key: cord-0776775-tp14zzje authors: Stulz, Virginia M.; Bradfield, Zoe; Cummins, Allison; Catling, Christine; Sweet, Linda; McInnes, Rhona; McLaughlin, Karen; Taylor, Jan; Hartz, Donna; Sheehan, Athena title: Midwives Providing Woman-Centred Care during the COVID-19 pandemic: A national qualitative study date: 2021-10-14 journal: Women Birth DOI: 10.1016/j.wombi.2021.10.006 sha: 0dea45dafbe5c59fe16254b9aced91863ad8eba8 doc_id: 776775 cord_uid: tp14zzje Background The COVID-19 pandemic has caused isolation, fear, and impacted on maternal healthcare provision. Aim To explore midwives’ experiences about how COVID-19 impacted their ability to provide woman-centred care, and what lessons they have learnt as a result of the mandated government and hospital restrictions (such as social distancing) during the care of the woman and her family. Methods A qualitative interpretive descriptive study was conducted. Twenty-six midwives working in all models of care in all states and territories of Australia were recruited through social media, and selected using a maximum variation sampling approach. Data were collected through in-depth interviews between May to August, 2020. The interviews were recorded, transcribed verbatim, and thematically analysed. Findings Two overarching themes were identified: ‘COVID-19 causing chaos’ and ‘keeping the woman at the centre of care’. The ‘COVID-19 causing chaos’ theme included three sub-themes: ‘quickly evolving situation’, ‘challenging to provide care’, and ‘affecting women and families’. The ‘Keeping the woman at the centre of care’ theme included three sub-themes: ‘trying to keep it normal’, ‘bending the rules and pushing the boundaries’, and ‘quality time for the woman, baby, and family unit’. Conclusion Findings of this study offer important evidence regarding the impact of the pandemic on the provision of woman-centred care which is key to midwifery philosophy. Recommendations are made for ways to preserve and further enhance woman-centred care during periods of uncertainty such as during a pandemic or other health crises. The COVID-19 pandemic has caused isolation, fear, and impacted on maternal healthcare provision. To explore midwives' experiences about how COVID-19 impacted their ability to provide womancentred care, and what lessons they have learnt as a result of the mandated government and hospital restrictions (such as social distancing) during the care of the woman and her family. A qualitative interpretive descriptive study was conducted. Twenty-six midwives working in all models of care in all states and territories of Australia were recruited through social media, and selected using a maximum variation sampling approach. Data were collected through in-depth interviews between May to August, 2020. The interviews were recorded, transcribed verbatim, and thematically analysed. Two overarching themes were identified: 'COVID-19 causing chaos' and 'keeping the woman at the centre of care'. The 'COVID-19 causing chaos' theme included three sub-themes: 'quickly evolving situation', 'challenging to provide care', and 'affecting women and families'. The 'Keeping the woman at the centre of care' theme included three sub-themes: 'trying to keep it normal', 'bending the rules and pushing the boundaries', and 'quality time for the woman, baby, and family unit'. Findings of this study offer important evidence regarding the impact of the pandemic on the provision of woman-centred care which is key to midwifery philosophy. Recommendations are made J o u r n a l P r e -p r o o f Woman-centred care is a fundamental and identifying feature of midwifery practice borne from the professional philosophy of being 'with woman'. 1, 2 The provision of woman-centred care is embedded in the National Midwife Standards for Practice 3 and is the foundational construct of the most recent strategic framework for Australian maternity services. 4 Recent primary research and reviews have contributed to the understanding of the features that exemplify woman-centred care which include: adaptability to provide individualised care, facilitation of informed decision making, advanced communication skills encompassing listening and reflection, supportive presence including touch and modification of the environment to suit the woman, authentic relationships and respect, freedom for midwives to make choices, and self-determination, and evidence-based care. 5, 6, 7, 8 The strong emphasis on sophisticated and nuanced communication skills and physical proximity are founded in the provision of relational care that is centred on the woman and is inclusive of her partner and support people. 5 The restrictions as a result of the COVID-19 pandemic requiring physical distancing, personal protective equipment (PPE) which obscures facial expressions, as well as unprecedented limitations of numbers of support people, such as the exclusion of family and restrictions on the presence of the midwifery students who are providing continuity of care 9 are all changes that potentially impact on woman-centred care. Providing midwifery care whilst avoiding spread of the COVID-19 virus and meeting women's needs is an ongoing balance of priorities. As midwives continue to provide care for women in isolation and during periods of lockdown, the management and collaboration with multidisciplinary teams during the pandemic has required a greater coordinated approach. 