The impact of COVID-19 on the provision of respectful maternity care: Findings from a global survey of health workers

BackgroundSignificant adjustments to maternity care in response to the COVID-19 pandemic and the direct impacts of COVID-19 can compromise the quality of maternal and newborn care.AimTo explore how the COVID-19 pandemic negatively affected frontline health workers’ ability to provide respectful maternity care globally.MethodsWe conducted a global online survey of health workers to assess the provision of maternal and newborn healthcare during the COVID-19 pandemic. We collected qualitative data between July and December 2020 among a subset of respondents and conducted a qualitative content analysis to explore open-ended responses.FindingsHealth workers (n = 1127) from 71 countries participated; and 120 participants from 33 countries provided qualitative data. The COVID-19 pandemic negatively affected the provision of respectful maternity care in multiple ways. Six central themes were identified: less family involvement, reduced emotional and physical support for women, compromised standards of care, increased exposure to medically unjustified caesarean section, and staff overwhelmed by rapidly changing guidelines and enhanced infection prevention measures. Further, respectful care provided to women and newborns with suspected or confirmed COVID-19 infection was severely affected due to health workers’ fear of getting infected and measures taken to minimise COVID-19 transmission.DiscussionMultidimensional and contextually-adapted actions are urgently needed to mitigate the impacts of the COVID-19 pandemic on the provision and continued promotion of respectful maternity care globally in the long-term.ConclusionsThe measures taken during the COVID-19 pandemic had the capacity to disrupt the provision of respectful maternity care and therefore the quality of maternity care.     

Caring for the carers: Ensuring the provision of quality maternity care during a global pandemic

The COVID-19 pandemic is impacting health systems worldwide. Maternity care providers must continue their core business in caring and supporting women, newborns and their families whilst also adapting to a rapidly changing health system environment. This article provides an overview of important considerations for supporting the emotional, mental and physical health needs of maternity care providers in the context of the unprecedented crisis that COVID-19 presents. Cooperation, planning ahead and adequate availability of PPE is critical. Thinking about the needs of maternity providers to prevent stress and burnout is essential. Emotional and psychological support needs to be available throughout the response. Prioritising food, rest and exercise are important. Healthcare workers are every country’s most valuable resource and maternity providers need to be supported to provide the best quality care they can to women and newborns in exceptionally trying circumstances.     

The United Kingdom and the Netherlands maternity care responses to COVID-19: A comparative study

BackgroundThe national health care response to coronavirus (COVID-19) has varied between countries. The United Kingdom (UK) and the Netherlands (NL) have comparable maternity and neonatal care systems, and experienced similar numbers of COVID-19 infections, but had different organisational responses to the pandemic. Understanding why and how similarities and differences occurred in these two contexts could inform optimal care in normal circumstances, and during future crises.AimTo compare the UK and Dutch COVID-19 maternity and neonatal care responses in three key domains: choice of birthplace, companionship, and families in vulnerable situations.MethodA multi-method study, including documentary analysis of national organisation policy and guidance on COVID-19, and interviews with national and regional stakeholders.FindingsBoth countries had an infection control focus, with less emphasis on the impact of restrictions, especially for families in vulnerable situations. Differences included care providers’ fear of contracting COVID-19; the extent to which community- and personalised care was embedded in the care system before the pandemic; and how far multidisciplinary collaboration and service-user involvement were prioritised.ConclusionWe recommend that countries should 1) make a systematic plan for crisis decision-making before a serious event occurs, and that this must include authentic service-user involvement, multidisciplinary collaboration, and protection of staff wellbeing 2) integrate women’s and families’ values into the maternity and neonatal care system, ensuring equitable inclusion of the most vulnerable and 3) strengthen community provision to ensure system wide resilience to future shocks from pandemics, or other unexpected large-scale events.     

