Sustaining quality midwifery care in a pandemic and beyond

The role of pandemic-related pregnancy stress in preference for community birth during the beginning of the COVID-19 pandemic in the United States

BACKGROUND

The COVID-19 pandemic introduced unparalleled uncertainty into the lives of pregnant women, including concerns about where it is the safest to give birth, while preserving their rights and wishes. Reports on the increased interest in community births (at home or in birth centers) are emerging. The purpose of this project was to quantitatively investigate psychological factors related to this birth preference.

METHODS

This study included 3896 pregnant women from the COVID-19 Pregnancy Experiences (COPE) Study who were anticipating a vaginal birth. COPE Study participants were recruited online between April 24 and May 15, 2020, and completed a questionnaire that included preference with respect to place of birth and psychological constructs: fear of childbirth, basic beliefs about birth, pandemic-related preparedness stress, and pandemic-related perinatal infection stress.

RESULTS

Women who preferred a community birth, on average, had less childbirth fear, had stronger beliefs that birth is a natural process, were less likely to see birth as a medical process, and were less stressed about being unprepared for birth and being infected with COVID-19. In multivariate models, higher stress about perinatal COVID-19 infection was associated with greater likelihood of preferring a community birth. The effect of perinatal infection stress on preference was stronger when preparedness stress was high.

DISCUSSION

Women's birth preferences during the COVID-19 pandemic are associated with psychological processes related to risk perception. Community births are more appealing to women who view being in a hospital as hazardous because of the pandemic. Policies and prenatal care aimed to increase access to safe in-hospital and out-of-hospital birth services should be encouraged.

Barriers and facilitators to mood and confidence in pregnancy and early parenthood during COVID-19 in the UK: mixed-methods synthesis survey

BACKGROUND

Parental well-being during pregnancy and early parenthood is critical for child development. Environmental stressors can significantly challenge parental well-being.

AIMS

To investigate how COVID-19 and associated restrictions influence mood and parenting confidence of expectant parents and those in early parenthood, identifying barriers and facilitators.

METHOD

We used a cross-sectional online survey to collect data from 590 expectant parents and parents of infants (564 women) during the most restrictive phase of lockdown in the UK. We included a mixture of forced-choice and open-ended questions pertaining to mood, perceived social support, media use, online interactions and parenting expectations. Quantitative data were analysed with multiple linear regression and proportional odds models; an inductive thematic analysis was used for qualitative data. Quantitative and qualitative data were qualitatively synthesised.

RESULTS

Since COVID-19, expectant parents and parents of new-borns reported a decrease in mood and parenting confidence. Barriers included practical difficulties (finding essentials, reliable health information), social difficulties (loss of physical contact, decreased support) and uncertainty during pregnancy. Facilitators included support from others and, for first-time parents, loss of child care resulting in greater parenting confidence. Although online resources and communication were not preferable to face-to-face interactions, technology was a helpful tool for communicating, getting support, and finding essentials and information during lockdown.

CONCLUSIONS

By mid-May 2020, mood and parenting confidence among expectant and parents of new-borns in the UK were significantly reduced. Consideration of barriers and facilitators in healthcare and psychological support provided is likely important for promoting parental mental health and healthy parent-child relationships.

Exploring the STEP-uP to practice: A survey of UK Lead Midwives for Education views of the STudent midwife Extended Practice Placement during the first wave of the COVID-19 pandemic

OBJECTIVE

to assess the effect of implementation of the extended placement option available to midwifery students during the first wave of the COVID-19 pandemic.

DESIGN

Online survey open from 2nd June 2020 to 15th July 2020.

SETTING

United Kingdom.

PARTICIPANTS

Lead Midwives for Education (LMEs).

FINDINGS

A total of 38 of 55 LMEs responded (response rate 69%). The majority of Approved Education Institutions (AEIs) offered an extended placement to students, but with some variation in the choices offered, unrelated to geographical location or size of student cohort. AEIs appeared to provide the majority of decisional support for students. Many practice learning environments became unavailable, particularly community, gynaecology/medical wards and neonatal units. LMEs experienced both internal and external pressures to instigate rapid change.

