key: cord-0756149-j9ljwqv0
authors: Ecker, Jeffrey L.; Minkoff, Howard L.
title: Laboring Alone?: Brief Thoughts on Ethics and Practical Answers During the COVID-19 Pandemic
date: 2020-05-15
journal: Am J Obstet Gynecol MFM
DOI: 10.1016/j.ajogmf.2020.100141
sha: aafdecac382839a969c348c0ca6c34cd4ef8d4f9
doc_id: 756149
cord_uid: j9ljwqv0

nan

Condensation: To minimize risk of exposure to health care workers, some have proposed eliminating 4 spouses, partners and other visitors to support women during their labor and delivery. An ethical and 5

pragmatic approach argues that with appropriate limits and safeguards, including personal protective 6 equipment, the option of having one support person in labor can be preserved for almost all patients. 7 8 9 10

The iconic image of mid-twentieth century childbirth is a woman's partner----always a man, always her 11

husband----pacing in a waiting room until a nurse in white bursts through the door to announce that his 12 wife (always again) had given birth to a boy or a girl. This is followed by much back slapping and cigar 13 smoking with the other expectant fathers until, hours later, the new father peers through a nursery glass 14 to pick out his child from the assembled rows of newborns. 15

Such has not been the norm for decades, and obstetricians and midwifes would have thought that the 16 days of sequstering partners outside labor and delivery units were long past. Yet these are 17 extraordinary times, and during the current COVID-19 pandemic, hospitals have been eliminating 18 patient visitors in an effort to promote social distancing and protect the health of their work force and 19

patients. We understand that asymptomatic individuals can carry and transmit COVID-19 infection, and 20 this recognition makes banning visitors from accompanying patients to their cardiologist's office and 21 banishing a partner from the bedside of a patient recovering from an MI in the CCU seem prudent. 22

In most institutions, however, labor and delivery units have been rare exceptions to the "no-visitor" 23 rules, for visitors there are felt to have, in the words of the New York Department of Health, an 24 "essential" role in process of care, and not having a partner present for the birth of a child seems 25 unimaginable,unkind and, for some, even traumatic. And yet as the pandemic grows, challenging and 26 sometime humbling the capacity of units to accommodate, some have begun to rethink this exception. 27

Several hospitals and systems in New York City, hit hard by an overwhelming number of COVID-19 28 patients, enacted a ban on labor and delivery visitors, hoping to reduce unnecessary staff exposures that 29

were challenging their ability to maintain a needed complement of providers and support staff. The 30 ensuing reaction and concern---a mix of grief, incomprehension and outrage---was both local and 31

national. Many worried that such policy would push women, including many with risks not conducive to 32 such, to plan home deliveries or uproot themselves during a time of quarantine and seek care and 33 delivery at hospitals elsewhere that still permitted an accompanying support person. Responding to the 34 publicity and controversy, The New York City Department of Public Health published guidance declaring 35 a support person in labor to be, as noted above, "essential," and the Governor of New York issued an 36 executive order requiring hospitals to allow (healthy) visitors. 37 38 As a matter of medicine, policy and ethics, what is right here? In this commentary, We will briefly 39 outline the considerations important to answer those questions. Unlike many choices in medicine, this 40 policy decision affects not just the patient but other individuals including the patient's family and the 41 health care team. Accordingly, the issue may be best considered from the perspective of the 42 community rather than just the individual. We recognize that to some the arguments laid out and 43 conclusions we reach may seem long settled or obvious, yet we still regularly hear questions 44 from others---providers, staff, hospital leaders and administrators, patients and the public--- 45 wondering why we don't allow more visitors or, conversely, why we allow any at all. Those This piece will consider visitor policy from an ethical perspective. It is important to understand, as this 51 conversation progresses, that ethics is not strictly an abstract or ethereal art. It is informed by facts. So, 52

for example, if an obstetrician is wrestling with the ethical question of whether to accede to a patient's 53 request for a cesarean section for a fetus at 22 and a half weeks, the ethical conundrum would be quite 54 different and perhaps vanish entirely if a sonogram revealed that the fetus was in fact only 19 weeks. In 55 this article the facts that are contributory are the risks and benefits of visitor policies, and as we will 56 discuss, those can vary widely based on technology and policy. Emotion is another factor that flavors 57 ethical positions. In Phillipa Foote's and Judith Jarvis Thomson's classic thought experiments about an 58 out of control trolley racing toward several innocent children, participants are asked whether they 59 would push a man onto the tracks in order to stop the train and save the children. When this thought 60 experiment is offered to a subject lying in a flow MRI, the decision to "kill" the man varies depending on 61

