key: cord-0873016-bhc33s55
authors: Monteblanco, Adelle Dora
title: The COVID-19 Pandemic: A Focusing Event to Promote Community Midwifery Policies in the United States
date: 2021-01-01
journal: Social sciences & humanities open
DOI: 10.1016/j.ssaho.2020.100104
sha: 51437840867a6e9857b9f130152f235430173879
doc_id: 873016
cord_uid: bhc33s55

The COVID-19 pandemic has placed unprecedented stress on health care systems across the globe. This stress has altered prenatal, labor, delivery, and postpartum care in the U.S., motivating many pregnant people to seek maternal health care with community midwives in a home or freestanding birth center setting. Although the dominant maternal health care providers across the globe, community midwives work on the margins of the U.S. health care system, in large part due to policy restrictions. This commentary extends previous research to theorize that the COVID-19-related disrupted health care system and the heightened visibility of community midwives may create a “focusing event,” or policy window, which may enable midwives and their advocates to shift policy.

2 government-recognized midwifery education program, where they are trained to detect complications and seek appropriate hospital assistance during obstetrical emergencies (4) . (Many U.S. Direct-Entry Midwives, who are also professional midwives, do not meet this definition, as will be discussed below.)

The benefits of midwives have long been clear: improved maternal and newborn health outcomes, reduction in unnecessary interventions, and cost savings to families and the health system (5, 6) . In fact, the midwifery model offers support and care to both the physical and psychosocial needs of their patients (7) , especially helpful to Black women who weather historical, structural, and/or personal racialized trauma (8) .

In particular, out-of-hospital or community midwives (henceforth referred to as community midwives) i have always thought of themselves as crisis responders (9) . As a study of community midwives' perception showed, participants believed that their unique flexibility (their constant preparedness to serve large geographic areas) and training in out-of-hospital care (particularly their ability to improvise when supplies are limited) prepared them well for crisis response. These skills, which seem to go unnoticed or undervalued in non-crisis times, become highly valued during a disaster that overtaxes existing medical systems and limits access to medical facilities.

For example, the midwives of Bumi Sehat and of Mercy in Action have long provided highly successful "low-tech/skilled touch" care in disaster zones, including in the aftermath of the 2004 Indian Ocean earthquake and tsunami, the 2013 Super Typhoon Haiyan in the Philippines, and the 2017-2018 volcanic eruptions in Bali (10) . In the United States, community midwives prepare their clients for extreme heat events (11) . These authors argue for the decentralization of maternity care in preparation for the increasing natural hazards that are bound to accompany the onrushing Climate Crisis, and for the integration and empowerment of local community midwives such as the ones I discuss in this commentary.

Although community midwifery is regarded somewhat tenuously by mainstream U.S. medicine, this pandemic is disrupting the health care system and creating demand for such services (2, 12, 13) . As J o u r n a l P r e -p r o o f 3 hospitals seem to be increasingly a site of real and/or perceived risk during this pandemic, community birth with a midwife is becoming increasingly popular among pregnant people who may not have considered this setting or provider before (2) .

It is necessary to briefly mention that coronavirus transmission risk is not simply eliminated with a move from hospital to home or birth center for prenatal, labor, delivery, or post-partum care; childbirth in particular, "creates multiple sources of exposure (air, fluids, surfaces) and requires frequent and repetitive physical contact with health workers in a concentrated period" (2) . While a pregnant person may feel safer among her and her family's own germs in the household, if community midwives do not have access to personal protective equipment and same-day testing, there is still risk of transmission, with the community midwife carrying the largest burden.

Still, pandemic-era increased use and visibility of community midwifery services may provide an opportunity for midwives and their allies to shift U.S. policy. This commentary extends previous research to theorize that this real and/or perceived disruption in hospital-based maternal health care, along with community midwives' heightened visibility during this pandemic, offers a "focusing event," or window of opportunity, in which to create and modify policies that support community midwives' legal practice and expand their scope of care.

As context for this argument, I begin with a discussion of community midwives' historical and current occupational marginalization and a brief overview of homebirth. The medical, political, and legal opposition to midwifery and the misinformation associated with planned out-of-hospital birth explains why midwives might seek to organize during the COVID-19 pandemic. The literature review concludes with a discussion of focusing events and how COVID-19 fits within the broad definition. I then offer initial evidence of midwives' current policy efforts, considering their wider implications.

