News: PQI Profiles

Responding and Adapting to the COVID-19 Crisis in a Birth Center Environment

Monday, March 30, 2020  
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By Amy Romano


COVID-19 has had a major impact on hospital labor and delivery units, but community birth settings such as freestanding birth centers face unique challenges. Margaret Buxton is the Lead Midwife and Angela Graham is the Director of Education and Programs at Baby and Company, a busy birth center in Nashville, TN affiliated with Vanderbilt Health. They shared how they have transformed their service model to keep patients and staff safe during the COVID-19 crisis.


Before the crisis: a model rooted in social connection


Social distancing has been a particular challenge for Baby and Company because, before the crisis hit, the care model focused on being socially connected, and the center itself was a hub of activity. “On any day, you would see families waiting in the great room for babies to be born, women having long face-to-face prenatal visits with their other children in tow, couples taking wellness and childbirth classes, and lots of staff moving around between births and visits at the center, births and patient rounds at Vanderbilt, and postpartum home visits to check in on mom and baby,” wrote Graham.


Angela Graham


Within a week of the first case of COVID-19 in the United States, the Baby and Company team had altered almost every part of this model.


A task force to nimbly adapt as the crisis evolved 


As news came that COVID-19 was in the United States, the birth center formed a task force aimed at keeping the birth center a safe and controlled environment to have a baby. “There were a couple members of the team who really turned out to be early adopters, urging us to take the spread of the virus seriously,” said Buxton. “We stay nimble, follow the evidence as it evolves, and implement plans in nearly real-time every day.”


Margaret Buxton


“When you’re in midwifery care, you’re all about hands-on, and this virus has forced us all to be the exact opposite of that!”


Baby and Company’s COVID-19 task force has made multiple changes to reduce contact between staff and patients—changes that impact the full spectrum of care, from prenatal visits to births, postpartum care, and gynecological care. Buxton and Graham shared some of the changes that have been implemented:


  • We are doing nearly all visits, unless they require an in-person evaluation, via HIPAA compliant telehealth platforms. We immediately moved to one entrance to the building for our clients so we could more easily control the flow of traffic. Before they enter, they have a verbal screening and a temperature check, and once cleared, they are directed to either wash their hands or are given hand sanitizer before entering. No one with signs of illness may enter the building.
  • We are encouraging clients to limit visitors during in-person appointments, and optimally, have visitors wait in the car. We're asking that they do not bring children.
  • We've instituted a drive-up lab. The client texts when they arrive, then an RN or MA meets the client at their car in our open parking garage, takes their temp, and then proceeds with any lab needs. The nurses have moved rugs and some of our patio furniture out to the garage so that it looks homey and comforting.
  • We're asking that clients limit their labor support to one support person or partner, and one doula. If they do not have a doula, then we're asking that they restrict their support to one person.
  • We're asking that siblings meet the baby at home.
  • Midwives previously floated between the birth center and the hospital and followed clients into the hospital when transfer was necessary, but now there is a hospital team and a birth center team. If a client needs to transfer care to the hospital, they will still get midwifery care, but from the hospital-based team.
  • All GYN appointments and procedures have been postponed unless they are deemed critical, and we are referring out all ultrasound services.
  • All of our postpartum home visits have been moved to in-center visits for the time being so that we can better control the environment for the exam. 


Buxton writes, “When you’re in midwifery care, you’re all about hands-on, and this virus has forced us all to be the exact opposite of that! We just keep reiterating to our clients that none of us want it to be like this, and one day, it won't be. But right now, we're doing everything we can to keep them safe.”


Moving education programs online 


Graham leads the education program for the center’s 500+ clients, the majority of whom are enrolled in classes. “Just as we got the news that there was a first COVID case in Tennessee, I remember being in a leadership meeting and saying, ‘You know, I think we should move our classes online’ At the time, I thought we might receive pushback from folks, but within 3 days of that decision, the world was socially isolating.”


For people planning birth center birth, Baby and Company requires participation in the education program. “So we had no choice but to make the switch quickly,” Graham writes. “Luckily, our education team is fast on its feet, and after a little tweaking, we moved the entire model online. The classes are still live with an educator but delivered remotely via Zoom.”


