Lital Kremer, a 34-year-old mother from Kiryat Ono, gave birth to her third child last month. Though she intended to have both her husband and her mother present with her in the delivery room, just as she did with her first two pregnancies, it became clear toward her due date that her plans would need to change. The country, and the world, were in the midst of a pandemic.
“It was a little nerve-racking knowing I was going to give birth” amid the crisis, she said, with “concerns about what will happen, where to go, how it will be in the hospital itself — and the fear that someone will get infected…”
Lital’s husband, Roi, ended up being able to stay with her for the birth, at Sheba Medical Center at Tel Hashomer Hospital. They both had to say goodbye to their brand-new baby girl soon after she was born, though, while she was bathed and taken care of in the nursery where parents are no longer allowed for fear of exposure.
Coronavirus protocols also dictated that Lital and Roi wore masks for the duration of their stay. “I had to be with the mask the entire time, including during labor itself, with contractions,” Lital said.
“It was hard to breathe and it was hot. What was weird was that the nurses and the doctors were wearing masks, so you can’t really always understand what they’re saying and what they’re facial expressions are. It felt like some movie; everyone was walking around with masks and it’s all white and sterile.”
Aside from the masks and the temporary separation from her baby, Lital’s labor and April 23 delivery went relatively smoothly. For other women, however, it hasn’t been as simple.
In fact, the different and challenging birth experiences of women over the last few months underscore how all aspects of our health – and women’s health in particular – have been impacted by the pandemic.
From fertility clinics to mental health centers, the threat and the fear of coronavirus has forced healthcare providers to limit their services
Since the outbreak in Israel in February of 2020, women in late stages of pregnancy have needed to navigate their own way through the confusion. With protocols and recommendations changing daily as the pandemic spread rapidly, answers to simple questions have been hard to find, leading to considerable distress. And while labor, which is clearly not postponable, left women with little choice as to whether to go to the hospital, not all of the affected components of women’s health are as obvious as pregnancy.
From fertility clinics to mental health centers, the threat and the fear of coronavirus has forced healthcare providers to limit their services. This has left women, from those relying on fertility treatments to conceive to those dealing with sexual assault trauma, largely on their own — forced to adapt, with providers adapting alongside them.
Pregnant, and COVID-19 positive
For the small minority of pregnant women who have contracted COVID-19, difficult decisions have had to be made in an already tense and stressful situation. Should they keep their newborns close, enabling emotional and physical bonding, or separate from them in order to protect them from infection?
Sheba Medical Center created the country’s first COVID-19 obstetrics and gynecology ward, where women who have tested positive for the virus can come to give birth and receive any medical treatments they need, completely separated from the regular maternity ward where Lital gave birth.
In normal circumstances, “naturally, right after the baby is born we give it to the mother, who puts the baby on her, and the first connection between the mother and the newborn is created that is so important,” said Prof. Eldad Katorza, Senior OB-GYN at Sheba who oversees the ward. He emphasized the importance of “the bonding, the empathy, the body heat, the first feeding…” which are planned for in the standard steps medical teams encourage for newborns.
But this routine has been thrown into question amid the pandemic, and especially in this specific ward, with the risk of exposure for infants. “In the beginning, it wasn’t clear what policy we should adopt: Should we request separation of the mother and newborn after birth, or can we maintain the connection between them under certain limitations,” he explained. “In the end we decided to leave that decision to the parents.”
In the COVID-19 ward at Sheba, Katorza and the rest of the medical team attempt to ensure that women’s stays are as positive as possible. “The interaction with the patients has been very good,” said Katorza, though naturally the staff has to keep in-person contact to a minimum and conduct whatever can be done from afar through a range of technological devices via their dedicated control room.