J o u r n a l P r e -p r o o f 4 Occupational status brings with it decision-making power and prestige (14, 15) , and community midwives' lack of prestige compared to other maternal health professionals, such as physicians, has its roots in history. The maternal health field's historical pathologization of pregnancy and birth and subsequent takeover of care by physicians (16) (17) (18) has left community midwives near the bottom of the maternal health occupational hierarchy. ii Community midwives are criticized by not only other maternal health care providers but also the public, the media, and lawmakers (19) (20) (21) (22) .

Until the late nineteenth century, though, community midwives-referred to previously as a variety of names (e.g., lay midwives, immigrant midwives, and grand midwives)-were the dominant maternal health care providers in the U.S. (23) , and in many areas of the world, they remain the primary providers of maternity care today (24) . It was not until the twentieth century in the U.S., that the pregnancy and birth processes came to be seen as the domain of medical doctors (17, 25) . Prior to that time, birth took place in the private sphere of the home (26) , and birth attendants were often laywomen who earned their knowledge and skills through observation and participation at births (27) . The history of U.S. Black midwifery begins in the 17 th century when these well-respected women were enslaved and transported to the Americas where they tended to a variety of health concerns from the plantation mistresses and enslaved women; these grand midwives continued to offer skilled caretaking and nurturing to their community after the Civil War (28) . Other early community midwives were highly-trained immigrant midwives who were educated in European professional midwifery schools. Yet they were unable to organize, because they spoke different languages and tended to attend solely to their own immigrant communities. These diverse community midwives, along with their acquired practical knowledge (such as the delivery of breech babies without surgery), were nearly eliminated in the U.S. in the twentieth century because of several connected factors. These factors include: cultural changes in the view of childbirth; the rise of biomedicine as the dominant medical discourse; the professionalization of medicine (which brought an increase in the number of health care providers, pressure from medical professional organizations aimed at eliminating competition, and the reconceptualization of birth from J o u r n a l P r e -p r o o f 5 something to be managed rather than attended); and increasing state regulation of birth care (16, 18, (29) (30) (31) (32) . iii These influences pathologized pregnancy, moving birth out of the private female sphere of the home and into the public, medicalized, male-led sphere of the hospital (26) . In the U.S. today, despite a midwifery renaissance, midwives assist with less than 10% of all births (33) and practice "on the fringes of the mainstream medical system" (34) . iv In light of these historical changes, birth came to be seen not as an ordinary everyday occurrence but as an extraordinary pathological event. These changes delegitimated lay, grand, and immigrant midwives (35) There are around 3,000 CPMs, who are legal, licensed, and regulated in only 35 states despite their proven excellent outcomes (37) ; they practice solely out-of-hospital, in homes and freestanding birth centers. Around half of these CPMs graduate from government-recognized programs and therefore meet the ICM international definition of the professional midwife. The other half learn via apprenticeships with one or more senior midwives; these CPMs do not meet the international definition, and thus are coded by ICM and the American College of Nurse-Midwives as "traditional birth attendants" (2) . Increasingly, states are requiring that CPMs meet the international definition by graduating from governmentrecognized schools; therefore, the time-honored apprenticeship route to becoming a CPM may eventually disappear.

J o u r n a l P r e -p r o o f 6 The modern Certified Nurse-Midwife (CNM) credential requires formal nursing training: a bachelor's degree in nursing (which certifies them as registered nurses, or RNs) and then a master's degree in midwifery. CNMs have prescription privileges, receive government insurance reimbursement, and are legally permitted to practice in every U.S. state. However, hospital bylaws and state laws strongly limit their scope of practice (for example, some states have laws that prohibit CNMs from using forceps to assist births and/or from performing abortions). vii There are over 12,000 CNMs in the United States; they practice largely in hospitals, but may also practice as community midwives, serving patients in freestanding birth centers and homes (33) .

While there are real and perceived differences between CPMs and CNMs, midwives of both types who work in home and birth center settings believe that their occupational identities generate prejudice based on false impressions of their skills (20) . This stigma shapes their professional interactions and the false impressions mean that midwives must frequently negotiate the stigma attached to their occupational identity.