10 It is therefore imperative that midwives continue to engage with other colleagues in a collaborative multidisciplinary way to address specific needs for childbearing women arising from the COVID-19 Pandemic. The pandemic has had a substantial impact on midwives' ability to provide usual midwifery care with the need to take on additional procedures aiming to reduce the spread of COVID-19. 10 These involve J o u r n a l P r e -p r o o f practising in different ways such as trying to maintain social distancing during face-to-face visits, replacing antenatal assessments with telehealth, and limiting postnatal care visits. 11,12 Other research has found that midwives have been confused with major discrepancies in guidelines between hospitals and the constant changing of the guidelines and the effect of COVID-19 on pregnant women. 13 Recent Australian research has shown that prior to the pandemic, midwives were facing both physical and emotional exhaustion, with high rates of stress and burnout, often related to their inability to provide woman-centred care within medical models. 14 Now, more than ever, social connectedness for the midwifery workforce is essential. 10 The study of midwifery practice during the Ebola epidemic in Sierra Leone may provide a comparison to midwifery during the COVID-19 pandemic. 15 In one study, 15 midwives' fear of becoming infected by the Ebola virus affected both their personal and professional lives. Some midwives hid the fact that they were working in an Ebola centre from their families as they did not want to heighten their anxiety, but felt obligated to contribute in their role as citizens of their country. Midwives believed that maternity care was severely hampered by infection control measures. 15 The midwives were working with limited guidelines that left them with ethical dilemmas about how to improve care for women, leaving them to make decisions about life and death autonomously. Midwives were motivated to use their creativity and competency to search for improved solutions for women's care under challenging circumstances; for example, innovations such as placing placentae in sawdust to avoid splashing of blood to reduce the spread of infection. Despite these limitations, midwives developed special relationships with their work colleagues including when caring for dying women. 15 Overall, it was reported that experiences during the Ebola outbreak resulted in midwives feeling better able to provide dignified and safe care for women and their families under exceptional circumstances. 15 There is therefore evidence that midwives strive to provide safe, woman-centred care even in difficult circumstances. During the early stages of the COVID-19 pandemic, widespread media J o u r n a l P r e -p r o o f reports highlighted variation in how preventative measures were implemented and interpreted around the world and their impact on women's care experiences. 16 Concurrently, a number of national and international surveys that aimed to elicit the general experiences of maternity care by women and families and by care providers were disseminated. 17, 18, 19, 20 This study has provided further evidence on how midwives navigated these variations in their efforts to provide womancentred care. A qualitative interpretive descriptive study 21 was conducted to describe how midwives provided woman-centred care during the COVID-19 pandemic. Guided by this approach, we (midwives) based and adapted our guiding questions for the in-depth interviews on the development of the Woman-Centred Care Scale -Midwife Self Report (WCCS-MSR) 8 Midwives were selected across all models of care (including standard public / private hospital care, midwifery group practice, publicly funded homebirth, and privately practising midwives), years of experience, and states and territories across Australia. To achieve this, participants were selected according to the maximum variation method as a form of purposive sampling. 22 We distributed a flyer with an expression of interest via social media networks and invited midwives via the Australian College of Midwives Facebook site. As we wanted a sample to address maximum variation sampling, midwives were asked brief demographic details in the expression of interest and notified that they may not necessarily be invited to participate in an in-depth interview. Forty-seven midwives responded to the expression of interest. The sampling strategy resulted in 31 being selected and those midwives were sent an information and consent form. From the 31 midwives, 26 were interviewed, one midwife changed her mind and four did not respond to the offer for interview. The 26 midwives interviewed represented a diverse sample, from every state and territory in Australia, every model of care, and from one to 40 years of midwifery experience. Data were collected by in-depth interviews conducted via phone, Zoom, or Skype at the participants' choice and interviews lasted between 20 to 70 minutes. The first author interviewed 23 of the midwives and three of the other authors interviewed one midwife each. All the interviews were recorded and transcribed verbatim. The data were analysed to provide description of the data with as much richness as possible, and interpretation with ongoing reflection about what this data conveyed. As the first author conducted most of the interviews, the author was able to build a solid and coherent line of inductive reasoning by connection of ideas throughout the midwives' stories. 