Experiences of Dutch maternity care professionals during the first wave of COVID-19 in a community based maternity care system

Innovative Regional Services and Heterogeneous Communication Channels: Results from the Nationwide German egePan Project for Pandemic Management

Background: In the COVID-19 pandemic, novel regional services and communication channels emerged across all sectors of the German healthcare system. To contribute to pandemic preparedness, this study aims to describe newly established services in response to the COVID-19 pandemic from a stakeholder perspective and to examine the interprofessional communication channels, applying a nationwide cross-sectional approach. Methods: A nationwide sample of German healthcare stakeholders comprising general practitioners, associations of statutory health insurance physicians, hospital medical directors, local health departments, rescue coordination centres, medical directors of emergency services, outpatient nursing services, nursing homes, community care access centres, and hospital nursing managers was surveyed. A web-based questionnaire asked for their level of participation in newly implemented regional COVID-19 services and communication channels. Stakeholders' level of recommendation was measured using the Net Promotor Score (NPS), a metric that assesses their satisfaction towards the services surveyed. Results: In total, 1312 healthcare stakeholders participated in the survey. Diagnostic centres (23.0-90.9%), COVID-19 wards in hospitals (40.5-92.1%), emergency medical vehicles designated solely for COVID-19 patients (16.5-68.4%), and crisis intervention teams (11.6-30.6%) exhibited the highest rates of engagement. The services receiving the highest recommendation for future use were COVID-19 focus practices (NPS: 33.4-43.7), COVID-19 wards in hospitals (NPS: 47.6-84.4), transportation of COVID-19 patients exclusively by predefined professional groups (NPS: 12.5-36.4), and newly implemented digitally supported nursing services (NPS: 58.3-100.0). Telephones emerged as the most frequently used communication channel (58.0-96.7%), while email was the primary digital channel (23.7-81.5%). Conclusions: During the COVID-19 pandemic, Germany experienced significant variation in the implementation of pandemic-related services across healthcare sectors, with stakeholders prioritising services built on existing healthcare structures. Developing a proactive digital infrastructure to connect healthcare professionals from different sectors is crucial for better future pandemic management.

Midwives' adaptation of their practice, role, and scope to ensure access to sexual and reproductive services during humanitarian crises: A scoping review

PROBLEM

Limited research has examined and synthesized the adaptation of midwives and midwife-led interventions during crises.

BACKGROUND

Evidence suggests that midwives are essential to respond to sexual and reproductive health care needs during disruptive times, and that they adapt to continue to provide their services during those circumstances.

AIM

To map the adaptations of midwives when providing care during crises globally. Secondary objectives include identifying which midwives adapted, what services were adapted and how, and the demographic receiving care.

STUDY METHODS

Scoping review using Levac's modifications of Arksey and O'Malley's methods. Publications and grey literature, in English and Spanish, with no limitations based on study design or date were included. Data was extracted and mapped using Wheaton and Maciver's Adaptation framework.

FINDINGS

We identified 3329 records, of which forty-two were included. Midwives' prior training impacted adaptation. Midwives adapted to the COVID-19 pandemic, epidemics, natural disasters, and World War II. They adapted in hospital and community settings around the provision of antenatal, labor and birth, postpartum, and contraceptive care. However, no specific data identified population demographics. Midwifery adaptations related to their practice, role, and scope of practice.

CONCLUSION

The limited available evidence identified the challenges, creativity, and mutual aid activities midwives have undertaken to ensure the provision of their services. Evidence is highly concentrated around maternal health services. Further high-quality research is needed to provide a deeper understanding of how midwifery-led care can adapt to guide sustainable responses to ensure access to sexual and reproductive health services during crises.

Shroud waving self-determination: A qualitative analysis of the moral and epistemic dimensions of obstetric violence in the Netherlands

