Abstract
Background
Aim
Method
Findings
Conclusion
Keywords
Statement of significance
1. Introduction
World Health Organization, WHO Recommendations: Intrapartum Care for A Positive Childbirth Experience, 2018. Available: 〈https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en〉.
World Health Organization, WHO Recommendations: Intrapartum Care for A Positive Childbirth Experience, 2018. Available: 〈https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en〉.
National Health Services England, Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care, 2016. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf〉.
National Health Services England, Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care, 2016. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf〉.
Human Rights in Childbirth, Human Rights Violations in Pregnancy, Birth and Postpartum During the COVID-19 Pandemic, 2020. Available: 〈http://humanrightsinchildbirth.org/wp-content/uploads/2020/05/Human-Rights-in-Childbirth-Pregnancy-Birth-and-Postpartum-During-COVID19-Report-May-2020.pdf〉.
2. Methods
2.1 Study design
ASPIRE-COVID-19, Achieving Safe and Personalised Maternity Care in Response to Epidemics, 2021. Available: 〈https://gtr.ukri.org/projects?ref=ES%2FV004581%2F1#/tabOverview〉.
2.2 Data collection
2.2.1 Document collection
United Kingdom | Netherlands | International |
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National Health Services England, Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care, 2016. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf〉.
2.2.2 Stakeholder interviews
National Health Services England, Better Births: Improving Outcomes of Maternity Services in England. A Five Year Forward View for Maternity Care, 2016. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf〉.
United Kingdom | Netherlands |
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2.3 Data analysis
3. Findings
3.1 Similarities and differences between the British and Dutch maternity care response during the COVID-19 pandemic
3.1.1 Choice of birthplace
United Kingdom | Netherlands | |
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Women without COVID-19 symptoms or with a negative test result | No national restrictions on choice of birthplace. However, there were differences in the home birth policy by region (AIMS_5; RCM_14,_33); several regions/Trusts limited home birth services to protect capacity in the hospitals and ambulance services (RCOG_2a, _11). | No restrictions on choice of birthplace, only the advice for women who were considered to be low-risk to not to give birth at the hospital to reduce the potential impact on hospital capacity. A document from the Dutch Royal Organisation for Midwives mentioned that if there was a future lack of capacity in the hospital, hospital births without medical reasons would not be possible (KNOV_1, _2). In contrast, the document also mentioned that if there was a lack of ambulances, home births might not be possible (KNOV_13). |
COVID-19-positive women with mild symptoms or women who were asymptomatic | All women with COVID-19 symptoms were advised to choose a hospital for the birth (RCM_7, _15). However, there needed to be an informed discussion about the place of birth in case the woman had mild symptoms or was asymptomatic (RCM_1; RCOG_1j). | No restrictions on choice of birthplace when a woman’s temperature was below 38 °C with no respiratory insufficiency (KNOV_4, _5; FMS_1, _4). If the woman’s temperature was above 38 °C or if the woman had respiratory insufficiency, a hospital birth was advised (KNOV_4, _5; FMS_1, _4). |
COVID-19-positive women with severe symptoms | The advice was to give birth in the hospital and have continuous cardiotocography (CTG) (RCM_7, _15). | The advice was to give birth in the hospital and have continuous cardiotocography (CTG) (KNOV_5; FMS_1, _4). |
‘Closure of services, so women haven’t had choices. Yeah, and might have ended up making choices like to freebirth that they wouldn’t otherwise.’ (Interview UK stakeholder 5, National Maternity Voices Partnerships)
3.1.2 Companionship
‘Pregnant women can face difficult and emotional decisions. In such situations, it is realistic that health care providers deviate from this advice’ [no companionship during antenatal check-ups]’ (Document of the Dutch College for Perinatal Care, CPZ_7, 27 March 2020).
‘Restrictions imposed by the majority of trusts (86%) have meant many women are alone in hospital during early labour which can last hours or even days. Although all trust policies allowed birth partners to attend once labour is established, the unpredictable nature of birth has meant that in some circumstances women have given birth alone’ (Document of the Association for Improvements in the Maternity Services, AIMS_8).
‘Especially in a clinical setting, where there are often unknown caregivers, a trusted person is so incredibly important. For these women, it is important that they are seen and heard during birth, with an extra person of their own choice. This allows a good start for them now and for the future of the baby that they are bringing into the world. For some women, this will be a doula, midwife or birth photographer, or their mother; for others, a trainee care provider is welcome.’ (Document of the Birth Movement, GB_2, 22 May 2020).
‘Neonatal services present a unique situation in terms of “visitors” and it is essential that the mother and her partner are never considered to be visitors within the neonatal unit – they are partners in their baby’s care, and their presence should be encouraged’ (Document of the British Association of Perinatal Medicine, BAPM_5, 6 May 2020).
3.1.3 Women and families in vulnerable situations
‘To prevent avoidable suffering – in some cases tragedy – and reduce the huge economic burden on society, the mental health of pregnant women and new mums needs to be given equal priority to physical health, including by mums and families themselves’ (Document of the Maternal Mental Health Alliance, MMHA_1, 5 May 2020).
