage. Taking this possibility away from women is clearly isolating. It exacerbates the risk of the psychological traumas referred to above, heightening suffering, stress and fear.
The potential impact of an isolation period on both mother and child also cannot be overlooked. The early stages of a baby’s life are critical. Attachments formed in this time impact the social relationships they build throughout their life. It is also crucial for mothers. A baby that is unused to touch, for instance, can be fractious when contact is eventually allowed – making it challenging to experience feelings of warmth and love towards them. Though bonding is by no means ‘completed’ in this time, it would clearly be jeopardised by such early separation. The drastic nature of this thus cannot be overlooked.
And Atypical Families?
Though statistically less pressing, the possibility also cannot be overlooked that some of the women giving birth in these circumstances will be surrogates. In these arrangements, the birth is a critical moment. For intended parents, the possibility of immediate skin to skin contact again promotes bonding with the baby – particularly if the mother is anxious about the absence of gestational link. Emotionally, for surrogates it is often their joy which makes the process ultimately worth it. Seeing the family unit she has created can help her to process the experience and relinquishment. In states that have elected to recognise the legitimacy of surrogacy, it is surely critical that real consideration be given to the psychological needs of these parties when developing Covid-19 protocol. This must be with regard not only to the short-term, but also the potential long-term implications of obstacles to bonding – all of which can be more emotionally complex in the context of third-party reproduction.
So What is To Be Done?
As is so often true with human rights issues, the situation seems to place hospitals and medical decision makers between a rock and a hard place. On the face of it, with an ever-rising death toll and vulnerable parties at play, it seems reasonable that any possible precaution be taken in order to ensure the well-being of those involved. In the absence of more widely available testing and comprehensive PPE, it is difficult to avoid the reality that interaction of any form elevates the risk of the virus spreading. Just as everyone is having to make sacrifices, it might be thought that women would simply have to accept that these restrictions are for their own good – as well as that of those around them.
In the face of such an obvious medical risk however, ‘tunnel vision’ by policy makers seems a clear risk: so focussed on controlling the disease that the other health problems such stringent measures might cause are not given adequate consideration. Yet for these women and babies, health is clearly not purely physical – and it is certainly not limited to being free of Covid-19. The psychological consequences of isolation during and after the birth are potentially significant and long-lasting. Though naturally measures need to be taken to protect doctors and other patients, maternal vulnerability demands at least consideration of whether there is a more proportionate approach than those described. It is strongly arguable however that discussion needs to be had as to where the middle ground might lie – ensuring that general protection is achieved without absolute subjugation of these reproductive rights.
It might be thought reasonable, for instance, that healthy women and babies spend less time in hospital than they otherwise would to reduce the general risk of transmission – with distancing measures carried out as far as space allows it. Limiting the time their birthing partner can stay after the labour would similarly reduce contact with other patients, whilst avoiding her having to give birth alone. This also limits the risk that she will not have a medical advocate in the face of an emergency, where she may not be conscious or competent to make critical decisions. Though lack of medical staff may make it impossible to isolate maternity wards from the rest of the hospital, it might be questioned whether mothers and their birthing partners could be asked to self-isolate prior to the birth as an alternative means of minimisation. It is likely that there are many other possible compromises – but without such conversations these may well go unconsidered. Whilst they may not seem a priority, these decisions may potentially have long-lasting consequences, thus should not be taken lightly.
One of the worst aspects of the current situation is the considerable uncertainty we are facing. It is vital, therefore, that these protocols are clarified relatively swiftly. This should not necessarily mean, however, simply imposing the most drastic measures conceivable without consideration of the other potentially detrimental health consequences. Reproductive rights still deserve full and proper consideration – even in times of crisis. A more proportionate balance than the current approach may therefore need to be found. Only with open discussion, however, is this likely to be achieved.
Sylvie Armstrong, PhD Candidate at the European University Institute