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\begin{document}

\title{``Never waste a crisis''. A commentary on the COVID-19 pandemic as a
driver for innovation in maternity care}



\author[1]{Lauri van den Berg}%
\author[1]{Gill Thomson}%
\author[1]{Ank de Jonge}%
\author[1]{Marie-Clare Balaam}%
\author[1]{Gill Moncrieff}%
\author[1]{Anastasia Topalidou}%
\author[1]{Soo Downe}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\section*{\texorpdfstring{``Never waste a crisis''. A commentary on the
COVID-19 pandemic as a driver for innovation in maternity
care}{Never waste a crisis. A commentary on the COVID-19 pandemic as a driver for innovation in maternity care}}

{\label{419809}}\par\null

Lauri M.M. van den Berg\textsuperscript{1}, Gill
Thomson\textsuperscript{2}, Ank de Jonge\textsuperscript{1}, Marie-Clare
Balaam\textsuperscript{2}, Gill Moncrieff \textsuperscript{2}, Anastasia
Topalidou\textsuperscript{2} and Soo Downe\textsuperscript{2} - on
behalf of the ASPIRE COVID-19 team (details below)

\subsection*{Affiliations}

{\label{523663}}

\textsuperscript{1} Amsterdam University Medical Centre, Vrije
Universiteit Amsterdam, Department of Midwifery Science, AVAG/Amsterdam
Public Health, Amsterdam, the Netherlands

\textsuperscript{2} School of Community Health \& Midwifery, Faculty of
Health and Care, University of Central Lancashire, Preston, United
Kingdom

\par\null

The coronavirus (COVID-19) pandemic has resulted in rapid changes in
many areas of health care worldwide.\textsuperscript{1} Some
organisational and governance controls on innovation have been relaxed,
to enable rapid adaptation to changing circumstances. The speed of
innovation raises a range of ethical, governance and organisational
issues. It is important to assess what changes have been instituted,
which ones should be maintained, and how to encourage effective
innovations in future. Maternity care provides an exemplar case within
the broader health care setting, given the imperative to provide both
safe and personalised care for optimal outcomes. Some pandemic-related
changes in maternity services, such as restricting women's opportunities
for companionship during ultrasound scans or throughout labour, or
limiting parental visiting to neonatal units, have been associated with
psychological harm.\textsuperscript{2} Other changes provide more
positive impacts, including reports of more individualised and efficient
care associated with the increased use of
telemedicine.\textsuperscript{3} We undertook a documentary analysis of
national policy and service-user organisation responses to the pandemic
in the United Kingdom (UK) and the Netherlands (NL), as part of the
Achieving Safe and Personalised Maternity Care In Response to Epidemics
(ASPIRE COVID-19) study. The overall aim of ASPIRE COVID-19 is to
identify `what works' in providing maternity care during the current and
future pandemics, or similar health crises. The NL was chosen as the
comparator to the UK because there were known differences in the
organisation of maternity services during the COVID-19 pandemic between
the two countries, especially for place of birth. Here we report on
activities described as new or expanded innovations in 290 documents
produced by seventeen key professional and service-user organisations in
the NL and the UK between February and December 2020 (see Table 1). We
included strategic papers, guidelines, protocols, and updates for health
care professionals, such as newsletters.

\subsubsection*{Table 1 Professional and service-user organisations
(n=number of collected
documents)}

{\label{847151}}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& United Kingdom & Netherlands\tabularnewline
\midrule
\endhead
Professional organisations & Royal College of Midwives (RCM)~(n=47)UK
Royal College of Obstetricians and Gynaecologists (RCOG)~(n=32) Society
of Radiographers (SoR) (n=12) Royal College of Paediatrics and Child
Health (RCPCH) (n=6) Mothers and Babies: Reducing Risk through Audits
and Confidential Enquiries across the UK (MBRRACE-UK) (n=1) National
Health Service England/Scotland/Wales/Northern Ireland~(NHS)~(n=21) &
Royal Dutch Organisation of Midwives (KNOV) (n=62) Dutch Association for
Paediatrics (NVK) (n=6) Dutch Society for Obstetrics and Gynaecology
(NVOG) (n=16) College of Perinatal Care (CPZ) (n=19) Knowledge Centre
for Maternity Care Assistants (KCKZ) (n=18) Professional Organisation of
Dutch Sonographers (BEN) (n=4)\tabularnewline
Service user organisations & Association for Improvements in the
Maternity Services (AIMS) (n=9) Birthrights~(BR) (n=27) Still Birth and
Neonatal Death charity (SANDS) (n=4) Birth Companions (BC) (n=3) & Birth
movement (BM) (n=3)\tabularnewline
\bottomrule
\end{longtable}

