International Changes in Maternity Healthcare Services During Covid-19
Medical care has seen unprecedented change during the Covid-19 pandemic, in many facets beyond care relating directly to Covid-19. One such domain of medicine that has witnessed significant change is maternity services, and a potential cultural shift in the delivery of maternity services is highlighted in the United Kingdom. The U.K.’s National Health Service (NHS) allowed for a third of its Trusts to suspend home birthing services, beginning in March 2020. Home birthing is a service that delivers a child within the comforts of one’s own home with the guidance of healthcare professionals, opposed to a pregnant patient traveling to a hospital inundated with Covid-19 positive patients. Although this policy may have originated out of a desire to maintain adequate staff to bear the weight of the Covid-19 caseload, it is deeply catastrophic for those who may feel pressured to “free birth”, which is delivering a child at home in the absence of any medical professional.
The current legality of home birthing is slightly complex. It stems from the base point that there are no entitled rights to an individual that allows them to demand a home birth, but there are also no laws to force an individual to visit a hospital to birth a child.[1-2] Additionally, it is coupled with a condition on hospitals and midwives who refuse their services to an individual asking for home birthing services, and if the mother or the child sustains an injury or dies as a result, the hospital and the midwives would be legally liable. To accommodate the situation of an individual being unable to demand a home birth, the preceding legal criteria assume that the mother would persist with their desire to give birth at home and in the process make the hospital and midwives aware of that sentiment. Furthermore, there is resounding evidence surrounding home birthing to establish it as a mainstream practice. Firstly, it is comparable in terms of safety to delivering a child in a labor or obstetrics ward of a recognized hospital. Secondly, it is associated with fewer obstetrical interventions, which could be confounded with the birthing taking place outside of an obstetrics ward but also potentially suggests that home birthing is not as dangerous as what the mainstream culture may believe. Therefore, the removal of home birthing poses a significant challenge to individuals interested in the practice during the Covid-19 pandemic because it forces them into either going to the hospital or delivering the child without the aid of medical professionals within their own home.
From a human rights perspective, the withdrawal of home birthing services could be deeply problematic. This is because it removes the liberty of an individual to choose a previously afforded option regarding the delivery of a child. Since the U.K. falls under the purview of the European Court of Human Rights (ECHR), the NHS Trusts are held to the same human rights standards. Therefore, even though there is no explicit mandate of home birthing offerings, a healthcare body cannot deny services such as home birthing if they routinely support such services, as referenced in Article 8.[2] This issue is further exacerbated by the remaining two-thirds of NHS Trusts maintaining their home birthing services because now the national NHS is indirectly discriminating its access to care to residents of particular regions.
Although home birthing is relatively more common in the United Kingdom (2.3%) than it is in the United States (1.61%), there are many similarities between the two regions regarding home birthing. Since the Covid-19 pandemic is an international phenomenon that has caused distress in individuals across nations, individuals in the United States are also looking into opportunities to engage in home birthing. This distress is certainly not unfounded. In a recent study from the New England Journal of Medicine, 88% of pregnant individuals who were positive for Covid-19 were asymptomatic. This underscores the fear of hospitals for delivery in pregnant individuals who believe that undetected and asymptomatic Covid-19 positive patients may also be present in the hospital, potentially transmitting the virus to them or their child after birth. Therefore, there is likely an increase in demand for midwives and home birthing options in the United States during the pandemic, as there is in the United Kingdom. However, in the United States, a different issue exists. Firstly, home birthing is not illegal, but to become a midwife and deliver children outside of a hospital setting, one needs a license. Secondly, several states do not offer midwifery licenses, which means that pregnant residents of those states cannot receive the services of a midwife because home birthing licenses are not available in those states, making home birthing virtually illegal because licenses are specific to states.
In conclusion, a similar theme exists between the United Kingdom and the United States – a transparent incompatibility between the pace of law and the pace of medicine. In many settings of clinical care, such as surgical care, law demands a high level of accountability from physicians, often pushing them to levels of care that are likely unsustainable. However, in services such as home birthing, a major impediment to changing trends and increased adaptability to novel situations such as Covid-19, is often law itself. It is therefore critical that legislators are able to provide legal protections and licenses to competent midwives and healthcare professionals to engage in midwifery in the United States, and also for their counterpart legislators in the United Kingdom to overturn the decreased access to home birthing for residents who fall in the jurisdiction of the Trusts that suspended those practices. It is a disservice to many patients to forbid, in an inconsistent manner, clinical care options that they normally would have access to.
Ashwin Palaniappan, who is a fourth-year student at Brown, is a BULR Staff Writer. He will be attending medical school next fall. He can be reached at ashwin_palaniapppan@brown.edu.
References
[1] St George’s Hospital Trust v. S [1998] 3 All ER 673.
[2] Ternovszky v Hungary [2011] ECHR 6.