COVID-19 FAQs for Obstetrician-Gynecologists, Ethics

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COVID-19 FAQs for Obstetrician-Gynecologists, Ethics

These FAQs are based on expert opinion and intended to supplement guidance from the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) Practice Advisory with information on how to optimize patient care in the context of COVID-19. The COVID-19 pandemic is a rapidly evolving situation and ACOG encourages local facilities and systems, with input from their obstetric–gynecologic care professionals to develop innovative protocols that meet the health care needs of their patients while considering CDC guidance, guidance from local and state health departments, community spread, health care personnel availability, geography, access to readily available local resources, and coordination with other centers.

As ACOG members continue providing patient care during this time, we understand that both they and their patients have questions about women’s health during the pandemic. These FAQs are developed by several Task Forces, assembled of practicing obstetrician–gynecologists and ACOG members with expertise in obstetrics, maternal–fetal medicine, gynecology, gynecologic subspecialties, pediatric and adolescent gynecology, infectious disease, hospital systems, telehealth, and ethics, who are on the front line caring for patients during this pandemic.

This is a rapidly changing landscape, and FAQs will be added or modified on a regular basis as the pandemic evolves and additional information becomes available. For additional information, see the Physician FAQs.

Last updated April 10, 2020 at 1:00 p.m. EST.

Patient care during the COVID-19 pandemic is clinically and ethically challenging. The focus of clinical care has rapidly shifted from prioritizing clinical outcomes for individual patients to safeguarding the health of the general population. For obstetrician–gynecologists, this shift can be distressing when actions that are necessary to promote the health of the larger population conflict with customary practice intended to benefit a single patient. Adding to this tension is the fact that the evidence available to inform care decisions amid the COVID-19 pandemic is rapidly evolving and often is incomplete or uncertain.

Health care institutions are implementing policies for clinical care triage and resource allocation to minimize the likelihood of being overwhelmed with acute COVID-19 cases and to preserve their ability to treat patients with urgent needs. For these policies to achieve their goals, exceptions to their implementation must be rare. Acceptance of the ethical and clinical impetus behind community-focused decision-making can help alleviate some of the moral distress experienced by physicians during the COVID-19 pandemic and promote physicians’ adherence to clinical care triage and resource allocation policies. Health care institutions should support physicians as they implement appropriate triage and resource allocation guidelines in the setting of a pandemic. Physicians who struggle with the implications of individual treatment decisions should be encouraged to consult colleagues and other institutional resources for support.

Institutional policies should be explained to patients as serving an important dual purpose: to maximize physicians’ ability to care for all who need help, and to minimize patients’ exposure risk. An appeal to community ethics may be understandably frustrating to individual patients and their families but is likely to be critical to allowing physicians to continue to provide clinical care while allocating scarce resources. Additionally, physicians should notify patients that usual care will resume as soon as it is safe to do so. It also may be helpful to explain that policies are collective decisions, and to emphasize the community focus of the decision-making process (ie, “this is the decision that we have made to safeguard the public, which it will do by…”).
Last updated April 10, 2020 at 1:00 p.m. EST.

Obstetrician–gynecologists will encounter rationing protocols for scarce health care resources during the COVID-19 pandemic. Although few obstetrician–gynecologists will likely be involved in allocating ventilators or ICU beds to critically ill patients, decisions about appropriate use of personal protective equipment (PPE), diagnostic testing for COVID-19, and health care resources in operating rooms or labor and delivery suites will be common. (See ACOG’s COVID-19 physician FAQs for more information on the prioritization of obstetric care and gynecologic care during the COVID-19 pandemic.)

Whenever possible, institutions and practices should create protocols for resource allocation that promote uniform application of standards and minimize the burden of ad hoc decisions. Protocols should be informed by relevant state and federal guidance, and ideally should be developed with input from relevant stakeholders (eg, clinicians, bioethicists, supply chain representatives, and patient advocates). Health care institutions and practices should be transparent with employees and the public about the principles used for resource allocation and the rationale underlying those principles.

