Pregnant nurses and doctors say they are being forced to go to work with no formal accommodations or extra protections to keep them safe from the coronavirus, even though they are immunocompromised and data is still emerging about the risks of fetal transmission.
Dozens of pregnant medical workers reached out to ProPublica, saying they were weighing whether to stay in jobs they view as dangerous or quit, which could add to the burdens of their beleaguered colleagues. Many said they didn’t have paid sick or maternity leave and couldn’t afford to take a break. Because some spoke out against employers or were threatened with firing if they spoke about COVID-19 cases at their facilities, their names have been withheld.
One nurse, in a psychiatric hospital in a hot spot area, said a co-worker tested positive for the virus and others were exposed, but the hospital has refused to test employees until they develop a fever or a cough. “You still have to come to work unless you have symptoms,” she said. She was told she cannot wear a mask, something reserved only for staffers whose patients have tested positive.
“I said, ‘If you don’t know who is positive, what about that?’ No answer.”
A nurse at a long-term care facility asked her supervisors if she could do the paperwork-heavy parts of her job from home. “They told me no and said if I did stay home, they would fire me,” she said. Alarmed by the fact that staff had little to no personal protective equipment, she asked if she could keep her office door closed. “They said no, I had to be available to the other staff.”
Over the weekend, she developed a cough, a sore throat and a slight but concerning fever. “I’m terrified,” she said.
The American health care workforce is overwhelmingly female — about 90% of nurses and home health aides are women — and at any given time, an unknown number of them, likely in the thousands, are pregnant. Many of those nurses, doctors and medical support staff continue to provide front-line patient care as the pandemic unfolds — whether they want to or not and without knowing the long-term consequences for their babies.
A Lack of Data, Guidelines for Pregnant Workers
The recommendations for protecting pregnant health care workers confronting COVID-19 are loose and broad. Meanwhile, the research on coronavirus and pregnancy is changing quickly, with the latest reports creating a new sense of urgency.
Based on very limited published data, the Centers for Disease Control and Prevention and professional physicians’ groups have said that so far, pregnant women don’t appear more susceptible to catching the virus than nonpregnant women. Mothers-to-be may be more likely to develop severe respiratory illness because of their weakened immune systems and diminished lung capacity, as has proved to be the case with H1N1 flu and SARS, but it’s not yet clear to what extent the same may be true of COVID-19.
Even less is known about the effects of the coronavirus in the first trimester, although high fever in general as been associated with miscarriage and fetal anomalies. Some babies born to women with COVID-19 symptoms in China have been premature. In a report on the coronavirus in seven pregnant patients in New York City, four women had to be hospitalized, and two — both asymptomatic at the time of delivery, and both with significant preexisting conditions — required treatment in the intensive care unit. Neither of the babies born to those mothers tested positive for the virus.
Until very recently, researchers were confident that the virus isn’t passed from mother to baby in utero. But new, small-scale studies from China suggest that so-called vertical transmission can’t yet be ruled out.
“Now that there’s some emerging evidence, it may be time to have that conversation for a pregnant mom to take extra precautions,” said Suzanne Baird, a board member of the Association of Women’s Health, Obstetric and Neonatal Nurses and nursing director for the consulting group Clinical Concepts in Obstetrics. “It’s time to start addressing this for our pregnant moms working as health care providers. It is essential that pregnant women are protected in the workplace.”
At the moment, the CDC’s guidance for pregnant health care workers is scant. The agency states that if the staffing is available, medical facilities “may want to consider limiting exposure of pregnant [providers] to patients with confirmed or suspected COVID-19, especially during higher risk procedures.” The American College of Obstetricians and Gynecologists reiterates the CDC position and does not currently recommend shifting pregnant health care workers away from direct patient care based on coronavirus alone. “Pregnant women do not appear to be at higher risk of severe disease related to COVID-19,” the ACOG statement, dated March 23, says.
