Navigating maternity service redesign in a global pandemic: A report from the field.

A building picture

A new respiratory disease which was to become a global pandemic started hitting the headlines of early January 2020. It became clear that maternity services as with the rest of the UK National Health Service (NHS) was needing to prepare itself for the potential impact, although a paper published on 12th February 2020 from a team in Hubei, China, painted a reassuring picture, reporting nine cases of COVID 19 in pregnancy with no severe maternal disease and no evidence of vertical transmission (Chen et al., 2020). As the year moved from February into early March with the impact of the pandemic being keenly felt in Italy and some other European countries, it was clear that we in the UK needed to prepare for an impending Public Health crisis unlike one ever seen before. On the February 22nd an article published in the Lancet, called for testing, data and follow up surveillance for pregnant women based on concerns over the impact of previous pandemics, SARS-COV, MERS-COV (Favre et al., 2020).

How do you prepare for the unknown? This was a very unsettling time as services started to work with NHS hospitals on emergency planning and considering where the impact might come. There was an initial rapid period of adaptation and change. The clinical preparation became the focus, increasing capacity and considering impact, together with a sense of urgency and purpose. With some hindsight there were also many things the service was unprepared to prepare for, the personal health social and economic impacts; unprepared for the multifaceted impact and ongoing challenge of adapting to working with those whom we usually work with ‘closely’, both colleagues and women and families, in a socially distanced context.

In a large teaching hospital supporting 5500 to 6000 births a year across serving a broad demographic, the initial priority was continuing to provide a functional and safe maternity service. This included consideration of the availability of staff, access to resources (including environmental repurposing) managing the demand for, and access to services. Alongside this was the ongoing and constantly updating flow of guidance, based on ever evolving ‘best evidence’ and recommendations from the government, policy makers and expert bodies.

Staff resources

At the start of March advice was being given about self-isolation where symptoms are present with individuals and family members. Maternity staff were starting to be absent from work, either shielding or through developing symptoms or through self-isolation as family members were suspected cases. With no staff testing available at that stage, staff were absent for 14 days or longer. There was an initial sharp decline in the workforce and specialist roles were mobilised into clinical shifts and clinical services prioritized. Despite this challenge our service continued uninterrupted. We continued to offer home birth and midwifery-led care, closely monitoring demand and the capacity to support of paramedic colleagues. A second hit to staffing came on 20th March 2020 when the schools and nurseries closed and many parents were unsure of how to balance childcare. Luckily as school places were confirmed for key workers this settled but there was a need to remain flexible to the needs of individual staff who normally would rely on family and friends, now socially distancing, for support around clinical shifts. There was a need to risk assess staff with underlying health conditions and those who may be considered vulnerable, including pregnant staff. This also took time and energy to complete those risk assessments and to determine how and where to place those staff within our evolving service. In March came guidance from Health Education England on how our student nurses and midwives could be moved into a paid clinical practice placement to support the workforce. Work was started to look at how this could be managed in conjunction with trust workforce teams and our local higher education institution in order to safely bring students into the workplace. The student midwife specific guidance and job descriptions would not come until the end of April, and in the meantime there was much discussion nationally and locally on how these placements would be supported. This was clearly an unsettling time for students, who had to make a decision regarding opting in and also considering their ongoing education and family demands.

This was a much pressured period for the workforce. Maternity staff had to re-position their roles and workplace demands; work in ways that were unfamiliar and also balance all this against a shifting landscape of home-life demands influenced by the wider impact of the pandemic. Despite this the service remained unbroken, and while this is a testament to the resilience of the maternity workforce we must not underestimate the impact this has had on an individual level.

Resources and environment

Many of the adaptations to the way midwives were working were as a result of environmental changes. Our familiar work places became to look less familiar as areas within the hospital were traffic light designated by COVID risk and spaces redesigned to separate those suspected or infected in an effort to protect our well women. Some departments were physically moved to other buildings and ‘COVID’ areas created. Tape appeared on the floor to mark out distancing and equipment was moved. Community midwives found themselves having to relocate due to family doctor (known as General Practitioners (GPs) in the UK) or children centre closures, or relocate to the hospital to undertake telephone consultations.

Another impact on the space and environment was personal protective equipment (PPE). As the guidance came in measure by measure, more unfamiliarity came. There was an ongoing national debate in the press about PPE availability and the clinical areas were receiving regular updates on PPE use, advice and guidance. Every day brought a new PPE issue and anxiety; midwives were unfamiliar with wearing masks for full shifts, visors and aprons for other care and lots of debate. As well as being keen to use PPE responsibly, midwives wanted to know they were doing their best for themselves and the women they cared for, either in hospital or when entering their homes. Understandable anxiety prevailed.

By far the physical impact of the changes were around separation; separation of partners now excluded from antenatal appointments and scans, separation from our colleagues and friends with a two metre gap and team meetings diminished or moved online, separation from the women with whom we usually seek to build relationships as antenatal appointments were conducted over the phone, including bookings. It became apparent quickly that the non-verbal communication, the close proximity and the ‘hands on’ care elements would be missed and diminished the rapport and ability to be ‘with woman’. Even the masks, needed for safety, took away the ability of women to see reassuring smiles.

Demand for services

Our overall demand for maternity service care did not change. Pregnant women still required antenatal, intrapartum and postnatal care, no-one could be deferred. It was business as usual. What did change was that some women re-considered their birth options and wondered if a home birth would be better for them at this time, or perhaps the midwifery-led unit. Being able to keep birth options open was a priority and this was further supported by the emerging national guidance urging maternity care providers to do so. Some areas that had been more acutely affected by the pandemic had restricted access to some midwifery led services and this was met with anxiety with women worried about their birth options and choices. This was difficult for maternity services too, faced with decision making around their organisation, local ambulance trust and staffing impacts in extraordinary and unprecedented circumstances.

