Caring for the carers: Ensuring the provision of quality maternity care during a global pandemic

(1)

Caring

for

the

carers:

Ensuring

the

provision

of

quality

maternity

care

during

a

global

pandemic

Alyce

N. Wilson

a,b,

*

,

Claudia

Ravaldi

c

,

Michelle

J.L.

Scoullar

a,d

,

Joshua

P. Vogel

a

,

Rebecca

A. Szabo

e,f

,

Jane

R.W.

Fisher

g

,

Caroline

S.E.

Homer

a,h

a_Maternal,_Child_and_Adolescent_Health_Program,_Burnet_Institute,_Melbourne,_Australia b

NossalInstituteforGlobalHealth,SchoolofPopulationandGlobalHealth,FacultyofMedicine,DentistryandHealthSciences,UniversityofMelbourne, Melbourne,Australia

c

CiaoLapoFoundationforHealthyPregnancy,StillbirthandPerinatalLossSupport,UniversityofFlorence,DepartmentofNeurosciences,Psychology,Drug ResearchandChildHealth,Florence,Italy

d

DepartmentofPaediatrics,RoyalChildren’sHospital,UniversityofMelbourne,Melbourne,Australia

e_Royal_Women’s_Hospital,_Parkville,_Melbourne,_Australia

f_Department_of_Obstetrics_and_Gynaecology_and_Department_of_Medical_Education,_University_of_Melbourne,_Melbourne,_Australia g

DivisionofSocialSciences,PublicHealthandPreventiveMedicine,MonashUniversity,Australia

h

FacultyofHealth,UniversityofTechnologySydney,Australia

ARTICLE INFO Articlehistory: Received26March2020 Accepted26March2020 Availableonlinexxx Keywords: COVID-19

Maternitycareproviders Maternityservices

Emotionalandpsychologicalsupport Pandemicpreparedness

ABSTRACT

TheCOVID-19pandemicisimpactinghealthsystemsworldwide.Maternitycareprovidersmustcontinue theircorebusinessincaringandsupportingwomen,newbornsandtheirfamilieswhilstalsoadaptingto a rapidly changing health system environment. This article provides an overview of important considerations for supporting the emotional, mental and physical health needs of maternitycare providersinthecontextoftheunprecedentedcrisisthatCOVID-19presents.Cooperation,planning aheadandadequateavailabilityofPPEiscritical.Thinkingabouttheneedsofmaternityprovidersto preventstressandburnoutisessential.Emotionalandpsychologicalsupport needstobeavailable throughouttheresponse.Prioritisingfood,restandexerciseareimportant.Healthcareworkersareevery country’smostvaluableresourceandmaternityprovidersneedtobesupportedtoprovidethebest qualitycaretheycantowomenandnewbornsinexceptionallytryingcircumstances.

Introduction

ThenovelcoronavirusemergedinNovember2019asacauseof viralpneumoniathathassincespreadwidelyandbeendeclareda globalpandemic[1],cripplinghealthsystemsinthosecountries heavilyaffected[2].Theinfectiousagenthassincebeenidentiﬁed asSARS-CoV-2andtheassociatedinfectiondesignatedCOVID-19. To minimise community transmission, many countries have implemented travel restrictions and quarantine, ‘stay at home’ andphysicaldistancingmeasureswhilsthealthsystemsprepare forincreasingworkloadsanddecreasingresources.

Previous disease outbreaks have demonstrated health care workersareatparticularriskofinfection[3],primarilythrough

increasedfrequencyofexposurebutalsolikelyduetoexposureto increased viralloadfollowing particular health procedures and aerosolexposuretothevirus.Whilstthenumber(denominator)of thoseinfectedwithSARS-CoV-2islargelyunknown,earlystudies ofhealthcareworkershavereportedratesofinfectionfrom3.8%to 63%[4].TheDirector-GeneraloftheWorldHealthOrganization,Dr Tedros, recently said that ‘We can’t stop COVID-19 without protecting our health workers’ [5]. Long hours, irregular shifts and working outside the usual scope of practice are common experiences for health care workers during an emergency. Constantlychanging policiesandprotocols,resource limitations andtheneedtoreassureconcernedpatients,womeninmaternity systems and family members during uncertain times are additionalstressors.

