"It's funny watching people whose entire worlds have been turned upside-down by COVID-19," my babyloss patient tells me. "It's as if this is the first time their lives have been destroyed. For me, it's like, welcome to the club."
The loss of a pregnancy brings a new perspective. The hopes and dreams of welcoming a healthy baby into the world and raising a new life are shattered and replaced with the many overwhelming symptoms of grief: sorrow, meaninglessness, anxiety, and confusion, to name a few. Many clients, like the one above, describe their entire perspectives shifting. Even if they have experienced prior losses in their lives, and even if they have cultivated resilience in the face of lengthy or unsuccessful fertility treatments, the goal of pregnancy has sustained them, and allowed them to hope. The loss of this hope, accompanying the loss of a baby, is demoralizing and tragic. They face the world again with sadder, wiser eyes.
And still, many babyloss mamas try to conceive again, when their desire for a healthy baby outweighs the anxiety and fear associated with another loss. Complicating these efforts today, a new threat has emerged in the form of the Coronavirus. Upending our lives and forcing us inside and away from our usual networks of support, causing us to question whether anybody is really "safe" and re-teaching us proper hand hygiene, COVID-19 has not only altered our physical daily routines but has deeply affected our mental health. For women of childbearing years who have experienced prior losses, COVID-19 presents a very palpable threat that piles onto existing anxiety about the ability to carry a healthy pregnancy. A real risk is present in mothers who have already experienced the overturning of their lives due to babyloss, now facing a rapidly-changing, unexpected environment of a pandemic. The word triggering feels too small for the huge feelings that my clients are expressing now in our weekly sessions.
The good news is, there is some research on the effects of this virus on pregnant women, risk to fetuses, and outcomes. Below, I will outline what is currently known, and provide some advice for women who are trying to conceive, currently pregnant, or postpartum. As important as the medical information is, equally important is managing mental health by accessing reliable scientific data, creating plans for ongoing care, and anticipating unexpected outcomes.
A word to the wise: Avoid personal blogs, profiteering "healthy-living" websites, or non-scientific sources of misinformation during this time. Everyone has an opinion on COVID-19, and thanks to the internet, they have the ability to share it. If your information is not coming from regulated, peer-reviewed (meaning that other scientists are reviewing the information for correctness) sources like the Centers for Disease Control (CDC), professional associations like the American College of Obstetricians and Gynecologists, or your local Department of Health, be wary. In the words of late-night host John Oliver, "There is a ton of misinformation out there… so please be careful before forwarding or retweeting stuff that you do not know to be true. Our personal actions are really going to count here.”
So...what do we know about Coronavirus and pregnancy?
What we Know: COVID-19 and Pregnancy, Childbirth, and Breastfeeding
The National Perinatal Association has provided a compendium of helpful resources on their website, including accessible infographs and fact sheets that tackle the topic of pregnancy, childbirth, and breastfeeding. While I encourage you to visit their page to review information that has already been vetted by experts in the field and is updated regularly, key points are highlighted below. Overall evidence suggests that pregnancy, childbirth, and breastfeeding in an environment of COVID-19 requires supervision and management, but outcomes are encouraging.
- Pregnant women are at an increased risk of contracting respiratory infections due to the changes that happen to their bodies. It is unclear, as of yet, if being pregnant increases the risk of contracting COVID-19, but it is helpful to act as though it does. This means following proper social distancing and hygiene procedures as you would during the flu season, including hand washing and sanitizing, avoiding sick people (even those who seem to have "mild" colds), and avoiding large crowds. Care for mothers who have the virus is supportive and not curative, as there is currently no curative treatment for COVID-19. Supportive treatment includes rest, hydration, supplemental oxygen, isolation, and very close monitoring. Not every pregnant woman who contracts COVID-19 will require intensive supportive treatment, and their response to the virus will be based on their own individual risk factors, such as other predisposing factors (immuno-compromised status, co-existing conditions such as high blood pressure, etc.).
