Women’s experiences of maternity care during COVID-19

Prof. Valerie Smith, Dr Sunita Panda, Dr Deirdre O’Malley: School of Nursing and Midwifery, TCD
Ms Paula Barry, Ms Nora Vallejo: Coombe Women and Infants University Hospital
Funding: Trinity College Dublin’s Office of the Dean of Research COVID-19 Response Fund.

Background

In a previous report of our two phase study which explored the impact of COVID-19 on maternity care, we presented the findings of phase one – a comparative review of maternal clinical outcomes four months before and four months after implementation of COVID-19 associated practice changes at one hospital site in Ireland. In this report, we present a synopsis of the key findings from phase two – women’s experiences and views of maternity care during COVID-19.

Changes in maternity care provision during COVID-19 have had the potential to impact both positively and negatively on women’s experiences of care. Restrictions on partner attendance at antenatal visits, and during labour and the postpartum periods, for example, may reduce women’s sense of support during pregnancy and childbirth and opportunities for partner bonding – issues which are gaining increasing media attention as the restrictions continue. Capturing women’s thoughts of care during the pandemic provides insight into how the pandemic affected their care experiences. It helps also to identify good practice innovations that have benefited women which may inform future care approaches as the pandemic continues, and beyond.

Study design

The study involved one-to-one interviews with 19 women who had experienced pregnancy, childbirth (between 37 and 42 weeks of pregnancy), and postnatal care during Ireland’s first COVID-19 national lockdown (March-May 2020). Due to COVID-19 restrictions, interviews were held remotely via telephone, and participant anonymity was maintained by assigning interview codes. Themes which represented women’s narratives overall were generated.

Findings

Participant characteristics
Interviews were completed at the end of October 2020. The total recorded interview time was 780 minutes. Table 1 presents the summary characteristics of the participants.

Table 1: Summary characteristics of study participants

Variable		N (%) Mean (range)
Model of care	Public	10 (53%)
	Semi-private	5 (26%)
	Private	4 (21%)
Age	-	35 years (30-39 years)
Nationality	Irish	19 (100%)
Parity (P) (number of previous children)	P0	8 (42%)
	P1	8 (42%)
	P2+	3 (16%)
Gestational age	37+0 to 38+6	6 (31%)
	39+0 to 40+6	10 (53%)
	≥41	3 (16%)
Mode of birth	SVB	10 (53%)
	Forceps assisted	1 (1%)
	Emergency CS	3 (15%)
	Planned CS	5 (26%)

CS: Caesarean section; SVB: Spontaneous vaginal birth

Thematic Analysis
Four core themes emerged from the data. These were: ‘navigating the system,’ ‘at the end of the day, it’s just you,’ ‘preparing for and adapting to uncertainty’ and ‘blessing in disguise.’ Here we present the key issues from three themes, with supporting quotes.*

Navigating the system

The changes to usual maternity care implemented in response to the pandemic presented women with navigational challenges when accessing care. These challenges, although various, appeared to arise more often for women when accessing postnatal supports.

Issue 1: Postnatal community support

Public Health Nurse (PHN) visiting was reduced, or home visiting ceased altogether for many women, with a request to attend local health centres to see their PHN. Some women described how they had to make several phone calls to determine who their PHN was and whether a PHN would visit them in their home.
“There had been no Public Health Nurses assigned to my area. Apparently, they had been redeployed because of COVID…She hadn’t been assigned to a particular area, so she was kind of just filling in and covering” (ID 13)
The logistics of getting to the health centre, worry that the health centre would be busy with the possibility of having to wait in a busy waiting area, and fear of transmission of COVID-19 caused stress for many women.

Issue 2: Mental health and wellbeing postpartum

Concerns over the possibility of mental health issues being overlooked or unnoticed after birth were evident in many women’s narratives, including experiences of feeling low, anxiety, and not being able to cope with the transition to motherhood being missed or going undetected.
“…..I found it hard with the night feeds and everything and nobody to talk to. But if you had something like that wrong with you [referring to postnatal depression], it must be … awful in this situation … Because you have very little connection with the outside world” (ID 09)

Issue 3: Support for breastfeeding

Many women talked about their difficulty in accessing support for breastfeeding, which was ‘daunting’ and ‘frustrating’ for women. Women described being directed to websites for further information. For some in rural areas this type of information was ‘useless’ as their internet connections were unstable. Mother and baby groups after birth were now unavailable to women, and while a few women described having video consultations with a lactation consultant, these were described as not quite meeting their needs. The lack of breastfeeding support and directed advice on where to go if experiencing breastfeeding issues was recounted as being stressful and frustrating, with women having to work through many of the issues on their own.
“I was a bit concerned about the latch and all that stuff…… so I was really just doing that all, that was just me on my own trying to work all that stuff out. So that was difficult like.” (ID 08)

Issue 4: Disrupted care

Antenatally, cancelled GP appointments resulted in longer intervals between antenatal assessments. This was worrisome for some women who felt that four weeks between antenatal assessments was too long. Postnatally, telephone consultations were used by some GPs, particularly for the routine two-week infant assessment. Many women were not left assured by these and their preference would have been for their GP to see them and their baby in person.
“And over the phone just doesn’t do it like. You don’t get the same, to look into somebody’s eyes and to trust them and for them to say, you’re okay.” (ID 08)

At the end of the day, it’s just you

This theme highlights the scenario of being alone which was an experience for many women. The scenario triggered strong emotions with many women using the language of ‘alone’, ‘lonely’, ‘just me’ and ‘isolated’ when recounting their experience.  