But in other countries, OB-GYN organizations have been more proactive. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends that, “where possible, pregnant health care workers be allocated to patients, and duties, that have reduced exposure to patients with, or suspected to have, COVID-19 infection.” The equivalent body in the U.K. revised its policy in late March, saying all pregnant women “should be offered the choice of whether to work in direct patient-facing roles.” For those in their third trimester (later than 28 weeks) or who have an underlying health condition, the organization “strongly recommend[s]” they avoid directly working with patients.
In a statement to ProPublica, Dr. Christoper Zahn, ACOG’s vice president of practice activities, said the U.K. and Australian recommendations are “based on historical data that is not specific to COVID-19.” He said ACOG’s approach is “to make recommendations based on data specific to COVID-19 and medical evidence.” To that end, “We are actively monitoring data on pregnant women and COVID-19 and are in frequent contact with the CDC and other experts in order to provide the most up-to-date information regarding the effects of the virus.”
Unanswered Worries, Imperfect Workarounds
ProPublica reached out to more than a dozen hospital and health care systems across the country requesting their written policies on pregnant workers during the coronavirus pandemic. Only two responded. In California, Stanford Medicine recommends that its pregnant health care workers limit direct care of patients with confirmed or suspected COVID-19 “whenever possible,” a spokesperson wrote. Employees in their 37th week of pregnancy or beyond are urged to avoid in-person patient care altogether. Baylor Scott & White Health in Texas says it is following the CDC guidelines; pregnant or breastfeeding health care workers “have the option, but are not required, to request exemption from caring for a lab-confirmed COVID-19 patient.”
Mostly, pregnant doctors and nurses told us that their employers have chosen to interpret the absence of information and guidance as a reason to let them continue working as normal — even when they raise concerns. “The lack of data ... does not mean there is no risk, which is the impression I have gotten so far from my medical colleagues, which worries me,” wrote a primary care doctor in her ninth month.
When an ICU nurse at a large regional medical center told her manager that she felt uncomfortable doing bedside work, she says her concerns weren’t addressed. “While she was sympathetic, she was like, ‘We have a lot of people who are uncomfortable with this,’” said the RN, who is in her second trimester. Accommodations have been made for staff with conditions such as cystic fibrosis, but the nurse has been told that they do not have the “organizational backing” to do the same for pregnant workers until their ninth month. The nurse said she’d be willing to take unpaid leave, “but it’s not something that has been offered. I think they’re too worried about staffing.” A plea to her OB-GYN for a letter that might help her make her case to her supervisor was rejected; the doctor works for the same medical system. “It seems they are operating as an arm of HR and not as my medical provider,” the nurse said.
A surgery resident in the South said she has had to rely on the kindness of her colleagues to keep her out of harm’s way. “Based on the hospital where I am rotating, I feel relatively safe because of the people I work with who say: ‘Maybe don’t come into this room.’ ‘We’ll take care of this,’” she said.
Even when organizations attempt to accommodate pregnant workers, they may not have the larger public health picture in mind. An RN for a nursing home company said she’s five months pregnant and the facilities where she normally works have suspected cases of COVID-19. To protect her, she was reassigned to visit home hospice patients to dole out medications and change medical dressings. “Probably over half of patients have respiratory problems,” she said. “Not only do I fear for myself and my unborn child, I’m worried about compromising those patients.”
One recent assignment, the nurse said, “I had to refuse because the patient had just come off a unit that had positive COVID-19 cases.” The homes are sometimes crowded with family members who have come to say their goodbyes. “With all these people around, I don’t know who’s been exposed. The more patients I visit, the more the risk is increasing.”
Battles for Personal Protection
Expectant mothers need to be especially vigilant about taking protective measures because pregnancy suppresses the immune system. But pregnant health care workers are encountering the same PPE shortages and institutional roadblocks as other front-line providers.
“We’re wearing gloves for any contact with any patient,” the home hospice nurse said. “We’ve been given hand sanitizer and told to Lysol our shoes and to change our clothes before going home. We’ve been given one mask and told we had to reuse it — not an N95 mask, just a basic mask. When we’re not using the mask, we’ve been told, put it in a Ziploc bag, put it in our car. We were told basically to use it until it falls apart.”