Obstetric violence is an urgent global problem. Recently, several studies have appeared on obstetric violence in the Netherlands, indicating that it is a more widespread phenomenon in Dutch maternity care than commonly thought. At the same time, there has been very little public outrage over these studies. The objective of this qualitative research is to gain insight into the working and normalization of obstetric violence by focusing on the moral and epistemic injustices that both facilitate obstetric violence and make it look acceptable. Following the study design of Responsive Evaluation, interviews, homogenous, and heterogenous focus groups were done in three phases, with thirty-one participants, consisting of ten mothers, eleven midwives, five doulas and five midwives in training. All participants were already critically engaged with the topic, which was a selection criterion to be able to bring the existing depth of knowledge on this topic of people in the field to the fore. Data was analyzed through Thematic Analysis. We elaborate on two groups of results. First, we discuss the forms of obstetric violence most commonly mentioned by the participants, which were vaginal examinations, episiotomies, and pelvic floor support. Second, we demonstrate two major themes that concern practices related to moral and epistemic injustice: 1) 'Playing the dead baby card', with the sub-themes 'shroud waving', 'hidden agenda', and 'normalizing obstetric violence'; and 2) 'Troubling consent', with sub-themes 'not being asked for consent', 'saying "yes"', 'saying "no"', and 'giving up resistance'. While epistemic injustice has been analyzed in relation to obstetric violence, moral injustice has not yet been conceptualized as a fundamental part of both the practice and the justification of obstetric violence. This research hence contributes not only to the better understanding of obstetric violence in the Netherlands, but also to a further theorization of this specific form of gender-based violence.

The impact of informal care provision on the quality of life of adults caring for persons with mental health problems: A cross-sectional assessment of caregiver quality of life

This study assessed the quality of life of informal caregivers for individuals with mental health problems in the Netherlands. An online survey was administered to a panel of informal caregivers in June 2020 (n = 261). Informal caregivers of persons with mental problems were found to have an exceptionally low quality of life. A high subjective burden (p < .001), lower perseverance time (p = .016), low caregiver overall health status (p = .004) and psychological wellbeing (p = .008), younger caregiver age (p = .011), child caregiving responsibilities (p = .025), and no social support network (p = .038) were associated with worse quality of life scores. These findings shed light on the significant challenges faced by informal caregivers of persons with mental health problem. This raises concerns about the long-term sustainability of informal care and mental healthcare reform.

Stakeholder perspectives on payment reform in maternity care in the Netherlands: A Q-methodology study

Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice.

Reflective, pragmatic, and reactive decision-making by maternity service providers during the SARS-CoV-2 pandemic health system shock: a qualitative, grounded theory analysis

BACKGROUND

Pregnant and postpartum women were identified as having particular vulnerability to severe symptomatology of SARS-CoV-2 infection, so maternity services significantly reconfigured their care provision. We examined the experiences and perceptions of maternity care staff who provided care during the pandemic in South London, United Kingdom - a region of high ethnic diversity with varied levels of social complexity.

METHODS

We conducted a qualitative interview study, as part of a service evaluation between August and November 2020, using in-depth, semi-structured interviews with a range of staff (N = 29) working in maternity services. Data were analysed using Grounded Theory analysis appropriate to cross-disciplinary health research.

ANALYSIS & FINDINGS

Maternity healthcare professionals provided their views, experiences, and perceptions of delivering care during the pandemic. Analysis rendered three emergent themes regarding decision-making during reconfigured maternity service provision, organised into pathways: 1) 'Reflective decision-making'; 2) 'Pragmatic decision-making'; and 3) 'Reactive decision-making'. Whilst pragmatic decision-making was found to disrupt care, reactive-decision-making was perceived to devalue the care offered and provided. Alternatively, reflective decision-making, despite the difficult working conditions of the pandemic, was seen to benefit services, with regards to care of high-quality, sustainability of staff, and innovation within the service.

CONCLUSIONS

Decision-making within maternity care was found to take three forms - where at best changes to services could be innovative, at worst they could cause devaluation in care being delivered, and more often than not, these changes were disruptive. With regard to positive changes, healthcare providers identified staff empowerment, flexible working patterns (both for themselves and collectively as teams), personalised care delivery, and change-making in general, as key areas to capitalise on current and ongoing innovations borne out of the pandemic. Key learnings included a focus on care-related, meaningful listening and engagement of staff at all levels, in order to drive forward high-quality care and avoid care disruption and devaluation.

Effect of COVID-19 on antenatal care: experiences of medical professionals in the Netherlands

BACKGROUND

COVID-19 has greatly affected the delivery of all health care services globally. Antenatal care is one area of care that has been impacted, despite the fact that attending antenatal check-ups is essential for pregnant women and cannot be postponed. Little is known about how exactly ANC provision has changed in the Netherlands, or how the changes have impacted midwives and gynaecologists providing those services.

