No Visitors in the Hospital … Unless You’re in Labor?
By Marielle S. Gross, MD, MBE
The pain of social distancing is never felt more acutely than at the patient’s bedside. People come to the hospital to be born, to die, in need of critical medical and surgical interventions and facing life changing challenges. It is never been more apparent how much the presence of patients’ loved ones contributes to the quality of care that hospitals are able to provide then when we start eliminating hospital visitors as a result of competing interests in infection control. The pain for patients is further multiplied by the decrease in “nonessential” bedside visits by physicians and nurses who are struggling to maximally leverage remote monitoring in order to preserve dangerously scarce personal protective equipment.
Indeed, hospitals nationwide and beyond have been progressively eliminating hospital visitation to address the rapidly evolving COVID-19 threat. In the United States, New York has been hit the hardest by the virus and experienced these visitor restrictions most stringently. Pregnant women and their partners were outraged last week when NewYork-Presbyterian and Mount Sinai Hospital banned visitors altogether, including for labor and delivery. The subsequent petition signed by over 600,000 went up to the level of the New York Governor Cuomo, who responded with an Executive Mandate requiring the permission of a support person in the labor and delivery room. This has been a welcome relief to many but creates a host of other questions.
First, we note that choosing one person to join you in the delivery room, when you planned on two or more, is still a huge personal sacrifice. Do you choose your partner over your mother, your sister, your doula…what about the medically critical in-person interpreter? Importantly, the allowance of a support person in labor and delivery is not necessarily extended to the postpartum recovery period: a time when psychosocial support has significant utility for staving off postpartum depression and promoting healthy maternal-infant bonding and lactation.
In academic centers, the elimination of students in clinical settings, similarly to decrease infection risk and PPE consumption, has also created a vacuum in patient support, one which may hit underserved patients and those without their own social support systems the hardest, since they are perhaps benefitted most by time and personal interest that students are uniquely able to provide.
There are also justice considerations, as hospitalized adults (pediatric patients are the only other exception to the ban) suffering from a wide range of other medical and surgical issues are unaffected by the injunction and will be forced to go without their essential support people. This includes patients who are dying—a loss compounded for both patients and their loved ones who do not get to say goodbye in person.
Notably, the initial restriction against visitors in the labor and delivery setting came after two asymptomatic laboring patients became critically ill immediately following delivery, resulting in over 30 healthcare worker exposures, and countless potential exposures of other patients and staff. The implications for potentially asymptomatic visitors to exponentially exacerbate this issue makes vivid the concern motivating the elimination of nonessential personnel, including visitors. There are real potential harms for pregnant women and others, consistent with the rationale for the broader visitor restriction. Some hospitals are now testing all laboring patients upon admission. Given established benefits of a labor support person, extending this to visitors is an option, but one that comes with a significant opportunity cost, particularly given current limitations in testing capabilities.
Finally, this brings up a major question regarding U.S. hospital practices in which both low-risk births and expected deaths typically occur in our highest acuity hospital settings. The extensive discourse around both these unique utilizations of U.S. hospitals must be revisited now that visitation is restricted, as there are major justice considerations at stake, both for the patients themselves, their families, the healthcare workforce, and for the anticipated surge in COVID-19 patients with whom those birthing and dying patients will compete for resources.