C'Anne Wolf is no newbie to the medical system, or to motherhood. She's a nurse who works one night a week in a free medical clinic in San Francisco. She also is the mother of six children, and currently pregnant. But she's scheduled to have a caesarean section on April 7, and she's scared.
That's because the U.S. Centers for Disease Control and Prevention (CDC) issued new guidelines this month recommending that new mothers with a confirmed or potential case of Covid-19, the disease caused by the new coronavirus known as SARS-CoV-2, consider allowing health care providers to temporarily separate them from their newborns — in a different room or in the same room separated by a barrier. Even amid the ongoing uncertainties attending Covid-19 and pregnancy, the recommendation presents a dilemma.
Scientists have known for years that separating mothers and newborns can cause stress in the latter. A wealth of scientific research stretching back 30 years supports the idea that skin-to-skin contact, also called kangaroo care, helps the baby's heart rate, temperature, and neurodevelopment; it's been the standard of care for preterm and low birthweight babies since 2015. At the same time, mothers and health care providers must now weigh the benefits of contact against the potential risks of a shared Covid-19 infection. Researchers are combing through the few studies available, but there is still much unknown about the virus and how it impacts pregnancy, birth, and newborns. And with no real treatment for the illness available, uncertainties abound.
Recommendations for mothers who test positive for other infectious respiratory diseases vary. For influenza, the CDC does recommend separation: "To reduce the risk of influenza virus transmission to the newborn, CDC recommends that facilities consider temporarily separating the mother who is ill with suspected or confirmed influenza from her baby following delivery during the hospital stay," the agency's guidelines state. "The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the health care team, and decisions about temporary separation should be made in accordance with the mother's wishes." In cases of newly diagnosed or untreated tuberculosis, separation is also recommended, though health officials say a case of TB that is being effectively treated does not warrant separation — and even breastfeeding is considered safe.
The stakes of getting it right with Covid-19 are potentially high. While early evidence seemed to suggest that children fared better than others when exposed to the novel coronavirus, a more recent study from China involving more than 2,000 children found that 125 became seriously ill. Sixty percent of these were younger than 5, including 40 infants.
But conflicting approaches from other health organizations and public health officials in other countries — the U.K. favors keeping even mothers with suspected and confirmed Covid-19 cases together with their newborns, for example, while China reportedly requires separation for two weeks — many American women are now left wondering just what should happen when they give birth in the coming months. "I am terrified of being separated from my baby for 14 days," Wolf wrote in an email message. "I am not concerned about getting the virus, but of what the consequences would be if I get it before/around delivery."
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Pregnant women are considered at high risk when it comes to Covid-19 — but that's not too surprising. "We know that pregnant women are a population who may be at increased risk of susceptibility to infection, severe illness, and mortality associated with other respiratory infections," Denise Jamieson, chair of the Department of Gynecology and Obstetrics at Emory University, said on a CDC teleconference held for clinicians on March 12. The reason, Jamieson added, is due to the various changes to the body during pregnancy, including "increased heart rate and oxygen consumption, decreased lung capacity" and a shift in immunity to allow the body to retain the fetus.
"This increased risk has been observed for other viral respiratory infections in pregnant women, specifically influenza and SARS," Jamieson said. "At this point, because of what we know about other respiratory infections, and given the paucity of data related to Covid-19 and pregnancy, pregnant women should be considered an at-risk population," she added.
When pregnant women are considered high-risk, it isn't entirely clear what it means for newborns. Outcomes in pregnancy and birth have not been well studied, the scientists on the call warned.
But researchers have started reporting outcomes for at least some pregnant women with Covid-19, and the results so far suggest newborns aren't typically infected. According to a CDC analysis of all available data for pregnant women in China, which had the world's first Covid-19 cases, there have been at least 34 such women, all of whom fell sick during their second or third trimester of pregnancy, said Romeo Galang, an obstetrician-gynecologist at the CDC's Division of Reproductive Health, during the CDC call. (High fevers in the first trimester can lead to certain types of birth defects, but there haven't been enough documented cases of Covid-19 diagnosis in early pregnancy to draw associations.)
