It has been one of the shadow, global stories of the pandemic: as countries moved to control Covid-19, maternity services were upended by restrictions. Only this month in the UK it was reported that a woman who was rushed to hospital due to complications following birth was not allowed to see her six-week-old son for six days because of the risk of coronavirus.
The disruption has varied from country to country and throughout the period, but it has been documented globally. Earlier this year, the UN Office of the High Commissioner issued an open call for reports on “women and girls’ sexual and reproductive health in situations of crisis”. In its submission, the Global Respectful Maternity Care Council (the Global RMC Council), which represents 150 organisations in 45 countries, stated: “Since the beginning of the pandemic women have reported a comprehensive suspension of reproductive health services worldwide, particularly in low- and middle-income countries.” This resulted from governments redirecting resources to Covid-19.
The submission continued: “As services were suspended in the early days of the pandemic, women also saw their rights denied and in the name of preventing Covid-19 transmission without sufficient evidence nor justification that these rights violations were necessary or proportionate.”
The Global RMC Council cited examples such as birth companions being banned during labour and delivery, separation of women from newborns if they had Covid-19 or were suspected to have it, and women being “prevented from or discouraged from breastfeeding their newborns” despite a lack of evidence that the virus can be transmitted via breastmilk. It also noted there had been “forced medical interventions, caesarean sections and inductions under the misguided assumption that interventions would accelerate labour and delivery, and minimise viral exposure for women and health providers, and free up hospital beds more quickly despite overwhelming evidence to the contrary”.
An editorial on Covid’s effects in a number of European countries, published in September in the journal Midwifery, reported an increase in virtual antenatal appointments, limits to companionship in labour and at antenatal scans, and some suspensions in the UK of homebirth and birth centre services.
In one extreme example, Midwifery reported that regions in Italy with the highest Covid-19 levels had at times stopped women’s access to epidurals for pain relief during labour because anaesthetists were redeployed to treat coronavirus patients. In Spain, in the early days of the pandemic, some hospitals isolated women with Covid-19 from their babies, with no skin-to-skin contact or breastfeeding allowed, until the mother tested negative. Restrictions have also been reported in the US. One study, published in May in Medical Anthropology, found that “partners and doulas [were] being excluded from birthing rooms” in the early months of Covid-19. The UK has also seen partner visits severely limited on post-natal wards.
A number of campaigns and surveys in the UK have highlighted the mental toll such disruptions have taken on pregnant women and their families. Experts have pointed out that factors such as a woman’s choice of birth partner are not a luxury. As the Global RMC Council put it, there is “tremendous evidence that birth companions improve the likelihood of safe childbirth”.
Throughout the pandemic, the World Health Organisation (WHO) has maintained that Covid restrictions should not undermine a woman’s right to a “positive” experience of birth and “respectful care”, Dr Anshu Banerjee, the director of the WHO’s Department of Maternal, Newborn, Child and Adolescent Health and Ageing, told me.
“We have had concerns that because of the issue of infection prevention and control that maybe some of these positive elements might be undermined,” said Banerjee. “We should make sure that services are provided in a safe manner, but that it still allows that positive experience and thereby also allowing to breastfeed and to have the companion there.”
WHO guidance most recently updated in September – six months after lockdowns or other national restrictions started in most countries – is clear that even if a woman has coronavirus, she should be able to hold and breastfeed her newborn, and have “a companion of choice present during delivery”. The guidance also states that women with Covid-19, or suspected to have it, do not need to give birth by C-section. “WHO advice is that caesarean sections should only be performed when medically justified. The mode of birth should be individualised and based on a woman’s preferences alongside obstetric indications,” it says.
In September the organisation reiterated that it “strongly recommends that all pregnant women, including those with suspected, probable or confirmed Covid-19, have access to a companion of choice during labour and childbirth,” citing its clinical guidelines of management of coronavirus.
“Again and again, research shows that women greatly value and benefit from the presence of someone they trust during labour and childbirth… The benefits of labour companionship can also include shorter length of time in labour, decreased caesarean section and more positive health indicators for babies in the first five minutes after birth,” according to the WHO.
The WHO doesn’t have “systemic data on specific restrictions”, says Dr Ӧzge Tunçalp, of the organisation’s Department of Sexual and Reproductive Health and Research, but it has been “running pulse surveys trying to gauge disruptions”. The WHO has “anecdotal reports and news from different countries across the world, both high-income and low- and middle-income, regarding restrictions on maternity services such as not allowing companions [and] separation of mother and the baby. This also extends to use of unnecessary C-sections.”
An investigation by OpenDemocracy documented violations of the WHO’s guidance in 45 countries, including examples of women in Latin America being pushed to have C-sections because of Covid-19 and the pressure on health services. Early in the pandemic, research on pregnant women in Wuhan found high C-section rates, though they were high in China before the pandemic. One researcher told me that there have been similar reports from countries in Eastern Europe.
There is already some evidence as to the effects of these disruptions. A study published in the Lancet in August looked at birth outcomes and care in childbirth during Nepal’s national lockdown, drawing on data across nine hospitals from January (around 12 weeks before lockdown started in March) to May. The study found that, while births in healthcare facilities decreased by 52.4 per cent during lockdown, the stillbirth rates at hospitals and birthing centres went up from 14 per 1,000 pre-lockdown to 21. Neonatal mortality increased from 13 per 1,000 births to 40.
