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.