4.1. Interpretation
One of the main findings of this study is that the focus on infection
control significantly restricted the choices and rights of women and
their partners/families over the perinatal period in order to achieve
the lowest possible risk of infection [8, 13]. Restricting women’s
rights in an attempt to prevent risk, with little attention paid to the
short and long-term effects on women’s psychological wellbeing, has been
argued to generate greater harm than benefit [14, 15]. For example,
it appears that separation of parents and new-borns may have negatively
influenced breastfeeding success, with negative emotional and health
implications [16-18]. Furthermore, restricting companionship during
antenatal ultrasounds can negatively influence the transition of
partners becoming parents [19]. However, the present study suggests
that it was difficult during a time of uncertainty (e.g., during an
international crisis) to weigh up the short-term and long-term risks,
especially as there was a lack of information relating to the risk posed
by COVID-19 infection, particularly at the beginning of the pandemic.
Measures taken to reduce infection during COVID-19 had a significant
impact on maternity and neonatal care for all who experienced it.
However, there may have been a particularly adverse impact for women and
families in vulnerable situations. In the UK, there was an
overrepresentation of pregnant Black and minority ethnic women admitted
to hospital with severe COVID-19 infection [4]. Moreover, based on
the views of national level stakeholders, the restrictions that were
introduced seemed to affect vulnerable women more than the general
population. For example, when women with low health literacy or with
communication difficulties were not allowed to be accompanied by a
companion during prenatal visits, the consequences were likely to be
greater than for those with better communication capacity [14]. Some
of the measures taken to prevent infection created inequities in
maternity care, and, potentially, increased risks for some [14]. It
is critical that measures taken to prevent one kind of harm in some
groups should not increase the risk of harm in other groups, or in other
outcomes [20].
Our findings highlight that service user (organisation) involvement in
decision-making and in the process of influencing policy is vital for a
functioning maternity and neonatal care system during a time of crisis.
In both countries, service user organisations played a key role in
advocating for all women and parents, including those with additional
needs or vulnerabilities. The documentary review highlights that service
user organisations put topics such as making exceptions for bereaved
families on the agenda of professional organisations. In the last few
decades, there has been increased attention placed on service user
(organisation) involvement in guidelines and research, which can
contribute to making policy more service-user centred, leading to a more
meaningful outcome for service users [21]. However, it has been
suggested that during the pandemic, service user involvement was
initially seen as a non-essential and time-consuming element of
guideline development [22]. This focus in the early days of the
pandemic was confirmed by some of the stakeholders interviewed in this
study. Genuine service user involvement requires a cultural change in
the production of healthcare guidelines during crises such as pandemics,
to ensure that women, birthing people, parents, and service user
organisations are seen as partners in decision-making and that women’s
and families’ needs are at the centre of decision-making, especially
when critical situations demand rapid responses that may result in
knee-jerk reactions from professionals and policy makers.
Finally, this study illustrates that local norms and values in the
maternity care system become magnified during times of crisis. For
example, in some regions, it was easier to maintain services for home
birth than in others. Home birth services were maintained in the NL but
stopped in 32% of UK regions. The NL has a long tradition of home
births, unlike the UK [23]. The decision to rapidly revert to
institution-based care in many UK settings might be reflective of a
dominant belief about the intrinsic safety of hospitals, even when they
may be a vector for infection, in line with wider UK rhetoric relating
to safety in maternity care [24]. This was despite the fact that
choice of birthplace and other personalisation issues are embedded
within UK maternity policy [25]. Given the contrasting move towards
maintaining or even increasing home birth in NL, as well as in some
regions of the UK, it may be that maintaining the capacity to offer a
range of choices to parents during a pandemic or similar crisis is
related to the prior organisation, beliefs and values of the maternity
care system, as much as with guidelines issued by national bodies.