The researchers found decreases in foetal heart rate monitoring during labour, in rates of breastfeeding within one hour of birth, and in women being accompanied in childbirth. There were some improvements in hand hygiene and “keeping the baby skin-to-skin with their mother”, but the paper concluded that “during the Covid-19 pandemic, women and their babies (both in utero and neonates) are susceptible and at risk due to gaps in care that can result in adverse birth outcomes including mortality. The decrease in the number of institutional births and increase in adverse outcomes are especially concerning because of Nepal’s fragile health system and raise questions on policies regarding strict lockdowns in low-income and middle-income countries.”
The results from Nepal mean that “most likely people came [to seek maternity care] late… because they were afraid of Covid or potentially being infected with Covid at the hospital, so they presented… late and then the outcomes have worsened”, said Banerjee, adding that the same was documented in Sierra Leone during the Ebola outbreak.
The WHO has also been concerned about rates of anxiety and depression among pregnant women and those who have given birth in the pandemic, Banerjee noted. Recent research in the UK found a spike in anxiety and depression among new mothers.
More evidence of the impact disrupted maternity services have had in high-income countries is emerging, too. A nationwide study in Australia, where there are around 300,000 births a year, has been tracking the effects of the pandemic on pregnant women and those who have had children since the coronavirus outbreak began. The researchers have surveyed more than 5,200 such women, and will be continuing the research through follow-up polls.
The study, which will be replicated in New Zealand, was modelled on research following flooding in Queensland in 2010-11, when thousands were evacuated from their homes and dozens were killed, explained Hannah Dahlen, a professor at Western Sydney University’s School of Nursing and Midwifery. The Queensland study looked at the effect of the disaster on women who had been pregnant, as well as on their children’s development in following years. The researchers behind it worked with Dahlen on the “Birth in the Time of Covid-19” study.
Similarly to the UK, in Australia there was a reduction of face-to-face antenatal care in favour of virtual appointments during the pandemic, as well as limits on women being accompanied during labour and at antenatal appointments. Services including water births and birth centres were restricted. Also, as in the UK, Covid-19 restrictions varied from hospital to hospital, sometimes even between those in close proximity, said Dahlen.
When we spoke last month, the Birth in the Time of Covid-19 research had already uncovered some worrying findings. While 16 per cent of respondents said they had considered a previous birth traumatic, 22 per cent of respondents who gave birth during the pandemic said the birth was traumatic, a significant increase. Prevalence of anxiety and depression was also high, said Dahlen.
Continuity of care – being in contact with the same midwife or obstetrician throughout the pandemic – meant respondents “felt buffered from the stress”. This was similar to a finding in the Queensland flood study, where “not only did women have better outcomes but also more babies had better outcomes”, Dahlen said. Some 77 per cent of respondents had experienced tele-medicine, but “it was generally not viewed positively”, she noted. Interactions over the phone were more transactional, and respondents missed the “chit chat” with healthcare providers, which “is powerful social stuff”.
But regarding the overall experience of pregnancy and birth during the pandemic, Dahlen and her colleagues were surprised that around 35 per cent of respondents responded positively. “The positive has been their partner was home, if they are in a happy relationship where they don’t have domestic violence and they have not financially been… really stressed over this event, like losing a job. They felt they fell in love more with their partners, they felt their partners got more engaged with the childcare, and they felt the partner was more attached to the baby because they’ve been there more they may have been.”
There were “still more women who see this [experience] as very negative”, however. Women with mental health issues have had a “particularly bad time”. Respondents reported anxiety about going out with their baby, “about being a bad mother and not giving this baby the same experience as the last”.
Birth, Dahlen pointed out, “is the only thing that happens in a hospital that is about being well and doing something that is a normal physiological life event”. It is medicalised, she said, but “having a baby is a deeply psychological, social, culture and spiritual event, and by only viewing it as a physical event we are potentially creating enormous trauma for women and their partners who are bringing babies into the world… and yet it’s caught in the same kind of mentality and restrictions as sick people encounter”. During the pandemic, things that matter to pregnant women and their families, such as choices over pain relief or where to give birth or the presence of partners, have been treated “like a fancy extra rather than a fundamental choice of a woman”.
Lockdowns and measures to control Covid-19 are likely to continue for the time being. In the UK, women are still reporting restrictions in maternity and neo-natal services. The NHS issued new guidance this week stating that partners are “a key component of safe and personalised maternity care”. The Covid-19 vaccine offers hope for a return to normal services in the future. “Once countries have introduced immunisation I think polices will slowly normalise again,” said Banerjee.
But he warned that, “in particular for countries with low health workforce density, repurposing of healthcare workers to plan for and implement the roll-out of the vaccine might lead to reduced services. This is hypothetical but needs to kept in mind in planning the vaccine roll-out.”
Covid-19 has put health services under enormous strain globally. It is striking, however, that not only were maternity services impacted in similar ways worldwide, but that a woman’s right to choose, hard fought for over decades within those services, was impacted in such a similar way. Earlier this year, Dahlen co-authored a paper arguing that the pandemic “exposed an underlying pandemic of neglect affecting women’s reproductive rights, particularly in the provision of abortion services and maternity care”.
“Underlying biases and agendas” have become clear, she told me. “In Australia [restrictions allow us] to half fill football stadiums and have 100 people gamble, but a woman could not have both her doula and her partner support her during her labour. Covid-19 has exposed the patriarchy in ways that were slightly hidden before.” Childbirth choices are a human right and, despite progress, there is still a lot to fight for.
This has implications for the achievement of the UN’s Sustainable Development Goals on maternal and newborn mortality, but it is also a more general warning for the future. As one paper on the US experience in the early days of the pandemic notes, Covid-19 – much like flooding, climate crisis-induced storms and other natural disasters – has seriously impacted maternity care provision. We must learn lessons from this crisis before we face such challenges again.