key: cord-1004297-som5k0l9
authors: Altman, Molly R.; Eagen‐Torkko, Meghan K.; Mohammed, Selina A.; Kantrowitz‐Gordon, Ira; Khosa, Rue M.; Gavin, Amelia R.
title: The impact of COVID‐19 visitor policy restrictions on birthing communities of colour
date: 2021-07-30
journal: J Adv Nurs
DOI: 10.1111/jan.14991
sha: 02e0d7e99840cfce6c70a04a8042d5068423324c
doc_id: 1004297
cord_uid: som5k0l9

AIMS: To explore the experiences of care for pregnant and birthing people, and the nurses who cared for them, during the COVID‐19 pandemic, with special emphasis on the impact of visitor restrictions policies. DESIGN: Qualitative study using critical thematic analysis. METHODS: We conducted semi‐structured interviews with 15 community members who were pregnant and/or gave birth and 14 nurses who worked in the perinatal setting between April and August 2020. Participants were recruited via purposive and snowball sampling, and interviews were conducted virtually via the Zoom platform. The research team used critical thematic analysis methods informed by other interpretive methodologies to arrive at resultant themes. RESULTS: Participants described experiences pertaining to how visitor restriction policies are not equitable and disproportionately impact Black, Indigenous, and People of Color (BIPOC) families, and the direct impacts of not having support people, and also provided recommendations for how to adapt current policies to be more equitable. CONCLUSIONS: Visitor restriction policies have had a disproportionately harmful effect on BIPOC patients and families, leading some patients to make decisions that increase their physical risks to alleviate their risk of labouring and birthing without desired support. IMPACT: While this pandemic is nearing the end, these results can guide structuring of policy not only for the next pandemic, but also for universal policy development. Mitigating the effects of racism in policies, by including diverse stakeholders in decision‐making, should be an inherent part of hospital administration procedures.

a widespread cultural norm. The perceived need for hospitals to reduce visitors to prevent spread of COVID-19 brought an abrupt end to this support system. The visitor policies varied from place to place and setting to setting-and sometimes even day to day-from no visitors at all in New York City at the height of the outbreak (Caron & Van Syckle, 2020) , to few or no restrictions on visitors in states with limited responses to the pandemic. However, a common model was to limit the birthing person to one visitor, generally the other parent, and perhaps a doula (trained labour support person) Saiman et al., 2020) .

Although visitor policy restrictions may be an effective way to reduce COVID-19 exposure potential from 'non-essential' persons in the hospital, the restrictions failed to take into account the role that visitors and support people played in the safety and well-being of birthing people, particularly Black, Indigenous, and People of Color (BIPOC). All of these communities already report experiencing significant bias and discrimination in accessing healthcare (Alhusen et al., 2016; Altman et al., 2019; Davis, 2018; McLemore et al., 2018) . Indigenous, Hispanic, and Black women are twice as probably as White women to report mistreatment by maternity care providers (Vedam et al., 2019) . Mistreatment includes being shouted at, ignored, or refused or delayed response to a request for help. Doulas and other support people can help recognize and counteract bias and mistreatment of birthing people (Wint et al., 2019) . Given the disparate impact of COVID-19 on marginalized communities, the intersectionality of existing racism with responses to the COVID-19 pandemic needs to be assessed (Lemke & Brown, 2020; Niles et al., 2020 ).

The purpose of this multidisciplinary, qualitative study was to explore the experiences of care for pregnant and birthing people, as well as for the nurses caring for them, during the COVID-19 pandemic. The main results from this study examined how the changes in the healthcare system due to COVID-19 pandemic impacted both patients and nurses in the perinatal setting (Altman et al., 2021) . In this analysis, we sought to specifically examine the role of visitor policy restrictions on the experiences of perinatal care for the birthing person using both patient and nurse perspectives.

This in-depth qualitative study used thematic analysis approaches (Braun et al., 2014) for its ability to exemplify the patterns of experience while keeping the focus of analysis closer to the shared participant experience rather than the researcher interpretation.

Braun and Clarke also provide space for data to be viewed in context (i.e. power, privilege), making it a well-fitting methodological structure for this study. As a way to further strengthen the contextual understanding of data in power structures, we also used Lawless and Chen's (2019) guidance on critical thematic analysis as well as author expertise from a broad range of qualitative backgrounds including discourse analysis, ethnography and grounded theory.

The two participant groups (patients and nurses) were recruited between April and August 2020 using targeted and snowball recruitment strategies via a state-wide social media group dedicated to birth professionals. Specifically, two recruitment requests were placed via this social media page: for birth professionals to share study recruitment information with patients and community, and for nurses practicing in the perinatal setting. Interested individuals were screened on expressing interest, with recruitment flyers explicitly prioritizing BIPOC patients and nurses to assure a diverse representation of participants. Inclusion criteria for patient participants included either being pregnant during or had given birth in Washington State since March 2020; criteria for nurse participants included actively working in a perinatal setting (inpatient or outpatient) since March 2020.