‘Women with known psycho-social vulnerabilities, operative birth, preterm/low birth weight baby and/or other medical or neonatal complexities need to be prioritised for face-to-face care’ (Document of the Royal College of Midwives, RCM_14, 20 May 2020).
3.2 Policy drivers behind the British and Dutch maternity care response during the COVID-19 pandemic
3.2.1 Focus on infection control
‘The RCM, in normal circumstances, takes the clear position that women should be given the full range of birthplace options, with evidence-based guidance to aid their decision-making and that midwives should staff women and not buildings. However, the current crisis requires those leading and managing services to make difficult decisions to ensure the safety of pregnant women, their babies and the staff supporting them’ (Document of UK Royal College of Midwives, RCM_23, March 2020).
‘But that's the message I'm hearing back and back from the trust, is that we only just kept our home birth services staffed and staff was super worried about going into people's homes and we had to put a lot of restrictions on to make them feel safer.’ (Interview UK stakeholder 12, Maternity Voices Partnership)
‘I didn't experience that the midwives were so scared of becoming infected. Of course, there were a few, but most of the measures were taken to prevent a shortage of midwives [if they had to go on sick leave because of COVID-19 infection]’ (Interview NL stakeholder 7, Royal Dutch Organisation of Midwives).
‘So it [perinatal experience] is a really crucial life event. And however difficult the circumstances, the wishes and the needs and the sort of thoughts and everything else to do, the women should remain paramount.’ (Interview UK stakeholder 18, Independent Midwifery Advisor)
3.2.2 Facilitators and barriers for personalised care
‘But it seems to me. And with my cynical hat on, a lot of trusts went great, we don't have to provide home births anymore and it was used as an excuse. And what always happens is that is that the sort of the wagons are circled around the labour ward. All the other options are dropped. And that has a really detrimental impact in so many ways (Interview UK stakeholder 18, Independent Midwifery Advisor)
‘We [maternity care providers] are not going to make an exception for you. We need to be consistent. Maternity care providers who made an exception did so under conditions of strict secrecy’ (Interview NL stakeholder 3, The Birth Movement)
‘And I think there is a bit of a vacuum because there isn't strong guidance from the centre, but that Trusts should be looking at relaxing those restrictions and maternity services. So, I guess that’s just left to the local dynamics.’ (Interview UK stakeholder 7, Birthrights)
‘The personalisation of care must remain a priority during this period. We suggest that Trusts should be advised to consider individual requests for support to birth at home, for example, on a case-by-case basis, bearing in mind the needs of the woman (including her mental health needs) as well as what can be done to mitigate staffing constraints.’ (Document of the Association for Improvements in the Maternity Services, AIMS_2, 9 April 2020)
3.2.3 Learning how to work together during a time of crisis
‘So, if you look at the collaboration, there were some incidents in the beginning. Parties were still communicating a certain message from their own sector. And later on in the process, things got better and better: there was more of a joint effort’ (Interview NL stakeholder 11, College of Perinatal Care).
‘Well, one party reported to the press on how they were going to do it, but then it was totally out of sync with the rest, which created a bit of a disagreement’ (Interview NL stakeholder 6, Ministry of Health, Welfare and Sport).
‘It was a such a technical discussion about how to reduce COVID-19 [infection rates] and the social aspect and the impact was forgotten. That would perhaps be my main recommendation. Why aren't there women, pregnant women, people who don't come from healthcare at the table? They were just not asked.’ (Interview NL stakeholder 3, The Birth Movement)
4. Discussion
4.1 Interpretation
Human Rights in Childbirth, Human Rights Violations in Pregnancy, Birth and Postpartum During the COVID-19 Pandemic, 2020. Available: 〈http://humanrightsinchildbirth.org/wp-content/uploads/2020/05/Human-Rights-in-Childbirth-Pregnancy-Birth-and-Postpartum-During-COVID19-Report-May-2020.pdf〉.
- Asefa A.
- Semaan A.
- Delvaux T.
- Huysmans E.
- Galle A.
- Sacks E.
- et al.
4.2 Strengths and limitations of this study
4.3 Recommendations for policy and practice
E. Waller, N. Kanani, Primary Care Networks – Plans for 2021/22 and 2022/23. NHS England, 2021. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2021/08/B0828-i-gp-contract-letter-pvns-21-22-and-22-23.pdf〉.
National Health Services, NHS Pledges to Improve Equity for Mothers and Babies and Race Equality for Staff, 2021. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2021/09/C0734-ii-pledges-to-improve-equity-for-mothers-and-babies-race-equality-for-all-staff.pdf〉.
National Health Services England, 2021/22 Priorities and Operational Planning Guidance: October 2021 to March 2022, 2021. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2021/09/C1400-2122-priorites-and-operational-planning-guidance-oct21-march21.pdf〉.
5. Conclusions
Funding
Ethical statement
CRediT authorship contribution statement
Acknowledgements
Appendix A. Supplementary material
Supplementary material
Supplementary material
References
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National Health Services England, 2021/22 Priorities and Operational Planning Guidance: October 2021 to March 2022, 2021. Available: 〈https://www.england.nhs.uk/wp-content/uploads/2021/09/C1400-2122-priorites-and-operational-planning-guidance-oct21-march21.pdf〉.
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