The pandemic has touched nearly every part of our lives. But for many of the littlest Americans, it’s even impacted where they’re born.
Before 2020, Utah and the nation were already seeing a rise in deliveries at home or birth centers. The number of midwife-led birth centers in the country more than doubled within the last 10 years to 400, according to the American Association of Birth Centers.
Now, many women who say they hadn’t considered giving birth anywhere other than a hospital have changed their plans, opting to deliver where loved ones can be there to welcome the child.
Leaders with both the American Association of Birth Centers and the National Association of Certified Professional Midwives note a marked increase in families looking for other options.
“Absolutely, there’s been an increase of both home births and birth center births,” said Mary Lawlor, executive director of the National Association of Certified Professional Midwives.
While there isn’t yet statistical birth data from the pandemic, there’s anecdotal evidence of a rise as mothers across the country were concerned, especially early on, about whether they could have their partners with them at labor, Lawlor said.
“I can tell you from feedback we’ve received from our member birth centers that across the board we’re seeing increases in people seeking care in birth centers last year, and it’s continuing still in this year. And for some birth centers, it meant reaching their capacity for the month. They had so many people interested in coming to the birth center,” said Kate Bauer, executive director of the American Association of Birth Centers.
Dani Reed, of Eagle Mountain, gave birth to all four of her previous babies in the same hospital and planned on delivering her fifth and final child there.
When she learned soon after COVID-19 swept into Utah that she could only have her husband with her — and that he potentially might not even be allowed into the delivery room — she considered another option “for the first time in my life.”
Libby Silva, a midwife at Utah Birth Center, said the center has seen its number of deliveries increase about 25% since the pandemic began last spring, requiring the business to bring on more employees to keep up with demand.
“I think it was pretty instant for a lot of people to start looking at other options,” Silva said.
She says she’s heard some are concerned about giving birth at the hospital and getting exposed to COVID-19 — a “basic health concern with the pandemic directly.”
Hospitals also implemented limitations due to COVID-19. While restrictions have changed over time, many hospitals were letting just one support person in during deliveries. In Idaho, where Silva worked at the start of the outbreak, some mothers weren’t allowed any guests.
“Do I still get to have my spouse, or my doula, or my mom? People felt really limited by their support system. And I think they felt like, you know, nurses and physicians might be minimizing time with them, because a lot of visits went virtual, and I think people were feeling not as supported and cared for,” Silva said.
Utah has at least 24 listed standalone birth centers.
Dr. Sean Esplin, senior medical director for women’s health at Intermountain Healthcare, Utah’s largest hospital system, also noted that the birth rate as dropped, affecting hospitals more than standalone birth centers and home births.
The birth rate was falling before the pandemic. In 2019, Utah residents had 46,832 live births, a rate of 14.6 per 1,000 residents, marking a small decrease from the 2018 birth rate of 14.9. The birth rate in 2019 was lowest in a decade, according to the Utah Department of Health.
Birth rate data for 2020 is not yet available.
“I think the pandemic kind of scared people. And as hospitals, we were trying to be as careful as we possibly can to protect both the mother, the baby, their partner and our own staff,” Esplin said, explaining that the hospital system followed guidelines from the Centers for Disease Control and Prevention and national hospital organizations.
During the height of the pandemic in 2020, Intermountain and other hospitals allowed one visitor for women in labor, and they all needed to wear masks. Now, the system allows two guests, even for women who are COVID-19 positive. All guests need to follow safety guidelines.
Hospitals also moved to a blended virtual approach to regular visits with providers to prevent women from needing to go out into their communities and risk infection. Esplin says the system will likely continue offering virtual visits because some actually prefer them.
He acknowledged that many have expectations about what they want during their delivery, and changes have made it difficult for some to have the birth they hoped for in a hospital.
Grace Fausett, speaking at 40 weeks pregnant and expecting her baby any day, said she always thought she would have her first child in a hospital “because of worries for risk and things like that” at other locations.