Much of the negative public and medical perception of community midwifery comes from the idea that planned hospital births are safer than planned home or birth center births. Because of data restrictions and an absence of an integrated health care system that provides effective transfer to hospital should the need arise during a home or birth center birth, we do not definitively know whether this is true or false. However, numerous studies have shown that planned home or birth center births have lower rates of medical intervention (e.g., C-section, Pitocin) than planned hospital births, and that there is no difference in maternal and neonatal outcomes between low-risk hospital births and home births (37) (38) (39) . viii The American Public Health Association (40) Home and birth center-related risks are mitigated in well-integrated health systems (42); more specifically, in places where midwifery is well-integrated into the larger health care system and midwives J o u r n a l P r e -p r o o f 7 can easily transfer patients to hospitals when necessary (including U.S. states such as Texas and New Mexico), rates of obstetrical interventions and adverse neonatal outcomes are lower (43) . However, in locations where midwifery is not well-integrated (such as Oregon), planned community birth carries a slight increased risk of perinatal death over in-hospital birth (44) .

Planned birth center and home births in the U.S. declined between 1990-2004, but have experienced a resurgence since 2004 (45) . Prior to the pandemic, women reported that their decision to birth at home was influenced by comfort, avoiding unnecessary medical intervention, and the perception that their home was the safest place to give birth (as determined by a diversity of health outcomes) (46) .

With the development of the pandemic, news outlets and a rapid response article are reporting that midwives are receiving an increase in inquiries about birthing at home or a birth center (2, 12, 13) .

Negative public perceptions and misinformation about community midwives and home or birth center birth contribute to policy decisions about licensing, ability to practice, and health care integration.

However, midwives have an opportunity to lobby for change during this pandemic, when hospitals are less appealing than ever for births. Community midwives' skills are right for this moment. Under current conditions, midwives and their advocates may successfully lobby for increased access to licensure and increased scope of practice in out-of-hospital settings, as indeed, many are doing when they are not too busy dealing with the increased volume of clients in their practices (2).

Social scientists have long noted the effectiveness of sudden events as triggers for policy change (47) .

These "focusing events" include disasters such as earthquakes, oil spills (48) , and terrorism (49, 50) .

Although policy change is typically (and frustratingly) gradual, focusing events can create faster and larger shifts in policy (51) because these events disrupt extant power structures. These disruptions offer windows of opportunity for politically disadvantaged interest groups to draw attention to previously ignored or overlooked problems (48) . While not all disasters are focusing events, extreme disasters are The COVID-19 pandemic fits the definition of a focusing event: an unexpected, rare, and harmful event that holds the attention of both policy makers and the public (54, 55) . It therefore offers an excellent opportunity for community midwives and their advocates to lobby for policy changes. Immediate policy changes might allow them to help mitigate the strain placed by the COVID-19 pandemic on hospitals, as many are already doing, while long-term policy changes might allow them to safely and legally practice in states where they have not yet obtained legalization and licensure. I argue that COVID-19 is a "focusing event" that is disrupting the medical care system while at the same time placing higher demands on it; this offers community midwives and advocates the best chance in decades to lobby for their policy agenda.

As of April 2020, local and national media are documenting a resurgence in home and birth center birth (56) (57) (58) . Google Trends notes that searches for the phrase "home birth" increased between March 1-28, (48) . Although this is a temporary stop-gap measure (48) , it may open the door to long-term changes in policy that advance midwifery as a field of practice.

This pandemic is a crucial moment, and an excellent opportunity, to study the concept of a focusing event in the context of U.S. midwifery-including stakeholders, policies, and health outcomes.

The success of focusing events is shaped by a variety of institutions. Because midwifery-friendly policy changes threaten the dominance of large players in the field of maternal and fetal health, such as the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association, these "status-quo oriented groups" (48) may downplay or even prevent the promotion of community midwifery as a response to the pandemic. For example, these groups might claim that the COVID-19related dangers to mothers giving birth in hospitals are being exaggerated, and for this reason, their participation in this context should be examined. Yet near the beginning of the pandemic, ACOG issued an uncharacteristic policy statement encouraging collaboration with CPMs. Noting the irony, one CPM said: "Now, after persecuting midwives like me, you want me during a pandemic!" (2). Importantly, "focusing events do not guarantee an opportunity for policy change" (61); thus future research will have to assess if this pandemic created the "right" conditions for community midwifery policy change. More specifically, how are community midwives and advocates leveraging this crisis and with what tactics, collaborations, imaginaries, and short or long-term success? (62) x There are J o u r n a l P r e -p r o o f 10 numerous policy measures that could be used to assess how well community midwives and advocates succeed in using this policy window and will likely differ across U.S. states.

