by Laura Tugores & Octavia Wiseman

During the Covid19 pandemic midwives and other front-line workers challenged PHE’s guidelines which said that Personal Protective Equipment (PPE) was not needed when caring for asymptomatic patients. In this blog post, two community midwives talk about what this was like for them. Now that guidance has finally been changed they ask: who else should be wearing masks?

Key Messages:

• National guidance on protecting ourselves against Covid-19 in the UK has lagged behind that of other countries triggering widespread concern among healthcare workers.
• The need for PPE for midwives and other carers who work intimately with asymptomatic (but potentially infected) patients was only recognised by Public Health England on April 1^st but they still do not recommend the wearing of protection outside of clinical settings.
• Essential workers doing office work, including midwives, like the general public during shopping or exercise, cannot realistically always stay at a 2-meter distance from each other. Do the general public, especially vulnerable people like pregnant women and essential workers in non-clinical situations, need additional protection?

PPE and Midwifery

The Covid-19 pandemic has shown the British to be a prescient lot. They stepped up and engaged with the barrage of information coming in from all sides – they went beyond the headlines and started reading and debating emerging research evidence, graphs and systematic reviews on social media as never before. They then engaged their common sense to fill the unknowns and took action, even as the government dragged its heels. Large corporations were cancelling conferences and imposing travel bans in the first week of March, as soon as the first UK fatality was announced, well before the government advised people avoid pubs, clubs and consider working from home on March 16. Universities announced they were moving to virtual teaching a week before the government closed schools on the 20^th of March. We may have cleaved to parks and pubs a bit longer than we should have, but many elderly, vulnerable and pregnant women started self-isolating weeks before Matt Hancock suggested they would be asked to do so ‘within the coming weeks’ (March 14) and they were stocking up on loo roll and honing their internet shopping skills well before lockdown on March 23.  Now social media is exploding with designs for home-made masks, while WHO and national guidance continue to remain silent on the subject.

So what does British prescience in this crisis have to do with midwives?  This blog is not about the brave front-line midwives caring for pregnant women with diagnosed Covid19 on the new isolation wards (many of which have been carved out of our existing midwifery-led units). Nor is it about the scandal of delivery-chain problems with PPE which have been well documented and remain, to some extent, unresolved. The virus claimed its first brave midwife on April 2^nd, and our focus is the quiet back-room midwives and maternity support staff who, like many other patient-facing carers, support workers, admin staff and porters across the NHS, continued to care daily for asymptomatic pregnant and newly delivered women. There were no supply-chain issues for us: we were simply told by Public Health England (PHE) that we did not need any Personal Protective Equipment (PPE) when caring for asymptomatic patients beyond the usual hand-washing, unless they presented suspicious symptoms or had a confirmed Covid19 infection. That’s right, none at all.  Yet midwives, like the general public, could see what was happening in the world and read the research – and they worried.

It was already well-known that asymptomatic carriers could shed the virus for days before showing symptoms of the disease – in February 2020, the quarantined cruise ship ‘Diamond Princess’ allowed researchers a golden opportunity to study the spread of the virus, its virulence and mortality/morbidity rates. One important finding of the study was that 50.5% of individuals who tested positive for the virus had been completely asymptomatic. But with no testing or contact tracing (another scandal we aren’t addressing here), midwives had to assume that anybody, including themselves, could be carrying the virus. Midwives’ work involves intimate contact, sometimes for extended periods of time: palpations, labour support. vaginal examinations, blood pressure, checking and weighing babies, heel prick tests, etc. As researchers continue to debate the differences between droplet-borne and airborne transmission, midwives knew that if you breathe out on a frosty day you can see the mist travelling at least a foot or two. Common sense told us that close-contact work increased the danger of transmission – if we could smell the coffee on a woman’s breath, weren’t we breathing in what she had exhaled?  And women knew this too. They knew that most of the young healthy victims of the virus were healthcare professionals and they grew increasingly worried about coming into contact with potential infected asymptomatic healthcare workers.

To those on the front-line, it seemed clear that providing midwifery care to asymptomatic women without masks was unsafe, yet PHE insisted that PPE was only required for people with diagnosed or suspected Covid19. Midwives felt increasingly guilty about the potential of transmitting the virus to pregnant women and babies, and they worried about their own and their families’ safety.  Women started declining appointments and home visits.  As Trusts adhered to PHE guidelines and worried about their supply of surgical masks, healthcare professionals took to social media to complain about the lack of protection. Some started buying or making their own masks and other protective equipment, forced into taking an ethical stand against the guidelines in order to protect themselves and their patients. The NMC Code supports autonomous risk assessment, requiring midwives to:

’take account of your own personal safety as well as the safety of people in your care’ (13.4).

Shockingly, some practitioners faced disciplinary action or even resigned from their jobs when managers told them they were not ‘allowed’ to use protective gear not indicated by PHE, even when they supplied it themselves.  The disconnect between the situation on the ground and PHE’s policy, which appeared to be based on pragmatic issues related to supply chain problems rather than research evidence, became increasingly acute, attracting more public attention as the number of healthcare professional deaths mounted. While the Royal Colleges backed PHE’s stance at first, the International Confederation of Midwives (ICM) made a statement about the need for PPE for all midwives, highlighted the lack of protection as a gendered issue internationally. Finally, on April 1, after a full month spent with midwives giving care to asymptomatic women without PPE, and under significant pressure from healthcare staff, PHE relented and revised its advice. From now on, those with:

‘direct patient/resident care assessing an individual that is not currently a possible or confirmed case (within 2 metres)’ there should be a risk assessment of what protection is needed: ‘Where staff consider there is a risk to themselves or the individuals they are caring for they should wear a fluid repellent surgical mask with or without eye protection as determined by the individual staff member’.

