Maternal request caesareans and COVID-19: the virus does not diminish the importance of choice in childbirth

Appropriately framing maternal request caesarean section

In their paper, 'How to reach trustworthy decisions for caesarean sections on maternal request: a call for beneficial power', Eide and Bærøe present maternal request caesarean sections (MRCS) as a site of conflict in obstetrics because birthing people are seeking access to a treatment 'without any anticipated medical benefit'. While I agree with the conclusions of their paper -that there is a need to reform the approach to MRCS counselling to ensure that the structural vulnerability of pregnant people making birth decisions is addressed-I disagree with the framing of MRCS as having 'no anticipated medical benefit'. I argue that MRCS is often inappropriately presented as unduly risky,without supporting empirical evidence,and that MRCS is most often sought by birthing people on the basis of a clinical need. I argue that there needs to be open conversation and frank willingness to acknowledge the values that are currently underpinning the presentation of MRCS as 'clinically unnecessary'; specifically there needs to be more discussion of where and why the benefits of MRCS that are recognised by individual birthing people are not recognised by clinicians. This is important to ensure access to MRCS for birthing people that need it.

Estratégias organizacionais no centro cirúrgico diante da pandemia de COVID 19: uma revisão integrativa

Introdução: os sistemas de saúde foram desafiados a desenvolver estratégias organizacionais para a prestação de cuidados cirúrgicos. Objetivo: apresentar as estratégias dos serviços de saúde no que se refere às práticas de cuidados cirúrgicos em tempos de pandemia de COVID-19. Materiais e métodos: revisão integrativa, desenvolvida em seis etapas, cuja busca dos artigos ocorreu na Biblioteca Virtual de Saúde, SciELO, PubMed e ScienceDirect. Os descritores controlados em saúde adotados foram “Centros Cirúrgicos” e “Infecções por Coronavírus”, de acordo com os sistemas DeCS e MeSH Terms. Foram selecionados 60 artigos de 405 estudos encontrados. Resultados: as principais estratégias utilizadas pelos serviços de saúde foram: a suspensão e adiamento de cirurgias eletivas durante as ondas de contágio da doença; e a triagem cuidadosa dos pacientes para COVID-19 antes e após intervenções cirúrgicas. Discussão: a suspensão e o adiamento de cirurgias eletivas devem ser avaliados com cautela pela equipe de saúde, de forma individualizada, para cada paciente, visto que situações clínicas não urgentes podem agravar ao longo do tempo, aumentando as chances de morbimortalidade desses pacientes. Conclusão: a triagem dos pacientes e dos profissionais da saúde para COVID-19 são estratégias importantes para evitar a contaminação desses sujeitos. A suspensão e o adiamento de cirurgias eletivas, durante as ondas de contágio por COVID-19, são recomendados para aumentar a capacidade de leitos disponíveis para pacientes graves hospitalizados por essa doença. Essa recomendação também auxilia no remanejamento de profissionais desse setor para as unidades com a demanda de cuidados de saúde mais elevada.

Giving birth in a pandemic: women's birth experiences in England during COVID-19

BACKGROUND

Expectant parents worldwide have experienced changes in the way they give birth as a result of COVID-19, including restrictions relating to access to birthing units and the presence of birthing partners during the birth, and changes to birth plans. This paper reports the experiences of women in England.

METHODS

Data were obtained from both closed- and open-ended responses collected as part of the national COVID in Context of Pregnancy, Infancy and Parenting (CoCoPIP) Study online survey (n = 477 families) between 15th July 2020 - 29th March 2021. Frequency data are presented alongside the results of a sentiment analysis; the open-ended data was analysed thematically.