Most of the women reported a fever and cough, most commonly starting within two days of delivery. In this sample, doctors delivered almost all of the infants by C-section, out of concern for their safety. Among the infants born alive, half were born late preterm, at between 34 and 37 weeks (a typical pregnancy lasts around 40 weeks). None of the babies tested positive.
The babies also tested negative for viral RNA, which would have indicated that they had the virus, called SARS-CoV-2. None of the mothers died, though two were admitted to the intensive care unit for critical care. One delivered a live born infant, and the other a stillborn, Galang said.
That's not unusual — mothers who are sick in pregnancy are more likely to have less-healthy babies because there's an increased risk of both low birth weight and preterm birth. "I think what we don't know is, is there is anything unique to maternal novel coronavirus infection that harms the baby in a specific way versus if mom had the flu or some other just bad illness," said Clay Jones, a pediatrics specialist in Newton Lower Falls, Massachusetts.
Most of the babies in this early Covid-19 analysis were separated from their mothers out of caution — not because they were sick. Jamieson told Undark that although transmission may be possible since it hasn't been well-studied yet, so far "there is not evidence that babies can get the virus while in utero, while still in the uterus, nor is there evidence that babies can be infected during the process of a vaginal birth or a caesarean delivery."
There is also no evidence that two other coronaviruses, SARS and MERS, pass from mothers to infants during pregnancy or birth. And even with the more common influenza viruses, Jamieson points out that such transmission is unlikely.
While there is no solid evidence that newborns are getting Covid-19 from infected mothers, the concern is reasonable. The major source of infection could be from a cough or sneeze, which would spread virus-laden droplets on a newborn, who could inhale or swallow those particles and become infected while being breastfed or held.
"That's where the difficulty comes in — we know the benefits of mother-baby bonding. We understand that early initiation of breastfeeding is really important, and so how do you weigh that against the risks of the mother potentially infecting the infant," Jamieson asks. The CDC recommendations, she adds, are really a continuum, not a black-or-white situation. "You have to weigh the risks and benefits, and the provider has to talk with the mom and the family."
The safest option, says Jamieson, is to separate the baby and have the mother express milk and then discard it — there could be a small risk of virus in the milk, although so far there is no evidence that this happens with SARS-CoV-2. (Three other viruses — CMV, HIV, and HTLV-I — frequently cause infection or disease from breast-milk transmission.) The next safest would be to separate mom and baby, pump milk, and have a healthy caregiver give the breastmilk in a bottle. Another less-safe option, according to the CDC, is to have the mom breastfeed the baby with a mask to prevent sharing respiratory droplets — that's where the American College of Obstetricians and Gynecologists has focused their messaging. The riskiest option, according to the CDC, would be breast-feeding and closely bonding with the baby.
The risks also depend on what stage the mother is during the course of her illness. For example, if she can control her coughs, the risk may be lower.
The guidelines, of course, are voluntary for mothers, and health care workers are not going to forcibly separate any mother and baby over Covid-19 concerns. "At our hospital, we have a similar approach where the mom can refuse," Jones says, "and then we just have to roll with it. We can only make a recommendation."
As for kangaroo care, babies didn't always get cuddled on a mother's chest right after birth. At the turn of the 20th century, when people began delivering in hospitals, babies were often left alone in nurseries away from their mothers to stave off any kind of infection. In the 1940s, researchers began to wonder how the mother-child separation at birth affected later family relations, which led the way to a new research field, according to a history of hospital births published in The Journal of Obstetric, Gynecologic, & Neonatal Nursing. One of the innovations was a rooming-in facility for mother and child. Now, baby-friendly hospitals, which encourage kangaroo care, are embraced by the World Health Organization and Unicef.