whether the emotional (save the man) or intellectual (kill the man) part of the study subject's brain 62 lights up. Hence, fears of contagion will undoubtedly play a role in how the issues discussed here are 63

viewed. As we have previously written, "The strength of the physician-patient bond is dependent, at 64 least in part, on patients' belief in their physicians' altruism, i.e., their willingness to do what is in the 65 best interests of patients (i.e., to fulfill their fiduciary obligation) and, historically, to occasionally do so 66 at some risk."(1) While those words-written in the context of the Ebola epidemic-focused on patients, 67 not partners, it is not extreme to recognize that the best interests of patients include having their 68 partners present. While partner issues cannot supersede substantive risks of contagion, they should not 69 be dismissed out of hand. 70

The Patient and Her Partner 73 74

In times free of COVID-19, having one or more visitor is important for all patients. We have been taught 75 the words of Hippocrates since medical school, "cure sometimes, treat often, care always." Facilitating 76 ongoing contact with loved ones is a critical component of caring. This is even more important in the 77 context of childbirth. Having individuals present to attend and support a woman during her labor and 78 delivery is not just expected but is, in fact, generally encouraged. These visitors/support people serve 79 many important roles: 80

• They provide emotional support and encouragement, distraction and just plain company to 81 speed the passing of what, in some case, can be many hours. Such support, especially when 82 knowledgeable and trained, has been associated with improved outcomes separate from a 83 patient's happiness and sense of well-being. 84

• They can contribute to decision making especially as parent-couples work to align choices with 85 shared values. A partner-visitor can often help patients process information and choices, 86 serving as a valuable second set of ears, articulating questions the patient may struggle to offer 87 and explaining key points in ways that are more readily heard and understood. 88

• They provide help during the process of labor and delivery, whether lifting a leg, obtaining water 89 or other appropriate hydration and nutrition and, on the postpartum unit, assisting in newborn 90 care and maternal recovery. Among other realities, removing these invited "assistants" would 91 challenge nurses' time and nursing staffing needs. 92

• As attendants they experience the joy of welcoming a new child, whether as a genetic or 93 intended parent, other relative or friend. 94 95

In short not having a partner present during labor seems both detrimental and unkind. Yet we must 96 acknowledge that the same could be said for end of life circumstances, and COVID-19 in some settings 97 has left patients dying without the comfort and presence of loved ones. These are extraordinary times. 98

Some have raised concerns that having visitors present risks the visitor's health by reducing physical 99 distance and exposing visitors to many in a hospital's halls and rooms, including the patient herself. As 100 noted above, the process of labor and delivery requires close quarters, but it is difficult to estimate the 101 true incremental risk that comes with accompanying and supporting a patient, especially if members of 102 the health care team are symptom free and wearing appropriate PPE. It also should be recognized that 103 most patients and their visitors will soon be sharing similarly close quarters at home as they recover and 104

care for a newborn. 105

The Health Care Worker 108

Both for the sake of their own well being, and so they will be available to care for current and future 109 patients with and without COVID-19 illness, health care workers (HCW's) have an interest in decreasing 110 their chance of unprotected exposures to those who are infected. The infectivity (R0) of COVID is 111 approximately twice that of the flu, and the mortality rate is apparently much higher as well. 112

• Decreasing the risk of exposure may be accomplished by screening patients and visitors (using a 113 questionnaire regarding symptoms and travel, and taking temperatures), but transmission from 114 asymptomatic but infected individuals has been recognized as a key avenue for spread both in 115

China and on U.S. labor and delivery units(2). Furthermore, screening for symptoms relies on 116 the honest and transparent reporting from a visitor who, eager to be present, may consciously 117 or unconsciously fail to disclose an early tickle in the throat, waning sense of smell, flushed 118 feeling or other early and/or subtle symptoms of infection. The risks of transmissions from 119 visitors will clearly diminish if and when viral or serologic screening of partners can be instituted. 120