21 The first author analysed seven of the interviews and each of the other authors J o u r n a l P r e -p r o o f analysed between two to three interviews each. The constructions of the data were framed around the guiding questions which were asked of every participant. Open codes were created for all the interviews to enable organisation of the data collected into a manageable form. 21 Initially, the first author identified the key themes that related to all these codes and then the first and last author themed the entire set of interviews together, enabling constant reflection that entailed an iterative reasoning process that identified the implications of aligning ideas in various ways. In this way, the authors were able to make sense of the ideas that were core to what we were studying. This analysis enabled scaffolding that supported the goal of this study. 21 These codes were analysed and reanalysed, until a final consensus was reached between the two authors following many reiterations. This final step led to a thematic summary that was agreed upon by the two authors in alignment with a qualitative interpretive descriptive study. 21 This final feedback was sent to all of the authors to check agreement on the final overarching themes and sub-themes. As all of the authors were midwifery academics, this placed the researchers in a position to side with the midwives' views and perceptions, that could have reflected on the research study's findings. Reflexivity enabled the researchers to stand back and look at our thinking and why we chose those particular themes and sub-themes. The high number of authors also discussing and agreeing on the findings provided a level of rigour to our study. Ethics approval was first gained from the primary researcher's institution (H13846) with reciprocal approval gained from the universities of all other authors. Twenty-six midwives were interviewed from May to August, 2020. All states and territories of Australia were represented in the sample. Midwives worked in all models of care. Participants had J o u r n a l P r e -p r o o f between one to 40 years of midwifery experience. Table 1 demonstrates the characteristics of the midwives in our sample. The For midwives, the COVID-19 pandemic was a quickly evolving situation that required regular policy changes. These changes resulted in midwives constantly adapting to new management decisions which were at times driven by misinformation and fear. The midwives worked in environments that were confusing, as management were making decisions that were not perceived to be evidencebased and incongruent with best practice. Responses to the COVID-19 pandemic initiated changes that were being instigated almost every few hours to a daily basis. As these midwives described: Other services were affected, resulting in antenatal classes being changed from face-to-face to online platforms, or in some cases stopped. Education was often delivered ad hoc using online methods that included Zoom classes or short videos. but some did not 'we were not allowing any students into the clinic, or if they were a continuity of care student, they were not even allowed to attend the labour and birth'. (P21) Some midwives advocated to retain the student in the woman's care as a means of providing woman-centred care, however, women would sometimes ultimately have to prioritise their friends and family over having a student present. Midwives found it challenging to provide care as they quickly had to change from all face-to-face home visits or appointments to a hybrid model that also included phone calls. This required reorganisation and negotiation with other health professionals and administration staff about how J o u r n a l P r e -p r o o f best to provide and plan their care for women. Without face-to-face contact, midwives found it challenging to build rapport and properly inform women, especially those women with vulnerabilities, and for whom English was not their first language. The changes required for midwives to revert to using telehealth services was perceived by the midwives as a barrier to providing woman-centred care. Midwives were implementing other COVID-19 measures and were very conscious of cleaning and sanitising all the equipment in use but felt that wearing a mask was a barrier to establishing calm connections with the women and were reluctant to request that women come into the hospital. Some midwives found it difficult to communicate with women without having access to appropriate telehealth resources, and different communication platforms were not supported by management. Other midwives found the extra technology that they were using quite challenging, especially with connection problems and even though Zoom meetings were useful, the way midwives were communicating was different. Midwives reported challenges building rapport with the woman's family that affected how they Midwives who were working in continuity of care models were protective and supportive