Access to services

Like other acute admission services, maternity also saw a drop in rates of antenatal admissions into triage areas. This became a cause for concern; were women avoiding raising their concerns in order to avoid exposure to COVID or out of a sense of not wanting to burden a service they expected to be under pressure? Communications were used to re-iterate maternity was open for business; and messages about reduced fetal movements and other concerning symptoms of pregnancy were shared to encourage safe access to care when needed.

Along with this came a concern for women who may ordinarily find accessing care more challenging. With a lockdown in place, accessing public transport and childcare in order to attend was difficult for many, and this was enhanced by the response to the pandemic requiring midwives to distance from even the most vulnerable women.

One key area of concern was the anticipated and then reported rise in domestic violence in the UK with the COVID lockdown (Singh et al., 2020).The one task that is difficult to undertake during virtual or telephone appointments is the recommendation in the WHO guidance (2016) to ask regarding domestic violence. Women could be put at risk by answering these questions if their abuser were present or in listening distance. Opportunities can be undertaken to ask domestic violence screening questions however when women attended hospital for maternity scans, which are currently unaccompanied due to visiting restrictions.

Changes to care delivery

Overall there was a rapid and evolving landscape to changing care delivery in the context of local and national guidance affecting all areas of care. Since the first joint RCOG and RCM guidelines were published on 9th March 2020 there have to date been eight additional versions with specialist guidance for specific situations such as maternal health, early pregnancy care and low-risk midwifery care and home birth, and in total service have had to respond to 26 guidance documents (see Fig. 1 ).

Fig. 1

Timeline of national maternity guidance against national pandemic related events.

In line with the national recommendations, antenatal care was delivered remotely until 28 weeks, with the exception of face to face contacts at ultrasound appointments. The WHO guidelines on antenatal care (WHO 2016) recommend a schedule of eight appointments as a minimum. The guidelines also discuss flexibility in the way appointments are offered and the use of multi-disciplinary team depending on the facilities and staff available. This is applicable to different countries across the world with different health systems and availability of health provision.

The “Saving Babies Lives Care Bundle Version 2” (NHS England 2019) does not specify the number of minimum antenatal appointments but focuses on strategies to prevent stillbirths and reduce preterm births.

Both reports highlight the need for assessment of smoking at the first appointment. The WHO recommends asking regarding tobacco use, and the Saving Babies Lives report recommends carbon monoxide (CO) monitoring at first appointment, and later at 36 weeks. Since the COVID pandemic use of CO monitoring is not recommended, but clearly conversations can still be had to support stopping smoking in pregnancy initiatives, not least the very brief advice message recommended (NHSE 2019).

All the recommendations about healthy advice in early pregnancy can be given by virtual or telephone appointments as is being adopted by most trusts during the COVID pandemic.

Changes to hospital visiting arrangements have had a significant effect on the clinical areas; it has been a long time since there were no partners on the clinics, on the wards, in scans, or at the start of induction of labour. Although birth partners have attended for labour and birth, some women have laboured alone due to partners looking after young children; this is something we did not expect to see again in our service. Midwives, as ever, have been that alongside support at this time, but so have other women, coming together by a shared experience of birthing at this unprecedented moment in history. Undoubtedly, some life-long bonds have been formed during inpatient stays. Midwives were shown national appreciation for their efforts and locally we were rewarded by multiple gifts, treat and donations and a sense of the enhanced perception of our profession put an extra spring in weary steps.

Women were discharged home quickly, and post-natal care was also delivered remotely, except for when the national neonatal screening test was taken. This distanced support will inevitably impact successful uptake of breastfeeding and the maternal mental health impacts of caring for a newborn without a wider social support network and access to wider family.

Long term impacts

Now as we emerge from the initial peak of this global pandemic we look to a new kind of future. What will be the long term impact? For individual women and families there is concern over what the distancing of antenatal care and postnatal support plus separation of partners might mean, both in short term birth outcomes and long term bonding and family development. In addition to this we must consider the impact that COVID itself may have on reproductive health outcomes as currently we have insufficient evidence on the full public and reproductive health impacts. Researchers that have modelled this with a view to the impact on low and middle income countries (Robertson et al., 2020; Stein et al. 2020) and the impact on maternal and child healthcare, ranging from family planning, vaccination services, antenatal care and interventions in childbirth. Using LiST data, Stein et al. (2020) estimated the indirect effects of reduced healthcare provision on maternal and neonatal health in India, Indonesia, Nigeria and Pakistan over 12 months to be 76,6180 additional deaths (31 980 maternal deaths and 395 440 newborn deaths, 338,760 stillbirths); a 31% increase in mortality. Roberton et al. (2020) modelled an additional 9.8–44.7% increase in under 5 child deaths per month, and an 8.3–38.6% increase in maternal deaths a month across 118 countries. While no such modelling has been done on UK services it is fair to say that within maternal healthcare providers there is concern on the impact of the alteration of antenatal and postnatal care pathways may have on maternal and infant mortality and morbidity, including the additional social and economic pressures as a result of this initial lockdown and those impacts we are yet to see.

Moving towards ‘Restoration’

Equally we should consider the long term impact of this period of acute adaptation of services, on the capacity of the service itself and those who work within it. An offer of personal restoration for midwives and maternity professionals could be offered and facilitated by Professional Midwifery Advocates, as well as resilience for leadership to look at where the innovations and beneficial changes can be protected and enhanced those which seem to be having an adverse effect beyond that of COVID protection quickly abandoned. This may require evaluation and research to determine and the efforts of midwifery leaders will need to remain focused to support and promote the benefits of effective midwifery care, minimise impacts on the workforce, women and families alike.