Trusts may still face shortages of PPE, but at least the policy now protects midwives and other patient-facing practitioners, care givers and support staff’s right to wear it and the NMC has recently released a statement supporting midwives and nurses making context-specific risk assessments, including about their own safety, if they feel they do not have sufficient PPE.

Where does that leave pregnant women and essential workers in non-clinical areas?

Government placed pregnant women in the vulnerable group on the 16^th of March. This was a precautionary approach due to lack of evidence on the effects of the virus on pregnancy. Pregnant women do not seem particularly susceptible to Covid19, and present a similar pattern of disease severity as non-pregnant individuals with about 86% of mild cases, 9% severe and 5% critical. However, it is well known that viral illness can cause more severe symptoms in pregnant women, due to changes in their immune system, especially in the later stages of pregnancy.

Now the question is: should pregnant women and other vulnerable people wear masks when out in public? This is an important question for vulnerable individuals, but we believe this question should also be extended to essential workers who undertake office or other work. Midwives, for example, spend many hours in cramped offices with narrow corridors doing admin work, checking results and making referrals. It is not the most glamorous side of our job, but it is an essential one. Yet PHE continues to say that midwives should not wear PPE other than for patient contact, that ‘social distancing’ should be sufficient (if unrealistic), and pregnant women are still not advised or required to wear masks to protect us during appointments.

PHE currently follows the World Health Organisation (WHO)’s advice that the general public and essential workers in non-clinical situations should not use masks is based on the fact that there is no clear evidence of a benefit. However, absence of evidence should not be mistaken with evidence of masks not being effective. We may lack well conducted studies that can prove that mass masking can reduce transmission, but there is a similar lack of evidence on keeping 2 meters apart or hand washing for 20 seconds (is it enough / too much?…). When there is so much we don’t know, and so many interventions based on expert advice and common sense, why is a different standard of evidence being used for masking? With the evidence showing that Covid-19 can be transmitted by asymptomatic and presymptomatic individuals for a significant period of time, it seems reasonable to assume that community transmission could be reduced if everyone wore face masks, especially those like office-based essential workers or pregnant women attending appointments which will bring them within 2 meters of others. Surely any help in “flattening the curve” would be valuable. In addition, calling for universal mask wearing would help reduce the stigma that symptomatic and vulnerable individuals suffer, which may lead them to avoid wearing a mask in the first place when in public.

Could supposed concerns about masks giving a ‘false sense of security’ mask (see what we did there?) the old supply-chain concerns?  Since the start of the outbreak, there has been a disparity in the official advice in different countries with regards to wearing masks. In some countries, like China, Hong-Kong and Japan, mask wearing in public has been widely embraced. In others, like Czech Republic, Slovakia and Turkey it is now mandatory. Some European countries like Spain or France, as well as the US, changed their initial advice and now recommend that the public wears masks for all outings.  Supply-chain issues are important: rationed PPE equipment must be directed at care workers who are most at risk. But because of this, many countries have now published guidelines on how to make your own mask. In fact, there is evidence that general mask use, including DIY and cloth masks, are likely to decrease aerosol exposure and infection risk at a population level, even with an imperfect fit, and there is general consensus: a cloth mask is much better than nothing at all.

Not all DIY masks have been found to offer the same protection against viral exposure: the material is relevant and layering is equally important. Masks can be sewed with materials found in any home: 2 layers of a tea towel, or 2 layers of tightly-woven cotton plus a filter (like a vacuum bag or kitchen paper) can offer a filtration efficiency for some pathogens which is similar to that of a surgical mask. In the last two weeks, the internet has exploded with DIY masks patterns. With uneven supply of PPE, some hospitals abroad have even proactively requested people to sew specific types of masks for their use, just as British hospitals are now accepting home-made scrubs.

Finding the balance between guidelines and common sense

Now more than ever we need to listen to our instincts. Midwifery has always been a very intuitive profession, and as midwives we are used to listening to our “inner voice”. We know that the clinical judgement which allows us to provide safe care but also critically evaluate the evidence, is a perfect balance of both clinical instincts, forged by years of learning in practice, and guidelines based on best available evidence. The disconnect between the emerging evidence on Covid19 and the government and PHE’s slow and possibly politically-motivated response has highlighted that we all need to be more like midwives (not least midwives themselves who all too often do not feel sufficiently empowered to challenge the guidelines). To quote Trisha Greenhalgh et al’s excellent review of the evidence on masks being used by the general public:

‘In conclusion, in the face of a pandemic the search for perfect evidence may be the enemy of good policy. As with parachutes for jumping out of aeroplanes, it is time to act without waiting for randomised controlled trial evidence… Masks are simple, cheap, and potentially effective. We believe that, worn both in the home (particularly by the person showing symptoms) and also outside the home in situations where meeting others is likely (for example, shopping, public transport), they could have a substantial impact on transmission with a relatively small impact on social and economic life.’