METHODS

This study used a qualitative research design to investigate changes in individual and national practice following the onset of the COVID-19 pandemic. The study involved a document analysis of protocols and guidelines for ANC provision to evaluate how those changed following the onset of the COVID-19 pandemic and semi-structured interviews with ANC care providers (i.e., gynaecologists and midwives).

RESULTS

Guidance was issued by multiple organizations, during the pandemic, on how to approach the risk of infection in pregnant women, recommending several changes to ANC to protect both pregnant women and ANC providers. Both midwives and gynaecologists reported changes in their practice. With less face-to-face consultations happening, digital technologies became critical in the care of pregnant women. Shorter and fewer visits were reported, with midwifery practices adjusting their guidelines further than hospitals. Challenges, with high workloads and lack of personal protective equipment were discussed.

CONCLUSIONS

The COVID-19 pandemic has had an immense impact on the health care system. This impact has had both negative and positive effects on the provision of ANC in the Netherlands. It is important to learn from the current COVID-19 pandemic and adapt ANC, as well as health care systems as a whole, to be better prepared for future health crises and ensure continuous provision of good quality care.

Policies and Practices on Out-of-Hospital Birth: a Review of Qualitative Studies in the Time of Coronavirus

Purpose of Review

The purpose of this review is to summarize the current knowledge on out-of-hospital births (at home or in an independent birth center) in high-income countries in the time of coronavirus. Qualitative studies published between 2020 and 2022 providing findings on women's and health providers' perspectives and experiences, as well as policies and practices implemented, are synthetized.

Recent Findings

During the COVID-19 pandemic, the number of women choosing the home or a birth center to deliver has grown considerably. Main reasons for this choice include fear of contagion in facilities and restrictions during delivery and the post-partum period, especially women's separation from their companion of choice and their newborn. Findings suggest that homebirth within a public model has several advantages in the experience of birth for both women and professionals during the pandemic period, maintaining the benefits of biomedicine when needed.

Summary

During the COVID-19 pandemic, the interest in out-of-hospital birth increased in high-income countries, and the number of women choosing the home or a birth center to deliver has grown considerably. This review aims to give a more in-depth understanding of women's and health providers' perspectives on and experiences of out-of-hospital birth services during this period. Twenty-five studies in different countries, including the USA, Canada, Australia, Switzerland, the Netherlands, the UK, Spain, Croatia, and Norway, were reviewed. Findings stress that out-of-hospital birth has allowed women to deliver according to their wishes and needs. In addition, the pandemic experience represents an opportunity for policy to better support and integrate out-of-hospital services in the health care system in the future.

Making maternity and neonatal care personalised in the COVID-19 pandemic: Results from the Babies Born Better survey in the UK and the Netherlands

BACKGROUND

The COVID-19 pandemic had a severe impact on women's birth experiences. To date, there are no studies that use both quantitative and qualitative data to compare women's birth experiences before and during the pandemic, across more than one country.

AIM

To examine women's birth experiences during the COVID-19 pandemic and to compare the experiences of women who gave birth in the United Kingdom (UK) or the Netherlands (NL) either before or during the pandemic.

METHOD

This study is based on analyses of quantitative and qualitative data from the online Babies Born Better survey. Responses recorded by women giving birth in the UK and the NL between June and December 2020 have been used, encompassing women who gave birth between 2017 and 2020. Quantitative data were analysed descriptively, and chi-squared tests were performed to compare women who gave birth pre- versus during pandemic and separately by country. Qualitative data was analysed by inductive thematic analysis.

FINDINGS

Respondents in both the UK and the NL who gave birth during the pandemic were as likely, or, if they had a self-reported above average standard of life, more likely to rate their labour and birth experience positively when compared to women who gave birth pre-pandemic. This was despite the fact that those labouring in the pandemic reported a lack of support and limits placed on freedom of choice. Two potential explanatory themes were identified in the qualitative data: respondents had lower expectations of care during the pandemic, and they appreciated the efforts of staff to give individualised care, despite the rules.

CONCLUSION

Our study implies that many women labouring during the COVID-19 pandemic experienced restrictions, but their experience was mitigated by staff actions. However, personalised care should not be maintained by the good will of care providers, but should be a priority in maternity care policy to benefit all service users equitably.

Challenges and opportunities for perinatal health services in the COVID-19 pandemic: a qualitative study with perinatal healthcare professionals

Background

Perinatal healthcare professionals (PHCPs) provide essential support to all parents in the perinatal period, including young parents aged 16–24, who are at an increased risk of morbidity and mortality. Little is known about the impact of COVID-19 restrictions on the provision of perinatal services, and on perinatal healthcare professionals, caring for young parents in the UK.

