Prefer to listen? Find the accompanying podcast episode on the Unschooled Homebirth podcast, Episode 8, wherever you get your podcasts!

At the time of this posting COVID-19 has descended upon one of my neighboring cities, with the epicenter at a skilled nursing and rehabilitation center. Unfortunately, our community has seen a handful of loses, and my condolences go out their families and friends.

In the wake of this situation, our local birth community has been carefully watching and assisting our expectant families and providing the best support we can. So I thought I would provide an update on what we are seeing in our local hospitals and what you can do to boost your immune health so if the 2019 novel coronavirus spreads further, you can be more prepared with the best information that I can provide at this time. The information about the situation is changing rapidly, even during the time it took me to put this information together, the recommendations have changed several times. But, my overall intent is to help you create a healthy environment for you and your baby, and those recommendations are not likely to change.

The facts about Coronavirus, SARS-CoV-2 and COVID-19

Coronavirus is a respiratory virus, and the novel 2019 strain, called SARS-CoV-2 we are experiencing this year is in the same category of virus as the coronavirus strains we have seen in the past that caused Severe Acute Respiratory Syndrome or SARS, and Middle Eastern Respiratory Syndrome or MERS. The virus we are seeing this year is genetically most similar to the SARS strain, thus the name SARS-CoV-2. There are actually a few other coronavirus strains that are less severe and we usually refer to as the common cold.

As for COVID-19, this is term for the group of symptoms that the infection causes, including fever, sore throat, a dry cough, malaise and body aches.

Contrary to common thought, it is not a flu as it is not in the influenza family.

What we are seeing in pregnancy

At this time, what we know about the effects on newborns is primarily from China, where the virus has been active for months and several pregnant women have tested positive for SARS-CoV-2. According to the reports, none of the newborns tested positive for the virus at birth, neither did any newborn tissues or fluids, including the placenta, amniotic fluid, urine, and saliva. Breastmilk of the mothers has also tested negative for the virus, despite testing positive for the virus themselves and even displaying symptoms of active infection, including fever, sore throat, cough and body aches1.

Close to a dozen cases have been reported in infants up to 11 months of age, however all cases have been mild and it appears they have all recovered 2,3.

Also interesting to note is that when breastmilk was tested in three newly postpartum women, not only were there no cases of virus seen, but one of the women also had antibodies to SARS-CoV-24, so breastfeeding, or offering your newborn breastmilk if possible may provide an extra safeguard for newborns, especially if born to mother's who have tested positive. What I don't have information about is whether the infants in China who tested positive and recovered were breastfed or formula fed, which would be really interesting to know more about, but I think we can have a lot of reassurance that this virus is not demonstrating high virulence toward newborns or infants at this time.

As for pregnancy, so far pregnant women who have tested positive for SARS-CoV-2 have had fewer complications and less adverse outcomes than would be anticipated based on what we have seen in the past for those infected with SARS or MERS, probably in part because at this time, SARS-CoV-2 seems to be far more dangerous for those over age 60.

Protecting yourself and your newborn

I am not going to spend time telling you to wash your hands, avoid crowded places as much as possible, be careful who you let visit you or your baby, because you already know that. I just want to be clear that it's not because I don't think those precautions are important, they are the best first line defense, but even using the best precautions, it can still be difficult to be 100% safe. So having some other tools to keep yourself and your family healthy is always a benefit in my book.

Nutrition

First I want to address nutrition, because nutrition is the foundation for strong immune health, and of course, strong immune health is vital for so many things, not just avoiding illness, but even more so right now as the infection response aspect of your immune system is precious right now.

Your immune system relies on your intake of protein and micronutrients, most importantly vitamins B6, folate, B12, C & E, as well as trace minerals including selenium, zinc, copper and iron. Deficiency in these micronutrients compromises immune function by affecting your fast acting immune response signals since these are comprised primarily of proteins and enzymes, called Cytokines.

When a pathogen damages a cell in your body, cytokines spill out and essentially become a beacon to your immune system to quickly dispatch immune cells to the scene to engulf the invader for analysis and identification. Further, deficiency in these nutrients will impact your T-cell-mediated immune response, which is your strongest defense system. These are the cells that try to destroy pathogens as soon as they are recognized by your immune system and contribute to your long-term adaptive or learned response, where you develop antibodies to the specific pathogen to better refine your response and prevent reinfection. Important antibodies that will likely be passed in your breastmilk should you be exposed, which I will cover shortly.

