Study looks at childbirth experiences during COVID-19 in the USA

The current pandemic of COVID-19 has led to extensive and deep-rooted changes in the number and nature of physician-patient interactions worldwide.

A new study by Elizabeth Mollard at the University of Nebraska Medical Center and Amaya Wittmaack from the University of Virginia School of Medicine published on the preprint server medRxiv* in October 2020 reveals that pregnant women may feel less supported during their childbirth experience due to the changes in maternity unit practices related to the pandemic.

Pregnancy and COVID-19

It is still a matter of debate whether pregnant women or their offspring are at higher risk of COVID-19 related complications. Policies in healthcare administration changed overnight with telehealth rather than in-person consultations, the universal requirement of masking, and facing the risk of contracting the virus during their hospital visits. In some counties, all pregnant women were tested for the disease.

Women no longer knew for sure whether they would have their birth partners, companions, or their doctors attending their delivery. Again, any symptom which could suggest COVID-19 often initiates practices to contain the virus.

Earlier, immediate isolation of the newborn and breastfeeding avoidance was routinely carried out in some centers, rather than immediate skin to skin contact after birth, early breastfeeding, and rooming-in. The Center for Disease Control (CDC) in the US recommended such a temporary separation. On the other hand, the World Health Organization (WHO) recommended rooming-in even for infected mothers.

Motivation for The Current Study

This disagreement has led to varying maternity unit practices. This includes not only the above practices but the length of hospital stay. These, coupled with the hospital's natural perception as a place where viral transmission was bound to be higher rather than lower, has reduced the readiness of some expecting mothers to have hospital deliveries.

Pregnancy is already known to trigger anxiety, depression, and physical health issues, such as diabetes and hypertension. Along with the uncertainty surrounding the hospital environment and the pregnancy outcome, this made pregnancy and delivery during the early months of the pandemic a particularly worrisome time for these women.

The current study focused on eliciting the experiences of being pregnant or having had a baby during this period, March to July 2020, in COVID-19-affected or uninfected women in the US. The researchers included 885 women.

Most women were married, White non-Hispanic, in full-time jobs, and living in their own homes. Just over half were multiparous, and the mean age was ~30 years. About 71% delivered normally.

Most were not infected or not tested, indicating they had no symptoms of COVID-19 during pregnancy or the peripartum period. Only 1% were positive for the virus, and no newborns. Being of Asian origin increased the odds for COVID-19 positivity, but this may not be significant given the sample's 3% Asian composition.

Increased Negativity About the Pregnancy-Childbirth Experience

Women in this study had twice the odds of hypertension compared to prior studies, which showed a 10% rate of hypertension in pregnancy. Anxiety was reported by over a third, compared to 20% of women in previous studies. Depression was also reported in nearly a fifth, compared to the usually cited figure of ~13%. However, this is not a universal finding, as other studies have reported comparably high figures.

Depression and anxiety may have been linked to stress, and their prevalence was comparable in mothers with and without a positive diagnosis. This indicates that the stress may have been related to the circumstances of giving birth during the pandemic and not the diagnosis per se.

Over a fifth of the women reported feeling unsafe in the maternity unit. In contrast, an earlier study reported that only ~13% said they would feel safe delivering their baby out of the hospital, whether or not they planned to give birth in or out of the hospital.

Again, over 60% of the women in this study said they were not well supported during childbirth, perhaps because they could not have their friends, doulas, or family members with them. It is noteworthy that this finding cropped up despite the fact that most women could have their birth partners with them.

Again, not having a birth partner and Cesarean delivery were correlated with a positive diagnosis. Women with a positive diagnosis were likely to be refused permission to have their birth partners with them. These women showed a trend towards breastfeeding for 6 weeks or less.

Pandemic-Safe, Mother-Unfriendly?

Professional bodies have emphasized that hospitals are safe places to give birth irrespective of the pandemic. Still, this study may show that the change in practices related to the pandemic has led to women losing their security and control during childbirth. This sheds light on the need to provide better support for laboring women and new mothers during this time without ignoring public health directives.

Cesarean delivery was more likely among the women with a positive diagnosis, perhaps reflecting the lack of knowledge as to the potential for vertical transmission at this time or because of an increased proportion of severe/critical illness in these women, making them less fit for the stress of normal childbirth.

A third possibility is that some of these positives may have been acquired during their hospital stay, especially if they had to have a Cesarean, which entails a more extended hospitalization period.

The shortening of the breastfeeding period could include traditional ones such as inadequate milk supply, anemia, and illness. However, it was found that women were equally likely to initiate breastfeeding whether or not they were positive for COVID-19, in this study, where a no-separation policy was practiced. This conforms to the latest guidelines of both the WHO and the CDC.

Implications

The study was based on self-reported data, with varying lengths of time since delivery and differing data collection dates, which would have affected the length of the period of breastfeeding. The researchers also point out that the women were not classified by point of positivity, whether in pregnancy, delivery, or after childbirth.

However, they recommend further research in a prospective design on pregnancy and childbirth during a pandemic to uncover the biological and psychosocial factors that affect the outcome. Causative associations between Cesarean delivery, breastfeeding, ethnicity, and COVID-19 infection should be explored.

The study concludes, “Healthcare policy and maternity care practices should focus not only on keeping women safe from COVID-19 infection but also on ways to increase women’s overall feelings of safety and control in their birthing environment.” In declaring hospitals to be safe for delivery, the patient's emotional safety in a highly stressed situation such as childbirth must also be ensured.

This is often one of the healthcare interactions that determine a woman's attitude towards this profession, both for her own care and that of her family. The utmost care should be taken to improve the experience. This shows the need for staff in these units to make appropriate changes such that women at this physically demanding and stressed time can feel a sense of control and be better satisfied with their birthing experience.

*Important Notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:
Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.

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