Exploring the COVID-19 pandemic experience of maternity clinicians in a high migrant population and low COVID-19 prevalence country: A qualitative study

BackgroundAustralia experienced a low prevalence of COVID-19 in 2020 compared to many other countries. However, maternity care has been impacted with hospital policy driven changes in practice. Little qualitative research has investigated maternity clinicians’ perception of the impact of COVID-19 in a high-migrant population.AimTo investigate maternity clinicians’ perceptions of patient experience, service delivery and personal experience in a high-migrant population.MethodsWe conducted semi-structured in-depth interviews with 14 maternity care clinicians in Sydney, New South Wales, Australia. Interviews were conducted from November to December 2020. A reflexive thematic approach was used for data analysis.FindingsA key theme in the data was ‘COVID-19 related travel restrictions result in loss of valued family support for migrant families’. However, partners were often ‘stepping-up’ into the role of missing overseas relatives. The main theme in clinical care was a shift in healthcare delivery away from optimising patient care to a focus on preservation and safety of health staff.DiscussionClinicians were of the view migrant women were deeply affected by the loss of traditional support. However, the benefit may be the potential for greater gender equity and bonding opportunities for partners.Conflict with professional beneficence principles and values may result in bending rules when a disconnect exists between relaxed community health orders and restrictive hospital protocols during different phases of a pandemic.ConclusionThis research adds to the literature that migrant women require individualised culturally safe care because of the ongoing impact of loss of support during the COVID-19 pandemic.     

Midwives’ experiences of providing maternity care to women and families during the COVID-19 pandemic in Northern Italy

ProblemThe COVID-19 pandemic has significantly challenged maternity provision internationally. Rapid and radical changes were implemented, with midwives facing anxiety and moral distress if not able to provide optimal and woman-centred care in line with professional values.BackgroundHealthcare professionals’ stress and burnout are commonly reported during other global emergencies, which may eventually contribute to reduced quality of care. There is lack of evidence of the challenges faced by midwives in Italy during the COVID-19 pandemic.AimTo explore midwives’ experiences of providing care to women and families during the COVID-19 pandemic.MethodsQualitative interpretive phenomenological approach, using semi-structured interviews and thematic analysis. The sample included 15 midwives. Ethical approval was obtained.FindingsFour themes were identified: 1) adjusting to the ever-evolving organisation of care; 2) physical, psychological and relational challenges; 3) support network; 4) deferred sense of awareness.DiscussionMidwives faced professional and personal challenges during the pandemic, displaying feelings of fear, anxiety, uncertainty, discomfort, lack of support and knowledge with potential long-term effects. Adjusting to the continuous, rapid and drastic re-organisation of maternity services was particularly challenging. Factors facilitating a safe, supportive and empowering workplace included support from colleagues and managers, access to appropriate PPE, reliable guidelines, good communication and emotional support. Positive aspects of personal and professional development included communication skills, establishment of trusting relationships, sense of empowerment and teamwork.ConclusionIn the context of a pandemic, optimisation of midwives’ physical, emotional and psychological wellbeing should be considered. Timely and comprehensive guidelines and appropriate resources should be provided to assist midwives in facilitating family-centred respectful maternity care and preserving childbirth as a bio-psychosocial event.     

The experiences of childbearing women who tested positive to COVID-19 during the pandemic in northern Italy

ProblemThe COVID-19 pandemic has significantly challenged maternity provision internationally. COVID-19 positive women are one of the childbearing groups most impacted by the pandemic due to drastic changes to maternity care pathways put in place.BackgroundSome quantitative research was conducted on clinical characteristics of pregnant women with COVID-19 and pregnant women’s concerns and birth expectations during the COVID-19 pandemic, but no qualitative findings on childbearing women’s experiences during the pandemic were published prior to our study.AimTo explore childbearing experiences of COVID-19 positive mothers who gave birth in the months of March and April 2020 in a Northern Italy maternity hospital.MethodsA qualitative interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 22 women. Thematic analysis was completed using NVivo software. Ethical approval was obtained from the research site’s Ethics Committee prior to commencing the study.FindingsThe findings include four main themes: 1) coping with unmet expectations; 2) reacting and adapting to the ‘new ordinary’; 3) ‘pandemic relationships’; 4) sharing a traumatic experience with long-lasting emotional impact.DiscussionThe most traumatic elements of women’s experiences were the sudden family separation, self-isolation, transfer to a referral centre, the partner not allowed to be present at birth and limited physical contact with the newborn.ConclusionKey elements of good practice including provision of compassionate care, presence of birth companions and transfer to referral centers only for the most severe COVID-19 cases should be considered when drafting maternity care pathways guidelines in view of future pandemic waves.     