KEY CONCLUSIONS

The impact of COVID-19 on midwifery education is significant and will need continual scrutiny to minimise future detriment. The pressures of providing midwifery education throughout the early phase of COVID-19 were substantial, but it is important that we learn from the immediate changes made, value and pursue the changes that have been beneficial, and learn from those that were not.

IMPLICATIONS FOR PRACTICE/RESEARCH

Student learning experiences have undergone significant change during the pandemic. It is essential to assess what effect the extended placement has had on student readiness for practice, their confidence, resilience, mental health, and attrition and retention. Educators transitioned to remote working, and rapidly assimilated new skills for online education; exploration of the impact of this is recommended.

How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application

BACKGROUND

Practical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements - the changes that need to be made in a healthcare process - remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study.

METHODS

Organised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus.

RESULTS

We gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video.

CONCLUSIONS

The proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation.

"They Would Have Stopped Births, if They Only Could have": Short-and Long-Term Impacts of the COVID-19 Pandemic-a Case Study From Bologna, Italy

This article addresses the short-term impacts of the COVID-19 pandemic in Italy and hints at its potential long-term effects. Though many might want it to, birth does not stop during a pandemic. In emergency times, birth practices need to be adjusted to safeguard the health of birthing mothers, babies, birth providers, and the general population. In Bologna, Italy, one of the emergency measures employed by local hospitals in response to COVID-19 was to suspend women's right to be accompanied by a person of their choice for the whole duration of labor and childbirth. In this work, we look at how this measure was disputed by the local activist birth community. Through the analysis of a social campaign empowered by Voci di Nascita-an association of parents, birth providers, and activists-we examine how social actors negotiated the balance between public health and reproductive rights in a time of crisis. We argue that this process unveils several structural issues that characterize maternity care at the local and national levels, including the (re)medicalization of birth, the discourse on risk and safety, the internal fragmentation of Italian midwifery, and the fragility of reproductive rights. The Covidian experience forced the reshaping of the birth carepath during the peak of the emergency. We suggest that it also offered an opportunity to rethink how birth is conceived, experienced, and accompanied in times of unprecedented global uncertainty-and beyond.

Impact of COVID-19 pandemic lockdown on exclusive breastfeeding in non-infected mothers

BACKGROUND

The COVID-19 pandemic has posed several challenges to the provision of newborn nutrition and care interventions including maternal support, breastfeeding and family participatory care. Italy was the first country to be exposed to SARS-CoV-2 in Europe. One of the measures adopted by the Italian government during COVID-19 pandemic was the total lockdown of the cities with complete confinement at home. We aimed to examine the impact of the lockdown caused by COVID-19 pandemic on exclusive breastfeeding in non-infected mothers.

METHODS

We prospectively enrolled 204 mother-baby dyads during lockdown (9 March to 8 May 2020) that we compared to previously studied 306 mother-baby dyads admitted during the year 2018. To reduce the possible effect of confounding factors on exclusive breastfeeding, a 1:1 matching was performed by using an automatized procedure of stratification that paired 173 mother-baby dyads. Feeding modality was collected at discharge, 30 and 90 days of newborn's life. Exclusive breastfeeding was considered when the infant received only breast milk and no other liquids or solids were given with the exception of vitamins, minerals or medicines.

RESULTS

At discharge 69.4% of infants were exclusively breastfed during lockdown versus 97.7% of control group, 54.3% at 30 days vs 76.3 and 31.8% vs 70.5% at 90 days (p < 0.001). The proportion of breastfeeding remaining exclusive from discharge to 30-day was similar between groups (about 80%), but it was lower in lockdown group than in control cohort (58.5% vs 92.4%, p < 0.001) from 30- to 90-days.

CONCLUSIONS

Lockdown and home confinement led to a decrease of exclusively breastfeeding in the studied population. Considering the timing to shift from exclusive to non-exclusive breastfeeding, differences between study groups were concentrated during hospital stay and from 30- to 90 days of a newborn's life, confirming that the hospital stay period is crucial in continuing exclusive breastfeeding at least for the first 30 days, but no longer relevant at 90 days of life.