of womancentred care as they were able to be more flexible and autonomous. Midwives described bending the rules and pushing the boundaries to ensure that women received quality care that was woman-centred. They worked around the system to ensure that women could still achieve what they wanted, despite the fear of the pandemic. We broke all the rules and had two support people in labour. Spending the extra time with the women and trying to reassure them that they're safe and their babies are Midwives were passionate about supporting the women and continued to practise in accordance with evidence-based guidelines, especially when there was still so little known about COVID-19. They wanted to support women with their decisions to ensure their pregnancy and birth were not compromised. Just contacting women, a lot more than I usually would between appointments and just texting or calling and saying, just checking in, making sure you feel like you've seen us enough. (P3) Midwives were also very conscious of meeting the women's cultural needs to ensure that their loved ones and support people were included in their care. This study is the first to explicitly explore midwives' experiences of providing woman-centred care during the COVID-19 pandemic. Factors that have hindered and enabled woman-centred care have been described. Midwives reflected on the rapid and radical changes to the provision of maternity care necessitated by the global pandemic. The frustration, confusion, and anxiety related to the frequent changes that were described by midwives in our study has been confirmed in professional commentary 23 and in the findings of an Australian cross-sectional study with 620 midwives and an Australian qualitative study about women's experiences that explored the impacts of COVID-19related service changes to maternity care. 17, 24 Midwives in our study described the move to telehealth services as disruptive and a barrier to woman-centred care. Findings from a recent Australian study of 3364 women revealed that more than half of the participants had experienced a move to telehealth for antenatal or postnatal care during the pandemic, which left them feeling deprived of their anticipated maternity experience. 12 Globally, a move to telehealth for antenatal and postnatal care has also intersected with reports of an overall reduction in the number of visits provided to women. 25 A recent scoping review has revealed that these changes are likely to come at the expense of quality care. 25 Further research is recommended to explore the impact of the provision of maternity care via telehealth services which would provide essential evidence regarding ways to support and care for women during the current and future health crises. The system-orientated policies that required women to be separated from their families including partners, support people, and children impacted midwives' provision of woman-centred care. Midwives described the challenges of providing care to women when they were unable to be attended by their loved ones or supported by their extended family members. The perspective of partners and support people was recently explored in a study that surveyed 44 partners and support people who reported feelings of isolation, psychological distress, and a sense of missing out. 26 A qualitative study of women's experiences of becoming a new mother during the pandemic in Australia also reiterated the distress that was caused to women through the required separation from their support people. 27 Further research into the impact of separating women from their support people during the important childbearing period warrants further exploration. Strategies to provide inclusive care such as 'family -bubbles' that limit repeated entry and exit from health services, rapid testing, enhanced PPE provision and environmental modifications have all been suggested. 28 If, during acute periods, in-person support is not possible, then virtual attendance and J o u r n a l P r e -p r o o f support should be facilitated at a minimum to preserve the opportunity for sharing of significant experiences between women and their partners. COVID-19 also impacted midwives' ability to support students in how they continued to provide their continuity of care experiences. Students are required to complete a mandated number of continuity of care experiences as a requirement of their midwifery education in Australia. 29 Continuity of care experiences in midwifery education are also practised (but not necessarily mandated) in other countries such as Canada, Indonesia, the Netherlands, New Zealand and Norway. 30 During the pandemic in Australia, midwifery students were able to complete their continuity of care experiences despite having some form of restrictions during their clinical placements. 9 However, some institutions excluded students from their continuity of care experiences and midwives navigated the system by knowing what team leader midwives would include and accommodate the students, enabling some students to participate in their continuity of care experiences. 9 Women's satisfaction of being with a student in a continuity of care relationship has been measured as high with women valuing the opportunity to spend their time with a familiar caregiver during their childbearing experience. 