The former is already in place in some sites. 121

• Use of appropriate hand hygiene, distancing and other health practices (not touching one's face) 122

are important in limiting risk of infection, but keeping one's physical distance is difficult in most 123 labor rooms, particularly when supporting a woman during the second stage. All who have 124 managed the second stage have experienced the tight huddle of provider at the perineum, a 125 nurse on the mother's one side with the partner on the other: the diameter of that circle is 126 often much less than six feet. 127

• Appropriate use of PPE is an important step in mitigating risk of close exposure, but in many 128 places individual elements of PPE have been in short supply. In many settings, it is not possible 129 to approach every patient and visitor as if they were COVID-19 positive and use enhanced PPE 130 (gown, gloves, mask of at least some kind, and face shield). While supplying and requiring 131 visitors to use masks themselves would limit their risk of their spreading infectious droplets, 132 even that may not be possible in systems with limited supplies. In such situations or if providing 133 PPE for visitors would compromise access to PPE for frontline workers, then the ethical balance 134

shifts away from supporting visitors in labor and moves towards honoring the societal 135 commitment to protect the health of physicians and other healthcare workers. 136

Limiting the number of people in the room would as a matter of simple math, limit the potential 137 exposure of HCW's. There are certainly other situations in which we accept limitations to a patient's 138 right to have visitors or limit their autonomy in choosing them. Individuals who are verbally or physically 139 abusive of staff or otherwise risk a provider's well-being are not permitted to attend their partner's 140 delivery, for example. It is also difficult to imagine that someone symptomatic with active TB would be 141

welcomed. When risk is manifest, whether as a cough or verbal challenge, the chance to exclude 142 provides an opportunity for keeping HCW's safe. When risk may be present without symptoms or other 143

warning, the risk is more insidious and there is not such a ready opportunity to identify and exclude 144 those who bring risk. 145

While in all these considerations, it is important not to dismiss these risks to those providing care, it may 146 be useful to contextualize them. When the health care worker leaves work and goes to shop for 147 essential goods in the local grocery mart, they will stand six feet away from someone who has not had 148 their temperature taken or filled out a questionnaire, and are likely not be wearing the type of PPE that 149 would be distributed in a hospital. In the delivery room, when the provider, patientand partner have 150 donned appropriate garb and make good faith efforts to maintain a distance, the risks would have to be 151 considered substantially reduced. 152 153 What Is to Be Done? Where Does Best Balance Lie 154 155 As laid out above, the dilemma here appears to be of conflicting interests and outcomes: the 156 unhappiness, potential trauma and other challenges of giving birth alone for the patient, the risk of 157 exposure and possible infection for the HCW. But this simple sketch ignores the shared goals important 158

to each: navigating the process and events of labor and delivery with a healthy mother and child at the 159 end. Moreover, eliminating risks by banishing all visitors is likely to discomfort, at least in some regard, 160 most providers, who would be asked to serve as agents in inflicting this unkindness. Separately, 161 eliminating visitors may impede the process of labor and delivery and post-partum recovery. 162

Accordingly, instead of pushing to eliminate all visitors/support, we suggest two menus of measures: the 163 first is designed to limit the chance that a visitor presents a risk; the second, recognizing that all visitor-164 risk cannot be eliminated, is designed to moderate any residual impact on HCW's. 165

166

A first step in limiting risk of exposure is to screen all visitors for symptoms of COVID-19 infection or a  168  known ongoing infection, and only allow those who are asymptomatic and infection free onto labor and  169 delivery units. This is consistent with hospital practice during times of other infections (flu season) and 170 the approach to individuals who at other times have highly communicable illness (e.g. active TB). The 171

utility of visitor screening, as with screening of the patient herself, relies on honest answers from the 172 individual screened. Some will see this as a key weakness, but appealing to the virtue of truthfulness 173 while emphasizing the implications for the health of the individual HCW's as well as the other patients 174 who require their continued health and care should find traction with many. Verbal screening can also 175 be supplemented by objective criteria, such as checking a visitor's temperature at intervals (once a shift 176 might be a practical option) and monitoring for readily observed symptoms such as cough. 177

Ideally, the screening process will yield to viral or serologic screening in the not too distant future. 178

When testing becomes more readily available, screening might include testing a visitor for viral RNA 179 either at the time of admission (tests that allow for very rapid resulting have already been rolled out in 180 some clinical settings) or at some point in the final weeks of pregnancy as the time for delivery nears 181

(although this latter approach cannot preclude incident infection subsequent to testing). Serologic 182 testing (i.e. testing for COVID-19 antibodies) can also identify individuals who have tested positive in the 183 past but are no longer shedding virus, and who therefore are appropriate to accompany a patient. 184