Experiences of receiving and providing maternity care during the COVID-19 pandemic in Australia: A five-cohort cross-sectional comparison

Introduction

The global COVID-19 pandemic has radically changed the way health care is delivered in many countries around the world. Evidence on the experience of those receiving or providing maternity care is important to guide practice through this challenging time.

Methods

A cross-sectional study was conducted in Australia. Five key stakeholder cohorts were included to explore and compare the experiences of those receiving or providing care during the COVID-19 pandemic. Women, their partners, midwives, medical practitioners and midwifery students who had received or provided maternity care from March 2020 onwards in Australia were recruited via social media and invited to participate in an online survey released between 13^th May and 24^th June 2020; a total of 3701 completed responses were received.

Findings

While anxiety related to COVID-19 was high among all five cohorts, there were statistically significant differences between the responses from each cohort for most survey items. Women were more likely to indicate concern about their own and family’s health and safety in relation to COVID-19 whereas midwives, doctors and midwifery students were more likely to be concerned about occupational exposure to COVID-19 through working in a health setting than those receiving care through attending these environments. Midwifery students and women’s partners were more likely to respond that they felt isolated because of the changes to the way care was provided. Despite concerns about care received or provided not meeting expectations, most respondents were satisfied with the quality of care provided, although midwives and midwifery students were less likely to agree.

Conclusion

This paper provides a unique exploration and comparison of experiences of receiving and providing maternity care during the COVID-19 pandemic in Australia. Findings are useful to support further service changes and future service redesign. New evidence provided offers unique insight into key stakeholders’ experiences of the rapid changes to health services.

Access to and Quality of Healthcare for Pregnant and Postpartum Women During the COVID-19 Pandemic

Introduction: During the COVID-19 pandemic, obstetric care has adopted new precautions to ensure services can be maintained for pregnant women. The aim of this study was to describe access to and quality of obstetric care for pregnant and postpartum women during the COVID-19 pandemic and to identify factors that predict quality of care at this time. Methods: Between May 3 and June 28, 2020, we recruited women who were pregnant or within the first 6 months after delivery to participate in an online survey. This included questions on access to obstetric healthcare (type and place of health care provider, changes to obstetric appointments/services, appointment preferences) and the Quality of Prenatal Care Questionnaire (QPCQ). Results: Of the 917 eligible women, 612 (67%) were pregnant and 305 (33%) were in the first 6 months after delivery. Sixty-two percent (n = 571) reported that COVID-19 had affected their healthcare; appointments were rearranged, canceled or occurred via virtual means for 29% (n = 166), 29% (n = 167), and 31% (n = 175) of women, respectively. The majority preferred to physically attend appointments (74%; n = 676) and perceived the accompaniment of birth partners as important (77%; n = 471). Sixty-two percent (n = 380) were permitted a birth partner at delivery, 18% (n = 111) were unsure of the rules while 4% (n = 26) were not permitted accompaniment. During pregnancy, QPCQ was negatively associated with disruption to obstetric services including exclusion or uncertainty regarding birth partner permissions [F (7, 433) = 11.5, p < 0.001, R 2 = 0.16] while QPCQ was negatively associated with inadequate breastfeeding support postpartum [F (1, 147) = 12.05, p = 0.001, R 2 = 0.08]. Conclusion: Pregnant and postpartum have experienced disruption in their access to obstetric healthcare. Perceived quality of obstetric care was negatively influenced by cancellation of appointment(s), suspension of services and exclusion of birth partners at delivery. During this time, continuity of care can be fulfilled via virtual and/or phone appointments and women should receive clear guidance on changes to services including birth partner permissions to attend delivery.