Issue 1: Restrictions on partner attendance
Women spoke about feeling teary, emotional, anxious and fearful when entering the maternity hospital on their own. While women described their midwives as being very supportive during their early labour experience, for most, this was not enough, and they ‘needed’ their partner. This need was described in terms of having their partner with them for reassurance and constant companionship, and for the simple yet important gestures such as hand holding and back rubbing. 
“You know going through something and he wasn’t allowed be there. You know, like, to hold your hand, or to tell you that it would be ok. To reassure you that everything was going to be okay. It’s just, I found that very hard, yea it was, that was quite difficult now.” (ID 11)
Many women described the unusual situation of their partner waiting in the car park while they were in early labour in the hospital. They spoke about going out to the car park to walk with their partner, to pass time and to be with their partner in sharing their experience.
“…and I went down and we did laps of an empty car park … he wasn’t allowed into the hospital but it was nice to be able to have a bit of contact there and a bit of support there.” (ID 13)

Issue 2: Postnatal isolation
The feeling of loneliness persisted for some women during their postnatal stay in hospital. All 19 woman spoke about feeling sad that their partner did not have the opportunity to know and bond with their baby during the first days of life. Isolation and sadness were also experienced by some women in the early postnatal weeks at home. Social distancing, COVID-19 restrictions, and concern about elderly or vulnerable family members meant that many women did not have opportunities to introduce their baby to loved ones.
                “…For my husband’s parents it was their very first grandchild …But to me I felt like that was the one thing I wanted my family and especially close family and grandparents, to be able to hold him. Because I felt like the journey to get to that stage had been a long time coming.” (ID 06)
COVID-19 restrictions also prevented women from seeking and having face-to-face access to the support of other mothers, female friends and joining mother and baby groups. Although most women were accepting of this as part of the reality of the pandemic, women were impacted both emotionally (sadness) and physically (being extra careful and isolating) as a result.

Blessing in disguise

The theme of blessing in disguise reflects some positive elements that women experienced while giving birth during COVID-19.

Issue 1: Streamlined antenatal care
Many women described ‘routine’ antenatal care as being streamlined, with reduced waiting times. This included efficient COVID-19 screening at the hospital entrance, quiet waiting areas, exposure to limited numbers of healthcare professionals and short consultations. Many women positively referred to these changes and were reassured by them.
“We were well distanced in the waiting area. … A lot of things went a lot quicker, the wait times and stuff… you were in and out a lot quicker whereas in a normal day it would be quite packed and you'd be, you could be waiting there a while.” (ID 04)

Issue 2: Benefits of restricted visiting
In contrast to feeling alone, isolated and sad because partners were unable to be present in the hospital after birth, many women drew comfort from the peace and quietness offered by less crowded postnatal wards. The visiting restrictions while in the hospital were valued by many women and were described as ‘pleasant’ because they provided women with the time and space to ‘bond’ with their baby, without any distraction or disruption from visitors.
                “…the whole experience with not having gangs of visitors coming in and out … it was just so pleasant.” (ID 01)
In particular, women who were breastfeeding described feeling more relaxed, comfortable and less exposed as a result of the hospital visiting restrictions.
“I was able to breastfeed without feeling really exposed and thinking about it now I think if there had been people around, strangers marching in and out of the ward I would have had the curtains pulled all the time and I wouldn't have put my foot outside you know.” (ID 13)
Following discharge home from the hospital a few women described their feelings of ‘bonding’ with the baby in their ‘perfect little bubble’ with other siblings and their partner. Many of these narratives centred on guests not arriving unexpectedly as might have occurred had COVID restrictions not been in place, which, as one woman described, was a ‘blessing in disguise’.

Conclusion

Positive aspects and associated challenges were described by women who experienced pregnancy and childbirth during the early stages of COVID-19. The longer-term effects presented by the pandemic for pregnant and postpartum women may not be fully revealed or understood for some time yet. Ongoing assessment and further research will be required.

Acknowledgements
We are grateful for funding from Trinity College Dublin’s Office of the Dean of Research COVID-19 Response Fund, which supported this valuable study. We sincerely thank the women who gave their time generously in sharing their experiences of maternity care during COVID-19.