COVID-19

This page seeks to provide information on working as a birth and lactation professional during COVID-19. Below you will find our statement on COVID-19, supporting a client virtually, and the evidence on COVID-19 and pregnancy, birth, and lactation. More comprehensive information on managing safety and infection prevention and control can be found in our “pay what you can” professional development course.

CBI Statement on COVID-19

CBI statement published March 19, 2020

Childbirth International, in all things, is an advocate for informed choice and autonomy among our students, graduates, and their clients. In the face of the COVID-19 pandemic, we are providing this statement on the state of birth support when hospitals and birthplaces are limiting the number of support people and visitors on their premises.

It is important to keep in mind that hospitals are restricting visitors to limit the spread of disease and to support social distancing initiatives. The fewer asymptomatic people who enter a hospital, the less risk posed to the healthcare professionals working tirelessly to address rising healthcare needs and hospitalized patients. Childbirth International, as an organization, supports hospitals in making decisions to mitigate risk in these situations for their staff, patients, and the community as a whole.

The support of a doula is invaluable and beneficial for birthing individuals which cannot be discounted. In times of crisis, though, we also may need to step back and consider the perspective of the hospital administrators and public health authorities who are trying to manage something that is largely uncontrollable, with limited resources. When you consider the average doula curriculum, there is very little involving standard precautions, safety, and infection control and prevention. Handwashing and being mindful of personal hygiene are often covered, however, that isn’t enough. Doulas and other practitioners need to be aware of how different pathogens spread, how to mitigate the spread, and what precautions can be taken to reduce the potential for transmission of disease.

It is our belief that birth and lactation professionals who are specifically trained in infection control and prevention can be an asset to the birth support team, instead of the liability they may be perceived as in healthcare institutions. We have identified that doulas and other birth and lactation professionals are in need of continued education in terms of infection control and prevention and are launching a 9.2 contact hour professional development course [on Safety and Infection Prevention and Control] on a “pay what you can” basis. Students and Graduates of Childbirth International can access this course at no cost.

Individuals who complete this course will receive a downloadable certificate of completion that will identify them as having demonstrated their competency in the knowledge, understanding, and skills needed to support their clients safely while supporting the hospital’s or birth center’s infection control initiatives.

It is important to consider a number of additional factors when advocating for doulas to continue supporting birthing individuals in the hospital. Among them is the importance of informed choice and decision making. Clients need to be aware of not only the benefits of in-person doula support but also the particular risks associated with the presence of additional people at their birth during a pandemic.

It has been reported that people who are not showing signs or symptoms of COVID-19 can still transmit the virus in the days before they begin to feel ill. Some individuals may test positive and never show symptoms either, which is why social distancing has been heavily encouraged and, in some countries, mandated. Clients cannot make an informed decision about whether they want in-person birth support if they are not aware of the potential risks. Birth and lactation professionals will also need to be sure they are considering the risks associated with taking clients and potentially bringing the virus home to their families, or sharing it with other clients they might be seeing.

If you cannot be physically present with your clients there are still plenty of options available for connecting with and supporting them. This might look like virtual and video support through Skype, FaceTime, Facebook Messenger, WhatsApp, Google Meet, or other available applications. Texting and email are still useful forms of communication and support when working with clients prenatally and postpartum. For many people, it can be particularly reassuring to hear another person’s voice during stressful and isolating times like this, making phone calls a great way to check-in with your clients. This is the time to bring people together however we can. You may have a cluster of clients who are all approaching their due dates or newly postpartum so you might explore how you can continue your prenatal and postpartum care virtually in a group or community-based setting to remind your clients that connection is still important, even if we can’t do it in-person.

We are in unprecedented times and we are seeing a virus spread more widely and more rapidly than most of us have ever experienced. There are a lot of scary things in the news right now and it can feel overwhelming not only for us as professionals but for our clients, peers, colleagues, and communities as well. While it may feel like we’ve lost a great many things, one thing we need to be sure we hold on to is our humanity and our drive to connect with, support, and raise up our community so everyone feels cared for and seen.

Virtual Support

CBI students can provide virtual support for their clients if they are unable to be with them face-to-face. Students can read about the specific requirements for virtual support on the student website. This position will be reviewed in January 2023.

Evidence on COVID, Pregnancy, Birth, and Lactation

COVID-19 has implications for your clients who are pregnant, giving birth, or are new parents. Although what is known about COVID-19 is limited and there is new research coming out every day, we have identified what the evidence tells us at the moment (as of October 2020). 

During Pregnancy

The Centers for Disease Control and Prevention (CDC) (2020a) have advised that, based on current knowledge, pregnant individuals may be at increased risk of severe illness if they become infected with COVID-19 and at increased risk of some complications such as preterm birth. They advise that, if a person is traveling to the hospital to give birth and they have suspected or confirmed COVID-19, they should call ahead first to ensure the correct PPE is available and an appropriate room can be found. 

During Labor and Birth

One of the challenges for people working with birthing individuals during COVID-19 has been limits on how many people can support the person giving birth. This has resulted in many hospitals across the world preventing doulas from attending births in-person. Some doulas have managed this by approaching the hospital directly and showing evidence that they have been trained and are knowledgeable in infection control. Others have moved to remote and virtual doula services. While many doulas have found these restrictions frustrating and are concerned about leaving their clients without doula support, it is important to be cognizant of the challenges for healthcare professionals in supporting a birthing person while at the same time protecting their staff and other patients. 