In general, allocation decisions should aim to maximize the benefit associated with use of scarce resources without unfairly harming or benefiting any single group. This means, for example, that medical risk and prognosis may be used to allocate resources, but ability to reimburse the hospital may not. Although the specifics of allocation principles may vary by local setting, health care institutions should strongly consider sharing their experience, expertise, and triage policies with others. Such collaboration increases efficiency, reduces burden on individual health care institutions, and helps promote fairness across institutions.

ACOG Resources
- Committee Opinion No. 390, Ethical Decision Making in Obstetrics and Gynecology
- Committee Opinion No. 649, Racial and Ethnic Disparities in Obstetrics and Gynecology
- Committee Opinion No. 563, Ethical Issues in Pandemic Influenza Planning Concerning Pregnant Women
- Committee Opinion No. 726, Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care
Additional Resources From Other Organizations

(These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):
- American Medical Association Code of Medical Ethics Opinion 11.1.3: Allocating Limited Health Care Resources
Last updated April 10, 2020 at 1:00 p.m. EST.

As experts in, and advocates for, reproductive health care, obstetrician–gynecologists should be involved in the development and implementation of institutional triage guidelines for clinical care. In deciding whether to proceed with an in-person clinical encounter (including surgery, medical procedure, or clinic visit) during the COVID-19 pandemic, several factors should be considered, including the direct effect on patient health; potential sequelae as a result of postponement of care; risk of COVID-19 exposure for the patient, other patients, and the health care staff; implications for the use of scarce hospital resources; and availability of alternative management strategies. Triage protocols should be developed at the institutional level to maximize consistency in implementation. The disposition of unclear cases should be resolved by consultation among colleagues in obstetrics and gynecology, as well as other specialties and ethics committees when needed.

Deferral of nonurgent clinical care may result in moral distress for obstetrician–gynecologists who are concerned about the ramifications of triage policies on individual patients. Given decreased clinical volume, physicians also may be concerned about their practices’ financial viability and thus, short-term and long-term ability to care for patients. Further, patients may feel abandoned by the shift in clinical focus toward prioritizing public health outcomes. It is important to convey to patients that during this pandemic, protecting community health is imperative to protecting the individual as well as the public at large, and offers the greatest chance of a more timely resumption of return to routine clinical care. Communicating with patients is important to maintaining a therapeutic relationship, even if temporarily limited by constraints on clinical care. Telehealth encounters may be useful for this purpose.

ACOG Resources
Last updated July 24, 2020 at 1:17 p.m. EST.

Obstetrician–gynecologists are essential to providing high-quality health care, whether or not this care is related to COVID-19. Physicians’ obligation to care for patients does not change during a pandemic. In general, obstetrician–gynecologists may not decline to care for a patient solely based on the patient’s infectious disease status. However, this duty to care is not absolute and must be balanced against other factors.

Obstetrician–gynecologists are obligated to protect themselves and others by using appropriate PPE and observing institutional, state, and federal guidelines for appropriate isolation of patients with suspected or confirmed COVID-19. Likewise, physicians who meet criteria for isolation based on symptoms or exposure should expeditiously remove themselves from in-person patient care.

Although shortages of PPE may be inevitable, the risk posed to unprotected physicians by COVID-19 exceeds a level that health care institutions and policymakers should require or expect of them. Physicians who lack access to adequate PPE amid the COVID-19 pandemic are placed in the challenging position of having to balance their strong commitment to care for patients with suspected or confirmed COVID-19 against the probability that they may contract and further transmit COVID-19, and be unable to treat other patients if infected as a result. Although individual physicians, after careful consideration, may opt to provide care without adequate PPE, physicians are not ethically obligated to provide care to high-risk patients without protections in place. In the context of the COVID-19 pandemic, physicians should recognize that they themselves are scarce, critical resources and must balance their responsibilities to individual patients against their responsibilities to act as good stewards of their own capabilities to care for the greater population.

Likewise, health care institutions and policy makers have an ethical obligation to protect the health and safety of health care professionals. Such protections include following federal public health guidance to the extent possible, ensuring adequate supplies of PPE, and discussing the reassignment of physicians who are at the highest risk of complications associated with COVID-19 (eg, immunosuppression or other comorbidities). As the personal risk that physicians are asked to assume escalates, the balance of competing duties and obligations becomes inherently personal. Thus, there should be no social or economic pressure exerted on physicians to assume unreasonable levels of risk.