In the first half of pregnancy, for women who are otherwise healthy, the general recommendation for protein intake is about 60-80 grams, or even more, per day. To reach that target means most women will need to try to include protein with each meal. The target for the second half of pregnancy is ideally around 100 -140 grams, depending on your specific needs and your health. Note that not everyone can consume that level of protein safely, so check with your prenatal care provider before making any major adjustments to your diet or protein intake to ensure these levels are safe for you, especially if you have any history of kidney disease or other kidney complications.

The reason that protein demands are so high is that the amino acids provided by dietary protein are needed for your immune system to function. Cytokines, the beacons that alert your immune system to an invader after a cell is damaged, consist primarily of amino acids and the antibodies that your immune system will begin to manufacture in response to an active infection are also composed primarily of amino acids. So ensuring you have sufficient and complete amino acid stores means your immune system can act fast, efficiently and sustain a high level of activity if needed.

That brings us to B vitamins. Foods highest in the B vitamins that are most beneficial for immune health, specifically B6 or pyridoxine, B9 or folate, and B12 or cobalamin include animal meats, fish like halibut, salmon, and tuna, eggs, and nutritional yeast.

B12 is primarily sourced from animal products, if you don't eat meat, you can find it in dairy and eggs, and in small amounts in fermented foods such as sauerkraut, fermented pickles, beets or other vegetables, kombucha, or kefir, though I know some of those might not sound so appealing if you are managing nausea in your pregnancy.

B6 and folate can be sourced from a few other vegetable sources including broccoli, spinach and other dark leafy greens, and beans can also be a source of folate, if they agree with your digestion.

The trace minerals that are most important for immune health include selenium, zinc, copper and iron. Many of these minerals can be found in seafood and animal meats, particularly organ meats, if you have a taste for them. Nuts and seeds are also generally a good source for trace minerals.

Selenium is known to be high in Brazil nuts, only a few nuts, several days per week are enough to boost your selenium levels. Fish and animal meats are also primary sources of selenium.

Zinc is found in small seafood sources like oysters, clams and shrimp, as well as liver. You can also find it in seeds like pumpkin and sunflower, beans and nuts.

Copper is also found in seafood, especially lobster, but also seeds, nuts and beans.

Perhaps the nutrient most pregnant women are concerned with at some point in pregnancy is iron as low iron, or anemia can be common during pregnancy. Good sources are animal proteins, dark leafy greens and beets as well as beans and seeds. Iron absorption can be boosted by eating iron rich foods with citrus fruits or fresh squeeze citrus juice to provide a whole food source of vitamin C.

Now that you're overwhelmed with information about what foods contains which nutrients, I want to make it super easy for you, because I remember what pregnancy brain feels like and no one want to put extra energy into food planning if you don't have to!

Here it is, hopefully you are eating animal protein, if so eat eggs 5-6 mornings per week with a healthy helping of dark leafy greens like spinach, collards, kale or arugula. These can be lightly cooked or just wilted by your warm eggs. You can pair it with bacon, sausage or pork for an extra dose of protein and a boost of zinc and copper.

The other mornings, try soaking sesame, sunflower, pumpkin, chia and/or flax seeds and berries in a high quality Greek yogurt or kefir overnight for a variety of trace minerals, B vitamins and vitamin C.

For lunch, try chicken salad with pumpkin seeds on top of a salad of baby greens with raw apple cider vinegar, and alternate that with tuna salad to get the benefits of seafood. One day a week have lentil or another bean based soup along with dark, leafy greens and some root vegetables like carrots, sweet potato, parsnip and rutabaga.

For dinner, mix up your routine by adding lamb one night per week, which is a good source of Selenium and B12 that I didn't mention before. Also aim to get salmon or another healthy fish 1-2 nights per week or have seafood medley based dinner with a mix of sources like shrimp, crab, lobster and mussels.

