Many voices have arisen as the COVID-19 pandemic unfolds to draw attention on the numerous hidden repercussions of the crisis. The magnitude of those consequences will probably be clear only in the aftermath of the pandemic. But one thing is certain: both patients and healthcare workers have been deeply impacted.

Since April 22, with the increased availability of screening tests via RT-PCR, Belgium recommends testing every hospitalized patient for COVID-19 infection [1]. To this day, 130 pregnant women have been tested positive in the Kingdom; no deaths due to COVID-19 have been recorded among pregnant women or newborns [2].

In Belgium, the COVID-19 has changed how women labour and give birth almost overnight. If a pregnant woman is tested negative for COVID-19, her partner is allowed in the delivery room and during the hospital stay, as long as this birth companion does not leave the facility until discharge. Yet, women are facing disruptions in their birth plans, particularly to pain relief options: epidurals are still administered but access to water birth and NO2 is limited. Women are also warned that their hospital stay is going to be shortened, sometimes to as little as 24 hours after an uncomplicated vaginal birth, the minimum recommended by WHO [3]. Some women are discharged with their newborn as soon as urine void is reported. If the woman is COVID-19 positive, they are not allowed a birth companion and skin-to-skin contact with their newborn is denied in some maternity wards despite the fact that WHO strongly endorses this recommendation [4]. Mothers are transferred to a COVID isolation unit along with their babies, where visits from partners are prohibited [5] [6].

Hospitals are perceived to be hotspots for COVID-19 transmission and women describe “an atmosphere of war” due to the lack of contact between patients and the use of protective equipment, provoking reluctance to give birth in such settings. Maternity wards and midwives receive numerous phone calls from women asking to give birth at home. These inquiries are systematically denied on the basis that home birth cannot be motivated by fear and requires a thorough preparation during antenatal period. Arising from those requests, midwives are calling to rethink how women give birth in Belgium, promoting home-births or birth-centres as a valid alternative to hospitals, which are seen more and more as a place where diseases are treated, unsuitable for physiological deliveries focused around women’s and new-borns’ well-being.

A climate of distrust and confusion also arises due to a lack of common policies between the various hospitals concerning the protective measures taken; every hospital having their own internal protocol. Some women have been offered caesarean sections which were not medically indicated, raising fear of increased medical intervention (“too much too soon”) and potential for obstetrical violence amidst the pandemic. We are currently witnessing a practice of medicine based on fear and not on evidence, sometimes leading to ignore the “do not harm” principle, which will have a profound impact on women’s experience of maternity, and more importantly on the quality of care on both mothers and newborns. As a clinician, I can appreciate the importance of guidelines and protocols for ensuring we deliver the best quality of care consistently. As a researcher, I can now acknowledge that sometimes changing guidelines without consideration to the evidence, or without input from patients can bring negative consequences, even though it is necessary to react to the rapidly progressing pandemic.

Midwives, the key health professionals involved in supporting women and families through pregnancy, childbirth and the postnatal period, fear long lasting effects on women and their new-borns due to the disruption in routine care: decrease in the number of requests for antenatal follow-ups, negative effects on mothers’ mental health, and suboptimal frequency/quality of postnatal care. As projected by Roberton and al, while the direct effects of COVID-19 are relatively mild in children and women of reproductive age, the indirect consequences might have major implications on maternal and child health if not addressed rapidly and comprehensively [7].

Self-practicing, or independent, midwives providing care within families’ homes are facing critical challenges, sometimes putting their safety on the line in order to ensure continuity of care. “We are the great forgotten of this crisis” said a midwife who responded to a rapid survey of maternal health professionals conducted by ITM [8]. They are asked, as often as possible, to organize consultations via videoconference. “But how can you provide good support and breastfeeding counselling via a video call?”, commented one respondent. Yet, visiting a woman’s home also comes with risks . The government has prioritised hospitals in their distribution of face masks to health workers. As self-practicing midwives, they were effectively denied access to essential personal protective equipment which would ensure continuity of postnatal care through home visits [5]. This is particularly urgent now due to shortened length of stay in hospitals after childbirth.

Along with the worries for their personal safety arise worries on their working conditions, midwives wonder, “Now there is a lot of respect for us, but what will happen when it’s all over?”. The strain applied on healthcare systems, due to financial and staffing restrictions, is magnified in the light of the pandemic. While working in several Belgian hospitals over the last few years, what was clear to me is that too much is being asked of the staff: entire wards have been forced to close because the vast majority of the nursing staff was on medical leave for burnout. Many nurses, midwives and doctors are experiencing a loss of purpose in their job as they’re asked to put financial performance ahead of patients’ well-being. We now are facing a global health crisis that will have repercussions on every aspects of our societies. It is well understood that difficult decisions need to be made to stem the pandemic, but these choices cannot be taken at the expense of good quality of care and safety of both patients and health workers.

About the author:

Constance Audet is a medical doctor working in Belgium, with an interest in maternal health. She is currently working as a researcher, leading a study with the Institute of Tropical Medicine (ITM Antwerp, Belgium) assessing the impact of COVID-19 on the provision of postnatal care in Belgium.

References

1.  Sciensano, “COVID-19 : définition des cas et testing.” .
2.  Belgian Obstetric Surveillance system, “Dashboard COVID-19 in pregnancy in Belgium.”
3.  WHO, “Postnatal care of the mother and newborn 2013,” World Heal. Organ., pp. 1–72, 2013, doi: 978 92 4 150664 9.
4.  WHO, “Clinical management of severe acute respiratory infection when COVID-19 is suspected (v1.2),” 2020. [Online]. Available: https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.
5.  S. Bocart, “Faire accoucher les mamans seules à cause du coronavirus ? ‘C’est inhumain’.,” La Libre, 2020.
6. GGOLFB, “Coronavirus et grossesse: recommandations pour la femme enceinte et sa famille,” 2020. .
7. T. Roberton, E. Carter, V. Chou, A. Stegmuller, B. Jackson, and Y. Tam.“Early estimates of the indirect effects of the coronavirus pandemic on maternal and child mortality in low- and middle-income countries,” Lancet Glob. Heal., 2020.
8.  A. Seeman and C. Audet, “Health providers’ insights on maternal and newborn care: The ‘great forgotten’ of the COVID-19 pandemic.,” Healthy Newborn Network, 2020.