Future analysis must include attention to a variety of policy changes, including but not limited to, a pathway to licensure in states where CPMs are still not legal, increased scope of care and professional autonomy (e.g., reduced oversight from obstetricians), Medicaid reimbursement (which some CPMs receive but many do not), and improved systems regarding credentialing and home to hospital transfer.

Due to the positive health outcomes associated with midwifery integration (42, 43) , these policy changes should be assessed on the ways they do or do not create conditions for safer home births in the U.S. These policies and outcomes will be of interest to providers or social scientists that promote healthy families.

Because of the altered hospital care, the real perceived risks associated with the hospital, and the increased visibility of community midwives, the COVID-19 pandemic offers a window of opportunity for midwives to demonstrate their skills to a wider audience and challenge the perception that hospital-based, physician-managed birth is the only safe type of birth. In fact, this crisis has already revealed that the U.S. needs community midwives' previously undervalued skills. Further, these circumstances may offer midwives the leverage to advocate for policies that support their legal practice and broaden their patient access and scope of care. With successful policy efforts, midwives and their advocates may create a new model of U.S. maternity care with more options for families across the country.

This research did not receive any specific grant from funding agencies in the public, commercial, or notfor-profit sectors.

i Many maternal and social science scholars have transitioned from the phrase "out-of-hospital birth" to the phrase "community birth"; this term, which refers to both place and space, is "meant to convey that the birth is occurring within a woman's own community" (63) . This is then applied to practitioners; the language of "community midwives" defines these practitioners for what they are and not for what they are not. Further, this language avoids the possibility of reifying hospital birth as the norm (63) . In this commentary, the phrase "community midwives" is used. ii The medical workforce and health care professions have never remained static; in fact, they are continually contested and evolving because of the changing expectations of illness and medicine, increased access to technology, and consumer demand (64) . iii The similarities and differences between the midwifery model of care and dominant medicine is often debated in the literature. Some scholars view the obstetrics and midwifery models in opposition (65), while other scholars see commonalities (66) . iv In the United States, midwives have always held a subordinate status, "because [their care] dealt with women and was conducted by women" (67); for example, their work was and is associated with the taboos of childbirth and abortion. v With the exception of Certified Midwives, DEMs who graduate from university training programs, are trained in the same way as CNMs without having to pass through nursing training first. They are certified by the American Midwifery Certification Board, a daughter organization of the American College of Nurse-Midwives, and are able to practice in hospitals; they are very few in number. vi In some states, homebirth midwifery without medical intervention is legal, but a midwife might be charged with practicing medicine without a license if, for example, she injects a client with the pharmacological agent like Pitocin in order to stop postpartum hemorrhage. Other charges that can be brought against a midwife include negligence, contributing to the death of an infant, and/or contributing to the death of a mother. The risk of criminal prosecution to midwives is substantiated in the legal literature (19, 22) . Charges can be brought by patients, by physicians, or by the state and can take a variety of forms (e.g., sanctions by state medical boards, civil lawsuits, and/or criminal charges). vii For a more complete comparison of types of midwives, see the American College of Nurse Midwives' report which aims to clarify the distinction among U.S. professional midwifery credentials: https://www.midwife.org/acnm/files/ccLibraryFiles/FILENAME/000000006807/FINAL-ComparisonChart-Oct2017.pdf viii The percentage of pregnant patients deemed "low-risk" and thus eligible for out-of-hospital birth is changing as scholars report an increasing prevalence of chronic conditions among childbearing women in the U.S.; still, chronic conditions that might deem patients "high-risk" occurred in 91.8 per 1,000 delivery hospitalizations, far from the majority of childbearing women (68) . ix For more information, see their websites (http://pushformidwives.nationbuilder.com/about; https://www.facebook.com/PushForMidwives/). x There are numerous examples of established and effective collaborations between midwives, obstetricians, and professional organizations that are already driving changes in maternity care in the U.S. For example, the Council on Patient Safety in Women's Health Care includes an alliance of nearly 30 organizations, although none which explicitly represent the interests of community midwives (69).

