Amanda Sigwart shuffled down the hall of Virtua Voorhees Hospital’s labor and delivery unit with prayer cards stuffed in her socks and anxiety filling her head.
Her womb was no longer a safe place for her baby: With the due date three weeks off, her amniotic fluid was low and doctors sent her from an appointment to the hospital for an emergency cesarean section.
The outside world didn’t seem much safer: It was late March and a mysterious virus was on the rise, swamping hospitals.
“Your mind goes crazy … the news had been talking about hospitals being overcrowded,” said Sigwart, 30, of Marlton. “What if I get there and they won’t let my husband in. ... The worst place of all was, am I going to have this surgery, have my son, and then get sick?”
But Sigwart didn’t have much choice. With St. Gerard, the patron saint of motherhood, hugging one ankle and a family prayer curled around the other, Sigwart climbed onto the operating table.
The coronavirus pandemic has dramatically changed the patient experience. In most Philadelphia-area labor and delivery units, women in labor are now allowed just one support person, must remain in their room during their stay, and can expect every doctor and nurse to be wearing extensive protective equipment. Not to mention the added anxiety about infection while at the hospital and about the virus’ unclear effects on pregnancy.
Sigwart would have needed a C-section, pandemic or not. But in some cases, the coronavirus has also affected the way babies are born: Philadelphia-area hospital data show that more women are opting for an induction, an intervention to bring on contractions and labor that, under different circumstances, they may not have chosen.
Hospitals say that they are not offering inductions to women who do not meet the criteria for one but believe that when presented with the option, more women rattled by the uncertainty of the pandemic are choosing a scheduled induction as a way to regain some control. At the same time, pandemic-crunched hospitals are eager to meet those requests. Some have expedited existing plans to make inductions more routine.
“They wanted to not be pregnant and have COVID-19,” said David Jaspan, chair of obstetrics and gynecology at Einstein Medical Center in North Philadelphia. “They were healthy, they were quarantining, they were doing everything they could. But they can’t control everything, and once the baby is delivered, their risk [for COVID complications] is less. They wanted to be able to come in when they were healthy.”
Shifting hospital policies
Until a few years ago, inductions were typically performed when a medical condition, such as hypertension or low fetal heart rate, made the pregnancy unsafe, or if the baby was past due at 41 weeks. Doctors advised against elective inductions because they were believed to be associated with a higher rate of C-sections and complications.
But a major study in 2018 found that inducing labor at 39 weeks for low-risk women may reduce the likelihood of a C-section, compared with women who are induced or go into labor spontaneously after 40 weeks.
The American College of Obstetrics and Gynecology, which sets standards for the specialty, now says it is “reasonable” to offer low-risk women an induction at 39 weeks.
Penn Medicine and Einstein Medical Center said they had planned to begin offering inductions more routinely later this year, in response to the study’s findings, and moved up those plans when the pandemic hit.
As Einstein prepared for a surge in COVID-19 patients in March, Jaspan sought advice from obstetrics colleagues in New York City, where the pandemic was already filling hospitals and had even, for a time, prevented women in labor from having a support person with them.
“They said, ‘We would have delivered anyone who was healthy to get them in and out of the hospital as quickly as possible,’” Jaspan recalled. “So we started.”
In March, Einstein began offering inductions to women who came to the hospital with a concern about their pregnancy within a week of their due date. Weeks later, doctors began having conversations about induction during routine prenatal appointments.
By May, 42% of births at Einstein were by induction — either scheduled or required when labor stalled — compared with a 36% induction rate in February.
The approach also gave hospitals more control over the number of women delivering at any given time — an important detail when space and resources are stretched thin.
“This isn’t something we said, ‘You must get induced.’ People were asking about it. Patients wanted it, and we wanted to have a more flexible approach,” said Sindhu Srinivas, director of obstetrical services at the Hospital of the University of Pennsylvania.
Srinivas said HUP saw an increase in inductions after the hospital adjusted its policy during the pandemic to offer the procedure at 39 weeks, but Penn Medicine declined to offer specifics.
Fear, anxiety influence birth preferences
The increase in inductions at health systems that have not changed their policies is more puzzling and concerning to doctors.
About a quarter of births at Temple University Hospital between February and June were by scheduled induction, a 17% increase from the same time last year, according to data provided by Temple.
The hospital has also seen a 20% increase in scheduled C-sections.
“I am concerned about the number of inductions and C-sections going up during the pandemic because any time you do an intervention, there’s going to be some kind of risk,” said Wadia Mulla, Temple’s medical director of labor and delivery.
At Virtua Health System, scheduled inductions between March and June nearly doubled to 6.1% of deliveries, compared with the same time last year.