31, 32 Ensuring midwifery students continue providing continuity of care is important during pandemics when women are unable to have other support people present. 9 As practising midwives provide role models, if woman-centred care is not routinely practised, midwifery students do not learn how to be involved in woman-centred care. 7 This can be problematic, to be able to prepare students for their future roles as midwives, especially during a pandemic. The current study found that some midwifery continuity of care models were reduced or cut back with no explanation as to why this decision had been made as a way of improving the COVID-19 situation. Midwifery continuity of care improves clinical outcomes for mothers and babies, 33 provides personalised care and trust through the midwife-woman relationship and increases women's satisfaction with their care. 34 Consequently, midwifery continuity of care should be J o u r n a l P r e -p r o o f available to women when they are experiencing changes to maternity care that include not being able to have selected people present, feeling overlooked and under-informed, and experiencing a lack of woman-centred care. 12 Midwifery continuity of care is an important model to ensure woman-centred care and is articulated in the international definition of a midwife. 35 Our study found midwives felt it was challenging to provide quality care to women during the early months of the COVID-19 pandemic. Some described an increased workload as a result of antenatal classes being cancelled, unclear messaging from their managers and inconsistencies of practice and PPE-wearing amongst colleagues. Excessive midwifery workloads have been known to lead to burnout and staff leaving the profession. 36 In particular, midwives have demonstrated that a lack of autonomy and a medicalised workplace further impact their ability to provide quality care to women. 14 Within a workplace environment with existing staff shortages, the knee-jerk reactions resulting in many of the policy decisions that impacted midwives during the pandemic could have future devastating results for the retention of the Australian midwifery workforce. Given the pandemic will likely have ongoing implications, certain COVID-19-related policies that are not woman-centred may remain in place for the foreseeable future, such as wearing of PPE and restriction of support people. Despite these challenges, midwives in our study tried to practise by keeping everything as normal as possible, which provides take-home lessons for the future. Midwives in this study were aware that many of the new policies appeared to be implemented as 'risk management' strategies to limit viral transmission. The possible consequences of introducing non-evidence-informed maternity policies have been discussed by some researchers who state, 'The loss of key evidence-informed aspects of safe, quality care will have long-lasting consequences for individuals, families, and wider society'. 37 As the restrictions placed on maternity care facilities have heightened during the COVID-19 pandemic, it is now more important than ever to warrant that restrictions in clinical practice are aligned to evidence-based recommendations. 38 Risk averse policies also promote the possibility of further centralisation of services and limitations on women's J o u r n a l P r e -p r o o f options for maternity care, including woman-centred midwifery-led continuity of care models. However, midwives in our study showed creativity in their practice, as shown in the sub-theme, In order to accommodate women's wishes, midwives juggled to provide woman-centred care as well as adhere to the ever-changing policies in their workplaces. It was apparent that midwives with more autonomy in their roles, such as those in midwifery group practice models, were more able to adapt their practice to suit women's needs than midwives working in standard hospital based shift work models. This type of midwifery practice has been discussed many years ago by one author who described midwives 'doing good by stealth'. 39 In our study, one example of bending the rules was spending more time with women than the new policy stated, especially in relation to helping to establish breastfeeding. Overall midwives described providing strong advocacy for women during the early months of the COVID-19 pandemic, which although embedded into the Australian midwifery code of conduct, 40 sometimes was at odds with institutional non-woman-centred policies. Even though this sample of 26 midwives provided a diverse sample of midwives' experiences practising in Australia during the COVID-19 pandemic in 2020, the findings may not be representative of midwives practising during the Delta strain of COVID-19 in 2021 and across the globe. A strength of this study is the collaborative analysis process and team discussion to agree on final themes. The relevance of woman-centred care to the provision of midwifery care has been previously emphasised. Descriptions from the diverse cohort of midwives in our study provide unique insights into the impacts of the rapid and radical changes and the challenges to the provision of maternity care on the provision of woman-centred care in Australia. These novel findings facilitate an