Improving pregnancy care during the COVID-19 pandemic

Routine healthcare services suffered severe setbacks in most parts of the world with the onset of the coronavirus disease 2019 (COVID-19) pandemic. This was largely due to the measures put in place in healthcare facilities to prevent the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of the pandemic.

A new preprint posted to the medRxiv* server shows how this situation could be avoided in maternal and neonatal care following childbirth.

Introduction

The physical and emotional impact of pregnancy is enormous for the typical woman and her family. In fact, the experiences of this period often continue to affect their lives long afterward.

During the COVID-19 pandemic, non-pharmaceutical interventions such as social distancing, restrictions on the number of individuals allowed into physicians’ offices at one time, visiting restrictions, and limits on the presence of doulas, partners and others during the childbirth itself, were some of the sudden changes that significantly affected women’s’ lives during pregnancy and post-partum.

Earlier studies from several countries showed that many women reported increased apprehension and sadness due to the lack of their preferred birth companions, the fear that the infection would be transmitted to their babies during the birth, and having to give up the option of water birth, in some cases, due to the perceived risk of viral transmission.

Of course, other reports show no difference in the level of satisfaction experienced before and during the pandemic when it came to giving birth.

The current preprint describes both the kind of perceptions women had about their pandemic pregnancies and childbirth experiences, compared to pre-pandemic studies, as well as the reasons for such perceptions. The raw data came from the responses to the international Babies Born Better survey version 3 (B3-survey). This was analyzed as part of the ASPIRE-COVID-19 study.

Findings

There were over 2,200 surveys in the analysis, with about 60% being from the UK and the rest from the Netherlands. About a third of these came from women who had given birth during the pandemic, namely, about 40% of those from the UK and a quarter of those from the Netherlands. The median age was in the early thirties for both cohorts.

When childbirth experiences were examined, more women in the Netherlands reported a vaginal birth independent of the time period. In the UK, more women had an in-hospital birth during the pandemic than pre-pandemic. Overall, about 45% of women in the Netherlands cohort delivered at home but this was less than a fifth for the UK cohort.

Interestingly, two out of three women in the Netherlands cohort were very satisfied with their birth experience, compared to half of the UK cohort, without respect to the time period. In the former, women with a higher standard of life were more likely to have a better birth experience, but not in the latter.

The reasons for dissatisfaction with the birth experience could be summed up by two themes: either the woman felt unsupported or felt deprived of her freedom to choose the circumstances surrounding childbirth.

In addition, women who did not expect as good care as before due to the pandemic situation were often pleasantly surprised, while the efforts made by the medical and supporting staff to provide the care appropriate for each patient helped mitigate the negative effects of other restrictions in force.

These factors were found to be a more influential theme during the pandemic than before it.

The lack of support was due to the inadequate number of staff, because of quarantine or illness, because of the enforcement of social distancing, or both. Preferred partners were also often barred from being present at birth or visiting afterward due to COVID-19 restrictions, causing significant stress on the new mother.

The closure of some home birth services in the UK during the pandemic restricted the freedom of some, but by no means all, women during childbirth, while this was not a factor in the Netherlands cohort. The availability of home birth was related to their positive evaluation of the childbirth experience in the latter.

On the other hand, some bending of the rules by the attending staff was viewed positively by the patients as an effort to improve the quality of their care and was reported as having made the experience a good one. This was also the case when women apparently expected a lower standard of care than would be normal pre-pandemic, and thus appreciated even the basic care that they ultimately did receive.

Implications

This study used data from two different countries encompassing two time periods to evaluate the standard of pregnancy and post-partum care during COVID-19, in terms of the patient experience. The results show that familiarity, empathy, and competence on the part of the healthcare providers was highly appreciated by the patients during this challenging period while they were experiencing childbirth.

The Netherlands cohort was mostly complimentary about their experiences compared to the UK cohort, with the standard of living and the birth setting playing major roles in shaping these perceptions. Interestingly, this was not related to the pandemic. In fact, women in the Netherlands who had a better standard of living seemed even more positive about their childbirth experiences during the pandemic than before it, even though they had less support, less freedom to choose the setting, and less control over their childbirth process than before.

The reasons for this appear to be that many women did not expect care to reach the pre-pandemic levels and were thus appreciative when it did. Secondly, they admired the efforts made by healthcare providers to compensate for the difficulties faced by their patients due to COVID-19 restrictions or other rules, to the extent of being more flexible than expected for the benefit of their patients.

The findings of this study bear out similar results from other studies that underline the importance of giving laboring women more control and support during childbirth. In addition, the results show that when healthcare staff went the extra mile for their patients, the overall experience belied the negativity of the pandemic situation and restrictions.

The researchers also noted that,

There is growing evidence of moral distress and compassion fatigue among staff who are trying to maintain services by continuously having to go ‘above and beyond’ their shift times, or by the stress of breaking rules that they feel are damaging to women, birthing people and families.” 

This “unsustainable” expenditure must be stopped by putting more realistic and humane rules into play.

Moreover, the association of positive childbirth experiences with a higher standard of living points to a basic inequity of services, especially during a time of crisis. Whether this is because women with higher socioeconomic status are better equipped to ask for and get what they need at such times, or because they are less stressed, overall, remains to be determined. However, according to the authors,

personalization should continue to be an important part of general policy in maternity care, including guidelines and staffing resources, to enable staff to benefit all service users equitably.”

*Important notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.