[Initially written and submitted for a postgrad course which goes someway to explaining the dryness, and the full way of explaining the lack of swearing]
The Covid-19 pandemic has impacted most lives. While every sector has suffered detriment and every negative consequence is of course harmful, maternity services[1] is potentially the locus of the most far-reaching consequences, causing stress not just to the affected persons but also harm to the new generation of ‘lockdown babies’ including through transgenerational trauma[i]. This essay will examine the restrictions in place within maternity care, discuss their impact on pregnant families and question why new parents have been so badly let down. As the situation is ongoing and rapidly changing, if insufficient evidence exists from the UK, research from other high-income countries has been used. The essay also highlights the disparity in trust given to different types of evidence; we have countless real-world experiences[ii] [iii] [iv] which run the risk of being dismissed by the scientific community, policy makers and governments for not conforming to the hierarchy of quantitative evidence.
Maternity service restrictions were implemented early in the pandemic, affecting most NHS Trusts with obstetric units.
| Area of Service Provision Affected | Percentage of Trusts Implementing Restrictions |
| Reduction of antenatal appointments | 70% |
| Partner restrictions at non-routine antenatal appointments | 95% |
| Gestational diabetes screening pathway | 70% |
| Partner restrictions at 12-week scan | 90% |
| Partner restrictions at 20-week scan | 88% |
| Partner restrictions in labour (inc. all labour, early labour, induction of labour) | 86% |
| Home birth or midwifery-led unit provision | 59% |
| Reduction of postnatal appointments | 56% |
| Partner restrictions at postnatal appointments | 50% |
| Remote consultation methods | 89% |
Table One: Restrictions on access to maternity services March/April 2020[v] [vi]
These figures show the conditions of those who responded (42% and 63% respectively); it’s possible that the on the ground reality was different – for better or worse, although it seems likely that those who did not respond would be those enforcing stricter restrictions, especially taken together with the lived experiences already referred to and elsewhere in this essay. The impact on the amount of and type of care provided during the first wave of the pandemic is evident, and these constraints are continuing (43%) or would be reinstated if cases rise again (24%)[vii]. It is notable that 32% of Trusts did not work with service users to co-produce the implementation of their policies even though there is an obligation on the NHS to involve patients in service production[viii]. That 89% of Trusts use remote consultation methods, and 32% of Trusts do not co-create services runs the risk of ‘losing’ families who do not have access to these mean of communication, either through ownership (those in poverty) or safely (those in coercive relationships).
Data shows most perinatal families in the UK have had restricted service provision, but more important is how they have been affected by them. 38% of pregnant women are concerned about getting reliable, accurate information about their pregnancies without having face-to-face contact with their care providers, 34% believe care at birth was not how they had planned because of the restrictions, and 38% believe that the restrictions impact their ability to cope[ix]. Worryingly, 86% of Trusts experienced a reduction in emergency antenatal care being sought [x]. Data from April to June 2020 shows the stillbirth rate rose from 24 to 40 from the same period in 2019[xi] and although causation is not yet linked to the decrease in care being sought, clinicians do seem to be treating it as such[xii].
Partner exclusion is having a big emotional and physical impact on both parents. Women have better birth outcomes through reducing induction of labour, reducing labour length, decreasing intervention rates, reducing maternal pain, reducing fear, reducing postnatal depression rates and improving birth satisfaction[xiii] when properly supported by their partners; without their presence there is more chance of adverse outcomes occurring. Partner participation in maternity care is so important to health outcomes that the World Health Organisation have reiterated their call for their continuous involvement[xiv]. It is plausible that excluding co-parents from pregnancy and birth will impact their ability to bond with their child and increase paternal postnatal depression[xv] [xvi]. Their being ‘locked out’ of maternity care is not merely a question of a nice-to-have not happening but a health crisis in and of itself.
How babies are fed has also been impacted by the pandemic:
| Area of Concern | Percentage of mothers affected |
| Lockdown helped protect breastfeeding relationship | 41% |
| Felt support was lacking | 27% |
| No longer exclusively breastfeeding | 41% |
| Of the above, felt ready to stop breastfeeding | 14% |
| Introduced unwanted formula | 69% |
Table two: impact of maternity restrictions on breastfeeding[xvii]
The lack of infant feeding support is not merely a perception of parents: infant feeding teams have closed their services entirely with staff redeployed from the service; reduced service capacity; changed service provision away from face-to-face; and/or restricted access to those in most need[xviii]. Not breastfeeding has a health impact on the child and on the mother, both physically and mentally[xix] [xx], this reduction in service could have costly long-term health impacts on mother and baby, costing the NHS financially in the long-term[xxi] as well as costing the family to use formula milk: effectively disadvantaging lower-income families to a greater extent and increasing socio-economic disparity.