Methods

A UK based qualitative study using semi-structured interviews with perinatal healthcare professionals (n = 17). Data were analysed using thematic analysis.

Results

Two themes were identified describing perinatal healthcare professionals’ perceptions of providing care to young parents during the pandemic. Perinatal healthcare professionals perceived that young parents’ needs were amplified by the pandemic and that pandemic-related changes to the service, such as the use of telemedicine to replace face-to-face interactions, did not manage to successfully mitigate the increased feelings of anxiety and isolation experienced by young parents. Concerns were raised by perinatal healthcare professionals that these changes reduced young parent’s access to vital support for themselves and their child and may contribute to exacerbating pre-existing inequalities.

Conclusions

This study provides insight into the impact of the COVID-19 pandemic on the provision of perinatal care to young parents. Perinatal mental health professionals felt these negative impacts could be overcome by using a blended approach of technology and face-to-face interactions allowing regular contact with young parents and facilitating the exchange of vital information, while maintaining access to opportunities for social interactions with other parents. Findings from this study could be used to future-proof services against further COVID-19 restrictions.

'Forgotten as first line providers': The experiences of midwives during the COVID-19 pandemic in British Columbia, Canada

OBJECTIVE

To explore midwives' experiences working on the frontlines of the COVID-19 pandemic in British Columbia, Canada.

DESIGN

Qualitative study involving three semi-structured focus groups and four in-depth interviews with midwives.

SETTING

The COVID-19 pandemic in British Columbia, Canada from 2020-2021.

PARTICIPANTS

13 midwives working during the first year of the COVID-19 pandemic in British Columbia.

FINDINGS

Qualitative analysis surfaced four key themes. First, midwives faced a substantial lack of support during the pandemic. Second, insufficient support was compounded by a lack of recognition. Third, participants felt a strong duty to continue providing high-quality care despite COVID-19 related restrictions and challenges. Lastly, lack of support, increased workloads, and moral distress exacerbated burnout among midwives and raised concerns around the sustainability of their profession.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Lack of effective support for midwives during the initial months of the COVID-19 pandemic exacerbated staffing shortages that existed prior to the pandemic, creating detrimental gaps in essential care for pregnant people, especially with increasing demands for homebirths. Measures to support midwives should combat inequities in the healthcare system, mitigating the risks of disease exposure, burnout, and professional and financial impacts that may have long-lasting implications on the profession. Given the crucial role of midwives in women- and people-centred care and advocacy, protecting midwives and the communities they serve should be prioritized and integrated into pandemic preparedness and response planning to preserve women's health and rights around the world.

More home births during the COVID-19 pandemic in the Netherlands

BACKGROUND

The aim of this observational study was to examine whether the course of pregnancy and birth and accompanying outcomes among low-risk pregnant women changed in the COVID-19 pandemic compared to the prepandemic period.

METHODS

We analyzed data from the Dutch Midwifery Case Registration System (VeCaS). Differences in the course of pregnancy and birth, and accompanying maternal and neonatal outcomes, were calculated between women pregnant during the initial months of the COVID-19 pandemic (March 1 to August 3, 2020) and the prepandemic period (March 1-August 3, 2019). We also conducted a stratified analysis by parity.

RESULTS

We included 5913 low-risk pregnant women of whom 2963 (50.1%) were pregnant during the first surge of the COVID-19 pandemic, and 2950 (49.9%) in the prepandemic period. During the COVID-19 pandemic, more women desired and had a home birth. More women used pain medication and fewer had an episiotomy in the COVID-19 period than prior. Multiparous women had a higher suspected rate of fetal growth restriction during COVID; however, the actual rate of small for gestational age infants was not significantly increased. We observed no differences for onset and augmentation of labor or for mode of birth, though the rate of vaginal births increased.

CONCLUSIONS

During the COVID-19 pandemic, there was a higher rate of planned and actual home birth, and suspected growth restriction and a lower rate of episiotomy among low-risk pregnant women in the Netherlands.

Evaluation of stillbirths and infant mortality before and during the COVID-19 pandemic: a retrospective study

OBJECTIVE

The maternal-child health services remain an important indicator to look at how different countries have handled the pandemic. This study aims to investigate the effect of the COVID-19 pandemic on maternal and child healthcare use and evaluate data on stillbirths and infant mortality.

