Responding to COVID in a midwifery setting in South Australia
Midwife Julie Tucker, from Lyell McEwin Hospital in Adelaide, provides a snapshot of changes made to maternity care as a result of COVID-19.
The COVID-19 pandemic led to rapid and ongoing changes to maternity care. The speed of change resulted in frustration, uncertainty and fear in our community. However, midwives, like other health professionals, stayed strong and used their skills to care for their patients and develop new strategies to deliver care. It was a stressful time for staff and the people in our care. However, the direct and emerging unknown threat of COVID-19 resulted in a focused approach to prioritise services and redirect resources in the acute-care setting.
A collective opinion from colleagues working within the maternity setting of a large tertiary facility — who provided care to women and families across the pregnancy and birth continuum — has been sought to better understand the impact of the pandemic.
Communication is key
Effective communication is paramount, especially in a crisis. Centralised communication from the hospital’s emergency management team provided updates regarding changes to care delivery, and acted as a consistent source of information and ongoing reassurance for staff, women and their families.
A snapshot of key changes is included in Table 1. Whilst not exhaustive, the list reflects how changes were viewed by the midwives providing care on the front line.
An immediate reduction in the footprint across the hospital involved focusing attention on those requiring direct physical care, installation of a central point of entry and flow of visitors, screening women and their families for COVID-19 symptoms prior to face-to-face care and limiting support people across all maternity areas.
Changes were made to available seating in outpatient departments (OPD) to meet social distancing standards, and the number of antenatal appointments was reduced. Face-to-face appointments were limited to women in at-risk groups and general OPD antenatal care kept to a minimum. Phone interpreter services replaced face-to-face services; however, these services were often underresourced and overburdened by the increased demand by all health services within the state.
The emergency management team was tireless in its review of guidelines at a state and local level to keep health workers safe in acute and community settings. Fit testing and safe wearing of masks, hand hygiene and social distancing were constantly reinforced, with increased use and management of personnel protective equipment, and a focus of resource provision to acute settings. Many supportive services were reduced to a minimum, or ceased (Table 1).
Antenatal care changed to incorporate teleconferencing/phone consultation, especially at the first appointment. This increased the need to review how women received pathology forms and their SA Handheld Pregnancy Record. Teleconferencing/phone consultations provided a whole new world in understanding the important skill set required to assess women with little or no visual clues. The added complexity of domestic violence/mental health screening was a particular concern.
Changes in birthing and postnatal care mainly involved reductions in support people for labouring women, as well as the cessation of nitrous oxide.
Response to change
The wearing of masks in daily practice posed a challenge — not just the physical discomfort but the veiling of visual cues and impact on the spoken word, particularly for those with learning difficulties or whose first language is not English.
Midwives noted the reduction in opportunistic screening and ability to build face-to-face relationships with women. Our hospital is situated within an area of poor social determinants of health, where opportunistic screening and care is of value — it is difficult to observe the true impact of changes to service delivery at this stage.
Overall, women were supportive of changes to keep themselves, their babies and their families safe. There was an appreciation by women and the public for the rapid response to change and diversifying the delivery of health care by midwives.
Midwives identified that the main concerns affecting women included effective communication, access to resources, services and fear (Table 2).
The reduction in services and support was identified as a source of stress and anxiety for women, with an increase in some women looking at different care options, including home birthing (Table 2). This is supported by a survey undertaken by the Australian College of Midwives (ACM), which examined women’s experiences during the pandemic, finding that 30% of respondents reconsidered their care provider and/or birthing venue, with trends towards women accessing private care and home birthing.1 The ACM study also reported that women felt isolated and unsupported by the evolving changes, leading to increased anxiety and concerns for their mental health and wellbeing.1 These findings were similar to those observed by midwives working within our health setting.
Preferences for patient consultations were mixed. Telehealth consultations reduced the risk of infection and many women noted the advantage of not needing to bring all their children to appointments. However, for some, physical attendance at appointments was important for seeking health advice and reassurance.
Although locking down hard and fast caused frustration and anxiety, there was recognition that it ultimately kept staff and women and their families safe. The focus was meeting people’s care in the new environment, in line with national professional nursing and midwifery standards.2
Table 3 outlines points for consideration moving forward. Certain changes had beneficial outcomes. For example, with the reduced footprint in the acute setting, midwives could help women with breastfeeding and parenting skills at the optimal time and there were more opportunities for 1:1 education. Often postnatal wards are busy places with many visitors, making this quality time difficult to achieve in the short window of opportunity in the acute setting.
For some, telehealth remains a difficult option, particularly in cases where a physical examination might be needed. In some cases, women have been unable to undertake telehealth calls due to limited internet access and data, limited capability to use telehealth resources or barriers relating to cognition, dexterity, language and culture. Additionally, people from low socio-economic areas may not have access to the devices or video platforms needed for a video or phone call. Populations at high risk of domestic violence or mental health concerns may be at greater risk of harm using these aspects of care. Moving forward there is opportunity to explore how we screen individuals and the criteria for care options, whilst placing the person at the centre of care.
Although the community lockdown and reduction in the footprint within the healthcare environment resulted in the reduction or cessation of many services, we were able to continue community services (although minimised) and return to normal community services as quickly as possible after the first lockdown. Fragmentation from the social fabric in which we live causes anxiety, and people unable to seek the support, care or information they need can result in anxiety and fear. The ACM (2020) survey put forward the question of whether the model of midwifery care can be reviewed to support women’s needs, whilst still maintaining safety for all. This included the development and provision of birth centres as a compromise between hospital and home.1 Additionally, there is a need to review community services and integration of care during future pandemics, the level of risk for communities with poorer social determinants of health and an increased need for these services to continue to provide safe care rather than just shutting down and further isolating people.
Further evidence-based research is required to review the impact of COVID-19 on all maternity settings including community services to inform safety in future pandemics and delivery of care.
- Cooper, M & King, R (2020). Women’s experiences of maternity care in the height of Covid 19 pandemic in Australia. Australian college Midwives https://www.midwives.org.au/news/womens-experiences-maternity-care-height-covid-19 web page access 22.3.2021
- Nursing and Midwifery Board of Australia (NMBA)(2021) webpage update Covid 19. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/COVID19-guidance.aspx
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