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Publicly Available Published by De Gruyter July 6, 2020

Giving birth and dying alone in hospital during the COVID-19 pandemic – a time for shifting paradigm toward continuity of care

  • Sandra Morano and Jean Calleja-Agius EMAIL logo

To the Editor,

We read with interest the article by Grünebaum et al. Professionally Responsible Counseling About Birth Location During the COVID-19 Pandemic (2020) [1] and we would like to share with you our experience in North Italy. In the current war against the COVID-19 pandemic, the healthcare professionals have become the frontliners in the defense against the enemy’s attacks, and the victims are “exposed” with photos of defenseless bodies lying in agony in hospital beds. As Italy is overcoming the first wave of the infection peak, it’s time for reflection. There is still a long way to go, and we are yet unable to imagine an end.

The death of innocent civilians is akin to a silent war: hundreds of coffins escorted by the army: a symbolic picture spread around the world. Distressed breathless bodies stuck to respirators without the comfort of a familiar person, deprived of a final greeting in the transition from this world to the next. Men and women dying alone, with the rituals and traditions which mark our civilization, denied of each victim and each affected family. The number of these inhumane deaths, although already high, is yet to be accounted for [2].

This is not the ideal time to be born either. During the last century, childbirth in hospital was deemed as the safest option. Initially women were isolated from relatives, including the partner, to deliver in aseptic wards with unknown caregivers. Decades had to pass to “humanize” childbirth, which normally is neither infectious nor pathological [3]. However, during the COVID-19 outbreak, in most countries, accompanying partners are prohibited from attending the delivery suites to support mothers during labor [4], [5]. Many healthcare professionals describe the desperation in the eyes of laboring mothers, whose day of delivery turns into the most feared day of their life, empty of any closeness and compassionate care. Akin to a spaceship, a harnessed and masked mother, and a distant healthcare professional in full PPE, representing the supposedly most normal of human events.

Both in birth and in death, the first to be stifled has been the human basic rights towards the entrance and the exit to our own humanity, with persons being born and dying alone.

Colleagues from Bergamo, Italy describe a mandatory paradigm shift: “we have been accustomed to a patient-centered model of care, while, on the contrary, facing the pandemic we need a community-centered model.” [6] We want to stress that we should have been community-centered to start off with even before the pandemic, but infact we were just hospital-centered. These current challenging times highlight the necessity for a global rethinking of today’s health needs. Issues concerning institutionalized normal childbirth in low risk pregnancies must be revisited. The interaction of the healthcare professionals, together with the birthing women, and all patients for that matter, needs to be revolutionalized, taking in account the respect for human dignity, with a renewed philosophy to influence the relationships among healthcare professionals and patients, and to re-design the health facilities/spaces . The “Italian case”, beyond the heroism, as well as the errors, can help other countries to learn the pivotal role of its neglected NHS, its limited facilities, its mistreated carers, and finally the huge number of avoidable deaths, even in this current uncertainty for our future. It’s time to address a radically different health agenda.

It is mandatory to think of continuity of care: between health and disease, between cure and well-being, between community and large hospitals, between life and death. We have already observed how a new infection forced us to stay “at home” as the best survival strategy. We observed that in China, self-isolation at home was the best solution to avoid spreading the epidemic and to limit hospitalizations. On the contrary, a spontaneous, worldwide movement of mothers, clinicians and associations, is circulating appeals for a respectful birth assistance, choosing to give birth out of hospitals, far from risk of infection, fear, and loneliness. Women are the first and the only ones experiencing on their bodies how closely life and death are intertwined.

Health systems must strive so that despite this particular pandemic, birth and death, become more humane. It is up to us as researchers, decision makers, clinicians, to plan the future of life on Earth by listening to the voice of survivors, and the experience of the resilient women who gave birth, alone. The lesson learned from this crisis is that finally the place that we call ‘home’ is an appropriate place to be born and die, and will resume being that safe place where today, during this COVID-19 pandemic, everyone still trusts to save us.

Corresponding author: Jean Calleja Agius, Faculty of Medicine and Surgery – Anatomy, University of Malta, B’Kara Bypass Msida 2080, Msida, Malta, E-mail:

  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.


1. Grünebaum, A, McCullough, LB, Bornstein, E, Klein, R, Dudenhausen, JW, Chervenak, FA. Professionally responsible counseling about birth location during the COVID-19 pandemic. J Perinat Med 2020 May 13. in Google Scholar

2. Ingravallo, F. Death in the era of the COVID-19 pandemic. Lancet Public Health 2020;5:e258. in Google Scholar

3. The Lancet Maternal Health Series Executive Summary. Available from: [Accessed 5 May 2020].Search in Google Scholar

4. Tran, NT, Tappis, H, Spilotros, N, Krause, S, Knaster, S. Inter-agency working group on reproductive health in crises. Not a luxury: a call to maintain sexual and reproductive health in humanitarian and fragile settings during the COVID-19 pandemic. Lancet Glob Health 2020 Apr 21. pii: S2214-109X(20)30190-X. in Google Scholar

5. Poon, LC, Yang, H, Kapur, A, Melamed, N, Dao, B, Divakar, H, et al. Global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium from FIGO and allied partners: information for healthcare professionals. Int J Gynaecol Obstet 2020;Apr;4. in Google Scholar

6. Nacoti, M, Ciocca, A, Giupponi, A, Brambillasca, P, Lussana, F, Pisano, M. At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation. NEJM Catal 2020.Search in Google Scholar

Received: 2020-05-21
Accepted: 2020-05-25
Published Online: 2020-07-06
Published in Print: 2020-07-28

© 2020 Walter de Gruyter GmbH, Berlin/Boston

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