But rules like mask requirements during labor and limitations on who could be there made her look into a home birth. She found a midwife who made her and her husband feel “at peace” with the decision to deliver at home.
She made the decision despite knowing that she won’t get help with pain that can only be administered at a hospital, including an epidural.
“I don’t think there’s one right way to do birth. However, just because of the other things they are requiring with hospitals right now, I thought it would be more traumatic for me to not have the other things I need rather than to have extra pain,” said Fausett, of Taylorsville.
She has been learning pain management strategies and looks forward to being able to return to her own bed after the water birth. She says it comforts her to know she lives five minutes away from a hospital should any complications occur.
Birth centers did not need to implement stringent restrictions like hospitals, according to Silva, as they work with a “very low-risk population.” If clients test positive for the coronavirus or have the infection when they’re about to go into labor, the birth center cannot care for them.
Silva said the business has been able to keep clients and workers “healthy and low risk.” Some mothers also switched their birth plan in order to continue having in-person visits with their provider, as hospitals moved to a partial-virtual model during the pandemic.
“And so it was a really good option for people who wanted to have a natural birth and have the support they were hoping for, without kind of missing their care or missing out on normal visits and lab work and emotional, mental check-ins,” she said.
The pandemic prompted the American College of Obstetricians and Gynecologists to warn pregnant women that hospitals and accredited birth centers are “still the safest way to give birth.”
But some studies have found little difference in risk between hospital and planned home births. A 2009 study in Canada found that a planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
The majority of births carry low risk, and a safe birth can be accomplished “in almost any situation,” Esplin said.
“However, the risk is not zero, and I think the reason why we are so cautious is that we actually have seen the cases where an unanticipated complication happens,” he said.
“There is clear evidence that there is an increased risk to the newborn for out-of-hospital births, and there are data from big studies to show that. But that absolute risk is low,” according to Esplin.
If someone wants a home birth, they should ensure they have “very low risk. ... And discussing that with a health care provider to say: ‘Am I a good person to have this type of birth?’ would be a very reasonable thing,” he said.
While some choose home births so they can have a say in how they want to deliver the baby and who gets to be there, Esplin says he believes hospitals can accommodate many of those desires “while still being at a hospital where if they experience a complication, they have access to the kind of care that would make it as safe as possible.”
Silva noted that home- and midwife-assisted out-of-hospital births were rising over the past 10 to 15 years even before COVID-19 hit.
Nationally, home births increased by 64% between 2004 and 2013. In Utah, they rose at an even more rapid rate of 89% between 2004 and 2013, according to the Utah Department of Health.
Planned home births made up 2.12% of all births in Utah in 2013, which was more than twice the national rate at that time, according to a report released in 2017 from the state health department. The report was based on birth-certificate data analyzed from 205,486 births among Utah mothers between 2010 and 2013, of which 3,701 were home births. It did not look at birthing centers or babies accidentally born at home. More recent data is not yet available in Utah.
“Women want more options. They want to have the experiences that they’re hearing more about on social media and from friends and family. I think out-of-hospital birth has been normalized culturally in a lot of ways,” Silva said.
She explained that midwives have specific scopes of practice based on their certification, and they make sure clients’ pregnancies are low risk before taking them on as patients. They also work and consult with hospital providers, Silva said.
“There’s not one that’s better than the other. It’s just about making sure that each individual is receiving appropriate care, and it’s about building trust with providers,” she said.
A national push to standardize training for midwives to decrease the rate of C-sections is underway. The more standardization that takes place, the more trust that will be built between in-hospital providers and out-of-hospital providers, Silva noted.
“There seems to be a lot of discussion right now about how to provide better maternity care in the U.S. as a big conversation bringing everybody to the table. And midwives are a huge, huge solution to that,” she said.
When complications occur during births at home or in birth centers that midwives can’t handle, women are taken to nearby hospitals for more advanced treatment. Esplin said hospitals see those cases “all the time,” but he doesn’t know if they’ve increased during the pandemic.