‘It’s both technically and physically difficult to operate with all of that equipment; you look like a little astronaut’
The ward has several delivery rooms, a unit for the newborns, a high-risk pregnancy clinic and even operating rooms for C-sections. Every staff member needs to put on a full suit of protective gear prior to entering, including face masks, gloves, full smocks and shoe covers. “It’s both technically and physically difficult to operate with all of that equipment; you look like a little astronaut and it limits your ability to walk and your range of motion,” Katorza added.
The ward will stay open until the pandemic has fully passed and the team at Sheba can be sure that no COVID-19 positive woman will arrive in need of specialized medical assistance. “We aren’t closing this unit and we are ready for any scenario, including a renewed outbreak in the near or far future,” stated Katorza.
In the time the ward has been open thus far, 10 pregnant women were treated there, four of them gave birth, and one of those four was in critical condition and was transferred after delivery to Sheba’s ICU for COVID-19 patients. Based on their experience with these women, combined with new information streaming in from around the world, Katorza assessed that most babies born to coronavirus-positive mothers are born negative for the virus, and that the virus is not transmitted through breast milk. This does not mean that the babies are protected from infection after their birth, though.
Tackling mental health
Giving birth during the pandemic, in strange hospital circumstances and with medical protocols changing, can have long-term consequences, both on the babies and on the parents, in particular the mothers. The added distress and the loss of crucial postpartum connection with their babies can intensify the anxiety many mothers of newborns feel at the best of times.
Katorza cited a heightened risk for postpartum depression, and raised the question “what will happen to [mothers’] relationship with their newborns and the emotional development.” We’ll likely only discover the full ramifications of the pandemic on men and women’s health over the coming few months and years, he said.
“The thing that worries me most is women’s mental health,” said Sara Tancman, Founder and CEO of the Briya Fund, an organization that aims to improve women’s health care in Israel.
During normal times, this anxiety might be alleviated by the company and support of others, as well as recognized and addressed by nurses in Tipat Halav (Family Care Center). However, due to fear of exposure to infection, mothers have mostly been isolated at home with their brand new babies. This has left many of them lacking the support they need to adjust to the addition of a first, or another, child into their home. After receiving a barrage of messages from women about their coronavirus-influenced birth experiences, the team at Keren Briya decided to try to help them navigate the difficulties they were dealing with.
“We created an online questionnaire for women to check themselves and see if they should be looking for assistance or if they’re okay,” Tancman said. “We just used a questionnaire that’s used globally to check for postpartum depression or anxiety.”
The online questionnaire provides women with an automatic answer as to the severity of their symptoms and lists contact information for all of the clinics that are currently offering online services. Within the first day it was available, 300 women answered the questionnaire.
“As expected, there were very high rates of postpartum depression,” Tancman said, explaining that when labor and delivery are traumatic, or are perceived as traumatic by the mother, the odds of her developing postpartum depression increase.
Early on in the spread of the pandemic in Israel, the lack of information about the effects of COVID-19 led to a problematic suspension of fertility treatments that has affected many women in Israel. Even though the Ministry of Health had initially stated that fertility treatments would not be stopped or otherwise influenced, they were halted indefinitely towards the end of March and only renewed fully on May 11. “The reasoning behind stopping fertility treatments was that we’re not sure yet what effect COVID-19 may have during the first trimester,” Tancman said.
“All of the information we have on the effects on newborns is from women who were infected very close to the time of delivery. From studies of other infections during pregnancy, we know that the effect on the fetus differs according to the time of exposure to infection,” Katorza explained. “What we know from the cousin of the current virus, from SARS1 and now we’re on SARS2, is that the previous virus did affect pregnancy. It caused more miscarriages, early births, small fetuses and other problems,” he warned.
“On the other hand,” Tancman commented, “there was no announcement to the public that women should avoid getting pregnant right now.”