The CDC does not have guidance on how individuals without symptoms should be managed, but in relation to those who have, or are suspected to have, COVID-19, they state (CDC, 2020a, para. 12):

Healthcare facilities providing inpatient obstetrical care should limit visitors to pregnant people who have known or suspected COVID-19 infections.

• Visitors should be limited to those essential for the pregnant person’s well-being and care (emotional support persons).
• Depending upon the extent of community-transmission, institutions may consider limiting visitors to one essential support person and having that person be the same individual throughout the hospitalization.
• Use of alternative mechanisms for patient and visitor interactions, such as video-call applications, can be encouraged for any additional support persons.
• Any visitors permitted to labor and delivery should be screened for symptoms of COVID-19 and should not be allowed entry if fever or other symptoms are present.
• Visitors should be informed about use of masks (including cloth face coverings) for any person entering the healthcare facility and about appropriate use of personal protective equipment according to current facility visitor policy. Visitors should be instructed to only visit the patient room and should not go to other locations within the facility, including any newborn nursery.

When working within a clinical setting (e.g., as a birth doula or lactation specialist) it is helpful to be prepared by sourcing and carrying your own PPE so as not to put stress on hospital supplies. Ensure that you are carrying enough PPE and know how to correctly put it on, remove it, and dispose of it safely. 

Immediately after birth, some healthcare providers have recommended that newborns should be isolated from their birthing parent until they have been observed for symptoms, particularly where the parent is suspected or known to have COVID-19. However, this is not evidence-informed. The Global Breastfeeding Collective (2020) outline several steps that should be taken by healthcare providers when working with new parents who are suspected or known to have COVID-19:

1. Maintain services that support new parents with lactation. Explore options for remote support when appropriate.
2. All new parents should remain with their baby, regardless of their COVID status, and should be supported in skin-to-skin contact and rooming-in, especially while they are establishing lactation. 
3. Individuals who are breast/chestfeeding and have COVID-19 should be instructed in practicing respiratory hygiene including wearing a mask, washing their hands before touching their baby, and cleaning and disinfecting any surfaces they touch.

This is reinforced by the World Health Organization (2020, p. 1) who note:

The numerous benefits of skin-to-skin contact and breast[/chest]feeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.

Lactation and Parenting

There has been no evidence that COVID-19 can be passed through human milk and the antibodies in human milk may provide protection if an infant is exposed to COVID-19 (Global Breastfeeding Collective, 2020; WHO, 2020). The WHO (2020) advises:

• A parent who has confirmed or suspected COVID-19, can safely breast/chestfeed their baby but should wear a face mask to prevent transmission and use proper hand hygiene before holding the baby. 
• Wash their breast/chest if they have coughed there while their breast/chest was exposed with warm water and soap for 20 seconds before feeding.
• Expressing milk is safe provided the person expressing uses hand hygiene and the equipment used for expressing is correctly cleaned. It is preferable for the baby to be fed expressed milk by a person who does not have symptoms of COVID-19 if that is possible. 

While it is known that COVID-19 can remain active on surfaces for several hours to days, depending on the surface, there is little evidence available to determine whether extra precautions should be taken when preparing equipment for breast/chestfeeding if the parent has no symptoms of COVID-19. The CDC (2020b, para. 12) state:

Currently, there is a lack of evidence to support precautions such as cleansing the breast prior to breast[/chest]feeding or milk expression, or disinfecting external surfaces of milk collection devices (e.g., bottles, milk bags), as steps to reduce potential transmission of SARS-CoV-2. Mothers may consider additional steps such as these to minimize theoretic potential routes of exposure.

If you are working in a client’s home, you might want to limit the number of clients you are seeing while COVID-19 is a risk. Limiting your workload to only have one client at a time, or moving to virtual support, minimizes exposure to COVID-19 for yourself, your family, and your clients. It is worth thinking about the additional stress that a client might be experiencing during the global pandemic which, together with social isolation, can increase the risk of depression and anxiety. Ensuring clients know who to reach out to within the community if they experience depression and anxiety may be particularly useful at this time.

References

Centers for Disease Control and Prevention (CDC). (2020a). Frequently Asked Questions (FAQs). Retrieved from https://www.cdc.gov/breastfeedhttps://www.cdc.gov/breastfeeding/faq/index.htm#handling-breast-milking/faq/index.htm#handling-breast-milk

Centers for Disease Control and Prevention (CDC). (2020b). Coronavirus Disease (COVID-19) and Breastfeeding. Retrieved from https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/covid-19-and-breastfeeding.html

Global Breastfeeding Collective. (2020). Key Advocacy Messages on Breastfeeding and COVID-19. Retrieved from https://www.unicef.org/breastfeeding/files/Key-advocacy-messages-on-BF-and-COVID-19.pdf

World Health Organization (WHO). (2020). Frequently Asked Questions: Breastfeeding and COVID-19 for Healthcare Workers. Retrieved from https://www.who.int/docs/default-source/maternal-health/faqs-breastfeeding-and-covid-19.pdf