ACOG Resources
Additional Resources From Other Organizations

(These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):
Last updated April 10, 2020 at 1:00 p.m. EST.

Obstetrician–gynecologists should reassure patients that they are working to continue care while implementing best practices for minimizing the transmission and morbidity of COVID-19. Notification that some visits and procedures may be postponed or accomplished by telehealth should be accompanied by an explanation that these steps are being taken to protect patients and vulnerable members of the population, and that routine care will resume when safe.

Some obstetrician–gynecologists and patients may find a transition to telehealth visits to be challenging and worry about negatively affecting the therapeutic relationship. However, clinical effectiveness and patient satisfaction scores for virtual visits are generally found to be comparable to those for in-person visits. To the extent possible, technical support should be made available to patients and clinicians to decrease the concern that logistical difficulties may impede virtual clinical encounters.

ACOG Resources

● Committee Opinion No. 798, Implementing Telehealth in Practice
● Managing Patients Remotely: Billing for Digital and Telehealth Services
Last updated December 16, 2020 at 11:03 a.m. EST.

It is critical to study the epidemiology and outcomes of COVID-19 in pregnancy, as well as vaccination and potential treatment modalities. Available data suggest that symptomatic pregnant women with COVID-19 are at increased risk of more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collin 2020, Delahoy MMWR 2020, Panagiotakopoulos MMWR 2020, Zambrano MMWR 2020). And, some studies have suggested that there may be an increased risk of preterm delivery and stillbirth in pregnant women with active SARS-CoV-2 infection compared with those in the general population (Knight 2020, Delahoy MMWR 2020, Panagiotakopoulos MMWR 2020, Woodworth MMWR 2020). Given the growing evidence, the Centers for Disease Control and Prevention (CDC) now includes pregnant women in its “increased risk” category for COVID-19 illness.

In light of emerging data regarding the increased risk to pregnant patients, it is particularly concerning that pregnant and lactating patients have largely been excluded from clinical trials for a coronavirus vaccine. Access to enrollment in clinical research related to COVID-19 should be equitable and guided by sound scientific principles. As such, investigators should not exclude pregnant patients from enrollment in prospective clinical trials without carefully balancing the risk of maternal or fetal harm with the potential for benefit and the importance of the information to be gained. Obstetrician–gynecologists should encourage their pregnant patients to consider participating in research protocols related to COVID-19 but also support those patients who decline to enroll.

ACOG Resources
Other Resources
(These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):
- U.S. Food and Drug Administration: Guidance for Industry on Development and Licensure of Vaccines to Prevent COVID-19
Last updated April 10, 2020 at 1:00 p.m. EST.

Exposed or infected obstetrician–gynecologists may be reluctant to report symptoms or exposure for fear of the implications of infection control protocols. Isolation is disruptive to routine life and may carry a substantial emotional and financial toll. Obstetrician–gynecologists may be further inclined to avoid self-isolation over fears of neglecting patient care duties and overburdening colleagues.

Obstetrician–gynecologists and clinical practices should recognize that some exposures among health care professionals will occur despite best efforts at infection control. Staffing procedures should proactively include contingency plans for expected reductions in available personnel because of COVID-19 exposure. Likewise, care should be taken to encourage health care professionals to report exposure promptly and follow recommended post-exposure protocols, without fear of recrimination or retribution. Messaging should emphasize that health care professionals who expeditiously follow post-exposure protocols, including self-isolation when required, do so to protect their colleagues and their patients.

Additional Resources From Other Organizations

(These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):
- American Medical Association, Code of Medical Ethics Opinion 8.4: Ethical Use of Quarantine & Isolation
Last updated April 10, 2020 at 1:00 p.m. EST.

Clinicians caring for patients during the COVID-19 pandemic may experience an unusually high level of stress. Health care institutions have a responsibility to safeguard physicians’ physical and emotional well-being; physician burnout can have negative consequences for individual physicians as well as for health care systems’ ability to manage clinical volume. Strategies to mitigate clinicians’ stress should be tailored to clinical practice environments. Clinical workload should be distributed equitably among the physicians available to participate in clinical care. Health care institutions should have physician well-being programs and policies in place and should adjust clinical roles and environments as needed to protect physical and emotional health.