Publichealthemergenciescanstretchandoverwhelmeventhe mostwell-resourcedhealthsystems.Healthcareworkersonthe front lineoften feel the bruntof theemergency response and ensuringtheirsafety,mentalandphysicalwellbeingisparamount.

* Correspondingauthorat:BurnetInstitute,85CommercialRd,Melbourne,VIC 3004,Australia.

E-mailaddress:alyce.wilson@burnet.edu.au(A.N. Wilson).

http://dx.doi.org/10.1016/j.wombi.2020.03.011

WomenandBirthxxx(2019)xxx–xxx

GModel

WOMBI1109No.ofPages4

Pleasecitethisarticleinpressas:A.N.Wilson,etal.,Caringforthecarers:Ensuringtheprovisionofqualitymaternitycareduringaglobal pandemic,WomenBirth(2020),https://doi.org/10.1016/j.wombi.2020.03.011

ContentslistsavailableatScienceDirect

Women

and

Birth

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Herewewillfocusonmaternitycareproviders andprovidean overviewof importantconsiderations in supportingtheir emo-tional, mental and physical health needs in thecontext of the unique and unprecedented crisis that COVID-19 presents. We know that implementing strategies is going tobe hard for all systemsbutespeciallylowtomiddleincomecountries.

Issuesformaternitycareproviders

Womencontinuetogivebirthwhichisusuallyatimeofjoybut canalsobeassociatedwithincreasedanxietyaswellasincreased riskofwellbeingdisturbances,bothduringpregnancyandafter birth [6]. Maternity service providers (including doctors, mid-wives,nurses and alliedhealth staff) must continue their core businessin caring and supportingwomen, newborns and their families,whilstalsoadaptingtoarapidlychanginghealthsystem environment due to COVID-19.Managing an infectious disease outbreakisanunusualeventformaternityprovidersandmany willfeeloutoftheir‘comfortzone’andburdenedbythepressureof managingnotonlynormalcareofpregnantwomenandcouples but also all their worries for COVID-19 pandemic and its consequences.

Therewilllikelybeasurgeinworkloaddespitethebestefforts torecruitextrastaff[7], shortenantenatalclinicvisittimes[8], move to telehealth and minimise non-urgent procedures and consultations.Providerswill needto make pragmaticdecisions aboutthe safest way toprovide quality care whilstconstantly adapting to system changes and resource limitations. The worldwideshortage of PPEequipment is alsoof great concern tohealthservicesandhealthcareworkers[3].

Anumberofnational[9]andinternationalguidelines[10]are alsonowrecommendinglimitingthenumberofbirth compan-ions,andtherearesomereportsthatwomenareinlabouralone [11]. Caring for women who are sad and anxious during pregnancyandin labour is challenging. Midwives anddoctors are likely to have their own inevitable sadness at having to support a practice that is contrary to their core practice principles.As a result of limited support people, the midwife mayalso betheonly personpresentwithwomenin themost crucialmomentsofbirthandduringtheirﬁrstencounterwiththe baby.Thiscanresultinanemotionalandrelationaloverloadeven inthemostexperiencedprofessional,particularlywhenadverse eventsoccur[12].

Maternityprovidersmayexperienceseveralsourcesofstress whilstmanagingtheoutbreak(Table1).Thesemayberelatedto infectioncontrol,riskof diseasetransmission,multiplemedical andpersonaldemandsandstigma[13].

Clearandconsistentcommunicationisessential

Duringanemergency,itisnormalforstressandanxietytobe elevatedamonghealthcareworkers.Providingregularandclear communicationandupdatesduringthistimeisessentialsothatall stafffeelinformedandcanpreparebothmentallyandphysically [14].Thespeedofthispandemicmeansthatthishasnotalways beenpossible,and guidance hasbeenchanging rapidly.This is equallystressfulandunsettling.