- We do not yet know if COVID-19 causes pregnancy complications, as we are only now starting to see the virus affecting larger groups of pregnant women. So far, no maternal deaths have been reported due to COVID-19. While the best management of risks is prevention, this editorial indicates that there may be some risk of pre-term labor or premature rupture of membranes as well as elevated fetal heart rate and distress in the third trimester based on a very small sample of pregnant women who contracted the virus in Wuhan and were "officially" diagnosed, though it is likely that many undiagnosed women delivered babies while carrying the virus as well.
- There is little evidence of placental transmission from mother to baby at delivery. COVID-19 has not been detected in amniotic fluid, placenta, breastmilk, or nasal secretions of neonates, though a few cases of postnatal transmission have been detected. This means that while babies likely do not contract COVID-19 in the womb from their mothers, they may be exposed to and contract it after birth due to contact with others who have it.
- The small amount of research on the effects of COVID-19 on children under the age of one indicates that the virus is not as severe, and infants did not require admission to the ICU or mechanical ventilation. However, it is likely, again, that many more infants have been affected than appear in the scientific literature, due to their being more asymptomatic or having milder versions of the virus. It is important to note that some children with underlying conditions may still be more severely affected by the virus than others who are generally healthier, and so, precautions should always be taken, including mindful sanitation and sterilization of toys, bottles, or cutlery.
- The American Academy of Breastfeeding Medicine agrees that while there is limited information on COVID-19 and breastfeeding, the existing research suggests that the virus is not transmitted via breastmilk. However, mothers who have been exposed to COVID-19 or are currently ill with the virus should take all necessary precautions when nursing infants, knowing that they can transmit the virus through coughing and sneezing. So, when nursing or holding their infants, mother should take care to wear masks, wash their hands, and avoid touching their faces. If a mother feels safer pumping breastmilk during this time and bottle-feeding, or if she is pumping anyway, she should be sure to sanitize all pump parts and bottles, as well as bottle warmers.
When considering how to manage mental health in a rainbow pregnancy during COVID-19, there are also useful strategies to consider.
If you are trying to conceive...
1) It is possible that you are also in the midst of fertility treatments being canceled, and managing disappointment around this. Grief and loss at conception planning during this time is understandable and normal. The mental energy, focus, and planning around having a baby does not simply disappear because you are no longer able to pursue this goal. Take this time to journal about your feelings, cry, vent, and check in with a therapist if you have one. Reconsider goals that you and your partner may have pushed aside in order to make having a baby a reality. Make plans for when you become a parent. Have you checked in with each other on parenting styles or baby names? Stopping fertility treatment does not mean abandoning your dream. You can plan to be pregnant and parenting while your life is on pause.
2) If you aren't in a fertility treatment cycle but thinking about having a baby, consider the timing of a pregnancy during COVID-19. If you have already experienced pregnancy loss, explore how becoming pregnant during a time of potentially limited contact with your care providers may trigger additional anxiety. For many babyloss mamas, the extra attention and care provided by OBs, genetic counselors, and therapists in a rainbow pregnancy can be essential to helping them through testing and scans. Due to social distancing, providers may not be as available or physically present to support you. Furthermore, scans that may have been considered elective, but valuable for calming your nerves, such as a 16-week or 24-week anatomy scan, may not be offered to you. If this is the case, how will you cope? Perhaps becoming pregnant will provide you with something hopeful to focus on, but it is important to consider if you feel psychologically ready to conceive at this time in history, especially since we do not know how long social distancing will be required to flatten the curve.
If you are currently pregnant...