“One of our center's core values is ‘community,’ and we have spent the last five years fostering it at every turn. I refuse to let this virus put a stop to it.”


Baby and Company’s care model put a large emphasis on support, but with classes moved online and group visits cancelled, the team needed a new model. “We quickly sent out a survey on what kind of support new moms and pregnant women would like, and we now have implemented free, online support groups at several times during the week. We are offering support groups for newly-postpartum moms, general pregnancy, and for wellness topics like stress-reduction during this time, and even cooking with what's in your pantry.”


“One of our center's core values is ‘community,’ and we have spent the last five years fostering it at every turn. I refuse to let this virus put a stop to it,” says Graham. Buxton adds, “It's been interesting to see that the thing that drives anyone who does this for a living - the love of helping others and making a difference - has only intensified during this time. And since the touchpoints can't be physical ones, we seem to be growing around the obstacle of physical distance to find other ways to do those things.”


Increased demand for out-of-hospital birth amid the COVID-19 crisis


Changes in hospital policies and practices and rising concerns about the safety and capacity of the hospital system during a pandemic has led to an increased interest in birth center and home birth in Nashville and around the country. Buxton writes, “We have seen an increase volume of calls from women in the community seeking information about community-based birth. While we are excited to introduce them to our care model, we want to emphasize that all women in our care are screened carefully and continuously to make sure they remain low-risk, and planned hospital birth may be needed if risk factors develop. We are seamlessly integrated with Vanderbilt University Medical Center, and they have gone to extraordinary measures to prevent the labor unit from being a source of viral exposure.”


Graham adds, “Since we've opened in 2015, we've been working hard to introduce our birth center to the community. In a strange way, this difficult situation has brought fresh attention to the birth options in our community and we are grateful for that.”


Supporting staff and keeping them safe and well


The COVID-19 pandemic has made front-line health workers vulnerable to both getting and spreading the virus. Buxton share, “Like the rest of the country, our biggest physical needs are PPE supplies. Every day is a new discussion on how best to preserve and prolong the supplies we have.”


The risk of infection is not the only vulnerability, however. The crisis has also added stress for the team. Graham writes, “We have quickly realized that we miss each other on a social level! We started a staff Facebook group so that we could interact, keep in touch, and feel a little normal. And each meeting we have (and there are many meetings these days) begins with individual check-ins to see how everyone is coping.” She adds, “We are so lucky that most of us at the birth center are health-oriented anyway. Even though the days are longer and more stressful right now, I think we've all doubled down on finding time to care for ourselves physically and mentally. Without that self-care, we wouldn't be able to sustain the energy it takes to flex and change daily and continue to serve the women who need us more than ever.”


Summary of Margaret Buxton and Angela Graham's advice to perinatal healthcare workers during the COVID-19 pandemic:


1. General Recommendations


  • Create an interdisciplinary task force that meets frequently to review new information and adapt to evolving information
  • Communicate frequently with patients and offer extra support through web-based methods
  • Organize staffing to reduce the number of possible exposures, for instance creating a hospital team and a birth center team.

2. Prenatal Visits

  • Conduct as many of the routine prenatal visits via Telehealth if possible
  • Reduce the length of in-person visits, and screen people prior to visits
  • Ask patients to come by themselves to visits, and use technology such as FaceTime to loop partners or children in to the visits, if desired
  • Add signage to help people navigate new processes when they arrive for visits

3. Education and Support

  • Conduct classes via Zoom and provide other web-based resources to teach important pregnancy, childbirth and postpartum topics
  • Provide additional opportunities for support and connection, since patients will not be able to socialize as much through classes, and will be seeking extra support and reassurance

4. Intrapartum

  • Reduce the number of labor support people
  • Update cleaning guidance and re-train staff in proper disinfecting procedures
  • Make a plan for the process of transferring a patient if they are symptomatic for COVID-19

5. Postpartum

  • Monitor mother-baby dyads in the center for longer than usual, and provide additional guidance on home monitoring for COVID-19 symptoms in both the mother and newborn
  • Replace home visits with clinic visits
  • Provide additional opportunities for support and screening for mood disorders

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