Navigating uncertainty alone: A grounded theory analysis of women’s psycho-social experiences of pregnancy and childbirth during the COVID-19 pandemic in London

ProblemMaternity care underwent substantial reconfiguration in the United Kingdom during the COVID-19 pandemic.BackgroundCOVID-19 posed an unprecedented public health crisis, risking population health and causing a significant health system shock.AimTo explore the psycho-social experiences of women who received maternity care and gave birth in South London during the first ‘lockdown’.MethodsWe recruited women (N = 23) to semi-structured interviews, conducted virtually. Data were recorded, transcribed, and analysed by hand. A Classical Grounded Theory Analysis was followed including line-by-line coding, focused coding, development of super-categories followed by themes, and finally the generation of a theory.FindingsIterative and inductive analysis generated six emergent themes, sorted into three dyadic pairs: 1 & 2: Lack of relational care vs. Good practice persisting during the pandemic; 3 & 4: Denying the embodied experience of pregnancy and birth vs. Trying to keep everyone safe; and 5 & 6: Removed from support network vs. Importance of being at home as a family. Together, these themes interact to form the theory: ‘Navigating uncertainty alone’.DiscussionWomen’s pregnancy and childbirth journeys during the pandemic were reported as having positive and negative experiences which would counteract one-another. Lack of relational care, denial of embodied experiences, and removal from support networks were counterbalanced by good practice which persisted, understanding staff were trying to keep everyone safe, and renewed importance in the family unit.ConclusionPregnancy can be an uncertain time for women. This was compounded by having to navigate their maternity journey alone during the COVID-19 pandemic.     

Childbearing women’s experiences of the maternity care system in Australia during the first wave of the COVID-19 pandemic

BackgroundSubstantial changes occurred in Australian healthcare provision during the COVID-19 pandemic to reduce the risk of infection transmission. Little is known about the impact of these changes on childbearing women.AimTo explore and describe childbearing women’s experiences of receiving maternity care during the COVID-19 pandemic in Australia.MethodsA qualitative exploratory design using semi-structured interviews was used. Women were recruited through social media and self-nominated to participate in an interview. Maximum variation sampling was used. Twenty-seven interviews were conducted with women from across Australia. Data was analysed thematically.FindingsThree primary themes and nine sub-themes emerged: ‘navigating a changing health system’ (coping with constant change, altered access to care, dealing with physical distancing restrictions, and missing care), ‘desiring choice and control’ (experiencing poor communication, making hard decisions, and considering alternate models of care), and ‘experiencing infection prevention measures’ (minimising the risk of exposure and changing care plans to minimise infection risk).DiscussionThe substantial changes in care delivery for pregnant and postpartum women during the pandemic appear to have reduced woman-centred care. In most cases, care was perceived as impersonal and incomplete, resulting in a very different experience than expected; consequences included missing care. The presence of a known care provider improved women’s sense of communication, choice, and control.ConclusionThis study provides unique insight into the experiences of childbearing women across Australia. The importance of respectful woman-centred care cannot be forgotten during a pandemic. The findings may inform future service planning during pandemics and disaster situations.     

Parental experiences with changes in maternity care during the Covid-19 pandemic: A mixed-studies systematic review

BackgroundDuring the COVID-19 pandemic, pregnant women were identified as a high-risk and vulnerable group. To reduce risk of transmission, maternity healthcare services were modified to limit exposure but maintain services for pregnant women. However, the change in hospital practice may have compromised quality maternal care standards. Therefore, this review aims to explore parental experiences and views with maternity care received from healthcare institutions during the COVID-19 pandemic.MethodsA mixed studies systematic review was conducted. Six electronic databases (Medline, CINAHL, Embase, PsycInfo, Web of Science, and Maternity and Infant Care) were searched for qualitative, observational, and mixed method studies from the year 2019 to February 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Quantitative findings were converted to narrative findings. Data was synthesised thematically using a convergent synthesis design.ResultsFifty-eight articles were included. Four themes were generated: (1) Distress associated with COVID-19 regulations (perception of hospital restrictions, confusion with ever changing policies), (2) adaptability with maternity services (prenatal: changes in birth plans, prenatal: altered antenatal appointments, education, and care, intrapartum: medicalization of birth, postpartum: varied views on care received and Breastfeeding woes, postpartum: skin-to-skin contact and mother infant bonding) (3) importance of support persons, and (4) future direction for maternity services.ConclusionsParental experiences highlighted how maternity care during the COVID-19 pandemic did not adhere to WHO standards of quality maternity care. This calls for healthcare institutions to continuously appraise the implementation of restrictive practices that deviate from evidence-based frameworks underpinning quality care.     