ACOG Resources
- Physician Wellness During the COVID-19 Health Emergency
Last updated June 16, 2020 at 1:19 p.m. EST.

Some health care institutions have implemented universal COVID-19 testing of patients in various health care settings, including before surgery or on admission to labor and delivery. When resources permit, routine testing can assist in risk stratification of patients, planning patient care, guiding the use of isolation practices, and appropriately allocating personal protective equipment (PPE).

When routine testing is planned, patients should be notified of institutional testing practices as soon as feasible, preferably in the outpatient setting. The pretest counseling and informed consent process should include an explanation of the rationale for universal testing and how test results will guide management decisions. If reporting of COVID-19 cases to third parties is required (eg, to state departments of health), this should be disclosed. Any hesitation that patients have about routine testing should be explored in a respectful and empathetic manner. Patients may consider declining COVID-19 testing for a variety of reasons, including stigma, mistrust, and fear of real or perceived effects of a positive test result (such as possible separation of mothers and their neonates while in the hospital). Clinicians should address patient concerns where possible and should advise patients of the ramifications of institutional policies regarding opting out of COVID-19 testing on their care. In some circumstances, patients may determine that it is preferable to undergo testing, for instance where patients who decline testing may ultimately be treated as presumed positive for COVID-19 for infection control purposes. As with any intervention, if a patient with decision-making capacity declines COVID-19 testing, this decision should be respected.

The policies for treating patients who have declined testing vary among institutions, and the following considerations may help guide management decisions. In general, clinicians have an ethical obligation to proceed with emergent care regardless of a patient’s COVID-19 status. However, physicians are not ethically obligated to provide care to high-risk patients without protections in place, although individual physicians may opt to provide care even without adequate PPE after careful consideration. (see What are my responsibilities to care for patients during the COVID-19 pandemic, particularly patients with suspected or confirmed COVID-19? in COVID-19 FAQs for Obstetrician–Gynecologists, Ethics). Patients with unknown COVID-19 status may be treated as presumptively positive or as persons under investigation, depending on physicians’ clinical judgment and institutional policy. In deciding whether to proceed with in-person nonemergent care (including surgery, medical procedures, or clinic visits) for patients who decline COVID-19 testing, several factors should be considered. These include the anticipated health effects of postponement of care; risk of COVID-19 exposure for the patient, other patients, and the health care staff; implications for the use of scarce hospital resources; and availability of alternative management strategies. After these factors have been considered, it is ethically permissible to defer care that is not time-sensitive until either a COVID-19 test result is obtained or until the population prevalence of COVID-19 decreases sufficiently. Consultation among colleagues in obstetrics and gynecology as well as other specialties and institutional ethics committees may be helpful when making decisions regarding time-sensitive care.

For additional guidance on resuming the provision of comprehensive obstetric and gynecologic care, see COVID-19 FAQs for Obstetrician–Gynecologists, Obstetrics and COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology.

ACOG Resources
- Committee Opinion No. 439, Informed Consent
- Committee Opinion No. 363, Patient Testing: Ethical Issues in Selection and Counseling
- COVID-19 FAQs for Obstetrician–Gynecologists, Obstetrics
- COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology
- Joint Statement on Abortion Access During the COVID-19 Outbreak (American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, American Association of Gynecologic Laparoscopists, the American Gynecological & Obstetrical Society, the American Society for Reproductive Medicine, the Society for Academic Specialists in General Obstetrics and Gynecology, the Society of Family Planning, and the Society for Maternal-Fetal Medicine)
Additional Resources on COVID-19 From Other Organizations
(These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):

If you have unanswered COVID-19 questions or comments, please send them to covid@acog.org.

Suggested Citation

American College of Obstetricians and Gynecologists. COVID-19 FAQs for obstetricians-gynecologists, ethics. Washington, DC: ACOG; 2020. Available at https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-ethics. Retrieved [enter date].

COVID-19 FAQs

This document has been developed to respond to some of the questions facing clinicians providing care during the rapidly evolving COVID-19 situation. As the situation evolves, this document may be updated or supplemented to incorporate new data and relevant information. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.

COVID-19 FAQs for Obstetrician-Gynecologists, Ethics

Suggested Citation

COVID-19 FAQs

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