EDITORIAL

Planned home birth and the COVID-19 pandemic: a necessary reflection

Clara Fróes de Oliveira Sanfelice1, Junia Aparecida Laia da Mata2, Nayara Girardi Baraldi3

1 State University of Campinas, SP, Brazil

2 Federal University of Rio Grande do Sul, RS, Brazil

3 University of São Paulo, SP, Brazil

Due to the pandemic caused by the new coronavirus (SARS-CoV-2), we are experiencing a historic moment of profound changes throughout society. Among them, we highlight those related to reproductive health.

Contexts of health crises, such as those caused by the H1N1 and Zica viruses, have already exerted their impacts on maternal and child health(1-2). In those associated with SARS-CoV and MERS-CoV (coronavirus associated with Middle East Respiratory Syndrome), there was a significant increase in severe maternal diseases, spontaneous miscarriages, premature births and maternal deaths(2-3).

The absence of resolute measures to ensure access to the health services and supplies during the pandemic can cause harms to women, such as: weaknesses in reproductive planning, increase in the number of unplanned pregnancies and low-quality prenatal care, with consequences for labor, birth and puerperium. Recent data show that the mortality rate due to COVID-19 among pregnant and postpartum women in Brazil is 7.2%, which represents a percentage 2.5 times higher than the national rate (2.8%). This places the country in the position of a record holder, with the highest number of maternal deaths caused by COVID-19(4).

Unfortunately, Brazil has stood out worldwide for the disastrous measures implemented during the pandemic, such as the attempt to privatize Primary Health Care, the absence of an effective national response plan to COVID-19, logistical failures in the vaccination campaign and intense scientific denialism(5), which further aggravates the current health crisis and reverberates throughout society, especially among pregnant and postpartum women.

In addition, during the pandemic, pregnant women may feel even more vulnerable by having to attend potentially contaminated environments, such as hospitals. Added to this aspect, the fear regarding the prohibition of the presence of a companion during labor and birth, an action contrary to the recommendation of the Ministry of Health(6) but practiced in some services, also seems to cause dissatisfaction with the assistance provided in the hospital environment.

It is in this context that Planned Home Birth (PHB) has come to represent a possibility for Brazilian women/families. Such situation was perceived from materials published in media vehicles and can be the object of future studies on PHB in the pandemic.

In the international context, a number of studies point to different actions related to PHB across the countries. In the United Kingdom, for example, there was a significant and generalized increase in the demand for PHB. However, the service that offers this type of assistance publicly began to suspend calls in response to COVID-19. Some regions of the country justified the reduction or restriction of the calls conducted by midwives due to lack of personnel, redirection of resources to fight against the new coronavirus, limited access to transfers through ambulances, and also in order to discourage women who may be contaminated with the virus to have their deliveries at home(7-8).

This recommendation is based on the guideline of the Royal College of Obstetricians and Gynecologists (RCOG), which strongly advises that women with suspected COVID-19 give birth in a hospital, taking into account all the risks involved for the mother and her newborn(9).

On the contrary, other regions of the United Kingdom chose to increase the effort to maintain such services in an attempt to reduce unnecessary hospitalizations and overload in the hospital environment. For this, they started to develop new transfer protocols using, for example, private cars in situations where transfers are not clinically urgent(7-8).

In England, the National Health Service (NHS) also observed more women requesting home birth as an alternative to hospital admission and, in its report, it released a guideline supporting continued choice of the birthplace, reiterating that home births are safer for women with low risk of complications and reduce the pressure on hospital health services in the pandemic context(10).

It is worth noting that, outside the pandemic scenario, there is vast literature that supports the safety of Planned Home Birth, presenting good maternal and neonatal outcomes(11-12).

In the United States of America (USA), the pandemic has drew the attention to a potential increase in the number of pregnant women interested in having a home birth, including those who may be at a greater risk of unintentional home birth. An increase in the interest in PHB was also noticed, even in women considered to be at high gestational risk, which, in fact, increases the chances of a negative outcome for the mother and the newborn(13).

The Dutch Association of Obstetrics(14) has published guidelines that emphasize PHB as safe to reduce the risk of infection, improve the care continuity models in Obstetrics, and reduce the number of caregivers in contact with women and infants.

In Italy, France and Spain, home birth care conducted by midwives is less common and is usually provided privately. Therefore, most of the women continued to give birth in hospitals(15).

The International Confederation of Midwives (ICM)(16) has published an official document stating that, in countries where the health systems can support births outside the hospital or in birth centers, PHB can be safer than in hospitals, where there are many individuals (even outside the maternity ward) with COVID-19. In this document, the ICM reasserts the need for these women to be healthy and receive care from qualified midwives, who have the necessary equipment/inputs for emergency situations(16).

In Brazil, several media vehicles reported the increase in the demand for PHB during the pandemic, reiterating the same movement that occurred at the international level. However, no governmental measures or strategies were proposed that could serve this population. A study pointed out that professionals working in PHB care considered the pandemic context as quite challenging, due to several issues such as frequent changes/adaptations in the provision of care, frustrations arising from these changes, fear of contamination, the need for distancing during care and the change in the prenatal care model, among others. The study also reinforced the need for official protocols to guide and support the professionals' work in this context(17).

We emphasize that, outside the COVID-19 pandemic, PHB also did not receive governmental initiatives that support it or include it in the list of procedures of the Unified Health System and health operators. As in Italy, France and Spain, it is offered on a private basis in Brazil.

We argue that the pandemic represents an opportunity to include this type of delivery care in discussions on assistance to the birth process, as a health system based on the doctrinal principle of equality needs to cover women who want and are eligible for PHB.

Choice of the birthplace must be supported by the diverse evidence available in the scientific literature, which must be understood by the woman/family. This includes benefits, associated risks, eligibility criteria and the professionals' work process, among other aspects that must be discussed prior to decision-making. Thus, opting for PHB in the pandemic context requires even more depth and understanding on the topic.

Finally, we consider that the health system's response to this pandemic requires a reflection on new possibilities for the care of parturients. The world's health situation mobilizes us to look at life from a different perspective, especially at its beginning. The pandemic brought us another opportunity to reflect on the place of delivery/birth, which should not be ignored, as the invisibility of this agenda already reflects on the current obstetric scenario and will certainly have repercussions in the post-pandemic period.

REFERENCES

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2. Al-Husban N, Obeidat N, Al-Kuran O, Al Oweidat K, Bakri F. H1N1 infection in pregnancy: a retrospective study of feto-maternal outcome and impact of the timing of antiviral therapy. Mediterr J Hematol Infect Dis. 2019;11(1):e2019020. http://dx.doi.org/10.4084/mjhid.2019.020. PMid:30858958.

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Submission: 08/02/2021

Approved: 01/10/2022