RESULTS

Two-thirds of expectant women reported giving birth via spontaneous vaginal delivery (SVD) (66.1%) and a third via caesarean section (CS) (32.6%) or 'other' (1.3%). Just under half (49.7%) of the CS were reported to have been elective/planned, with 47.7% being emergencies. A third (37.4%) of participants reported having no changes to their birth (as set out in their birthing plan), with a further 25% reporting COVID-related changes, and 37.4% reporting non-COVID related changes (e.g., changes as a result of birthing complications). One quarter of the sample reported COVID-related changes to their birth plan, including limited birthing options and reduced feelings of control; difficulties accessing pain-relief and assistance, and feelings of distress and anxiety. Under half of the respondents reported not knowing whether there could be someone present at the birth (44.8%), with 2.3% of respondents reporting no birthing partner being present due to COVID-related restrictions. Parental experiences of communication and advice provided by the hospital prior to delivery were mixed, with significant stress and anxiety being reported in relation to both the fluctuating guidance and lack of certainty regarding the presence of birthing partners at the birth. The sentiment analysis revealed that participant experiences of giving birth during the pandemic were predominately negative (46.9%) particularly in relation to the first national lockdown, with a smaller proportion of positive (33.2%) and neutral responses (19.9%).

CONCLUSION

The proportion of parents reporting birthing interventions (i.e., emergency CS) was higher than previously reported, as were uncertainties related to the birth, and poor communication, leading to increased feelings of anxiety and high levels of negative emotions. The implications of these findings are discussed.

Challenges for maintaining surgical care practices in the COVID-19 pandemic: an integrative review

OBJECTIVES

To present the knowledge produced on challenges of health services for maintaining surgical care practices in times of the COVID-19 pandemic.

METHODS

This is an integrative literature review, performed with descriptors 'Operating rooms' and 'Coronavirus Infections' in the MEDLINE/PubMed Central, IBECS, LILACS, BDENF, Coleta SUS, BIGG, BINACIS, SciELO, PubMed, Science Direct, and Cochrane Library databases.

RESULTS

Of the 405 studies analyzed, 27 met the inclusion criteria. The main challenges for surgical services during the pandemic were: (i) rearrangement of general practice in surgical units; (ii) administration and management of resources and elective surgeries; (iii) follow-up and control of preoperative patients to medium term; (iv) maintenance of patients' and health professionals' autonomy and mental health in this context; and (v) teaching health residents in the operating room.

CONCLUSIONS

For surgical care services, the challenges caused by managing the high demand of patients in need of care resulted in the transfer of own resources to other units and the consequent hiring of professionals to meet the demand for these services due to the damming of postponed elective surgeries. This knowledge will allow us to propose strategies in decision making in this scenario, considering the new waves that may arise from this disease.

The impact of perinatal healthcare changes on birth trauma during COVID-19

Background

Since the onset of COVID-19, giving birth has involved navigating unprecedented healthcare changes that could significantly impact the psychological birth experience.

Aim

Research has demonstrated increasing rates of birth trauma and birth plan alterations during the COVID-19 pandemic. This study specifically examined these intersecting experiences to understand how COVID-related healthcare changes have impacted birth trauma during the pandemic.

Methods

269 people who gave birth in the U.S. during COVID-19 completed an online survey between November, 2020-May, 2021 which included questions about COVID-related perinatal healthcare changes and birth-related posttraumatic stress disorder (PTSD; The City Birth Trauma Scale). T-tests were run on birth demographics to assess for significant indicators of PTSD; variables having significant effects were used to build a hierarchical regression model to predict PTSD symptoms.

Findings

5.9% of the sample met criteria for PTSD and 72.3% met partial criteria. The overall regression model predicted approximately 19% of variance in total PTSD symptoms. Labor and birth demographics were entered in Step 1 and predicted approximately 11% of variance: limited length of stay for support person, being allowed 1 support person who had to be the same, and mask requirements were significant predictors of PTSD. Variables related to birth plan changes were entered in Step 2 and predicted approximately 8% of variance: changes to support person(s) for labor and birth, breastfeeding plans, and birth location were significant predictors of PTSD.

Conclusion

The present study demonstrates the importance of COVID-related perinatal healthcare changes to the development of trauma symptoms following childbirth.

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

Background

Significant 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.

Aim

To explore how the COVID-19 pandemic negatively affected frontline health workers’ ability to provide respectful maternity care globally.

Methods

We 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.

Findings

Health 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.

Discussion

Multidimensional 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.

Conclusions

The 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.