It is well known that the onset of the coronavirus disease 2019 (COVID-19) pandemic disrupted most non-essential healthcare services, including antenatal care. A new study from Belgium presents a snapshot of the experiences of midwives in that country during the months of May and June 2020.
A preprint version of the study is available on the medRxiv* server, while the article undergoes peer review.
Belgium has been one of many European countries to suffer severely from the COVID-19 pandemic. On March 12, 2020, the country entered a “federal crisis management phase,” where crisis cells were set up to coordinate resources and guidelines between the federal and state governments.
These cells comprised multiple authority types and levels, all of which would be required to contribute to an effective pandemic response. Part of this included an emergence phase for all hospitals, beginning on March 14th, where intensive care unit (ICU) beds were increased, along with a concomitant cancellation of non-urgent patient visits.
Instead, all healthcare staff who would have otherwise participated in such consultations were redirected to COVID-19 treatment facilities. This has had an adverse impact on obstetric and postnatal services, among others.
The study was a qualitative one, carried out during the first wave, comprising interviews conducted online with midwives who were working in hospitals or practicing privately, in Wallonia and a French-speaking region of Brussels, in Belgium.
Earlier data, although scanty, indicates high discomfort among maternity workers with the reduction of routine maternity care in both low- and high-income countries.
One reason for this was the need for physical distancing, another the use of personal protective equipment (PPE), and a third the exclusion of doulas and partners from the birthing process. All of these have an impact on the very essence of midwifery practice.
An earlier report observes:
Face-to-face psychological support is as important as physical checks, and good quality maternity care requires a trusting relationship between professionals and families. Good eye contact, touch, and tone are critical elements of care, particularly during labor.”
Some of the undesirable effects of COVID-19-related guidelines included physical difficulties, such as having to wear masks during labor and delivery, and a more general perception that they were being treated with less compassion and empathy due to the need for healthcare workers to protect themselves.
On the other hand, the recognition that such precautions were necessary to protect both the midwife and the mother led to stress when personal protective equipment (PPE) was unavailable for these staff. Caregivers have been shown to experience high levels of mental stress, exhaustion and anger, with an increased risk of burnout and distress.
Lack of recognition
Midwives are trained to care for both the mother and the baby from the beginning of pregnancy to the end of the newborn period in uncomplicated pregnancies. In Belgium, both hospital-attached and privately practicing midwives are found.
Midwifery is at the crossroads between different health professions, whereby midwives possess a broad and competency-based approach to maternity care,” say the researchers.
In Belgium, midwifery is mostly within hospitals and clinics as part of an obstetrician-dominated system.
During the initial period when PPE stocks were inadequate, Belgian doctors and nurses were prioritized in the distribution of masks. This was not the case with hospital and independent midwives, who had to make do.
The lack of PPE challenged their ability to protect themselves, their patients and their families from the virus. This, in turn, engendered anger and distrust towards authorities for their poor management, the researchers observed.
Confusing guideline changes
Many midwives were confused and frustrated by the frequent changes to COVID-19 guidelines, even while acknowledging the need for evidence-based updates. The need to keep remembering new guidelines was a constant strain as well as breeding a sense of insecurity as to whether they were keeping themselves and their patients safe while providing good care.
Midwives reported disagreements between various members of the medical team, such as obstetricians and pediatricians, as well as those working in different parts of the hospital.
Moreover, the results suggested that no midwife was included in the decision-making process to create guidelines for maternity care. Not only did this create a feeling of exclusion, but the decisions taken were often contrary to their values.
Some midwives reported that viral testing protocols, which depended on the hospital, were often driven by profits, or fear-based, or inefficient in terms of preventing the spread of the virus. One reported routine CT scans on all pregnant women to exclude COVID-19, as well as routine induction of labor at 38 weeks following a negative COVID-19 test.
This midwife commented, “I hear all the fears and anxieties, but for me it still sounds like violence [against women].”
Moreover, midwives were not offered testing if a patient tested positive, leading to their feeling that they were “cannon fodder.”
Clinical decisions, including discharge timing, were taken by the medical team, with the single aim of reducing the duration of hospital stay. This often led to disagreements between medical practitioners and the mothers (and their midwives).
Early discharge placed a burden of immediate postnatal care for the new mother and baby on independent midwives without either training them or providing PPE, placing further stress on them.
Humanizing care during COVID-19
The researchers observed that:
Most of the midwives reported bending the rules to ensure the implementation of what they considered as non-negotiable elements of respectful care to women and their babies.”
The guidelines offered greater challenges to midwives than to obstetricians and nurses. This is because of the midwifery values of physical and non-verbal communication to build a trust relationship with the patient, and the difficulty in understanding and responding to the patient’s psychological distress.
This was worse for COVID-19-positive patients (in isolation), with fewer midwife visits due to the need for PPE each time.
Particularly hard for the midwives to face was the emotional stress faced by high-risk patients in maternity intensive care units, since partners and companions were debarred. Meanwhile, psychologists also drastically reduced their frequency of visits.
Midwives felt that their home visits were often the only social link for their patients. They also overlooked some breaches of social distancing they witnessed at such homes out of empathy for the new mothers.
What are the implications?
This limited study cannot provide a definitive picture of the challenges faced by midwives during the early pandemic. However, it does indicate the need for a more detailed study, with direct observation of midwifery practice as well as a wider range of participants, to understand the issues they face because of this situation.
The lack of emotional and professional support harmonizes with the widely perceived lack of recognition for this segment of healthcare practitioners, and contributes to psychological and occupational stress. A better connection between hospitals and independent midwives would improve the quality of care without compromising on infection containment.
The study summarizes five lessons:
- Recognition of the role midwives play in maternal and newborn health
- Clear and unified guidelines to maintain safe, effective, equitable and people-centric maternal care
- Rebuilding trust in the authorities by truthful and effective communication
- Mental health support
- Adapting solutions to fit particular situations
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.