The nature of the innovations In both countries, some innovations
emerged in response to the pandemic, and some that were already in place
gained momentum, such as telehealth and early discharge following birth.
The innovations and expanded practices described in the included
documents are summarised in Table 2, organised by topic. We then discuss
the type of innovations and practices that were reported, and the
potential ethical, governance, and organisational implications of rapid
innovation in maternity care specifically, and for health care in
general.

\subsubsection*{Table 2 New innovations and expanded practices in NL and
UK maternity care as reported in documents produced by national
organisations during the COVID-19
pandemic}

{\label{440982}}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Innovation category & Mentioned innovation & NL & UK\tabularnewline
\midrule
\endhead
Telehealth & Telephone appointments (prenatal and postnatal) & X &
X\tabularnewline
& Video appointments (prenatal and postnatal), which needed other
innovations: Technology so that healthcare providers can perform digital
consultations securely (e.g., Mobilea) Training for maternity care staff
on the provision of remote antenatal and postnatal consultations & X X X
& X X\tabularnewline
& Video calling partner/other preferred person for women during
appointments attended alone & X & X\tabularnewline
& E-Health: Blood pressure monitoring at home Glucose monitoring at home
Urine monitoring at home & X & X X X\tabularnewline
& More focus on digital information and education for pregnant women,
e.g. via a Q\&A with care providers, online information videos, and
online communities & X & X\tabularnewline
& Online Centering Pregnancy and antenatal classes & X &
X\tabularnewline
& Use of headphones during birth to hear the voice of the private doula
& X &\tabularnewline
& Telephone or video call helplines, or email for urgent enquiries from
pregnant women, to be reviewed and responded to by maternity care staff
& & X\tabularnewline
& Video tours of hospitals & X & X\tabularnewline
& Provision of a (short) film of ultrasound scans for women to give to
their partners & X & X\tabularnewline
& Increased use of social media and local charities in the dissemination
of important information, such as positive social media narratives. & X
& X\tabularnewline
Digital communication & Improved digital sharing of patient information
between care providers, such as Use of electronic record systems Use of
phone, computer or web-based applications to share patient data easily
and securely & X X X & X X\tabularnewline
& Improved digital communication between different care providers:
through meetings, webinars, online conferences and education courses & X
& X\tabularnewline
Staff wellbeing & Psychological support to improve staff wellbeing & X &
X\tabularnewline
& More frequent and improved rest and break facilities (such as more
comfortable seating) & & X\tabularnewline
& Additional practical support, e.g., availability of childcare
facilities and parking spaces & & X\tabularnewline
& Shorter working shifts & X & X\tabularnewline
A resilient maternity care system & Escalation plans in case of major
capacity problems & X & X\tabularnewline
& Digital storage of important work documents to run a midwifery
practice/hospital department, in case of major capacity problems & X &
X\tabularnewline
& Crisis app groups on phones to connect different disciplines in
maternity care quickly in an emergency (organisational emergencies, not
patient emergencies) & X &\tabularnewline
& Development of novel ways to transfer women in non-urgent situations
during labour (e.g., by dedicated taxis), for potential ambulance
capacity issues & & X\tabularnewline
& Novel locations for birth, such as such the use of hotels as birth
centres & & X\tabularnewline
Strengthening community provision & Altered methods for induction of
labour, enabling women to be at home during early labour. & &
X\tabularnewline
& Commissioning of new off-hospital locations e.g., ultrasound scans in
new community locations & & X\tabularnewline
& Increased individualisation in the schedule of antenatal appointments
(e.g., fewer appointments where that is the woman's preference) & X &
X\tabularnewline
& Provision of access to midwifery support at home in early labour,
enabling women to remain at home for longer & & X\tabularnewline
& Establishment of new continuity models of care & & X\tabularnewline
& Early discharge from hospital & & X\tabularnewline
& Expansion of the role of the primary care midwife, so that secondary
care is less likely to be necessary & X &\tabularnewline
& Attention for financial support of parents (to be) (e.g., active
providing of financial information) & & X\tabularnewline
\bottomrule
\end{longtable}