Therearemanythingsthathealthservicesaredoingtomanage andpreparefortheCOVID-19response.Physicalpreparationsmay includemodifyingthefacilitylayout,bedallocationsandpeople ﬂow.Movingtotelehealthservices,reducedcontactwithwomen andreducingvisitorstothehospitalarealsohappening.Staffmay alsoneedtomakepreparationsathomeforthecareoftheirown children and other relatives, and preparations for longer and irregularshifts.Thesehealthsystemchangesandadaptationsare

criticalatthistimeandarealreadyoccurringincountriesaffected byCOVID-19.

Maternity services need to relay up-to-date information to womenwhoarepregnantorhaverecentlygivenbirthandtheir families.Informationregardingwhenandhowpregnantwomen who have suspected or conﬁrmed COVID-19 will receive care duringpregnancy, labourandbirth isimportanttoaddressany uncertainties that may prevent people from seeking care. The infection control measures and the use of personal protective equipment (PPE) needs to be explained to women and their companions.Itwillbedauntingforwomenandtheirfamiliesto seehealth careproviders in fullPPE behindmasks, gownsand glovesandsoclearguidanceonwhenthiscanbesafelyminimised isimportant.

Considerationsforpreventingtransmission

Maternity providers have direct contact with women and babiesandasaresulthaveanincreasedriskofbothbeingexposed toandcontractingSARS-CoV-2.However,carefor pregnantand postnatalwomenandnewbornsisanessentialserviceandneeds to continue alongside the COVID-19 response [10]. Maternity services need to adapt to continue to provide antenatal and postnatalcareandconsideralternativemethodssuchas telecon-ferencingand videoconferencingtominimisetransmissionrisk, withconsiderationforthoseinself-isolation[10].

Maternityandnewborncareunitsfaceparticularchallengesin consideringspaceandstafﬁngneedswithinthefacilitytoprevent transmissionofSARS-CoV-2,whilstalsoenablingessentialsupport forwomeninlabourandbondingofmotherandnewbornafter childbirth. Considerations may include additional training and simulationsregardinginfectioncontrolpractices,useandhandling ofPPEandisolationofpregnantCOVID-19conﬁrmedorsuspected women[15].

Somematernityproviderswillbepregnantthemselvesandwill have an added level of concern about their own health and protectingtheirunbornbaby.TheUKRoyalCollegeofObstetricians andGynaecologists(RCOG)arenowrecommendingthat health-careworkerswhoaremorethan28weekspregnantshouldavoid direct patient contact [16]. It may be worthwhile reallocating pregnantmaternityproviderstolower-riskduties,workingfrom homeorallowingalternativeleavearrangements[9].

Of course, having access to appropriate PPE, appropriate preparedness training and monitoring of practices the risk of infectionforallmaternitycareprovidersisessential.Thisisagain newterritoryformany.PPEtrainingandsupport,notonlyonhow toputthemonand takethemoff, but alsoonhowtoprovide empathiccarewhilewearingthemisneeded.

Keepaneyeoutforstudents

Medical,midwiferyandnursingstudentsarebeingdrawnonto assist with the COVID-19 response. Several jurisdictions in Australiaandin othercountriesareworkingthroughwaysthat studentsmaybeabletoassistwithscreeningclinicsandcontact tracing.Weneedtotakeextracareofthesestudentswhoalthough areyettocompletetheirtrainingwillbeﬁndingthemselvesin positionsofresponsibilityandauthoritybeyondtheirusualscope ofpractice.Moreexperiencedcliniciansandhealthcareworkers willneedtolookoutfortheirsafetyandwellbeingandadvocatefor themasneeded.