Neither Virtua nor Temple is entirely sure what’s behind the increase because neither believes that doctors are offering inductions to patients who do not meet the hospitals’ criteria.
“COVID-19 itself is not an indication for a C-section or induction,” said Nicole Lamborne, director of women’s health at Virtua. “Although this is a fearful time, we don’t want to risk what we consider good care.”
Rather, Lamborne and Mulla suspect that when an induction is an option, women with COVID-19 on their minds might go for what seems a more planned choice.
Similarly, Temple’s increase in C-sections could be partly due to women who had previously had a C-section and were planning for a vaginal birth with a subsequent pregnancy opting instead for another C-section, Mulla said.
“When we have an option — we can induce you or we can increase surveillance — the idea of having to come in for more testing, more appointments was concerning,” she said. “They felt every time they came in they were exposing themselves.”
That’s exactly how Brittney Biederman felt, when the pandemic hit during her third trimester.
Biederman, 31, of Williamstown was already anxious because she’d lost twins in a miscarriage at four months last year. This baby, her and her husband’s second child, was conceived on their fourth round of IVF.
Then came the news stories about women with COVID-19 being separated from their newborn babies to avoid infection, and hospitals barring partners from the delivery. She stayed home as much as possible, leaving only to go to the doctor.
Several weeks before her due date, Biederman started asking her doctors about an induction — an option she would not have chosen under normal circumstances.
“Every time I’d go back to the doctor, I’d sit in the office and cry because I was so nervous,” she said. “I thought if I could just get [the baby] out and get her home and have no one come over, I could keep her safe.”
Eventually, Biederman’s doctor at Virtua relented, and at 39 weeks she was induced. Her daughter, Hadley, was born April 17.
Despite the anxiety of giving birth during a pandemic, and the stress of constantly changing rules, both Biederman and Sigwart said their experiences were surprisingly peaceful.
When Sigwart checked in to the hospital March 23, her husband was allowed to pace the halls and run to the cafeteria for snacks. Two days later, when it was time to bring baby Mason home, the rules had changed: Everyone wore masks, no one was allowed out of their room without permission. The overnight rule change was unsettling, but the experience taught Sigwart an important lesson that she will keep close as she raises her son.
“Giving birth during the pandemic really taught me you can’t plan every little thing,” Sigwart said. “What’s going to happen is going to happen.”
Pandemic’s effect on preterm births
The coronavirus pandemic has had profound effects on the way patients interact with the health-care system and their health outcomes.
Hospitals have seen fewer heart attack and stroke patients, and diagnoses for common — and preventable — cancers are down.
Add to the list: fewer premature babies.
Doctors at Thomas Jefferson University Hospital have found that premature births, meaning births before 37 weeks, between March and July were down close to 30% compared with the same period last year. Premature births before 28 weeks dropped even more — by at least half — compared with last year.
“I haven’t seen this in my 20 years as director,” said Vincenzo Berghella, director of Jefferson’s division of maternal-fetal medicine. “I couldn’t believe it when I looked at it. We’ve looked many different ways now, double-checked it with two independent teams — it’s absolutely right.”
While Berghella is confident in the trend at Jefferson, he’s not sure how to explain it.
Many of the potential factors relate to working from home and state-ordered lockdowns, which Berghella believes could alleviate a lot of the stress and anxiety that affects pregnancy:
Better nutrition due to home cooking
More time for exercise
Better air quality
More support from a partner or family
Fewer social interactions that could lead to any kind of infection
“The social factors of preterm birth come up as a huge issue,” Berghella said.
Doctors in Ireland and Denmark who found similar declines in preterm birth during the pandemic speculated that the drop was due to the national lockdowns in those countries.
It’s unclear whether the trend is occurring elsewhere in the United States, which did not enforce such strict — or lengthy — lockdowns as Europe.
Other hospitals in the Philadelphia area surveyed by The Inquirer said they have not seen such a dramatic change in premature births.
At Einstein Medical Center, about 11% of babies are born premature, and that trend has held steady so far in 2020, said Rachel Fleishman, an attending neonatologist at Einstein Medical Center Philadelphia.
Working from home, access to child care, good health insurance, and the ability to socially isolate are luxuries that many workers in Philadelphia do not have.
“European women, and a select group of privileged women in the United States, are shielded from some of the most pernicious stressors during the pandemic,” Fleishman wrote in an op-ed in The Inquirer. “Just as more Black and Latinx women contract COVID while pregnant, the pandemic compounds and creates stressors for women already at high risk of preterm birth.”
Berghella said that regardless of whether preterm births are declining at other hospitals, the findings at Jefferson are worth studying more closely.
“We haven’t been very successful in reducing preterm birth,” he said. “This will be a major change, and if it’s true — a big if, still — then the question is why.”