\subsection*{Telehealth}

{\label{154388}}

There is significant interest in telehealth/remote health care as a
result of the pandemic.\textsuperscript{3} Our data documents the
general move, in both countries, to shift in-person appointments to
virtual appointments where possible and appropriate. The pandemic has
hastened digital developments within healthcare. Some prenatal and
postnatal appointments became remote in both countries, particularly
where no physical examinations were required and there was no known
indication for face-to-face input. Innovations were then implemented to
make digitisation of care possible, including different ways to provide
secure remote care. The NL documents provided relevant detail, such as
examples of online and telephone applications that meet the safety
standards required by Dutch law. In the UK, healthcare documents placed
more emphasis on advice around the appropriate use of telemedicine by
staff, for example to use a neutral background in a video conversation.

As the pandemic progressed, more attention was placed on the advantages
and disadvantages of remote care, with the aim of optimising the
benefits and reducing any risks. Various organisations, including KNOV,
NVK, RCOG and RCM, emphasised the benefits of using video consultations
over telephone appointments. Video consultation then became the
preferred method for remote appointments. However, there was heightened
awareness among service user organisations and professional
organisations such as BC and RCOG, that remote care was not suitable for
all, and that certain groups of women could be disproportionately
disadvantaged due to digital poverty, lack of privacy at home, or
language restrictions. Organisations within both countries identified
safeguarding concerns in relation to the difficulties associated with
identifying domestic violence and/or mental health issues, where remote
technology is used.

Digital information innovations for parents were stimulated by the need
to provide structured, regularly updated, and congruent information. In
both countries there was an emphasis in policy documents on the use of
social media, and on helplines and online groups for service users.
Information for parents was provided through the digital platforms
available to healthcare organisations and videos on YouTube (for
example, videos on breastfeeding and how to bath a baby were produced by
maternity care assistant organisations in the NL) and hospital tours
were provided online.

\subsection*{Digital communication}

{\label{870892}}

The pandemic boosted developments around the digitisation and digital
exchange of patient data. In the UK, the emphasis was on the increased
use of electronic patient records. In the NL these developments had
already occurred, and the concern was how to share electronic patient
records across healthcare providers, leading to the implementation of
phone (e.g., Siilo), computer, (e.g., BabyConnect) and web-based
applications (e.g., CareCodex foundation).

Several organisations from both countries, including KNOV, NVOG and
RCOG, highlighted the opportunities for organising remote activities for
healthcare providers. These included digital meetings which could be
both national and international, webinars, education courses and online
conferences.

\subsection*{Staff wellbeing}

{\label{763578}}

Innovations to improve staff wellbeing were implemented in both
countries in response to reports of high levels and exhaustion and
stress amongst maternity care providers. In the NL, the KNOV COVID-19
taskforce stated that, while staff had initially been stimulated by the
unique and pressing nature of the situation, as the crisis progressed
they had become fatigued. Organisations in both countries produced
manuals and strategies to prevent stress and to stimulate staff
wellbeing. These included so-called `wobble rooms' where staff could
relax if they were feeling they could not cope during a shift, and
broader policies, such as not to message colleagues after 6pm.

\subsection*{A resilient maternity care
system}

{\label{808382}}

The COVID-19 pandemic exposed vulnerabilities in both countries'
maternity care systems, particularly in terms of hospital and staff
capacities. Both countries introduced innovations to help mitigate these
vulnerabilities and to develop a more resilient maternity care system.
These included more community-based birth locations (e.g., the use of
hotels as birth centres), the development of escalation plans
(illustrating the actions that need to be taken when there is a crisis
that has an impact upon capacity), and the digital storage of key
documents. WhatsApp groups to communicate were set up among maternity
care providers, and alternative transport options (e.g., dedicated
taxis) were put in place for non-emergency transport during birth in
case of shortages in ambulance provision.

