Midwives in a pandemic: A call for solidarity and compassion.

In March 2020, the World Health Organization (WHO) announced, the spread of the Novel Coronavirus (COVID-19) as a pandemic. The virus is now affecting more than 155 countries and territories worldwide – and growing. According to a report on lessons learned from the COVID-19 outbreak in China, published in JAMA, 1716 of 44672 (3.8%) health care personnel were infected in China, and in Wuhan 63% (1080 of 1716) health care professionals were infected, 247 of these were critical including 5 health care professionals who died [1]. However, the situation continues to evolve. At the time of writing exact figures cannot be given and they change every day; we therefore advise visiting the resources at the end of this editorial for up to date statistics. What is important is not to become complacent in low risk regions where community infection have not occurred. COVID-19 has already caused more deaths than SARS and MERS combined due to its greater infectivity and pandemic spread. We all need to be vigilant.

In situations such as this, our thoughts are with our colleagues around the world who are currently demonstrating their dedication, commitment and compassion daily. This pandemic is causing growing concern amongst all health care professionals leaving behind a legacy of trauma and suffering. This year is the Year of the Nurse and The Year of the Midwife, highlighting the critical role midwives and nurses play globally during this challenging time.

The rise in popularity of social media has been a source of panic, spreading immense anxiety and fear as people voice their experiences, concerns and opinions. It has also been a source of information to many in places where information has been limited or complicated. Accurate information as it becomes available is vital in reducing the confusion caused by the fear-based rhetoric. Untangling fear-based rhetoric from the truth is something as midwives we do daily. As always, we need to respond with sensitivity and compassion and not get swept up by this disempowering rhetoric. Rather than fear, the focus on providing accurate, and factual information from reliable sources is paramount. Our focus needs to be on eliminating discrimination and the racial undertones that further isolate and increase risk for those most vulnerable. The fluid nature of this emergency is unprecedented in our time and requires us all to come together in solidarity.

Various educational meetings and conferences have been cancelled which is also leading to anxiety and probably, financial distress. As a result, some midwives who work alone or in small groups may feel isolated. For example, the International Confederation of Midwives (ICM) have made the difficult decision to postpone the Congress until 2021 in order to comply with the public health recommendation to maintain social distancing. Now is a time for midwives to provide support (informational and emotional) for each other. Social media (e.g. WhatsApp, Twitter, blogs) has proved useful for this purpose, strengthening the midwifery community by sharing each other’s experiences and timely access to accurate, reliable resources. It is important that midwives’ voices are present in this discussion to reassure pregnant women. Due to social distancing and those colleagues working alone and/or in higher prevalence regions, virtual communication opportunities have a vital role in keeping the profession connected. Importantly, this distancing concerns ‘physical’ distancing and does not require us to socially isolate ourselves from each other. The International Day of the Midwife Virtual (VIDM) conference in May is one conference that does not need to be postponed and may prove to be an important connecting opportunity.

Challenges for midwives

Recent experience in Italy has shown that many pregnant women (especially women with previous loss) are really afraid of being COVID19 positive and feel insecure and anxious. This means that many women have an increased need for support and reassurance by all health care professionals, both during pregnancy and also during childbirth and puerperium.

Moreover, in the current pandemic, many women and midwives live, give birth and work in high risk areas. Midwives have been and continue to meet unprecedented circumstances for which they may feel underprepared. Preparing midwives to work in risky situations and stem the spread of infection whilst meeting the needs of women is an ongoing balance of priorities. Some midwives may even feel they are working outside their regional scope of practice. The Ebola outbreak highlighted how practice can be affected. For example, midwives working in Sierra Leone during the Ebola outbreak feared becoming infected, which affected their professional and personal lives [2]. In the study, motivation and support impacted the ability of the midwives to cope in these challenging circumstances. Midwives sense of duty obligated them to step into risky situations in a time of crisis. Likewise, similar scenarios are playing out with the COVID-19 pandemic in China, Iran and Italy. The Erland study highlighted the need for competency, creativity and courage when faced with challenges and ethical dilemmas.

Midwives cannot address the needs of those in their care in isolation. What is important is that midwives engage with colleagues, the community, primary health care and health promotion activities. This is not limited to education and practices such as hand hygiene and physical distancing, but also embrace working across professional boundaries and collaborating with other disciples. Midwives need to learn from previous experiences with SARS, Ebola and H1N1 that foregrounded how professional silo thinking is unhelpful. COVID-19 calls for a coming together, a blurring of traditional professional boundaries in ways that promote greater coordinated cooperation between all stakeholders. Irrefutably midwives have the skills and experiences to do this in exemplary ways.

Leadership is important both clinically and academically in addressing the COVID-19 pandemic. While teams of dedicated researchers have rapidly produced a plethora of guidance and policies (see below), and fast-tracked the open-access publication of research in The Lancet in the public interest (see below), our understanding of this virus continues to unfold daily. At the time of writing there is no vaccine and those on the frontline put their lives at risk every day. COVID-19 has shown us (again) how the world, now more than ever, needs a robust proactive investment in public health infrastructures, for which midwives are key in reproductive health strategies globally.

Supporting one another

We also know that there is an ongoing significant impact on midwives as they continue to provide usual midwifery care but now also take on all the new procedures related to prevention and treatment of COVID-19. Midwives face overload, both emotional and practical. All countries need to ensure that there are systems and processes in place early in the trajectory of the pandemic to support and care for midwives and all other health care professionals. We need to all develop and implement practical strategies maintain well-being and reduce the risk of post-traumatic stress disorder and burnout. Psychological support, social connectedness and care for the health workforce is essential.

Finally, the Women and Birth editorial board urges everyone to advocate for global solidarity and unity at this time. We acknowledge and pay tribute to all health workers, including midwives, who have lost their lives due to COVID-19 and extend our compassion to their families and communities. We are thinking of all – women and health workers – who are at the frontline of this crisis and hope it will be over soon.

Recommended resources

The following list is not definitive. This is proffered as a beginning to ensure you remain updated and informed in a very changeable landscape.

World Health Organization. (https://www.who.int/emergencies/diseases/novel-coronavirus-2019)

Royal College of Obstetricians and Gynaecologists (RCOG) 2020 Coronavirus (COVID-19) and pregnancy Version 2 published online 13th March 2020 https://www.rcog.org.uk/globalassets/documents/guidelines/coronavirus-covid-19-infection-in-pregnancy-v2-20-03-13.pdf (Accessed online 16th March 2020)

The Lancet COVID-19 Resource Centre https://www.thelancet.com/coronavirus

Futurelearn online course from the London School of Tropical Hygiene beginning 23rd March for 3 weeks: COVID-19: Tackling the Novel Coronavirus https://www.futurelearn.com/courses/covid19-novel-coronavirus?