Add seeds and nuts to your salads, soups, warm cereals or yogurts. Sesame seeds can pair great with hard boiled eggs. Or just snack on a mix of Brazil nuts, hazelnuts, walnuts, cashews and almonds, 1-2 ounces several times per week is all you need to get a boost of trace minerals and B vitamins from nuts. And though not as tasty as the fresh versions, snacking on canned oysters, mussels or sardines can add the extra boost of trace minerals and protein in an easy to grab and go snack.

That should get you started on some high protein, nutrient dense foods that will support a healthy, strong and efficient immune response.

Herbal Medicine

Lemon balm, and herb in the mint family, is known to have antiviral properties when extracted in hot water, so a cup of lemon balm tea may be a general preventative measure that is also pleasant to drink and safe in pregnancy. The bit of research that has been done demonstrates that it's properties seem to inhibit early viral replication, so lemon balm is probably most effective as a preventative measure.

Sleep

Next, I want to stress the importance of sleep for building immune health. Sleep has major impacts on metabolism, appetite, hormone balance and immune system health, and yet less than 50% of Americans report feeling rested from a night's sleep, whether or not they experience sleep disturbance. Most pregnant women I work with report negative effects on their sleep during pregnancy, in part from hormones, nausea, or pain and discomfort from being pregnant and of course, frequent nighttime trips to the bathroom.

While we are talking about sleep, did you know that not all species sleep in the way we know sleep? Species like fish, reptiles and birds only half-sleep, in fact sometimes they actually sleep with one eye open, because they can rest half of their brain at a time.

But, your human brain requires deep sleep and both halves of your brain have to sleep at once. At different stages of life, we can get away with more or less sleep and there is some variance among people, but on average, we need 7-9 hours of restful sleep per night broken into several stages and phases. I'm not going to cover each stage and phase, but if you have a sleep tracker, you have probably seen them on your sleep logs.

You know sleep is important because if you get too little of it, you notice it, but why?

During sleep, your brain is getting some much needed regeneration and reboot time. In addition, your whole body is experiencing the benefits of the state of sleep: your blood pressure drops, your hormones shift into a more parasympathetic, or restful state, growth hormone is released which helps regulate metabolism and repairs and regenerates cells and tissues for healing from the day's activities and the oxidative damage we experience day-to-day, and it's probably one of the primary mechanisms by which sleep helps reduce our chances of developing chronic disease and potentially even cancer.

More specifically to immune health, during sleep your body regulates its T-cell production, remember these are the important cells of your adaptive immune system that will promote your recovery and your antibody response to ensure you recover fully and prevent reinfection.

Research has also shown that cytokine production levels are increased during sleep. Cytokines are the proteins that alert your immune system to the presence of the foreign invaders by being a beacon for your immune cells5.

I don't need to tell you that sleep is important, you already feel that, but if you have trouble sleeping, what do you do about it?

The first step is to assess your sleep hygiene.

One big problem of today is exposures to screens and electronic lights and even your home lights. Your retina in your eye sends signals of changing light to the pineal gland deep in your brain, so when light levels drop, your retina triggers melatonin release, which helps you fall and stay asleep at night. Electronic screens and even your house lights confuse your retina and affects your pineal gland's ability to identify day from night. Over time, the health of your natural biorhythm, or circadian rhythm, diminishes and this can lead to insomnia, especially the ability to get into deep sleep so you no longer wake feeling refreshed in the morning, and chronic sleep disturbance affects various aspects of your immune system.

I know what you might be thinking, can't I just take melatonin supplements so I can continue to use my screen at night? It turns out, supplementing with melatonin is not an ideal long-term solution as it has been found to reduce your natural production of melatonin and some people even find they become dependent upon melatonin supplements.

So finding ways to cope with reducing your screen use in the evening is ultimately the most healthy thing you can do to improve your sleep habits, help your immune system and your pregnancy.

Other aspects to promote more restful sleep are avoiding stimulants at night such as sugar and caffeine and even environmental factors that have stimulating effects like television or radio that is loud and bright or triggers a lot of adrenaline. We know that the part of our brain that responds to adrenaline triggering events cannot distinguish reality from television, so limiting this type of entertainment and relegating it to earlier in the day may help your body relax into a more restful nights sleep in the long term. This doesn't even have to be action movies or horror flicks, it can result from any programming that is simply too emotionally triggering for you, like most of the media outlets these days. If you find yourself reacting to the things you are watching or listening to or reading online, avoid these channels in the evening so they don't affect your melatonin release.