\subsection*{Strengthening community
provision}

{\label{919862}}

Further innovation strengthened the provision of both primary and
community care. The aim of these innovations was primarily to reduce the
volume of patients within hospitals, in order to minimise capacity
problems and infection risk for both service users and staff. Examples
included the increased use of methods to enable early labour at home
after induction of labour , unless there were complications requiring
hospital attendance. Women booked for hospital birth were also advised
to remain at home during early labour. In the UK, the pre COVID-19 drive
for continuity of carer (CoC) continued, although some CoC projects were
temporarily discontinued. Some hospital Trusts established new CoC
provision during the pandemic.

\section*{Comment}

{\label{112658}}

The documents we reviewed highlight many innovations in maternity care
resulting from the COVID-19 pandemic. Some were completely new; others
had previously been used, but were rolled out rapidly as the need arose.
In addition to the more familiar technical innovations (e.g.,
telemedicine), we identified innovations relating to staff wellbeing,
resulting in a more resilient maternity care system and in strengthening
community care.

The innovations which were implemented during COVID-19, largely to
minimise infection risk, may be continued post-pandemic, due to the
benefits that have been observed for organisations, staff and
service-users. The benefits of fully embracing pre-existing guidelines
also became apparent, according to national documents. For example,
there was increased encouragement for women to remain at home during
early labour, with the support of a midwife, to reduce the impact on
hospital capacity as well as minimising infection risk. This guidance
was in place pre-pandemic because women who remain at home during early
labour have a lower risk of intervention, and support at home during
this phase of labour increases maternal satisfaction.\textsuperscript{4,
5}

A resilient maternity care system requires the resources and capacity to
cope with largescale stressful events, such as natural disasters and
pandemics.\textsuperscript{6} Some of the innovations we identified are
directly linked to short-term challenges, such as the development of
escalation plans and digital storage of key documents needed to run a
midwifery practice and/or hospital department, in case of major capacity
problems. The pandemic also highlighted long-term challenges, such as
strengthening the workforce.\textsuperscript{7} This was particularly
apparent with the increased risk of anxiety, stress and burnout as a
result of working during COVID-19. These conditions decrease staff
quality of life and increase the potential for staff to leave the
profession or take early retirement.\textsuperscript{8} During the
pandemic, attempts were made to limit the risk of emotional exhaustion
and to increase staff wellbeing, via better rest and break facilities,
as well as psychological support. The continuation of these
psychological support mechanisms may contribute to a more positive work
environment, to lower staff attrition rates, and to improve outcomes for
women, birthing people, infants, and families.

All of these innovations (including the roll out of existing practices)
have potential ethical, governance, and organisational implications, for
maternity care specifically, and for health care in general. In contrast
to the idea of careful development and testing of new practices for
efficacy, effectiveness, feasibility, acceptability and equity, there
was no time for evaluation, and many new practices were implemented
almost overnight as solutions and work-arounds to emerging
problems.\textsuperscript{9} This has resulted in a dynamic and creative
space that has generated or catalysed valuable new approaches to
healthcare. Some of these changes (such as support for staff wellbeing)
are self-evidently beneficial. However, the rapid introduction of others
(such as telehealth) raises the potential for over-extension of
techniques that might not work for all; might not be affordable in the
longer-term; could disadvantage some; and that may have longer term
adverse effects. It is critical to invest time and resources to find out
what works, for whom, in what circumstances and why, and to ensure that
the use of new approaches is equitable, acceptable and
feasible.\textsuperscript{9} There are some studies addressing this
issue, particularly in relation to
telehealth.\textsuperscript{10}Extension of such analyses to other areas
of innovation is especially important in a context where pandemic
innovations are already becoming normalised in practice, as
de-implementation can be more challenging than
implementation.\textsuperscript{11} The time has come to learn which
innovations worked best from a service-user, professional and
organisational perspective, and to use this knowledge to build
infrastructure and practices to enable resilient and sustainable
maternity care systems, both for a post-COVID-19 future, and in
anticipation of any future health care crisis.

\textbf{Disclosure of interests}

The authors declare no conflict of interest.