At a large trauma center, an ER nurse in her second trimester was assigned to work the triage desk for several shifts in a row as the coronavirus began to infiltrate her community. “I was surprised,” she said. “Why on earth would they put a pregnant woman out there sorting through patients who might be sick?” At first, she didn’t complain, because it’s difficult to turn down assignments. The next shift, “I finally reminded them: ‘I’m pregnant. I’m really uncomfortable doing this,’” and they said, ‘OK.’”
The next battle was over masks. She was reprimanded when she wore a surgical mask while outside a patient’s room. “They said no one could wear masks unless they were in direct contact from aerosolized droplets from a person who was confirmed or highly suspected to have the virus. They said pregnancy wasn’t a high-risk category and didn’t have any bearing on the COVID situation.” She felt compelled to take off her mask and didn’t wear one the next shift, either. Within a few days, the entire staff was so worried that almost everyone was wearing surgical masks.
For an East Coast nurse who is halfway through her pregnancy, the problem wasn’t just that her hospital refused to limit her interactions with patients who might have been exposed to the virus or to offer adequate PPE. “My OB refuses to write me a note to require my employer to provide additional protection for me.” She had been planning to work through the end of her pregnancy, but the anxiety became too overwhelming. “To protect myself and my baby, I chose to start maternity leave early and I no longer work at the hospital.”
One internist in her second trimester works as a traveling doctor in hospitals across the country. In her case, wearing a mask constantly to protect against accidental exposure isn’t the answer. “I tried it for one or two patients, but the protective gear really changes the physician-patient interaction,” she said. “My glasses fog up. The patients can’t hear me; I have shortness of breath because I’m pregnant, and I can’t speak. It scares them, and I think it’s important to provide a sense of security for people who are coming into the hospital already scared.”
The director of her current hospital has agreed that she should be allowed to avoid potential COVID-19 cases. But that doesn’t mean she’s safe. “Throughout the day I get called from the ER to admit patients. We get a lot of respiratory cases and pneumonia. If I get a call for a COVID rule-out, I can’t give that patient to somebody else, I just go do it,” she said. “I think in general my colleagues all have this mentality that exposure is imminent.”
Unable to Stay Home
Health care providers who want to leave their jobs, or take a break, are finding they don’t have the resources to do so. For some, paid time off and maternity leave are not a given. Some are single parents or have spouses who have been laid off. It remains unclear how the Coronavirus Aid, Relief and Economic Security Act will affect their options.
“I didn’t plan on being pregnant, but once it happens, this is where I’m at,” said the traveling doctor, whose job is financially lucrative but pays by the shift. She’s due to give birth this summer: “I’m not planning on quitting, it’s just not reasonable. I need health insurance, I need money. I’m fortunate in that I am actually still allowed to make money right now.”
The psychiatric nurse working from a coronavirus hot spot finds herself with minimal paid time off. She works for a large hospital that won’t be required to give her extra leave under the new federal legislation. Though she recently requested and received 14 days of medical leave, she knows she’ll soon have to return to a job that remains risky. “COVID cases are increasing every day,” she said. “Now it’s everywhere in the hospital.”
A few women who spoke with ProPublica have opted to stop working, a decision that often carries as much guilt as relief. “I feel almost ashamed to not feel comfortable to serve my community right now,” said Lauren Paz, a nurse at a large regional hospital in central Oregon who is eight months pregnant with her second child. “It’s an ethical dilemma. I want to serve. In this profession, we have a duty to serve and I want to be there. It pains me.”
But her husband is also on the front lines as a paramedic, and they have a 1-year-old at home. When the hospital began rationing face masks, she decided to stop working at 28 weeks and spent three weeks on the sidelines. “The kicker for me are the unknowns surrounding the baby,” she said. “I would take that risk for myself any day, but I will not take that risk for an unborn child who doesn’t have that choice.”
After several weeks off the job, she spoke with her supervisors about her concerns. They’re working to reassign her to the hospital system’s 24-hour COVID-19 hotline, a job she can do from home. She said she’s pleased with their responsiveness.
But she couldn’t rely on hospital policies or the CDC to help her locate the best way forward. “I have to be my own advocate,” she said.
Annie Waldman contributed reporting.