Birth Environment

The last point I want to cover today is to consider carefully where you will be having your birth. Those of us who support natural out-of-hospital birth have spoken to the point that one of the benefits of being in a birth center or your own home is that it limits your risk and your baby's risk of exposure to hospital acquired infections.

So that brings me to what our local doulas are seeing in the hospitals where they are supporting families. In an attempt to prevent exposure to SARS-CoV-2 for newborns and their families, many hospitals are enforcing support person limitations, allowing only one or two support people to be present for the entire birth, generally being the pregnant person's birth partner and maybe a doula if they are using one. Additionally, in most facilities, children are not permitted on hospital premises as visitors at all.

If you are not birthing at home, and your expecting date is getting near, I would recommend you contact your birth facility so you know what their precautions are ahead of time to help you best prepare for what you can expect for your support team and birth environment. Reducing any stress that you can as your birth approaches is only going to be of benefit.

Initially, another CDC recommendation we were hearing about was to consider temporarily separating mom and her newborn for up to 14 days if the mother tests positive for SARS-CoV-2, though I am unaware of any cases of this happening as of yet. As of the date of this posting, that recommendation appears to have been updated by the CDC to now recommend that mothers choosing to feed with breastmilk continue to do so and use precautions, such as hand washing and wearing a mask, to prevent spread of infection to her newborn.

This update is a relief to those of us in the birth work field as we know that breastmilk and skin-to-skin contact are some of the most beneficial things for a newborn's immune system, and since we have no evidence that COVID-19 is a major concern for healthy newborns, best practice for mothers who test positive may be to encourage mother and newborn safe skin-to-skin contact and breastfeeding for the immune system benefit.

My question for you is do the recent events have you thinking carefully about your choice of birth location? If you are opting for a hospital birth, are you reconsidering due to rising concerns of hospital acquired infections? Or, if you are opting for out-of-hospital birth, has the uncertainty of the situation caused you to have thoughts about transferring to a hospital to have access to medical care? These are important things for you to be asking yourself.

If you are already planning an out-of-hospital birth, I hope the information I have shared about the low-risk we have seen in the few newborns who have tested positive helps you to feel more at ease and that the recent events have not deterred you from your original choice. At this point, the evidence does not support transferring an out-of-hospital birth to the hospital for low-risk women with a healthy pregnancy.

If you have an expecting date in March or April of 2020 and you are opting to have your birth in the hospital by choice, you may want to research your out-of-hospital options, even if just to have them as a backup, so you know the full range of what's available for your birth. I know it may sound scary, and it may not be what you have been picturing throughout your pregnancy, but sometimes scary becomes relative and maybe this is your chance to reflect more on your birth, on your fears about birth, and on the choices you are making. Sometimes you are presented with difficult choices, and those choices can become opportunities that make you stronger in the end for having made them.

Maybe birthing in the hospital is still the best choice for you, or maybe it's the only option for you for medical reasons or because of lack of access to other options in your area. If that's you, follow the advice in the first part of this article on nutrition and sleep so you can support your immune system to the best of your ability and then you can focus more of your energy on having a healthy and amazing birth experience.

Let me know how you are doing and managing with all of the information out there on the Coronavirus. I know it might be feeling overwhelming. Is it affecting your birth plans? What are you hearing from your prenatal providers? Let continue to create a community of support and wellbeing for families everywhere.

If you love birth podcasts that support positive, natural birth approaches, the please subscribe to The Journey to Birth podcast so you don't miss any episodes and please share this information with anyone you know who might benefit from our important discussion of this rather uncertain topic. Wishing you a wonderful and safe journey to birth.

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1https://www.contagionlive.com/news/covid19-sarscov2-and-pregnancy-does-the-past-predict-the-present

 2https://www.sciencenews.org/article/new-coronavirus-china-infections-very-few-infants-getting-sick

3Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang Z. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China. JAMA. Published online February 14, 2020. doi:10.1001/jama.2020.2131

4https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-faq.html

5Besedovsky, L., Lange, T., & Born, J. (2012). Sleep and immune function. Pflugers Archiv : European journal of physiology, 463(1), 121–137. https://doi.org/10.1007/s00424-011-1044-0