1) Create some expectations around prenatal appointments and your birth plan. If you haven't already, contact your obstetrician's office to see if telemedicine is an option for prenatal checkups, and if they can email you any lab paperwork needed for upcoming tests. While some parents are considering home birthing during this time to avoid the risk of COVID-19 infection, I would strongly advise talking about this with your provider, as every woman reflects her own unique level of risk that may make having a homebirth unsafe. One thing to consider is the availability of emergency transport should you need it last-minute, as resources are currently strained and you may not be able to get to the hospital as quickly as needed. Other considerations include the possibility that your partner may not be allowed into the labor and delivery suite with you. Preparing for this may mean acknowledging birthing without support, and making alternate arrangements to have your support person present via Facetime. Draw on other coping mechanisms that may need to be enhanced during birth, such as having your partner writing a letter for you to read while you are in labor, preparing a playlist, and gathering comfort objects/items that remind you of the people you love the most. Check in with your providers about what precautions they are currently taking to avoid the spread of COVID-19 on their floor, and, if your baby needs NICU admission, what that protocol will look like. Finally, prepare for the possibility that if your labor and delivery are smooth and your baby is healthy, you may be discharged from the hospital sooner than later. The transition back home can be rough under normal circumstances, so expect to experience these bumps sooner than later.
2) If you can, create time to connect with your pregnancy and do normal pregnancy-related things! It can be hard to be pregnant and isolated. Buy cute clothes, take bump shots, play music for your baby. Some babyloss mamas may have an even harder time connecting with their pregnancy during this time and that is normal, too. The fear of loving and losing a baby during a pandemic, especially during the wake of a prior loss, is still palpable for many. Allow yourself some grace to also detach if needed, and know that not connecting while pregnant is in no way an indicator of your love for your baby and the connection you will feel once baby arrives.
If you just had a baby...
1) There is no better time than now to follow the strictest rules of social distancing while also reaching out to support networks online and through teletherapy. The adjustment to bringing a baby home can be hard and isolating enough as you experience physical and psychological changes related to hormones, parenting a rainbow, potentially integrating a new baby into a family with multiple kids who are also at home, possibly restless, and wanting to be as close to mommy as possible. Create a schedule for quiet times where you can rest and bond with your baby, even if it means giving other children extra screen time. If you have a partner at home, set clear boundaries by using "I" statements and asking for what you need. This may mean that your partner needs to renegotiate working from home responsibilities to ensure that you are healing and resting as needed. It is a good time to look into spousal leave policies if your partner's organization offers these.
2) As above, if breastfeeding, be sure to wear a mask and sanitize equipment, particularly if you feel any symptoms of sore throat, chills, aches, or have a fever. Be sure to follow safe sleep requirements for baby, putting them on their back in a separate sleeping area. You may feel more compelled to co-sleep to snuggle with your baby for your own comfort during these uncertain times, but try to avoid doing so at night when you're likely to fall asleep with baby in your bed. Reach out to your older kids or partner for extra touch and affection of you are feeling deprived.
3) Keep an eye out for symptoms of postpartum anxiety or depression. Without the presence of COVID, these mental health challenges present a real risk, particularly in rainbow pregnancies and postpartum. You may feel both grateful and resentful for welcoming a living child as you struggle with adjusting to the reality of having a healthy baby in your life. While adjustment difficulties are normal, be on the lookout for ongoing crying spells, suicidal thoughts, intrusive images of hurting yourself or your baby, panic attacks, or feeling completely flat. If these symptoms start to feel unmanageable and interfere with your life, reach out to your mental health provider or trusted support network, call 911, or the Postpartum Support International Helpinge (English and Spanish).
What's the Bottom Line?
It is so important to adjust your expectations for what trying to conceive, pregnancy, and postpartum life will look like during COVID-19. While women who have experienced babyloss are already familiar with their worlds being turned upside down, they may also be especially prone to anxiety, panic, and feeling a loss of control. The abundance of unreliable information on the internet, social distancing, and mass panic can create feelings of hopelessness, in addition to shifting expectations for what prenatal appointments, childbirth, and available support will look like. Now is the time, more than ever, to consider teletherapy. Working with a compassionate, client-centered, dedicated therapist on a weekly basis can help you create manageable routines and realistic expectations, as well as provide tools for coping with anxiety during this vulnerable time. You do not have to walk through this alone, so please reach out for help.