Establishing information needs and research priorities in response to the Covid-19 pandemic in the local maternity setting

The purpose of this project was to identify gaps in the current evidence base and to identify research priorities in the local context during the Covid-19 pandemic. This paper reports on the application and adaptation of the CHNRI methodology which follows a series of criteria setting, filtering and scoring exercises. The views of maternity care professionals, midwifery managers and leaders, women and families were continually sought throughout the project stages. We found the CHNRI methodology to be a useful framework to highlight topics with greater or smaller consensus within a relatively short time frame and with minimal burden to participants. The criteria were defined to focus on research topics where no existing or on-going studies were identified and topics likely to lead to improvements in care with relevance beyond the Covid-19 pandemic.

Experiences of breastfeeding during COVID-19: Lessons for future practical and emotional support

The COVID-19 pandemic and subsequent lockdown and social distancing led to changes to breastfeeding support available to women in the United Kingdom. Face-to-face professional support was reduced, and face-to-face peer support was cancelled. Anecdotal media accounts highlighted practices separating some mothers and babies in hospitals, alongside inaccurate stories of the safety of breastfeeding circulating. Meanwhile, new families were confined to their homes, separated from families and support networks. Given that we know breastfeeding is best supported by practices that keep mother and baby together, high-quality professional and peer-to-peer support, and positive maternal well-being, it is important to understand the impact of the pandemic upon the ability to breastfeed. To explore this, we conducted an online survey with 1219 breastfeeding mothers in the United Kingdom with a baby 0-12 months old to understand the impact of the pandemic upon breastfeeding duration, experiences and support. The results highlighted two very different experiences: 41.8% of mothers felt that breastfeeding was protected due to lockdown, but 27.0% of mothers struggled to get support and had numerous barriers stemming from lockdown with some stopped breastfeeding before they were ready. Mothers with a lower education, with more challenging living circumstances and from Black and minority ethnic backgrounds were more likely to find the impact of lockdown challenging and stop breastfeeding. The findings are vital in understanding how we now support those women who may be grieving their loss of breastfeeding and are affected by their negative experiences and how we can learn from those with a positive experience to make sure all breastfeeding women are better supported if similar future events arise.

Sustaining quality education and practice learning in a pandemic and beyond: 'I have never learnt as much in my life, as quickly, ever'

The context of healthcare and of healthcare education has radically changed as a result of the Covid-19 pandemic. To identify positive strategies for midwifery education in this context, five case studies from the UK and beyond were conducted using an appreciative enquiry approach, from the perspectives of students, the maternity services, cross-university collaboration, and digital learning. A health system analysis was used to identify strategies to cope, adapt, and transform for the future, at the levels of individuals, teams, and the whole system. Findings showed that the implementation of effective responses was possible. Responding effectively and rapidly to a shock as profound as this pandemic requires courageous, respectful, evidence-based, innovative, collaborative, cross-sectoral working and leadership across education institutions, practice settings, the regulator, government, and with students themselves. Pre-existing trusting relationships and collaborative systems supported rapid responses. Effective digital learning requires a pro-active, student-centred approach, and addressing the problems of inequitable access to equipment and space. Joint problem-solving and focussing on the key outcomes that matter contribute to developing successful strategies and robust processes. The pandemic provides an opportunity for student midwives to be re-imagined as essential members of midwifery teams and not 'just students'. Transformative actions identified include whole-system working, tackling longstanding problems including racism, poverty, prejudice, and systemic discrimination, and keeping students at the heart of the education system.

Polish maternity services in times of crisis: in search of quality care for pregnant women and their babies

The current COVID-19 pandemic put a burden on healthcare services around the globe and impacted many areas of care delivery, including maternity services. Prioritizing ringfenced community care to keep women away from hospitals may be the best strategic response to ensure pregnant and laboring women receive optimal care. By analyzing the structure of maternity services in Poland and their response to the current crisis, we show that while the available model allows to provide large share of prenatal services outside hospital settings, it allows no alternative to hospital births. In addition, medicalization, inequalities in access and fragmentation of care hinder services' ability to respond in a way it ensures best possible care.

The impact of the Covid-19 pandemic on maternity services: A review of maternal and neonatal outcomes before, during and after the pandemic

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No negative impact on maternal or neonatal outcomes during the course of pandemic.

