Denying pregnant women access to their support network during maternity care may have a lasting negative impact, warn Benjamin Black, Jane Laking, and Gillian McKay
Community engagement has long been a central pillar of outbreak response and covid-19 is no different. This is vital across all healthcare, including maternity, not only the vertical covid-19 response. Maternity services must ensure that women and their loved ones feel welcomed even in the midst of a pandemic.
We know that delays in seeking, reaching, and receiving care for complications of pregnancy increase the risk of poor maternity outcomes. Previous epidemics have documented this happening amid the disruption to society, the economy, and healthcare, resulting in direct recommendations to reduce delays at every step of the pregnancy journey.
Despite all this, during the covid-19 pandemic, there have been distressing stories of pregnant women being given life changing news alone. Of birth partners not being permitted on antenatal wards, leaving women to undergo an induction of labour without their support and while in pain. Of restricted access to postnatal wards, leaving women who have been through one of the most physically and emotionally challenging experiences of their lives to manage exhaustion and a newborn baby with minimal assistance.
These restrictions in the name of social distancing and infection control may have a lasting negative impact, even when mother and baby emerge healthy. Birth partners may struggle without having been able to fully interact with the pregnancy process, feeling isolated or undervalued. The knock-on effects on all members of the family unit are yet to be fully understood. It is unlikely, however, that history will look back on these restrictions kindly.
Pregnancy and birth are daunting prospects for many women. Attending a hospital alone can be intimidating. The power dynamics between the health worker and the woman are often complex and unbalanced. To ensure the safest services, women and their partners have to want to seek care—not fear, resent, or defer it.
Early in the pandemic, many maternity services changed their policies with the intention of providing continued safe care for patients and staff. However, decisions to curb the rights of pregnant women to have birth partners present were made according to local judgment and with little or no consultation. Fear of the unknown, conflicting information, and anxiety were the likely driving forces behind these adjustments.
This approach was in contravention to global guidance. The World Health Organization upheld the position that all women should continue to have access to a birth partner of their choice during the pandemic. We should maintain, not rescind, gains made in respectful maternity care. At the start of the pandemic, we warned that maternity services would need to make plans which maintain women’s confidence and reduce the risks of them delaying seeking care.
Fear has proven to be infectious too. The early inconsistencies of government and public health policy undermined the confidence of healthcare workers and provided an open platform for conflicting influential opinions. Rather than health services maintaining a holistic approach that balances risks against benefits, paranoia and tunnel vision have flourished in many places. Decisions were taken without due consideration of their wider consequences, leaving person centred care approaches sidelined. Gaps in knowledge were filled by assumptions. However, what makes us feel safe is not always the same as what makes us safer.
The loss of support from a birth partner has increased work for the “shop floor” clinicians, particularly midwives, at a time of reduced workforce numbers. Policy decisions intended to protect staff may have unintentionally made their jobs harder, reducing morale and team resilience in the process. Frontline staff, in addition to the women they treat, have often been absent from decisions on what is needed or wanted to maintain safe and pleasant working conditions, and the positive impact of having birth partners present on wards and during consultations has been overlooked.
The loss of confidence women have in their health service has grown with each policy shift that reopens society, but which fails to re-establish maternity services. Through the Twitter hashtag #butnotmaternity, women have used contrasting examples to point out the absurdity of being able to go to the pub or join a shooting party, while still not being allowed to have someone with them during labour. We should also be asking on what basis the restrictions were enforced to begin with, and avoid repeating them as we move forward.
There are of course situations where some restrictions made sense. It is, for example, unfair to compare a small, poorly ventilated room used for clinical ultrasonography where health workers will interact with many people every day, with a spacious pub full of patrons choosing to have a drink. Our understanding of covid-19 disease transmission and interpretation of test results among different populations continues to evolve. Every hospital and department will have their own unique clinical space and it is appropriate for them to consider how to best mitigate nosocomial transmission within it. However, asymptomatic birth partners abiding by sensible hygiene standards are unlikely to be a major driving factor of disease transmission.
When restrictions on having a birth partner present are implemented, they should be transparent, offering up an explanation and space for discussion. Where decisions to implement restrictions have been made, a root cause should be sought to resolve the perceived problem in a sustainable way. Could ultrasonography take place in a better location to improve comfort and safety for all? Could covid-19 testing be scaled up to include birth partners if this is the underlying concern? Could healthcare workers and managers be better informed and supported to balance perceived transmission risks alongside maintaining patient trust?
Respecting the standard response pillars to outbreaks of disease provides better ways of mitigating nosocomial spread of covid-19 than denying pregnant women access to their support network. These measures have been known long before the advent of this pandemic, and will still apply in future outbreaks of disease, whether novel or not.
Community engagement needs reprioritising so that maternity services can hear and react to all sectors of society. Furthermore, this is the time to take stock of the harm caused by restrictive visiting policies across the health service more broadly. There is an urgent need to learn and change approaches before the winter surge of covid-19 transmission, and for the foreseeable future waves.
Acknowledging the frustrations of all those affected, apologising, and rectifying the situation where possible is essential. Without a joint, realistic assessment of risk we may drive a wedge between health workers and patients at a time when mutual trust and confidence is vital. At a time when the safety of each of us will depend on the actions of all, we must face these challenges united.
Benjamin Black is a specialist adviser in sexual and reproductive health for humanitarian contexts working with national, international, and humanitarian organisations. He is also an obstetrician and gynaecologist at the Whittington Hospital, London. Twitter @benjamblack
Jane Laking is the midwifery matron for inpatients at the Whittington Hospital, London covering the labour ward, midwifery led birth centre, and antenatal and postnatal wards. Twitter @enajbos
Gillian McKay is at the London School of Hygiene and Tropical Medicine where she researches the impacts of outbreaks on reproductive health. Gillian is in the third trimester of her first pregnancy. Twitter @gillianleemckay
Competing interests: None declared.