METHODS

In this descriptive, cross-sectional study, a retrospective analysis was performed on 293 stillbirths and 324 infant deaths, which occurred in Samsun province of Turkey between March 1, 2018, and March 1, 2021. The study period was examined in 3 groups as pre-pandemic period 1 (01.03.2018 -28.02.2019), pre-pandemic period 2 (01.03.2019-29.02.2020) and pandemic period (01.03.2020-28.02.2021).

RESULTS

The study found that the share of difficulties in delivering healthcare services to the families (may be due to reasons such as difficulty in accessing health services for those living in rural areas, disruption of the referral chain) in stillbirths and infant deaths has decreased during the COVID-19 pandemic compared to previous years (p= 0.037 in stillbirths, p= 0.002 in infant deaths). The mean number of follow-up visits during pregnancy has partially reduced during the pandemic (p> 0.05). Other variables of the healthcare services have remained similar to years before the pandemic (p> 0.05). The rate of families without health insurance (p= 0.001 in stillbirths, p=0.001 in infant deaths) and unemployed persons contributing to family budget (p= 0.012 in stillbirths, p= 0.016 in infant deaths) has significantly decreased during the pandemic.

CONCLUSIONS

In our study, it was determined that the variables of stillbirth and infant mortality during the COVID-19 pandemic period, and maternal and child health services in primary care and hospitals continued to provide services in a similar way to the pre-pandemic period. Compared to pre-pandemic periods during the COVID-19 pandemic, it was found that while the number of stillbirths was similar, there was a significant decrease in infant mortality.

Cesarean delivery in Iran: a population-based analysis using the Robson classification system

BACKGROUND

The rise of Cesarean Sections (CS) is a global concern. In Iran, the rate of CS increased from 40.7% in 2005 to 53% in 2014. This figure is even higher in the private sector.

OBJECTIVE

To analyze the CS rates in the last 2 years using the Robson Classification System in Iran.

METHODS

A retrospective analysis of all in-hospital electronically recorded deliveries in Iran was conducted using the Robson classification. Comparisons were made in terms of the type of hospital, CS rate, and obstetric population, and contributions of each group to the overall cesarean deliveries were reported.

RESULTS

Two million three hundred twenty-two thousand five hundred women gave birth, 53.6% delivered through CS. Robson group 5 was the largest contributing group to the overall number of cesarean deliveries (47.1%) at a CS rate of 98.4%. Group 2 and 1 ranked the second and third largest contributing groups to overall CSs (20.6 and 10.8%, respectively). The latter groups had CS rates much higher than the WHO recommendation of 67.2 and 33.1%, respectively. "Fetal Distress" and "Undefined Indications" were the most common reasons for cesarean deliveries at CS rates of 13.6 and 13.4%, respectively. There was a significant variation in CS rate among the three types of hospitals for Robson groups 1, 2, 3, 4, and 10.

CONCLUSION

The study revealed significant variations in CS rate by hospital peer-group, especially for the private maternity units, suggesting the need for further attention and audit of the Robson groups that significantly influence the overall CS rate. The study results will help policymakers identify effective strategies to reduce the CS rate in Iran, providing appropriate benchmarking to compare obstetric care with other countries that have better maternal and perinatal outcomes.

Experiences of Dutch Midwives Regarding the Quality of Care during the COVID-19 Pandemic

This study assessed how the quality of care during the COVID-19 pandemic has been experienced by Dutch midwives. At the beginning of May 2020, 15 Dutch midwives were interviewed during the first wave of the pandemic. The interviews included questions based on the value-based healthcare framework by Porter. The interviews were transcribed verbatim, coded, and analyzed according to recurrent themes using the directed content analysis approach. Key themes identified included high quality midwifery care, information provision, costs, under/over treatment, interprofessional collaboration, and shared decision making. The quality of midwifery care during the COVID-19 pandemic was experienced to be sufficient, given the challenging circumstances. The midwives experienced the lack of face-to-face check-ups to be problematic. Unclear information and lack of personal protective equipment caused stress and confusion, and they worked an additional 2–4 h per working day. Some pregnant women were hesitant to call or visit them when they thought something was wrong. The midwives perceived some advantages in using video or telephone calls. Considerations for future pandemics include an additional face-to-face check-up between 16 and 27 weeks of pregnancy and one postpartum visit. For post-pandemic care, providing a check-up through telephone or video call could be offered in certain cases.