Dear Social Sciences & Humanities' Reviewers, I sincerely thank the reviewers for detailed and thoughtful feedback on the commentary, "The COVID-19 Pandemic: A Focusing Event to Promote Community Midwifery." Such feedback has immensely improved the argument, content, and grammar while bolstering the literature I pull from. Those are detailed in the Response to Reviewers document.

The reviewer comments are below (in Seguo size 10 font), with my changes in response as bullet points (in Times New Roman size 12 font).

Reviewer 1 wrote: "There are two separate policy initiatives that the manuscript conflates. One is advocacy for midwifery and the second is advocacy for homebirth.

• Thank you for this helpful comment. The focus on this commentary is specifically out-ofhospital or community midwifery but you are right to suggest that midwifery and out-ofhospital birth can be considered separate. I hope I have made that clearer throughout the manuscript. I have made the following changes:

o Clearer language (in response to reviewer 2) regarding direct-entry midwives, Certified Professional Midwives, Certified Nurse-Midwives and traditional, grand, and lay midwives and where they practice (pgs [4] [5] . There is also brief mention of traditional birth attendants (pg 5) and Canadian Registered Midwives (pg 9) based on recommendations from Reviewer 1. Because midwifery differences are so confusing, I have included a link in Footnote vii to the American College of Nurse Midwives' report that aims to clarify the distinction among U.S. professional midwifery credentials (pg 15).

o Clearer language throughout regarding my focus on the care of midwives in an out-ofhospital location. I recognize the dominant work location for midwives is in a hospital, but the focus within this commentary is settings separate from the hospital.

Reviewer 1 wrote: "Although midwives are the obstetric provider of record in only 10% of US births, they are well integrated into the clinical care model in many delivery centers in the USA. Hospitals with CNMs on staff are able to offer a full scope of delivery services, and midwifery care for low-risk women likely improves hospital-based delivery outcomes in the carefully selected low-risk population. See PMID: 31599830. Selection is paramount given that population prevalence of co-morbidities is increasing (See PMID: 29112666), along with welldocumented increases in maternal morbidity and mortality. In a hospital setting, technical expertise of midwives may be combined with other institutional resources to promote vaginal birth, and to decrease risk of unnecessary interventions, while at the same time avoiding maternal and perinatal harm. Effective partnerships between midwives and obstetricians, and partnerships between professional organizations (e.g., https://urldefense.com/v3/__https://safehealthcareforeverywoman.org/patient-safety-bundles/safe-reduction-ofprimary-cesareanbirth/__;!!Cx0GcAwIk107!tqE1uiZrosUxLvqoMiiV1aA4_f0d4Y6ss9q0fqT5WbUFY2xCooaBOM0xSqoZ2iARqQ5uB9A $ ), are already driving changes in maternity care in the USA. The national NTSV cesearean delivery rate peaked in 2009 at 28.1%, and declined to 25.6% in 2019 (https://urldefense.com/v3/__https://www.cesareanrates.org/__;!!Cx0GcAwIk107!tqE1uiZrosUxLvqoMiiV1aA4_f0d 4Y6ss9q0fqT5WbUFY2xCooaBOM0xSqoZ2iARAyQKmms$ ), the lowest rate since 2003."

• The author extends their appreciation for the reviewer's specific comments, references, and links.

J o u r n a l P r e -p r o o f

• The author completely agrees with the reality that many U.S. delivery centers thoughtfully integrate midwives, with important health benefits to mother and child. However, the author's focus in this commentary is out-of-hospital or community birth, due to the changes in maternal health care and the real or perceived risks associated with hospitals during the pandemic.

• In response to PMID 31599830: The author agrees that this article offers an exciting conclusion that, in low-risk pregnancies, midwifery care is associated with decreased intervention and cesarean birth. However, the focus of PMID 31599830 is on hospital births and thus is less relevant to this submitted commentary focused on out-of-hospital birth with midwives who are typically not trained as nurses.

• In response to PMID 29112666 o I have added more specific language regarding patient risk: "there is no difference in maternal and neonatal outcomes between low-risk hospital births and home births" (pg 6). Reviewer 1 wrote: "Homebirth is a completely separate issue. For home birth to gain significant legal and social acceptance in the United States, investigators must address the small but measurable differences in neonatal risk with respect to perinatal death and neonatal seizures (e.g., PMID 26716916). Large systematic reviews that include data from Europe suggest that risk is mitigated in "well-integrated" health systems (e.g., PMID: 31709403). A careful analysis of the differences between the current healthcare system and a system with "well-integrated health services" would be helpful to envision the specific systematic changes that might create conditions for safer home birth in the USA. What are the specific public health policies, credentialling systems, and systems to ensure safe and timely hospital transfer, that enhance safety in well-integrated European systems? In addition, please define the limits of this opportunity. Specifically, given population prevalence of comorbidities (PMID 29112666) in the USA, what percentage of the delivering population qualifies for attempted homebirth? Among those who qualify in "well-integrated health systems," what percentage of women transfer to the hospital before or after delivery?"