Impact of COVID-19 on breastfeeding intention and behaviour among postpartum women in five countries

BackgroundStudies regarding the impact of COVID-19 on breastfeeding have mostly used single- country samples or a qualitative design.AimThe objective of this study was to examine breastfeeding intention during pregnancy and breastfeeding behaviour among postpartum women in five countries during the COVID-19 pandemic and the associated factors.MethodsAn online questionnaire survey was conducted in Thailand, the United Kingdom, South Korea, Taiwan, and Brazil from July through November 2021. The study participants included 3253 mothers within six months of birth.FindingsAbout 90% of participants intended to breastfeed during pregnancy and 85.7% reported breastfeeding in the past 24 h. More than half reported their breastfeeding duration being as planned or longer despite COVID-19. Multivariate logistic regression models showed that being multiparous, ever tested COVID-19 positive, and having positive breastfeeding beliefs were associated with increased odds for intention to breastfeed during pregnancy. Lower maternal educational level, being primiparous, ever tested COVID-19 positive, and experiencing food insecurity were associated with decreased odds for breastfeeding duration being as planned or longer. Vaginal birth, currently working or on maternity leave, breastfeeding beliefs, breastfeeding support from spouse/partner/friend/relative, online support groups, and in-person or telephone contact with healthcare professionals were associated with increased odds for breastfeeding duration being as planned or longer.ConclusionBreastfeeding intention and behaviour remained high during the COVID-19 pandemic. Online support groups and telephone contact with health professionals were effective during the pandemic.     

Creating coherent perinatal care journeys: An ethnographic study of the role of continuity of care for Danish parents in a vulnerable position

BackgroundWhile continuity of care is a core element of high-quality maternity care, it is potentially even more important for pregnant women and their partners who are at risk of adverse health outcomes because of psychosocial vulnerability. However, little is known about how a coherent care journey can be ensured for women and families who may require interdisciplinary and inter-sectoral services during pregnancy and the postnatal period.AimTo explore the role of continuity of care in creating a coherent care journey for vulnerable parents during pregnancy and the postnatal period.MethodsAn ethnographic study conducted in Denmark based on interviews with, and field observations, of 26 mothers and 13 fathers receiving services due to mental health problems, young age, past substance abuse and/or adverse childhood experiences.FindingsThree key findings emerged: 1). Developing relationships allowed parents to know and feel known by care providers, which helped them feel secure and reach out for support. 2). Handover of information allowed parents to feel secure as their need for support was recognised by care providers; some parents, however, felt exposed when information was shared 3). Receiving relevant services allowed parents to have their needs for support addressed, which requires easy referral pathways and coordination of services.ConclusionAll forms of continuity of care should be prioritised in the organisation of maternity care services for women and families in vulnerable positions. While relational continuity is important, continuity of care must also reach across providers, sectors and services to ensure coherent care journeys.     

Receiving maternity care during the COVID-19 pandemic: Experiences of women’s partners and support persons

BackgroundIn Australia, the provision of maternity care during the COVID-19 pandemic was significantly altered to limit transmission of the virus. Many hospitals limited face-to-face appointments to only the pregnant woman and restricted the number of support people present during labour, birth, and postnatal visits to one person. How these restrictions were experienced by partners and support persons of childbearing women are unknown.AimTo explore the experiences of partners and support persons of women receiving maternity care during the COVID-19 pandemic.MethodsA two-phased qualitative study including an online survey and interviews. Analysis was undertaken using content analysis.FindingsPartners and support persons experienced a sense of ‘missing out’ from the pregnancy and maternity care experience because of changes in the provision of care during the pandemic. They reported feelings of isolation, psychological distress, and reduced bonding time with babies. Conflicting information and processes within and across maternity services contributed to feelings of uncertainty and a perceived reduction in the quality of care. Partners and support persons were negatively impacted by restrictions on maternity wards, however they also perceived these to be of benefit to women.DiscussionMany partners and support persons were negatively impacted by restrictions in maternity services during the pandemic; strategies to ensure their active involvement in maternity care are needed.ConclusionThis study offers insights from the unique perspective of partners and support people of women receiving maternity care during the pandemic. Policies and processes that exclude partners and support persons need to be reconsidered.     