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A decrease in preterm birth rate was found during the Covid-19 pandemic.

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During the peak of the pandemic, there were less disclosures of domestic violence.

Objective

To explore any apparent trends in maternal or neonatal outcomes during the Covid-19 pandemic by comparing the maternity outcomes before, during and after the pandemic.

Study design

A retrospective review was performed of maternity statistics recorded on the hospital database of a large tertiary referral centre in Dublin with over 8000 deliveries per annum from 1st January to 31st July 2020. This time period represented the months prior to, during the peak and following the pandemic in Ireland.

Results

There was no correlation between the monthly number of Covid deaths and the monthly number of perinatal deaths (r = 0.465, NS), preterm births (r = 0.339, NS) or hypertensive pregnancies (r = 0.48, NS).

Compared to the combined numbers for the same month in 2018 and 2019, there were no significant changes in perinatal deaths or preterm births in the months when Covid deaths were at their height. The rate of preterm birth was significantly less common in January-July 2020 compared to January-July in 2018/2019 (7.4 % v 8.6 %, chi-sq 4.53, P = 0.03).

Conclusion

The was no evidence of a negative impact of the Covid-19 pandemic on maternity services, as demonstrated by maternal and neonatal outcomes.

COVID-19 and the risk to black, Asian and minority ethnic women during pregnancy

Black, Asian and minority ethnic (BAME) women in the UK have increased maternal mortality rates compared to other groups of women. Unfortunately, according to preliminary findings, the COVID-19 pandemic has contributed to mortality rates for BAME women, raising concerns that pregnant BAME women are facing greater health disparities during the pandemic. A review of 427 pregnant women admitted to hospital in the UK with confirmed COVID-19 infection found that over half (56%) were from black or other ethnic minority groups. How BAME women navigate maternity services during the COVID-19 pandemic requires a vigilant review of their needs on an individual basis. This is particularly relevant for hard-to-reach women, such as recent immigrants and asylum seekers, who may encounter difficulties accessing or engaging with maternity services. Therefore, it is imperative to reassess and highlight the challenges faced by pregnant BAME women during the pandemic. The disruption of maternity services and diversion of resources away from essential pregnancy care because of prioritising the COVID-19 response is expected to increase risks of maternal mortality.

Pregnancy-related anxiety during COVID-19: a nationwide survey of 2740 pregnant women

The aim of this study is to explore the impact of the COVID-19 pandemic on pregnant women's anxiety and identify factors most strongly associated with greater changes in anxiety. An anonymous, online, survey of pregnant women (distributed April 3-24, 2020) included a modified pregnancy-related anxiety scale (PRAS) reflecting respondents' perception of pregnancy anxiety before COVID-19 and a current assessment of pregnancy-related anxiety. The difference between these scores was used as the outcome variable. Data were analyzed using bivariate and multivariate linear regression analyses. Two thousand seven hundred forty pregnant women from 47 states completed the survey. 25.8% (N = 706) stopped in-person visits, 15.2% used video visits (N = 415), and 31.8% (N = 817) used phone visits for prenatal care as a result of COVID-19. Those planning a hospital birth dropped from 2641 (96.4%) to 2400 (87.7%) following COVID-19. More than half of women reported increased stress about food running out (59.2%, N = 1622), losing a job or household income (63.7%, N = 1745), or loss of childcare (56.3%, N = 1543). More than a third reported increasing stress about conflict between household members (37.5%, N = 1028), and 93% (N = 2556) reported increased stress about getting infected with COVID-19. Slightly less than half of respondents (either selves or family members) were healthcare workers (41.4%, N = 1133) or worked in essential services (45.5%, N = 1246). In multivariate analysis, those reporting higher agreement with COVID-19-related stressors had greater changes in pre- to post-COVID-19 pregnancy-related anxiety. The COVID-19 pandemic is profoundly affecting pregnant women's mental health, and factors independent of pregnancy appear to be driving changes in pregnancy-specific anxiety.