Unsurprisingly an increase in perinatal anxiety has been observed: women reporting higher levels of depression and anxiety, disassociation, post-traumatic stress and health anxiety for themselves and their unborn child[xxii] [xxiii] [xxiv]. 68% lack confidence that they could find appropriate support for their mental health[xxv] with 14% being reluctant to talk about their mental health over the phone[xxvi]. This is a huge mental health crisis on top of an existing one: suicide is already the biggest cause of maternal death in the first year post- birth, the second biggest in the first forty-two days post- birth and the fifth biggest during pregnancy[xxvii] –the removal and changes to services on top of increased stressors could create a massive mental health crisis in mothers. Indeed, we have already sadly seen the consequences with four women dying by suicide between March and May 2020 whose deaths were wholly attributable to changes in service provision[xxviii]. Maternal stress hormones can affect children as well as mothers, causing low birth weight, earlier gestational age, altered neurobehavioural development, psychopathology, poorer cognitive and socioemotional development and increased neonatal stress hormones in the child[xxix] [xxx].
The pandemic also appears to be widening the gap in care that already vulnerable groups receive, putting babies in those groups at greater long-term disadvantage[xxxi]. Women from Black and Asian backgrounds, and those living in areas or households with poverty are more likely to be infected with and have more serious cases of Covid-19[xxxii]. Clinicians should be considering women in these categories with a lower threshold of risk[xxxiii] and implementing a four-point action plan[xxxiv] to offer additional support to women of these ethnic backgrounds, however in many Trusts this is not happening[xxxv]. Fewer Black and Asian women feel they have the information they need during pregnancy and postnatally than White women, and Black women are less likely to have accessed information and support[xxxvi]. These factors will almost certainly have an adverse impact on families.
It is important communities work together to support maternity services to protect health[xxxvii] yet we saw earlier that 32% of Trusts are not working with their users to create or implement new policies, causing concern that the service is very quickly losing its co-production culture[xxxviii], potentially leading to a long-lasting quietening of women’s voices – ground that has been hard gained[xxxix]. Not listening to or involving those with lived experience of the issues causes unnecessary harm: Liverpool Women’s NHS Foundation Trust wrote and shared information with no involvement from their community. The backlash received ran into thousands of social media comments and an appearance in the press – not helpful to the information they were trying to release[xl] or the anxiety of the women in their care. Is one of the barriers to the consideration given to maternity services, its users, and the importance of the messages they give across one of the gender imbalances within NHS senior teams[xli]?
Keeping people safe from the disease is rightly a priority for the NHS, but what happens when the cure is greater than the disease[xlii]? Separating the familial unit when receiving bad news, through labour and after a child is born is cruel and has a demonstrable impact on the health of all. Despite affecting so many across the UK, the impact of these restrictions barely reached the nation’s consciousness until grassroots campaign #butnotmaternity launched in September, igniting attention from the Daily Mail[xliii]. There has been no government-fronted campaign to ease harm, as there has been with the hospitality industry’s Eat Out to Help Out campaign. It is easy to conclude that ‘women’s issues’ are lower in the food chain than ‘men’s issues’ of drinking in a pub from the coverage given to both in the media[xliv] and at policy-making level – especially when there is no immediate visible economic benefit.
The situation is so new and fast-changing that research must rely on rapid-return forms of evidence; there just has not been time for longer-term research to take place. However, bountiful qualitative evidence exists; to ignore it would be a huge disservice to those lived experiences.
There has been a big impact from the restrictions on pregnant families in the UK, and there continues to be so for many while the pandemic continues. The immediate impact is clear to see, however the longer effects may take years to be realised. Does the lack of women’s voices at a senior level impact the value given to righting this wrong? And we must give thought to low- and middle-income countries where the impact must surely be felt more deeply[xlv]. The consequences could be reduced by finding a way to lift restrictions without compromising safety. With so many already affected, it seems necessary to ensure there will be sufficient healthcare provisions, especially in mental health, to deal with the consequences of these restrictions.
[1] From the initial booking in appointment through antenatal, intrapartum, and postnatal care to 10 days, alongside specialist infant feeding and perinatal mental health support.
[i] Chan JC, Nugent BM, Bale TL. Parental Advisory: Maternal and Paternal Stress Can Impact Offspring Neurodevelopment. Biol Psychiatry. 2018 May 15;83(10):886-894. doi: 10.1016/j.biopsych.2017.10.005. Epub 2017. PMID: 29198470; PMCID: PMC5899063
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[iv] https://www.facebook.com/informedchoicematters
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[xviii] [redacted]
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