Testing may also be useful in reducing the risk from a visitor who, though asymptomatic, has had an 185 identified significant exposure to an individual known to be COVID-19 infected. 186

If a planned visitor/partner needs to be excluded, whether due to symptoms or concerning test results, 187 a patient should be permitted to turn to an asymptomatic substitute: mother for husband, sister for 188 partner, second best friend for best friend. Discussing or otherwise communicating visitor policy and 189 restrictions in advance will allow patients to understand when such substitution will be needed and to 190 prepare accordingly. 191

The spread of coronavirus from those not undergoing aerosol generating procedures is through 192

droplets. As such, requiring visitors to wear an appropriate mask supplied by the health care facility for 193 as much time as possible can be part of a visitorcontract. Requiring visitors to remain with their patient-194 partner in their room throughout the course of labor and delivery and postpartum recovery should be 195

another key stipulation in limiting staff exposure. In addition, limits on the number of visitors should also 196 be instituted. Given the extraordinary current circumstances, and the work and resources involved in 197 the measures proposed above, allowing just one visitor who cannot be swapped for another throughout 198 the course of labor and delivery seems appropriate and is, in fact, where many have settled. Some have 199

argued that a policy of one, impacts those who have planned to use a doula or an experienced family 200 member or friend to provide support that a partner/father may be less able to offer or comfortable 201

offering. Allowing exceptions and extra visitors for some, however, would push against the virtue of 202 providing care that is equitable, and, as just noted, allowing more for all would be a significant 203 additional strain on resources. An appropriate solution may be to encourage additional support and 204 participation by using phones and other technology to share conversation and images. Facilities should 205 consider relaxing any rules limiting live communication and streaming during the process of labor, 206 delivery and recovery. Equity in this virtual solution might be facilitated by loaning needed devices and 207

technologies to interested families who do not have such access. 208

As is true when an individual provider is caring for a woman with known or suspected COVID-19 211 infection, the risk for being infected by a visitor-partner will be mitigated by appropriate use of PPE. The 212 availability and type of PPE has varied widely across health care settings. Some require and provide 213 masks for continuous use by HCW's and may be able to provide similar masks to patients and their 214 partners and require that they use them continuously as well. Other facilities may limit use to partners 215 of those patients with symptoms or known COVID-19 infection. In cases in which masks are not worn, 216 encouraging or even requiring distancing of the partner may offer another route of mitigation. Such 217 distancing may be undertaken, as room architecture permits, by assigning a visitor a space appropriately 218 distanced from where a nurse, midwife and/or physician will be stationed for needed clinical care. 219

Clinicians will recognize the limits of this latter approach given the close quarters of the labor room and, 220 especially, the huddle of patient, providers and visitors that often is the reality of second stage pushing. 221

Given these concerns and real-world limitations and, as suggested above, some may judge the overall 222

balance of adding a labor support person to be unacceptable when PPE cannot be available to visitors. 223 224 None of the suggestions above is perfect, and admittedly there may be chinks in the armor of 225 protection. As with medical care and protocols in general, all will need to be tailored thoughtfully to 226 individual circumstances, including the circumstances of individual facilities where supplies, space and 227 staffing may limit implementation of some proposed steps for risk mitigation. Used in combination, 228 however, the measures suggested here will contribute to promoting the goals that patients and 229

providers share and hold paramount: promoting healthy maternal and neonatal outcomes, protecting 230 the safety and health of all involved in patients' care, and creating an experience of childbirth as 231 satisfying as possible to all. A recent article (3) discussed intrusions on civil liberties in times of rampant 232 infection noting that, "To respect civil liberties, courts have insisted that coercive restrictions must be 233 necessary; must be crafted as narrowly as possible -in their intrusiveness, duration, and scope -to 234 achieve the protective goal… "(4) With appropriate PPEs and screening, we believe that in most settings 235 and circumstances, that mandate would allow women to have a chosen partner, spouse or support 236 person present with them without posing undo risks to their providers. 237 238 239

Physicians' obligations to patients infected with Ebola: echoes of acquired 241 immune deficiency syndrome

244 pregnancy: early lessons

Disease Control, Civil Liberties, and Mass Testing -Calibrating 249 Restrictions during the Covid-19 Pandemic

Covid-19 -the law and limits of quarantine