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First, Do No Harm — But in a Pandemic, How?

By Elizabeth H. Byrne and Ilona T. Goldfarb
Elizabeth H. Byrne ’14 is a graduate of Harvard College and a fourth-year medical student at Harvard Medical School. Ilona T. Goldfarb is a maternal-fetal-medicine specialist at the Massachusetts General Hospital.

As U.S. hospitals braced for the onslaught of coronavirus cases this past spring, they radically restructured and reorganized to help ease the burden on staff and minimize transmission within the hospital. Along with ceasing elective surgeries and transforming floors to allow for care of intubated patients, visitors were forbidden from entering hospitals with few exceptions.

Now, several months removed from the peak of the pandemic here in Boston, a limited number of visitors are allowed at a time. As we reflect on our interventions and make plans for the next wave or the next epidemic, it is worth wondering: While limiting visitors allows some additional element of physical distancing, how much does a ban actually help our patients, and how much does it hurt them — especially mothers-to-be in the vulnerable perinatal period? Is it possible to limit visitor-spread virus while allowing our patients the dignity and the peace of companionship during one of the most stressful periods of their lives?

While the presence of a visitor may not be a strict medical necessity, a support person may be psychologically essential. Patients in the antepartum ward feel the visitor ban with particular salience: New mothers-to-be are facing the physical and emotional stressors of bringing a child into the world in a time of uncertainty and chaos, often on top of their own medical issues. The COVID-era visitor policies forced these women to confront pregnancy-associated complications on their own, isolated in a sterile hospital room, unable even to walk through the hospital, and interacting only with masked healthcare providers.

Initially, hospitals in New York City banned visitors even from the labor and delivery unit. But the presence of a support person during labor and delivery not only improves the experience of childbirth; it also correlates with concrete improvements in clinical outcomes. These labor and delivery policies were thus reversed relatively quickly, and they were never adopted in Boston. However, the remainder of the no-visitor policy did permeate other critical parts of Boston-area hospitals, including antepartum units.

A patient was one such first-time mom-to-be who endured the isolation brought by pregnancy complications in the era of COVID. Just after she reached 29 weeks, the patient’s water broke. In these cases of preterm premature rupture of the membranes, patients are admitted to the hospital’s antepartum unit given the risk of premature labor and life-threatening infection. But according to the strict visitor policy, as long as the patient was not in labor, she could not receive any visitors.

Fortunately, she made it to nearly 33 weeks before delivering her healthy baby boy. As soon as she went into labor, her partner was able to join her in the labor and delivery unit, hold her hand as she pushed, and cut the umbilical cord, welcoming their child into the world.

However, she had been hospitalized for nearly a month before the birth without any in-person support from her partner, family, or friends. Neither the support of hospital staff nor frequent FaceTimes with her loved ones could take the place of her partner or her mom being able to sit with her as the days turned into weeks, waiting for the baby to come. The patient will never get back those 25 days alone at the end of her pregnancy.

Although the patient has been doing well since the birth of her son, scenarios like hers may cause significant psychological pain, not only in the antepartum period but also in the already challenging postpartum period. Approximately one in eight women experience postpartum depression. While we have not experienced such widespread perinatal isolation prior to the COVID pandemic, studies have found that other types of traumatic birth experiences marked by pain and loss of control, such as emergency cesarean sections, predispose women to post-traumatic stress disorder and postpartum depression.

Thankfully, while the visitor ban was an early policy during the pandemic surge, multiple infection control interventions for hospital staff have successfully been implemented in the hospital such as universal masking, hand hygiene, and daily symptom attestation so that a limited number of visitors may now safely return. In future pandemic surges, hospitals should also consider additional safety measures short of banning visitors — such as limiting the number of support people per patient per day and staggering arrival and departure times with staff shift changes to facilitate physical distancing in entrances, hallways, and elevators. As coronavirus testing ramps up, visitors could undergo viral testing prior to arrival, just as admitted patients are now universally tested in many healthcare settings.

If we fail to maintain visitor accommodations, our patients will likely suffer. Not only will some patients suffer the psychological consequences of isolation; others may avoid coming into the hospital entirely. Patients have appeared to avoid the hospital even in emergencies during the COVID pandemic, likely out of fear of coronavirus — perhaps compounded by fear of isolation. In the case of pregnant patients, anecdotally, demand for out-of-hospital births rose during the COVID-19 pandemic; according to the New York Homebirth Collective, pregnant patients may be resorting to home births without proper screening and preparation.

In medicine, we are sworn into a practice that prioritizes, above all else, doing no harm. In medical ethics, this is elaborated in the principles of beneficence — doing good for all patients, with consideration for those patients’ circumstances and medical issues — and non-maleficence – minimizing harm to our patients and our society in any way possible. A pandemic puts the benefit of infectious disease risk reduction at odds with the benefit of social support and puts the potential harm of exposure at odds with the harm of isolation. While initial pandemic policies rightly emphasized infectious disease precautions, we now know enough both about infection control and about deleterious effects of isolation to inform our future healthcare policies.

As we continue to move through the phased reopening of hospitals and society more broadly, and as we simultaneously prepare for a potential second wave of coronavirus this fall, we must take this time to reflect on our hospital policies. We must map out clear visitor rules that limit spread of the virus as much as possible without isolating our patients.

Elizabeth H. Byrne ’14 is a graduate of Harvard College and a fourth-year medical student at Harvard Medical School. Ilona T. Goldfarb is a maternal-fetal-medicine specialist at the Massachusetts General Hospital.

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