A soon-to-be-mother makes last-minute changes to her birth plan as she sees COVID-19 cases climb at her chosen hospital. A young professional cancels her scheduled OB-GYN appointment, anxiously considering the risk of infection. A college student watches her supply of birth control dwindle as her campus clinic remains closed.
Since the onset of COVID-19, women have faced new and formidable challenges when pursuing gender-specific care. Concerningly, many of these barriers have appeared as side effects of our pandemic response efforts.
During the early days of the pandemic, state governments and healthcare professional groups encouraged patients and providers to postpone or limit all “elective” procedures. As I’ve written before, the intentions behind these recommendations were twofold: first, to limit the potential for disease spread and, secondly, to free up more facility space and resources for COVID-19 patients. These restrictions have gradually loosened as COVID-19 infection rates trend downward; however, the impact on care access has been tremendous.
According to a recent report from the Kaiser Family Foundation, more than half of surveyed women reported that they or a family member either delayed or skipped medical care due to the coronavirus in May. Researchers for Strata Decision Technology further found significant drops in traffic across the reproductive health vertical. Obstetrics alone has seen a 75 percent decline in patient encounters. Similar reductions have been reported in preventative health services, infertility care, and sexually transmitted infections.
Even women seeking essential services may be unable to access care. In March, Vice reported that many college-age women who typically receive their birth control and gynecological care via on-campus clinics have been unable to do so as those clinics remain closed.
While it is true that these services are not immediately “essential,” they are crucial to long-term health. Thankfully, the lack of immediate patient traffic doesn’t seem to indicate a lack of interest. The KFF polling data referenced above notes that most women who chose to forego procedures during COVID-19 intend to seek care eventually.
But pinpointing when that return might occur is challenging — because even as state governments and providers encourage women to seek care, women may be too anxious to go. Patient behavior indicates that barriers to access stem from psychological factors as much as they do administrative ones.
Consider patient anxieties around pregnancy care as an example.
During normal times, the vast majority of prenatal care occurs in-person, and almost all deliveries occur in hospitals. According to data published in Birth, just one in every 62 births in the United States took place outside of a hospital in 2017. But since the onset of the pandemic, a significant proportion of expectant mothers have sought other means of delivery out of fear that they — or their baby — will be exposed to COVID-19 during their time at the hospital.
As one New York midwife commented in a recent New York Times article on the trend, “It’s not that they don’t want to be in hospitals; it’s that they don’t want to be in a COVID hospital.”
It is worth noting that literature to date indicates that the odds of an asymptomatic pregnant woman exposing hospital staff is higher than the reverse. According to research recently published in the New England Journal of Medicine, 88 percent of expectant women who tested positive for COVID-19 at New York-Presbyterian Allen Hospital and Columbia University Irving Medical Center were asymptomatic upon their arrival.
However, patients’ fear of exposure has been both pervasive and influential. In late April, the New York Times reported a massive uptick in interest in home birth and out-of-hospital delivery. Reporters noted that the Brooklyn Birthing Center, one of just three independent birth facilities in New York, has experienced a considerable increase of queries since the start of the pandemic. Last year, it averaged 15 calls per week; in April, that number rose to 200.
That said, it needs to be stated that midwifery isn’t an analog for hospital services. Midwives provide support and guidance to women with low-risk pregnancies and often don’t rely on doctors or drugs unless an emergency occurs.
“I’m having women call saying, ‘I want a C-section here,’” Trinisha Williams, the director of Midwifery for the Brooklyn Birthing Center, told reporters for the Times. “But we don’t do that.”
The solutions we pursue in the women’s health sector need to address women’s fears as much as their care needs. Even as providers extend new resources, they should consider what they can do to alleviate the “quarantine state of mind” that holds women back from accessing routine care.
There are a few obvious stopgap measures that providers can put into place during COVID-19. The first is telemedicine; women should have more freedom to access routine consultations and contraception prescriptions via digital channels. Providers specializing in women’s health should also implement outreach initiatives to ensure that their patients have a clear understanding of how they can safely access routine care.
Resolving access barriers to pregnancy care is somewhat more involved. While hospitals will always remain a safe and valid environment for expectant mothers, recent interest in outpatient delivery options indicates that more should be done to support low-risk patients who want to give birth outside of a hospital setting.
Freestanding birthing centers are relatively few and far between; however, one 2019 research review indicates that low-risk pregnant women don’t have a greater risk of developing complications at home than they do at the hospital. Women who give birth outside of a hospital tend to have lower rates of c-sections, major tearing, and induction. In an article for Healthline, Dr. Jessica Illuzzi, the chief of laborists and midwifery at Yale Medicine, roughly 80 to 90 percent of births deemed “low-risk” can conclude without complications.
Given these positive outcomes and persistent interest in non-hospital delivery environments, increasing outpatient birthing centers seems worth considering. But even as we expand these resources, providers and payers will need to address reimbursement concerns.
While there is relatively little available data on private compensation for non-hospital delivery centers, research indicates that birth center providers struggle to receive adequate benefit from Medicaid. According to a recent report from the Urban Institute, birth centers often struggle to obtain contracts with Medicaid-managed payers and, even when they do, often face reimbursement rates that do not fully cover the cost of care.
As we move forward, public and private payers should aim for reimbursement strategies that can adequately support the providers who support women who seek out-of-hospital delivery services and remote care. Even as COVID-19 numbers trend downward, fear of infection is not going away. Those of us in the women’s healthcare sector need to ensure that we are doing all that we can to empower female patients to access routine care safely and without anxiety.