Itisworthnotingthatseveralcountrieshavealsoconsidered drawingonretiredhealthcareworkerstoassistintheresponse. Retired doctors and nurses were recruited in Italy, which is problematicgiventhehighermortalityassociatedwithincreasing age.Atthetimeofwriting,thepopulationcasefatalityrateforItaly

2 A.N.Wilsonetal./WomenandBirthxxx(2019)xxx–xxx GModel

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is5.0%,but15.3%forthoseaged70–79years[17].Similarlyearly studiesinChinaindicatedahighercasefatalityrateforthoseaged 70–79at8%,comparedtoageneralpopulationcasefatalityrateof 3.6%[4].

Avoidingburnout

Asoutlined,maternitycareprovidersmayexperienceseveral sourcesofstress,andburnoutandsecondarytraumaticstressare serious risks for maternity providers in responding to this pandemic.Secondarystressmayincludefeelingsofstressresulting from exposure to another individual’s traumatic experiences, ratherthandirectexposuretothetraumaticevent[18].Burnout includesfeelings ofextreme exhaustion,beingoverwhelmedor becomingcynicalanddetached andmayonlybecomeapparent someweeksormonthsaftertheimmediateeventshavepassed, buthasanadverseimpactonsensitivitytotheneedsofwomen. Burnoutmayresultindecreasedrelationalskills,animpairmentof empathicskillsandanegativeorhastyapproachtotheneedsand fearsofwomenandcouples[12].

Health services need to be proactive in providing and encouragingsupportforstaffinanon-judgementalwaywithout fear of negative consequences. Burnout can be prevented or reduced,keepinginmindsomecrucialaspectsofpsychophysical well-being.Herearesomekeystrategiesformanagersandleaders toconsiderfromabriefreviewoftheliterature:

Workforce planning including reasonable shifts and rosters [18].

Havingworkforcepoliciesthatareproactiveaboutenablingand encouraging maternity providers to get plenty of sleep, eat healthyfoodsandexercise.

Developingcreativemethodstokeepyourstaffsafesuchasfood andself-care‘stations,’enablingexercisebreakswiththefacility. Havingregularopportunitiesfordebrie_ﬁngtoenableyourstaff toexpresstheirfeelingsanddiscusstheirexperiences.Thiscould includea‘buddy’system[18],toenableproviderstocheckinand

encourage each other, ensure adequate breaks and reinforce safetyprocedures [14]. Inexperienced providers maybe part-nered withmore experienced ones.Having regularaccess to psychologistsorcounsellorsislikelytobeimportant.

Providinginformationtoassistproviderstorecognisesignsof stressandburnout(fatigue,illness,fear,withdrawal,guilt)and strategiesforcopingcanhelpprovidersstaywell[18].

Managerswilllikelyneedextrasupportastheybalancetheir ownstressandtheneedtolead,guideandencouragethosearound them,withaparticularneedtoberole-modelsofself-care[14].

On anindividual level, there are things that we can alldo, including:

Tryingtoavoidtheuseofsmoking,alcoholandotherdrugsto dealwithstress[14].

Usingsocialmediaselectively—socialmediacanbeanexcellent source of information but equally can increase worry and agitation[19].

Accessing or seeking out support including psychologists or counsellorsasavailable.

Keepingconnectedwiththeworldoutsidethehealthfacilityand keepingintouchwithfriendsandfamilythroughonlinesystems ifthatistheonlymeans.

Recognisethatthistimewillpassandthatatanindividuallevel, everyoneisdoingtheirbestinextraordinarycircumstances. Bekindtoyourselfandtooneanother—ﬁndjoyinsimplethings

andlooktoabetterfuture.

It is important to recognise health care workers are often alreadyresilientandexperiencedindealingwithdifﬁcult circum-stances but will needadditional system orientatedsupports to reducetheirburden.Leaders,managersandindividualscanallplay aroleinimplementingstrategiesandsupportingoneanother.

Manyofthesestrategiesaregoingtobechallengingespecially asthebroaderhealthsystemisstretched.Thiswillbeevenharder inlowincomesettingswhereresourcesarealwayslimited.Adding

Table1

SourcesofstressformaternityprovidersduringCOVID-19responsea

.

