San Diego Midwives: The State of Midwifery During COVID-19

midwife examining pregnant woman

Midwives are seeing more inquiries for home birth during the COVID-19 pandemic, and while expectant families try their best to get the healthcare they require, the midwife community in San Diego, California is responding with much of the same personalized and natural care they’ve provided for years.

Changes During COVID-19

Hospital staff around the country are working hard to manage the number of COVID-19 cases and hospitals are insituiting stricter visitation guidelines in delivery rooms to prevent potential spread of the virus, but San Diego Midwife and Hormone Specialist Karly Nuttall says that the way people birth at home hasn’t changed much. “I’ve just had to work a bit faster for some people who switched birthing plans because we don’t have as much time to prepare for a home birth,” shey says.

Nuttall started her career path toward midwifery at the age of 17. She’s attended more than 700 births and now runs her own midwifery practice in San Diego, CA where she provides reproductive, prenatal and postpartum care as well as natural hormone therapy. “It’s a lot of working with people and it’s different every time which is nice. You have to be comfortable with being on call all the time, and also not be intimidated by being in vulnerable situations.” 

Like other midwives in the area, Nuttall is receiving more inquiries for home birth each week, many as a result of new hospital visitation rules. “There has been a significant increase since the beginning of COVID-19, and at first it was just because people were afraid to give birth in hospitals,” she says. “Then they started saying ‘Doulas probably can’t come to the birth,’ and then ‘Partners probably can’t come to the birth,’ and I think that made a second wave of people think about home birth plans.”

Midwifery Care and Social Distancing

While the work of midwives still hinges on maintaining a close connection with families, social distancing is changing some of the ways they interact with clients. According to San Diego Midwife Kayti Buehler, her clients understand the need to limit social contact and have maintained social distancing measures throughout care.

Beuhler is the founder of Birth Local Midwifery in San Diego, CA where she provides complete midwifery care and specializes in well-person care and insemination. She’s also an advocate for teen sexual health and works to help teens understand sexual and reproductive health and self-care. 

Buehler says she’s receiving more calls for midwifery care and is currently meeting with clients in-person to draw blood at 12-14 weeks, at 28 weeks and again at 37 weeks. Usually, she would meet with her clients many more times, but like many other health professionals, she’s often connecting with her clients through telehealth meetings.

Some midwives report that their potential clients’ social distancing practices will partly determine whether they can work together. Both Buehler and Nuttall say they’ve been making a point of staying in contact with clients about social distancing measures and how they and their clients are managing safety during the pandemic. 

Buehler and Nuttall maintain a fairly far reaching network of midwives and families. Nuttall says it’s important that she practices social distancing to protect herself, her clients and their families and also notes this is a particular consideration for clients who may be later to care. “Some families live with a parent who has an underlying condition so I have to think about who I’m interacting with and who that might impact,” she says.

Another change Nuttall notes is that she’s been giving new clients consent forms so they understand what she can do at her office with regards to sanitation and her control over the environment and how that differs from a hospital setting. She wears a mask when meeting clients in-person and is sanitizing every surface before and after client visits and also says she’s spacing out office visits when she does hold  in-person meetings so there’s very little interaction, nor people crossing paths.

As the health community waits on more COVID-19 data to guide their protocols, midwives are doing their best to strike a balance between limiting social contact while maintaining a personal touch. Nuttall says she’s still conducting postpartum visits in person because she feels she and her clients are in a safe position to do so and some care can only be provided in person. “I feel like it’s a really important time to not leave people vulnerable and there are many things we just can’t do over Skype. I can’t help a mother and baby latch or really assess and see what’s going on,” she says. It also gives families a chance to have more time together throughout the process and mothers know their birth team is close by.

Families that give birth in hospitals may worry about access to postpartum care which is an important part of maternal care, but Nuttall says she’s also providing in-person postpartum care for mothers who delivered at the hospital.

Transferring to hospital

Not all midwives are able to provide the same type of postpartum care because of social distancing measures, and strict hospital guidelines aimed at preventing viral transmission of COVID-19 means midwives are unable to accompany families and mothers who are transferred to a hospital during a homebirth. “Usually if my clients transfer to the hospital I go with them and I stay the whole time until the baby is delivered,” Nuttall says.

With more people becoming aware of their options and considering new birthing plans it’s important that people know the likelihood of transferring to hospital during birth and what that process involves. “Sometimes people who are preparing for a home birth might not be aware that there’s about a 15 to 20 percent chance that a first time parent will transfer to the hospital for long labor, exhaustion, needing an epidural or something else,” she says.

Changing Birthing Plans

Many American families still aren’t aware of all their birth options and the differences between birthing in a hospital setting versus at home. Buehler says that mothers should do their best to learn about all their options early on because switching plans later could be a challenge. “It’s important because getting set up with supplies and all of your health records and information can be a time-consuming process,” she says.

Another important consideration for families thinking about adjusting their birthing plans is the time it takes to connect with a midwife and build rapport. Nuttall says that trust between care providers and expectant families is paramount when it comes to choosing a care provider and while families switching birthing plans might have less time to find a healthcare professional, they must still take care to find someone they connect with. “It’s about relationships and it’s about me knowing my clients, their story, their blood type and allergies,” she says. “It’s also about my clients trusting me and my judgment and us being able to work together. I don’t advise rushing to transfer to a home birth if you cannot find a provider who you feel totally comfortable with.”

It’s also important for people to consider how the chances of transferring to hospital might impact their financial planning and to become familiar with their midwife’s policies regarding care if they’re transferred to the hospital. “I would get to know midwives and their policies and find out if they’re  going to continue in person postpartum care because it’s usually a really valuable part of midwifery care,” Nuttall says

Financial Planning For Home Birth

Navigating the world of insurance plans and how to finance an alternative birthing plan can be quite an undertaking. Most midwives don’t maintain any contracts with insurance as out of network care providers. Nuttall says she’s sometimes able to be reimbursed through a client’s PPO insurance, but for new clients without PPO insurance plans, it becomes difficult for Nuttall to receive payment that way. Any payment from insurance doesn’t usually come until three to six months postpartum so midwives and clients must wait to see the type of reimbursement.

“Every midwife that I know begins to charge the client upfront and they can pay as they go, usually paying everything by 36 weeks,” she says. Once the baby is born, Nuttall bills insurance plans according to the global maternity fee, but if there’s a transfer to the hospital and the baby is delivered there, then the hospital charges the fee. 

Only one party can charge the fee, so under the current system, if Nuttall’s client is transferred to the hospital during her home birth, seeking reimbursement for some of her work is a challenge.

“If we transfer to the hospital sometimes we can be reimbursed for itemized billing like pain or labor management but in that case there’s no guarantee,” she says.

For the most part, midwives are considered out of network care providers but Nuttall notes some important considerations for people who plan to see midwives outside of the care network continuously. “If you have a care provider who you want to continue seeing, but they are out of network, it could work out depending on the policy because your insurance could kick in once you meet the deductible and the company may start reimbursing the out-of-network car,” she says.

With so many changes to everyday life as well as momentous life experiences, midwives are working hard to provide families in their local communities with up-to-date information, personalized care and education that will help guide families through a safe and enjoyable experience. 

As more people start to explore different birthing options, midwives like Buehler and Nuttall who are familiar with a wide variety of settings and situations are working hard to help make families more aware of the benefits of home birth. “I just feel like it’s the missing piece of the puzzle,” says Buehler.

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