An illustration of a pregnant person wearing a mask sitting down and looking out a window.

Even under the best of circumstances, planning for birth requires parents to make many decisions: about where to have their baby, which providers to entrust with their care during and after pregnancy, and what kind of experience they want during delivery.

Working out a birth plan far in advance of going into labor, and in conjunction with your obstetrical care provider, can help you figure out your preferences.

The process of planning ahead for birth, however, has become both more complicated and more important during the COVID-19 pandemic. The limitations hospitals have placed on numbers of visitors, for example, may mean that you won’t be able to have as many people supporting you in person during labor as you had planned for. 

And with our knowledge about COVID-19 constantly evolving, says Shannon M. Clark, MD, professor in maternal fetal medicine at UTMB-Galveston in Galveston, Texas, policies and procedures at healthcare facilities are changing, too. “What [someone] might be told at the beginning of her pregnancy may change a few times throughout the course of her pregnancy, as far as what’s allowed and what’s not allowed,” Clark says.

To help you navigate the process of birth planning during the pandemic, we talked with obstetricians and other birthing experts about the most important adjustments to make and questions to ask as you’re planning for the arrival of your baby. Whatever you decide about the issues below, it’s also crucial to discuss your preferences and decisions early on with your provider, Clark says—long before the day you give birth.

Take Extra Precautions Against COVID-19

Everyone should be taking measures right now to help limit the spread of COVID-19, to protect yourself and those around you from the disease. But this is especially important if you’re pregnant. 

That’s because evidence is mounting that, as with other respiratory diseases such as the flu, COVID-19 can cause more severe disease in people who are pregnant. A study the Centers for Disease Control and Prevention published earlier this month, involving about 400,000 women who were diagnosed with and had symptoms of COVID-19, found that pregnant women were more likely to need intensive care unit admission, ventilation, and advanced life support techniques. 

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Another study from the CDC found that being infected with SARS-CoV-2, the virus that causes COVID-19, increases the chances of having a baby prematurely—from a 10.2 percent chance in the general population prior to the pandemic to a 12.9 percent chance among those with COVID-19.

In the earliest days of the pandemic, preliminary data suggested that this might not be the case. But we now know that the early evidence was misleading, according to Denise Jamieson, MD, professor and chair of the department of gynecology and obstetrics at Emory University School of Medicine in Atlanta. And the latest findings are no surprise. An increased risk of severe disease in pregnant people “is exactly what we would expect with a viral respiratory disease,” Jamieson says. With illnesses like flu and COVID-19, “there are shifts in the immune system with pregnancy that make people more susceptible to diseases and more likely to have severe diseases.”

Jamieson points out that although the risks of severe disease from COVID-19 are higher for pregnant people, they’re low overall. In the CDC study on severe COVID-19 disease in pregnant women, for example, the risk of ICU admission occurred in about 4 out of every 1,000 cases of symptomatic COVID-19 among nonpregnant people, compared with about 11 out of every 1,000 cases among pregnant people. 

Still, it’s critical to take precautionary measures. The CDC’s advice on how to protect yourself doesn’t change if you’re pregnant—it’s still crucial to wear a mask while out in public, keep your distance from others while out (especially from anyone not wearing a mask), and frequently wash your hands or use hand sanitizer.

Unfortunately, some key preventive measures, like working from home, aren’t possible for everyone, says Neel Shah, MD, assistant professor of obstetrics at Harvard Medical School in Boston—especially for people who work essential jobs that can’t be done from home. That group disproportionately includes Black, Native American, and Latinx people, he says, and these are also the people who make up a disproportionate share of hospitalizations and deaths from COVID-19. “That fundamental inability to protect against exposure is just an example of how the pandemic took every inequity in society and threw it into a pressure cooker,” he says. We need to enact policies designed to support all pregnant people and allow them to stay isolated from potential exposures to COVID-19, Shah says.

He says that given the constraints many face on their ability to stay home, one strategy is to prioritize minimizing your contact with others, to whatever extent possible, as you draw closer to your due date. That’s because if you have COVID-19 when it comes time to give birth, there could be significant changes to how you’re cared for, such as a greater need for masking and other protective equipment while you’re in labor or more restrictions on people supporting or visiting you. “Knowing that most pregnant people are already extra cautious and careful,” Shah says, “in that window around when your expected due date is, it’s particularly important to limit exposures to the degree possible. Things do change very much if you find out you’re COVID-positive on the labor floor.”

Keep Up With Prenatal Care

Talk with your doctor about your prenatal care schedule. According to the American College of Obstetricians and Gynecologists (ACOG), early evidence suggests that in-person prenatal visits haven’t been implicated as major risk factors for COVID-19 transmission. 

Still, the organization recommends considering changes to the typical prenatal care schedule to limit the need for any potential exposures to COVID-19. These might include measures like combining various pieces of care into one visit—like getting a flu shot and cholesterol screening at the same time. And while procedures like ultrasounds have to be performed in person, it might be possible for some of your prenatal visits to be conducted via telehealth. Ask your provider about how you might monitor some of your vital signs, like blood pressure, at home. And ask about what precautions the office is taking to keep both staff and patients safe.