• Thank you for your attention to risk. The reviewer references PMID 26716916; this Snowden et al article, including a mention to the "increased risk of perinatal death", is already present in the manuscript (pg 7).

• Regarding PMID: 31709403: The Hutton et al. article does offer a helpful analysis of the risk of fetal or neonatal loss among low-risk women who begin labor intending to give birth at J o u r n a l P r e -p r o o f home compared to low-risk women intending to give birth in hospital. This article is now cited briefly. The updated commentary now includes "Home and birth center-related risks are mitigated in well-integrated health systems …" citing Hutton (pg 6).

• I have added Footnote vii in response to the reviewer's concern regarding chronic conditions: "The percentage of pregnant patients deemed "low-risk" and thus eligible for out-of-hospital birth is changing as scholars report an increasing prevalence of chronic conditions among childbearing women in the U.S.; still, chronic conditions that might deem patients "high-risk" occurred in 91.8 per 1,000 delivery hospitalizations, far from the majority of childbearing women" with a citation to the Admon et al 2017 article (pg 15).

• The manuscript author believes a careful analysis of the differences between the current healthcare system and a system with "well-integrated health services" would be helpful but is beyond the scope of this short commentary. However, this important information is now mentioned near the end of the manuscript, under the heading "Current and Future Assessment."

The new text now reads: "Due to the positive health outcomes associated with midwifery integration…these policy changes should be assessed on the ways they do or do not create conditions for safer home births in the U.S." (pg 10).

Reviewer 1 wrote: "The increased interest in homebirth may be driven by consumer frustration with hospital and birth center <https://urldefense.com/v3/__https://www.birthcenters.org/page/toolkit-covid19__;!!Cx0GcAwIk107!tqE1uiZrosUxLvqoMiiV1aA4_f0d4Y6ss9q0fqT5WbUFY2xCooaBOM0xSqoZ2iAR18tcQ 9I$ > policies that are designed to limit the risk of facility-based transmission of COVID-19. Labor can be a presenting sign of COVID-19 (https://urldefense.com/v3/__https://www.nejm.org/doi/full/10.1056/NEJMc2009316__;!!Cx0GcAwIk107!tqE1uiZ rosUxLvqoMiiV1aA4_f0d4Y6ss9q0fqT5WbUFY2xCooaBOM0xSqoZ2iAR35ZiPQE$ ), prior to the development of fever or other symptoms. Hospital or Birth Center policies may include universal screening, universal masking, and visitor restrictions. In addition, hospitals that deliver women with documented COVID-19, may forbid visitors entirely, and require infant separation at birth to limit risk of vertical transmission. Given the risk of otherwise asymptomatic presentation, many institutions now require women to be tested negative to receive standard care, and have developed special care pathways for women who are untested or who are tested positive. These policies (particularly visitor restrictions) have scared women and are driving demand for alternative solutions. But birth at home does not eliminate risk of COVID-19, nor does it obviate the need to implement policies to decrease risk of transmission between midwives, doulas, and their patients. Furthermore, there may be implications for integration with health systems. If hospitals require RT PCR negative testing within 72 hours of treatment, then care pathways for women who need transfer from home to the hospital may be impacted."

• Thank you for the important mention of hospital-based policies used to protect patients. My first paragraph, under the heading "1.1 Introduction" is now updated to include the text "…and newly implemented hospital policies intended to reduce transmission, such as universal masking, mother-infant separation, and labor companion restrictions…" (pg 1).

• The author agrees completely with this notion that risk cannot be simply eliminated based on a move from hospital to home. Now in the introduction section, I add an entire paragraph that references the risk that is still very present and that the burden is on community midwives if they don't have personal protective equipment. It is too long to include here, but the paragraph begins, "It is necessary to briefly mention…" (pg 3).

