The Pandemic's Impact on Reproductive Care Isn't Over

The Pandemic's Impact on Reproductive Care Isn't Over

Nicole, a 35-year-old OBGYN in Boston, works a few 24-hour shifts a month, sleeping in a small hospital room with one window, one computer, and one cot. On Mother’s Day this year, she worked one of those punishing days. Nicole’s work spans the whole spectrum of reproductive healthcare—or what was left of it, during the months when her area severely limited clinical visits and procedures considered dispensable by the state.

Like every state in the country, Massachusetts has reopened large swaths of its economy recently. You can eat inside of a restaurant, return to a less crowded office, get your nails done—the dominant theory being that the impact of lost wages over the longterm outweighed transmission risk.

In healthcare settings, the pandemic’s indirect effects haven’t been fully realized: millions of surgeries were postponed, acute care facilities transformed into covid-19 triage wards, and patients feared stepping foot in clinics, terrified of contracting the disease. The consequences of deferring all that care for months is yet to be seen. In reproductive health, a uniquely time sensitive form of care, those disruptions in service will continue to ripple long after elective surgeries have resumed.

Nicole’s work addresses nearly every aspect of reproductive medicine. Those disruptions have been obvious in the patients she has—or hasn’t—seen. In her positions at two separate hospitals, Nicole cares for expectant mothers and delivers children. She also provides abortion care, which is why she requested Jezebel refer to her using a pseudonym. “The anti-choice groups are very sneaky,” she says, “and they’ve been more active during quarantine.” Her colleagues, she says, have recently received handwritten letters delivered to their homes or the homes of their parents: “The subtext is that we know where you or your family live.”

Nicole’s alarm goes off at 6:00 in the morning, but she’s usually up earlier. The grief and uncertainty of the moment, she says, has made her sleep fitful. Massachusetts was hit early and hard by the virus. Some of the patients from the now-famous Biogen conference, where 100 of 175 attendees contracted covid-19, were tested in one of the hospitals where she works. She remembers getting on the subway in those early days and having the sudden realization that what she was doing was risky. By the time we spoke, more than 6,000 people had died from coronavirus in Massachusetts. The state was in virtual lockdown, and only the most stripped-down essential reproductive services were being performed in her hospital’s eerily empty halls. But as Nicole moved through her day, helping patients navigate their new realities, it was clear how long the tail of a sudden reduction in services, even if it was only for weeks or months, might turn out to be.

To prepare for her extraordinarily long day, Nicole packed an entire grocery bag full of food so she didn’t have to spend time in the hospital cafeteria during her shift. In her apartment, she put on clean scrubs and tucked a used N-95 mask from another shift into her coat pocket, just in case. The hospital where she works has created an app to screen its workers for covid-19 symptoms: She opened it on her phone and ran through its questions. She had no fever, no sore throat, no loss of smell or taste. The app generated a pass she’d show at the hospital to indicate she’d been cleared. “I think it reminds people to be vigilant about their symptoms,” Nicole tells me. “And gives them a sense they’re doing something, whether it works or not.”

Inside the hospital there was the sanitization routine: Nicole washed her hands and put on a new mask. In the small room where she’d spend most of the next 24 hours she wiped down everything she might touch. The halls were quiet, with almost no visitors: “there are no new grandmas or grandpas, aunts or uncles,” she says. She tried to wish a “happy Mother’s Day” to everyone she passed.

First, Nicole examined a new mother who’d come in for an emergency c-section the night before. Many of her patients are “ready to go home with their new babies as soon as possible,” Nicole says, “worried about the risk of being in the hospital during the pandemic.” Where in the past Nicole might have seen between five and 15 patients arriving at the hospital with a question or concern about their pregnancies—or post-partum bodies—that number has dropped to nearly zero, she says. Now, “it’s rare that I see someone who doesn’t actually come in for labor … People want to avoid coming to the hospital at all costs. ”

And even when they were in the hospital, with many services until recently unavailable, patients who made it to the wing didn’t have access to the full range of options they might have desired. One mother Nicole saw on that shift, having recently given birth, asked for a tubal ligation—to get her “tubes tied”—but the procedure was currently on hold. Instead, Nicole and her patient settled on a Depro-provera shot, which would at least get her through the next few months.

When Nicole wasn’t being paged to visit a patient from her tiny call room, she prepared for tomorrow’s task, looking through the charts of the patients she would see the next day over a teleconferencing line. As in many states, Massachusetts requires women seeking an abortion to fill out a consent form; Nicole would be walking the women through that process and letting them know what to expect during the procedures they’d scheduled for the coming week. Nicole says she doesn’t mind doing these visits over video conference, rather than in a clinical setting: She thinks it might make her patients feel more comfortable, more inclined to ask questions, unburdened by the institutional baggage they might have once they walked through a hospital’s doors.

Looking over the charts, Nicole saw that both patients were in their second trimesters. One, having worked hard to conceive using IVF, had recently found that her child’s heart hadn’t formed properly. Nicole wondered how the mother must feel, on Mother’s Day, expecting tomorrow’s call. The other patient already had one child. She and her partner had both lost their jobs when the pandemic stretched across the state. They didn’t think they could support another baby.

“I don’t worry that any of these patients are making the wrong decision,” Nicole says. “Patients know what is best for them and their families. But the gravity of the pandemic and its impact on women and their support systems weighs on me.” She tells me, later, that she’s counseled or performed abortions on a handful of women with near-identical stories: Women who, due to pandemic-related restrictions, had been unable to secure the birth control they’d desired.

Nicole was interrupted from these preparations by a page. A patient had arrived. She grabbed a covid-19 test swap and put on her N-95. Much of the shift blurred together, she says, but one patient who arrived around midnight did stick out in her mind. The woman had arrived completely dilated, nearly seconds from giving birth, two months before her due date and carrying twins.

“Normally,” says Nicole, “a patient like this would be encouraged to come in at the first sign of labor, so we could prepare the support her premature babies would likely need.” But everyone is afraid of the outside world now. “People wait,” she says. It was 4:00 a.m. by the time the babies were delivered. Nicole returned to her room to try to get some sleep, but soon another patient had started pushing. Around hour 25 of Nicole’s shift, another baby had been successfully delivered. “Adrenaline,” she says, “keeps me awake.”

“Nothing feels right during a pandemic,” Nicole says. “But helping women into—and out of—motherhood remains a profound honor.” As the weeks have worn on and Nicole’s state has begun to gradually reopen, she’s seeing more in-person patients. She’s once again able to provide IUDs to women who ask. But the impact of weeks of restrictions—and persistent fears about visiting doctors—has yet to be seen. One projected study has suggested that worldwide, covid-19 and related issues may cause a 10% reduction in access to reproductive care. In the United States, where states fought to classify abortion as a “non-essential” procedure, we’re barely four months into a pandemic that could last years.

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