Lived experiences of the partners of COVID-19 positive childbearing women: A qualitative study

ProblemSeveral maternity units worldwide have rapidly put in place changes to maternity care pathways and restrictive preventive measures in the attempt to limit the spread of COVID-19, resulting in birth companions often not being allowed to be present at birth and throughout hospital admission.BackgroundThe WHO strongly recommends that the emotional, practical, advocacy and health benefits of having a chosen birth companion are respected and accommodated, including women with suspected, likely or confirmed COVID-19.AimTo explore the lived experiences of the partners of COVID-19 positive childbearing women who gave birth during the first pandemic wave (March and April 2020) in a Northern Italy maternity hospital.MethodsA qualitative study using an interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 14 partners. Thematic data analysis was conducted using NVivo software. Ethical approval was obtained from the relevant Ethics Committee prior to commencing the study.FindingsThe findings include five main themes: (1) emotional impact of the pandemic; (2) partner and parent: a dual role; (3) not being present at birth: a ‘denied’ experience; (4) returning to ‘normality’; (5) feedback to ‘pandemic’ maternity services and policies.Discussion and conclusionKey elements of good practice to promote positive childbirth experiences in the context of a pandemic were identified: presence of a birth companion; COVID-19 screening tests for support persons; timely, proactive and comprehensive communication of information to support persons; staggered hospital visiting times; follow-up of socio-psychological wellbeing; antenatal and postnatal home visiting; family-centred policies and services.     

Survey of Australian maternity hospitals to inform development and implementation of a stillbirth prevention ‘bundle of care’

Background‘Bundles of care’ are being implemented to improve key practice gaps in perinatal care. As part of our development of a stillbirth prevention bundle, we consulted with Australian maternity care providers.ObjectiveTo gain the insights of Australian maternity care providers to inform the development and implementation of a bundle of care for stillbirth prevention.MethodsA 2018 on-line survey of hospitals providing maternity services included 55 questions incorporating multiple choice, Likert items and open text. A senior clinician at each site completed the survey. The survey asked questions about practices related to fetal growth restriction, decreased fetal movements, smoking cessation, intrapartum fetal monitoring, maternal sleep position and perinatal mortality audit. The objectives were to assess which elements of care were most valued; best practice frequency; and, barriers and enablers to implementation.Results227 hospitals were invited with 83 (37%) responding. All proposed elements were perceived as important. Hospitals were least likely to follow best practice recommendations “all the time” for smoking cessation support (<50%), risk assessment for fetal growth restriction (<40%) and advice on sleep position (<20%). Time constraints, absence of clear guidelines and lack of continuity of carer were recognised as barriers to implementation across care practices.ConclusionsAreas for practice improvement were evident. All elements of care were valued, with increasing awareness of safe sleeping position perceived as less important. There is strong support from maternity care providers across Australia for a bundle of care to reduce stillbirth.     

Effects of the COVID-19 pandemic on perinatal mental health in Spain: Positive and negative outcomes

BackgroundPrevious studies have shown that perinatal distress has a negative influence on pregnancy outcome and the physiological development of the baby.ObjectiveThe aim of this study was to describe the effects of the COVID-19 pandemic on maternal perinatal mental health in Spain.MethodsSeven hundred and twenty-four women (N = 450 pregnancy, N = 274 postpartum) were recruited online during the pandemic. The Edinburgh Postnatal Depression Scale, the Positive and Negative Affect Schedule, and the Satisfaction With Life Scale were administered. Variables related to sociodemographic information, the COVID-19 pandemic, and perinatal care were also assessed.FindingsThe results showed that 58% of women reported depressive symptoms. Moreover, 51% of women reported anxiety symptoms. On the other hand, a regression analysis for life satisfaction showed that besides the perception about their own health, marital status or being a health practitioner were also significant predictors during pregnancy. However, perception about baby’s health and sleep, perception about their own health, and marital status were significant predictors of life satisfaction during the postpartum stage.DiscussionWomen assessed during the COVID-19 pandemic reported high rates of psychological distress.ConclusionThese results highlight the need of clinical support during this period. Knowing the routes to both distress and well-being may help maternity services to effectively cope with the pandemic.