\textbf{Contribution to authorship}

Conceptualisation: GT, AJ, AT, SD. Methodology: LB, GT, AJ, MB, GM, AT,
SD. Investigation: LB, GT, MB, GM. Formal analysis: LB, GT, MB, GM. Data
Curation: LB, GT, AT. Writing -- original draft preparation: LB. Writing
-- review and editing: LB, GT, AJ, MB, GM, AT, SD. Visualisation: LB,
AJ, SD. Supervision: GT, AJ, SD. Project administration: GT, AT, SD.
Funding acquisition: AT, SD, GT, AJ. All authors have read and agreed to
the published version of the manuscript.

\textbf{Details of ethics approval}

Documents and materials used in this inter- and intra-national policy
and public information documentary review are publicly available on
Trust, governmental and professional organisation websites, or available
on request. Ethics approval is not required for this.

\textbf{Funding}

This research is funded by the Economic and Social Research Council
(ESRC), as part of UK Research and Innovation's rapid response to
COVID-19 {[}grant number ES/V004581/1{]}. Full details of the main study
are available via ResearchRegistry (researchregistry5911) and via UKRI
Gateway (https://gtr.ukri.org/projects?ref=ES\%2FV004581\%2F1).

\textbf{Acknowledgments}

The authors are grateful to all selected maternity care organisations
for their willingness to share their policy documents with us, even if
they were not publicly available anymore. Furthermore, the authors would
like to thank the ASPIRE COVID-19 collaborative group for their input.

\section*{ASPIRE COVID-19 Collaborative
Group}

{\label{626200}}

\textbf{Co-investigators}

Soo Downe; University of Central Lancashire, George Ellison; University
of Central Lancashire, Alan Fenton; Newcastle upon Tyne Hospitals NHS
Foundation Trust, Alexander Heazell; University of Manchester, Ank de
Jonge; Amsterdam University Medical Center, Carol Kingdon; University of
Central Lancashire, Zoe Matthews; University of Southampton, Alexandra
Severns; NHS England and NHS Improvement North West, Gill Thomson;
University of Central Lancashire, Anastasia Topalidou; University of
Central Lancashire, Alison Wright; Royal Free Teaching Hospital in
London

\textbf{Research Staff}

Naseerah Akooji; University of Central Lancashire, Marie-Clare Balaam;
University of Central Lancashire, Jo Cull; University Of Central
Lancashire, Lauri van den Berg; Amsterdam University Medical Center,
Nicola Crossland; University of Central Lancashire, Claire Feeley;
University of Central Lancashire, Beata Franso; Amsterdam University
Medical Center, Steph Heys; University of Central Lancashire, Gill
Moncrief; University of Central Lancashire, Rebecca Nowland; University
of Central Lancashire, Arni Sarian; University of Central Lancashire

\textbf{Steering committee}

Maria Booker; Birthrights, Jane Sandall; Kings College London, Jim
Thornton (chair); The University of Nottingham, Tisian Lynskey-Wilkie;
University of Central Lancashire, Vanessa Wilson; East Lancashire
Hospitals NHS Trust

\textbf{Stakeholder Group}

Rebecca Abe and Tinuke Awe; FivexMore, Toyin Adeyinka; MVP BAME group,
Ruth Bender-Atik; The Miscarriage Association, Lia Brigante; RCM,
Rebecca Brione; Birthrights, Franka Cad\selectlanguage{ngerman}ée; International Confederation
of Midwives (ICM), Elizabeth Duff; Expert, postnatal care, Tim Draycott;
Royal College of Obstetricians and Gynaecologists (RCOG), Duncan Fisher;
Fathers included/Family included/ the Family Initiative, Annie Francis;
Neighbourhood Midwives, Arie Franx; Erasmus MC, Lucy Frith; University
of Liverpool, Louise Griew; National Maternity Voices, Clea Harmer;
SANDS, Caroline Homer; Burnet Institute, Australia, Marian Knight;
National Perinatal Epidemiology Unit (NPEU), Amali Lokugamage;
University College London, Amanda Mansfield; London Ambulance Service
Trust, Neil Marlow; University College London, Trixie Mcaree; NHS
England, David Monteith; Grace in Action, Keith Reed; Twins Trust, Yana
Richens; UCL \& City University, Lucia Rocca-Ihenacho; Midwifery Unit
Network, Mary Ross-Davie; RCM Scotland, Seana Talbot; BirthWise NI,
Myles Taylor; British Maternal and Fetal Medicine Society, Maureen
Treadwell; Birth Trauma Association

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{\label{847396}}

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