understanding of ways that philosophically-aligned midwifery care may be sustained during the J o u r n a l P r e -p r o o f pandemic and potentially during other periods of health crises. Midwives in our study continued to provide woman-centred care by trying to keep everything as normal as possible and by bending the rules and pushing the boundaries to enable the provision of safe and quality midwifery care. Australian College of Midwives Midwives being 'with woman': An integrative review Nursing and Midwifery Board of Australia. Midwife Standards for Practice Woman-centred care: Strategic directions for Australian maternity services. Canberra: Department of Health Midwives' perceptions of being 'with woman': a phenomenological study Woman-centred care: An integrative review of the empirical literature ISeeYou': A womancentred care education and research project in Dutch bachelor midwifery education Development of the Woman-Centred Care Scale-Midwife Self Report (WCCS-MSR) A cross sectional study of midwifery students' experiences of COVID-19: Uncertainty and expendability Midwives in a pandemic: A call for solidarity and compassion A double-edged sword-telemedicine for maternal care during COVID-19: findings from a global mixed-methods study of healthcare providers Australian women's experiences of receiving maternity care during the COVID-19 pandemic: A cross-sectional national survey a qualitative case study of the experience of Belgian . medRχiv 2021 Midwifery workplace culture in Australia: A national survey of midwives Midwives' experiences of caring for pregnant women admitted to Ebola centres in Sierra Leone Pregnancy and Perinatal Outcomes of COVID-19) Pneumonia: A Preliminary Analysis Midwives' experiences of providing maternity care during the COVID-19 pandemic in Australia International Year of Midwifery-In the midst of a pandemic Adaptation of independent midwives to the COVID-19 pandemic: A national descriptive survey COVID-19. The new normal for midwives, women and families Interpretive description: qualitative research for applied practice Qualitative Research and Evaluation Methods: Integrating theory and practice The impact of covid-19 on midwives' practice in Kenya, Uganda and Tanzania: A reflective account Australian women's experiences of receiving maternity care during the COVID-19 pandemic: A cross-sectional national survey Restructuring maternal services during the covid-19 pandemic: Early results of a scoping review for non-infected women Receiving maternity care during the COVID-19 pandemic: Experiences of women's partners and support persons Becoming a mother in the 'new' social world in Australia during the first wave of the COVID-19 pandemic Improving provision and experiences of maternity care during the COVID-19 pandemic -lessons from the COVMAT study Acknowledging the primacy of continuity of care experiences in midwifery education Continuity of Care Experiences' within preregistration midwifery education programs: A scoping review Women's experiences of having a Bachelor of Midwifery student provide continuity of care Evaluation of a Student-led Midwifery Group Practice: A woman's perspective Midwife-led continuity models versus other models of care for childbearing women Continuity of care by a primary midwife (caseload midwifery) increases women's satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial Revised and adopted at Toronto Council meeting Australian midwives' intentions to leave the profession and the reasons why Sustaining quality midwifery care in a pandemic and beyond Balancing restrictions and access to maternity care for women and birthing partners during the COVID-19 pandemic: the psychosocial impact of suboptimal care The culture of midwifery in the National Health Service in England We would like to thank the midwives who gave up their time to participate in the interviews.Christine Catling -Conceptualisation, methodology, data collection, data interpretation, formal analysis, writing, reviewing, editing.Karen McLaughlin -Conceptualisation, methodology, data collection, data interpretation, formal analysis, reviewing, editing.Jan Taylor, Donna Hartz -Conceptualisation, methodology, data interpretation, formal analysis, reviewing, editing.Athena Sheehan -Conceptualisation, methodology, data collection, data interpretation, formal analysis, reviewing, editing. Linda Sweet and Allison Cummins have editorial duties with this journal. To reduce any real or perceived conflict of interest, neither of them had a role in the processing or peer review of this paper. Ethics approval was obtained from Western Sydney University Human Research Ethics Committee, reference number H13846 with reciprocal approval gained from the universities of all other authors.Midwives were offered to participate in the study and assured of the voluntary nature of the research, the ability to withdraw, maintenance of confidentiality and written consent was obtained from those willing to participate. Virginia Stulz -Conceptualisation, methodology, recruitment, data collection, data curation, data interpretation, formal analysis, writing, reviewing, editing. Zoe Bradfield, Allison Cummins, Linda Sweet, Rhona McInnes -Conceptualisation, methodology, data interpretation, formal analysis, writing, reviewing, editing.