Infectioncontrolmeasures Riskofdiseasetransmission

PhysicalstrainofPPE(skinirritation,dehydration,heat,exhaustion) Uncertaintyregardingimpactofillnessonmothersandnewborns(limiteddata), butstillneedingtoadvisewomenandtheirfamilies

Physicalisolation—practisingsocialisolationwhilstalsomaintaining healthcare.Isolatingfromfamilymembersathome,includingchildren

Fearsforpersonalsafetyandriskofinfection Constantvigilanceregardinginfectioncontrolmeasuresformultiple

people—women,newborn,companions,otherstaff

Tensionbetweenpublichealthstrategies,newguidelinesfortheinfectionsand desiresofwomenandtheirfamiliesregardingsocialdistancingandquarantine measures

Strictprotocolsandprocessesespeciallylimitingsupportinlabour

Multiplemedicalandpersonaldemands Stigma

CoreworkcompetingwithCOVID-19preparationandmanagement FearoftreatingwomenandnewbornswithCOVID-19 Preparationofmaternityunitstoreducetransmissionincludingincreased

trainingaroundinfectioncontrolmeasuresandPPEuseandhandling

Providers’stigmaaboutvoicingtheirneedsandfears Attemptingtomaintainongoingessentialservices

(antenatalandpostnatalcare)andhighqualitycareinthefaceof regularlychangingpoliciesandresourcelimitations

Fearsaboutinfection

Innerconﬂictaboutcompetingneedsanddemands

a

AdaptedformaternityprovidersfromManagingHealthcareWorkers’StressAssociatedwiththeCOVID-19[13].

A.N.Wilsonetal./WomenandBirthxxx(2019)xxx–xxx 3 GModel

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apandemicofthisproportionwillbeoverwhelmingandadditional supportandserviceswillbeneeded.

AfterCOVID-19

We are in the midst of an unprecedented public health emergencyimpactingallfacetsoflife.Whilstthispandemicwill pass, its impact will likely be tangible for years to come and adjustingtolifeaftertheCOVID-19responsemaybedifﬁcultfor somehealthcarestaff.Encouragingstafftocheckinand debrief with colleagues, seek support early, providing access to free counselling and psychological services and approving leave of absences to provide time for gradual reintegration into usual schedules may be helpful. If maternity providers experience several weeks of stress which interferes with work and life functioning,formalmentalhealthcareshouldbeencouraged[13]. Maternityprovidersneedtobesupportedtoprovidethebest qualitycare theycantowomenand newbornsin exceptionally tryingcircumstances.Cooperation,planningaheadand thinking about the needs of maternity providers to prevent stress and burnoutisessential,sothattheyinturncancontinuetocarefor women and newborns whilst managing the demands of the COVID-19response.AdequateavailabilityofPPEisacriticalﬁrst stepfollowedbytoporderprioritiesoffoodandrest[3].Emotional andpsychologicalsupportneedstobeavailableandencouraged before, during and after the response. In responding to this pandemic,healthcareworkersareeverycountry’smostvaluable resource[3]. Nowand overcomingmonths,thematernitycare systemwillfaceuncharteredterritoryasdoctors,midwives,nurses andalliedhealthstaffattempttoprovideusualqualitymaternity carewhilstjugglingcompetingdemandsrelatedtotheCOVID-19 pandemicresponse.

Author’scontributions

All authors contributed to the content of this manuscript. WilsonandHomerperformedthedraftmanuscriptandallauthors contributedtothemanuscriptandapprovedittobesubmitted. Funding

Nonedeclared. Ethicalstatement Nonedeclared. Conﬂictofinterest

Caroline Homer, as Editor in Chief, commissioned this commentary. As Co-Program Director of Maternal and Child HealthattheBurnetInstitute,shecontributedasanauthor.Asa commentary,itwasnotexternallypeerreviewed.

Acknowledgments

Weacknowledgethematernitycareprovidersworkingonthe frontlineandstandinsolidaritywiththemduringthisdifﬁculttime.

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