“I think that’s also probably the difference between talking to someone who does home birth versus talking to a physician or midwife who does deliveries in the hospital,” Esplin said.
“We’re seeing thousands of deliveries every year. We see the people who have complications. We see the ones who are brought in from home who have the problems, and that’s the perspective that we have because we’re at the narrow part of the funnel where all those problems come in,” he said.
Esplin encouraged women to consider where they can have the delivery they want at the safest location possible.
Now, Utah remains above the threshold of COVID-19 transmission considered high — meaning restrictions need to remain in place. But Esplin said he believes more vaccinations and decreasing case counts mean hospitals could begin rolling back their precautions within a few months and eventually let more people back into delivery rooms.
“At this point, the only reason why we’re not allowing them is because the more people that are in the room, the more likely it is that one of them will have either an exposure to COVID, or will have COVID,” Esplin said.
“We’ll get to a point where we’re back to kind of that baseline, but we’ll do it in a safe way, and we’ll do it following the scientific guidelines that are laid out by people who have expertise in this area,” according to Esplin.
The pandemic has likely led to more understanding of the benefits of birth outside of the hospital, and led to more awareness that there are other choices, said Lawlor, with the National Association of Certified Professional Midwives.
While the exact extent of the rise in home and birth center births is unknown, Lawlor guesses that it will stay elevated.
“The trend is toward growth, so my guess is now that there are so many more people in the country who know about this as an option, that it will stay higher,” she said.
She believes the pandemic simply “speeded up the process” that was already happening as more people became aware of out-of-hospital choices.
“Because more women and families were looking at their options for birth, and not just kind of going with the status quo of a traditional birth and labor and delivery in the hospital. They were looking at what’s available to them,” Bauer said.
A support system
Tia Stout, of St. George, also had her first four kids at a hospital, where she says she had great experiences.
But when she delivers her next baby in a few weeks, she wants a birth photographer, her mom, a doula and her husband there.
“It just wasn’t even an option for those support workers to be there for me, and so I was really lucky in the fact that I knew a lot of the midwives already because I’m a birth photographer, and so it was kind of a really easy decision for me because I’d been to home births and I’d seen the midwives doing their work, and I’d had a little bit more education in the home birth space,” she said.
She said she’s also seen many more clients looking into home or birth center deliveries than before the pandemic.
When she gives birth, her other kids will likely be at home. She’s told her older children they can be there for the delivery if they want to, or they can sleep through it and wake up to meet their new brother.
Reed, who also works as a doula, urged other expectant moms “to fully educate yourself on the benefits and risks of all birth options … and to make a decision based on knowledge and intuition instead of fear.”
While most of the births she assisted with before the pandemic took place in hospitals, Reed said she’s recently helped with many more out-of-hospital births. The number of women opting for home births might decrease as the pandemic winds down, but Reed believes the numbers are on a permanent upward trajectory as women’s eyes have been opened to other options.
Reed wanted her daughter to be able to witness the birth of her new sister. The mother also wanted a photographer there as well as labor support.
“I agonized over the decision for weeks, just sick about it, feeling afraid either way that I was going to make the wrong choice,” she said.
But a friend advised her that she needed to do what would be best for her family, and she decided that they should be together for the birth. She contacted a home birth midwife, who had a last-minute opening.
Her delivery ended up taking much longer than her other kids because her baby’s head was turned, “and so I was even more grateful that I was surrounded by support, because I needed every support I could get,” Reed recalled.
Her team of doulas and midwives helped her, and they got the baby girl positioned correctly, she said. After delivering her new daughter, Reed says she started hemorrhaging due to the duration of the labor, but her midwife was able to stop the bleeding quickly.
“And I know that if she felt unable to handle that, she would’ve called paramedics,” Reed said.
She then recovered at home.
“That was the best part. So I just stayed home and snuggled my baby and had my family all with me, and it was so great,” Reed said.