Finally, talk with your provider to make sure you understand the signs that might indicate a problem—and could warrant an in-person visit. According to Megan Davidson, a labor and postpartum doula and childbirth educator in New York City and author of the book “Your Birth Plan” (Rowman & Littlefield Publishers, 2019), these include things like a spike in your pulse or blood pressure, as well as noticeable decreases in how much your baby is moving. 

Build Your Support Team

One of the biggest changes to birth planning in the pandemic is limits to the number of people who can be with you during your labor or visit you while in the hospital. That can be tough on people. “Childbirth is a team sport that requires human connection,” Shah says.

Some hospitals may allow only one support person, such as a partner, while others may also allow an additional person, such as a doula. Find out what your hospital or birth center’s policy is and plan accordingly. (An accredited birth center is a freestanding facility, often staffed by midwives, designed with a homelike atmosphere for people expected to have uncomplicated births that need minimal intervention.)

Even if you may be allowed only one support person during labor, it can still be worthwhile to consider enlisting the help of a labor support professional such as a doula. In the prepandemic world, the benefits were clear: A 2017 Cochrane review of 27 randomized controlled trials found that people who had continuous labor support from a professional had a shorter duration of labor and were less likely to have a Cesarean section, need painkillers, or have negative feelings about the experience of childbirth. 

Working with a doula during your pregnancy, even if your hospital’s policy means they can’t be in the delivery room with you, can help you make sure you’re clear on your own preferences and how to advocate for them in the moment. That’s typically part of a doula’s role during labor, says Olivia Samples, a holistic doula based in Des Moines, Iowa. “Educating [yourself] about informed consent, your rights as a patient, and common medical interventions in advance is more important than ever.”

And Samples says that even if doulas can’t be physically present during labor, they can provide continuous labor support virtually. She has done that twice so far during the pandemic. 

You’ll also need to think carefully about what your support system will look like once you’re home from the hospital. Given various quarantine requirements after interstate travel and the rising risk of COVID-19 infections from small family gatherings, it may be tricky to have family and friends visit or help with childcare, Davidson says. Talk with family members and friends about how they might support you virtually, or whether they can quarantine in between traveling to your city and visiting you in person. 

And ask your providers about how to get critical follow-up care for yourself and your baby. As with prenatal care, it may be possible to do some visits or screenings virtually.

Decide on Where to Give Birth

In the early days of the pandemic, Kiki Jordan, LM, a home birth midwife based in Oakland, Calif., says she saw a big uptick in people interested in giving birth at home. “Way more people are considering home birth because they are wanting to avoid being in a hospital,” she says. 

But Jordan says that while home birth may be right for some folks who value an unmedicated and uninterrupted birth experience, it’s not for everyone. Only those whose pregnancies are considered low-risk are candidates. And choosing to give birth at home isn’t something you should do just because of the pandemic. “You don’t want to choose home birth just because you’re afraid of going to the hospital,” she says. 

The ACOG says a hospital or an accredited birth center is the safest place to give birth, even in the pandemic. Expect facilities to have implemented protections such as universal masking, screening everyone for COVID-19 symptoms at the door, testing anyone admitted to the hospital for COVID-19, limiting crowds, enforcing distancing in waiting areas, and more. Measures will vary from facility to facility.

In general, Clark, the UTMB-Galveston obstetrician, recommends not letting the pandemic change where you’re planning to give birth. Like Jordan, she advises making a decision based on your preferences about the type of care you want to receive rather than fear of COVID-19. 

Ask Key Questions in Advance

Wherever you decide to give birth, find out what its policies and procedures are around labor and delivery. Some may be limiting movement around the hospital, and amenities such as cafeterias may be closed, Clark says, so you and whoever you bring for support would need to plan for that.

Many hospitals are now screening all people coming in to give birth for COVID-19 because cases frequently present without symptoms. Ask what will happen if you test positive and how the hospital handles that, both if you’re symptomatic and if you don’t have symptoms. 

Find out how your providers will support you if you test positive. Though policies vary, early research suggests that people with COVID-19 can still safely breastfeed and even “room in” with their infants. A July study in The Lancet Child & Adolescent Health examined data on 82 newborns in New York City hospitals born to COVID-19-positive mothers. Most of the babies were breastfed, with the special precautions of hand hygiene and breast cleansing, and they slept in a room with the mothers in an isolette (a clear plastic enclosed crib that protects the baby from germs). Of the 82, 79 were tested for COVID-19 at 5 to 7 days old, and none were positive, nor did any of the 82 display any COVID-19 symptoms. This data suggests that with proper precautions, breastfeeding can be done safely, even if you have COVID-19, Jamieson says. 

Finally, ask specific questions about the logistics of arriving at the hospital or birth center. Samples says she usually takes clients to their chosen birth location to take a tour so that they know how to get where they need to go. That’s not possible now, so she advises asking plenty of questions about which entrance to use, where to park, what you need to bring, whether your support people can come and go freely, which floor to go to, when you need to be wearing a mask, and more.