At the end of last month, five weeks after fertility treatments were first halted, the Ministry of Health announced that treatments would be renewed, but only for women aged 39 and over (as well as cancer patients seeking fertility conservation), leaving many other women still unable to resume their quest for help in conceiving a child. Naturally, this forced pause has led to anger, frustration and anxiety for many women, prompting various organizations and individuals – including female Knesset members – to lobby for a change in policy. It was largely due to this pressure directed towards the Ministry of Health that the treatments were then approved for women of all ages on May 11.
Aside from the change in initial policy regarding fertility treatments, guidelines on abortion services were also updated along the way. Early on it seemed that abortions would not be provided at this time, raising concerns that women would be left with unwanted pregnancies. “We were afraid that if some services closed down they would just remain closed,” Tancman said. “We were very worried that if some hospitals stopped giving abortion services, they may just not open again, but thankfully right now all hospitals are giving abortion services.”
Online services, wherever possible
While fertility treatments were stopped both due to uncertainty as to the effect of COVID-19 on fetuses and due to the risk of infection among clinic visitors, other healthcare services were also halted for logistical reasons.
“In the Be’er Yaakov-Ness Ziona mental health center there’s a ward for women who have been through sexual trauma,” Sara Tancman commented. “That ward was closed in order to open a coronavirus ward, so women were sent home.” (In response to an article on the closure of the mental health center published by The Times of Israel’s sister site, Zman Yisrael, it was announced the women’s psychiatric ward will soon be reopened.)
With many women unable to receive the therapy and guidance they needed from mental health centers such as Be’er Yaakov-Ness Ziona in person, various clinics began to adopt e-therapy solutions, such as the Lev Hasharon mental health center north of Tel Aviv, which provides both inpatient and outpatient treatments. The Keren Briya Fund helped Lev Hasharon assemble cameras and all of the equipment it needed to provide online services.
Online solutions as a whole, where applicable, have been a welcome aid for many professions and an instrumental tool for helping individuals avoid unnecessary exposure. This is especially true in the case of psychiatric treatment and therapy. The mental health centers at both Sheba and Jerusalem’s Hadassah-Ein Kerem medical center are also operating online now and receiving patients. Meanwhile, Bayit Cham, which operates six mental health clinics throughout the country (under the supervision of the Ministry of Health), has launched a special coronavirus hotline. Callers seeking emotional support and guidance can receive it in Hebrew, English, Arabic, Russian or Yiddish.
‘People were scared to come to the hospital and as a result, they neglected their health situation and caused themselves damage’
Unfortunately, digital solutions for physical issues are, by nature, less effective, and those who need medical attention must still receive it in person despite the risks. Medical professionals fear the long-term consequences of patients avoiding seeking assistance due to a fear of being infected.
“There have been cases reported of people delaying [seeking treatment], even with very serious health events, such as heart attacks, strokes, urgent surgeries and more. People were scared to come to the hospital and as a result, they neglected their health situation and caused themselves damage. We want to avoid this as much as possible,” Katorza said.
To ensure a sense of safety for all patients and in particular for women, Katorza said Sheba’s guiding policy — in common with many hospitals — is to separate all COVID-19 related care from regular care. The hope is that the separation will both encourage regular patients to come to the hospital in the first place, and protect them when they get there. “If women didn’t do all of the necessary tests, didn’t receive the necessary treatments… all of these things can cause long-lasting health ramifications.”
Despite all of the challenges facing the healthcare system and the difficulties women in particular have been dealing with during this crisis, there are silver linings to be found, such as the potential for online treatments remaining available.
‘You no longer think about the fact that the birth took place with masks and craziness’
“If you would have asked a psychiatrist a while ago if they could imagine the whole hospital providing online treatment, it was like a dream,” Tancman said. “We thought it would take years, but now within days they moved online. I’m hoping that it will be long-term; the option of online service is very helpful for many women.”
As for the new babies being born into a global crisis, they are the proof that life goes on. “You no longer think about the fact that the birth took place with masks and craziness,” said Lital Kremer. “At the end of the day, it’s behind us. After the birth, I left with a healthy baby, and everything is okay.”