Jessica Madden, a pediatrician in Cleveland, Ohio, says that in a hospital that is crushed with Covid-19 patients, it's unlikely that there would even be another room to separate the baby, so the separation could happen behind a curtain, with six feet between mother and child, and with another available family member caring for the infant. The baby would be handed over to breastfeed, and then given back to the caregiver. "I think this is a situation where we need to be better safe than sorry," she says. "So although it breaks my heart to think about separating a newborn baby and a brand new mom, I think until we have more cases to be able to base recommendations on, that the absolute worst thing would be to have a baby get really sick because we haven't taken the proper precautions."
Madden explains that other respiratory viruses including influenza and RSV can make babies seriously ill — especially premature babies, but also full-term healthy babies. But even though those illnesses can be serious, it's not that common that they spread from mom to baby.
Jones sees that his patients are fearful. "I mostly see newborns, so 100 percent, virtually every family I have discharged home over the past week has asked me specific questions about what to do in order to reduce risk for their baby," says Jones. "And my advice is the same as, to be honest, if we didn't have this concern because there are plenty of viruses out there that are active that are much more harmful to the baby, like RSV and influenza." He advises good handwashing, keeping the infant away from anyone who is sick, and being careful about who comes in close contact with the baby. He adds that he worries more about grandparents traveling to see the baby, since Covid-19 has a higher fatality rate in people over 65.
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Mixed media reports add to the confusion over newborn guidelines. For instance, according to The Sun newspaper in the U.K., a newborn at North Middlesex Hospital in London tested positive for SARS-CoV-2 and was separated from its mother after birth. The Royal College of Obstetricians and Gynecologists in the U.K. has created guidelines suggesting that any separation is up to the mother, and if she feels well enough, she can continue skin to skin contact.
Still, according to Jones, since the baby was swabbed and tested minutes after birth, it's quite possible the test was contaminated. If the test happened minutes after birth, "the baby is going to be covered in maternal fluids — and mom could have sneezed on the baby for all we know," says Jones. He adds that he hasn't seen any cases of where infants have gotten very ill from Covid-19. "Even kids and infants who've tested positive, I don't think we had much in the way of critically ill kids being hospitalized," he says.
There are other examples where young infants have contracted Covid-19. In one small study, published in the Journal of Medical Virology, three newborns in China tested positive. But in all cases, the babies were likely infected after their birth, rather than directly from their mothers during pregnancy or birth. One baby, born to a mother infected with Covid-19, tested positive 30 hours after birth. Another second baby had a sick mother and developed a fever when he was five days old. The third baby also had sick household members, and showed symptoms when he was 17 days old, including fever, cough, and vomiting.
All three babies recovered.
Still, as far as the outbreak in the U.S. is concerned, it's early days, there is still much to be uncovered. Jamieson adds: "There have not been a lot of children infected so I think what it looks like in young infants is not well characterized.
The confusion over pregnancy, childbirth, and Covid-19 has led some expectant moms to make drastic changes in their birth plans. In an online community of women due to give birth in April, one user fretted about women minimizing symptoms because they were fearful of getting tested. "I do think denial of symptoms or minimizing reporting of exposure risk will be much more prevalent if mothers are afraid that being completely truthful will result in changes to their delivery plans and separation from one's infant,'' the user wrote. "Even if they're caught relatively quickly, an hour delay in identifying a possible case could make a big difference in how many other people are exposed."
Madden has also noticed what she sees as an unsettling conversation popping up in the online communities she follows, with some expectant mothers thinking about changing their plans for a hospital birth to a home birth. Madden suspects the separation guidelines may be partly to blame. "I think that if you are pregnant and you know you have this virus, or are suspected to have this virus, that that's extraordinarily dangerous to deliver at home," she says, not only for the mother's wellbeing, but also because the newborn will not receive the same heath monitoring it would in a hospital.
For some women, having birth at home isn't an option. Wolf, for instance, needs to have a C-section for medical reasons. As of now, she's still on schedule for her hospital appointment on April 7. If she and her newborn are separated, she says: "I cannot even begin to imagine how this would impact our bonding time and establishing breastfeeding, or my mental health. It would be devastating."
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Katharine Gammon is a freelance science journalist based in Santa Monica who has written for The Atlantic, The New York Times, The Guardian and more.