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Sociological factors affecting the medicalization of midwifery

Medicine as discursive resource: legitimation in the work narratives of midwives

Old Wives' Tales: The History of Remedies, Charms and Spells. The History Press

Disparities in chronic conditions among women hospitalized for delivery in the United States

Council on Patient Safety in Women's Health Care

Please cite evidence to support the claim that delivering facilities are being overrun with nonobstetric patients infected with COVID-19. In general, labor and delivery unit beds are not interchangeable with other hospital beds, and obstetric providers are not being diverted to provide care to non-obstetric COVID-19 patients. The number of women who become pregnant each year has not changed dramatically, at least based on currently available data

• The author did not intend to communicate that delivering facilities were "overrun," but did indicate the potential or fear of hospital overcrowding. It's important that many of the fears associated with the pandemic-like overcrowding at the local hospital-aren't supported by data, but importantly those fears are still driving women's decision of where to birth; human risk perception is quite subjective. The author now aims to be more explicit in the commentary, including the frequent use of the phrase "real and/or perceived" when discussing dangers and risks (now found throughout the manuscript). The author also aims to highlight risk less, due to its subjective nature, and add attention to the very real changes in hospital care (e.g., labor companion restrictions) because that is also shaping women's choices of where to birth. Lastly, I also reference a paper, that was written prior to the pandemic, that concludes that women's desire to birth at home was largely shaped by perceived safety (pg 7).Much of Reviewer 2's (the esteemed Dr. Robbie Davis-Floyd) comments were communicated via track changes in the original submission. However, her overall comments are included here.Reviewer #2 wrote, "Throughout your article, you use the term "out-of-hospital," which I have abbreviated as OOH. A suggestion: many of us are now calling them "community midwives" instead of OOH midwives, to define them for what they are, and not for what they are not, and to avoid reifying hospital birth as the norm (see the "Notes on Language" at the end of Chapter 1 of Birth in Eight Cultures). Up to you whether you wish to substitute this term for "OOH." You could introduce it by first calling them OOH, then put "OOH/community midwives," and then use "community midwives" throughout the rest of your article."• This is an important language change. The commentary, including a minor change to the title, now reflects the use of the term "community" midwives and now Footnote I describes why that decision was made -with a citation to Chapter 1 of Birth in Eight Cultures (pg 15).• Most of the language of "out-of-hospital" birth or midwives was changed to "community midwives" throughout the manuscript (15+times).Reviewer 2 wrote, "Also, rather than just review your article, I have edited it freely, all in Track Changes, as that's just easier and more productive for me."• These were thoughtful and critical comments regarding grammar, specificity of type of midwives, and important additions regarding U.S. context of midwifery. There are too many to list, but as a few examples:o "visitor restrictions" has been changed to "labor companion restrictions" (pg 1).o o Addition of the phrase "despite a midwifery renaissance" in the following sentence: "In the U.S. today, despite a midwifery renaissance, midwives assist with less than 10% of all births" (pg 5).o Specifics to the New York lobbying efforts (pgs [8] [9] .o Newly added paragraphs, including:"For example, the midwives of Bumi…" (pg 2) "There are around 3,000 CPMs…" (pg 5)Reviewer 2 wrote, "There is no Methods section, so the reader has no clue as to where you got your information.If it is all from your lit review, then say so." I like your theoretical use of the concepts of "focusing events" and "windows of opportunity." Yet your article reads more like a grad school paper than an professional article, as it is not based on any identifiable data."• Thank you for this comment. The call for papers (from an e-mail dated April 3) on "Coronavirus and Society" included the following language: "We are interested in receiving both empirical research -such as it may be conducted in these times -and (shorter) theoretical and critical commentaries on the longer term -and present -implications of the coronavirus." This is a theoretical and critical commentary, and now that has been more clear stated in the abstract and the main text.o To improve communication to the readers, the following sentence has been added to the abstract: "This commentary extends previous research to theorize that the COVID-19related disrupted health care system and the heightened visibility of community midwives may create a "focusing event," or policy window…" (pg 1). Within the Introduction section, the following sentence has been added: "This commentary extends previous research to theorize that this real and/or perceived disruption in hospital-based maternal health care, along with community midwives' heightened visibility during this pandemic…" (pg 3). J o u r n a l P r e -p r o o f

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Signed: Adelle Dora Monteblanco. Sept 2, 2020 J o u r n a l P r e -p r o o f