Recruitment continued until emerging concepts were deemed complete and described fully by the research team.

Virtual, semi-structured interviews were conducted between April and August 2020 via the Zoom platform by three members of the research team, with audio and video recordings captured after verbal consent was obtained. Audio recordings were professionally transcribed and transcripts were reviewed for accuracy and de-identified by the lead researcher. Interviews were open-ended, approximately 1 hour in duration, and guided by prompts when necessary, with the initial prompt directed to elicit the participant's experiences of care (or providing care) during the pandemic (interview guides included in Tables 1 and 2) . Demographic variables such as racial/ethnic, sexual and gender identities were all self-described by participants prior to starting the interview.

Participants were provided $50 as remuneration, and human subjects research approval was obtained through the University of Washington Institutional Review Board. Participants were provided a consent information sheet prior to their interview, which was then reviewed with the participant with opportunity to ask questions before initiating recording. As part of this information sheet, participants were offered mental health and emotional support resources if needed, and reminded that they can stop the interview at any time. After each interview, the interviewer offered an opportunity to debrief without recording to address anything that may have surfaced for the participant during the interview process.

The research team used critical thematic analysis as the main methodology for this study (Braun et al., 2014; Lawless & Chen, 2019) , with additional methodological techniques from critical discourse analysis and situational analysis (Clarke, 2003; Powers, 1996) overlayed as part of the group analysis process to ensure rigor and reflexivity. The lead researcher performed inductive coding on all transcripts, with additional members of the team also reviewing transcripts using individually oriented interpretive qualitative methods to add context and deeper understanding to resultant codes and constructs. Each transcript was then reviewed as a team, resulting in a group analysis memo. Themes were constructed from triangulating the initial coding and group analysis memos, with exemplar quotes identified through this process.

The COREQ guidelines were followed in the development and conduct of this qualitative study (Tong et al., 2007) . The research team was comprised of researchers with expertise in qualitative methods, health disparities, racism and discrimination and intersectionality, with three of six researchers identifying as BIPOC, all of which contributed to the context and positionality held for this study. Rigor was maintained via frequent team meetings, group memos with a process for reaching consensus on themes and constructs, triangulation between the participant and nurse themes, and the use of processes from several qualitative methods to capture multiple perspectives and understandings (Braun et al., 2014; Clarke, 2003; Powers, 1996) . The inclusion of a BIPOC community member with lived experience both personally and professionally as an advanced practice nurse as part of the research team also strengthened the methodological approach, providing avenues for input from those in and caring for the affected communities.

Overall, we obtained a diverse sample of both patients and nurses, with 60% of the patient sample (9 of 15 total participants) and 43%

of the nurse sample (6 of 14 total participants) identifying as people of colour, with diverse gender identities and sexual orientations included. Of the patient participants, the majority (60%) were experiencing their first pregnancy and birth and 40% were pregnant at the time of the interview. Nurse participants had on average 7 years of registered nursing work experience and 6 years of experience in perinatal care (Table 3 ).

The following themes were identified as related to the policy restrictions enacted in hospital settings due to the COVID-19 pandemic: Policies are not equitable and disproportionately impact BIPOC families, restricting visitors has a profound impact on the experience of pregnancy and birth, and recommendations for centering community in policies.

Both patient and nurse participants clearly described a disparate im- White/Caucasian 6 (40) 8 (57) Asian b 3 (20) 2 (14) Latinx 1 (7) 3 (21) Indigenous 1 (7) 1 (7) Gender Man (transgender) 1 (7) 0 (0) Woman 14 (93) 14 (93) Non-binary/genderqueer 0 (0) 1 (7) Sexual orientation Straight/heterosexual 13 (86) 12 (86) Queer 1 (7) 1 (7) Bisexual/pansexual 1 (7) 1 (7) Geographic location 

Both patient and nurse participants described multiple impacts from not having the desired support systems available for labour and birth. One impact described repeatedly was a loss of agency and support needed during a transformational family event like child- 

The majority of participants, both nurses and community members, advocated for visitor restriction policies to be flexible and able to be altered to fit particular patient needs. A Southeast Asian nurse participant shared support for the rationale behind visitor policies, but a need to change the policy to support patients on an 

Our study highlighted multiple impacts from visitor policy restrictions due to the COVID-19 pandemic on patients, particularly those from marginalized communities. By restricting visitors, many BIPOC patients had their support networks disrupted, reducing sources of advocacy and protection from racism and mistreatment in the hospital setting. In addition, nurse participants highlighted how these policies were biased in nature and likely contributed to furthering health disparities in BIPOC communities. Visitor restriction policies were one vital concern among other failings seen in the health care system's response during the COVID-19

pandemic, such as adaptations to care delivery that did not meet patients' needs, an unmet need for additional support and mental health resources, and inconsistencies in policies and procedures that frayed trust between nurses and institutions (Altman et al., 2021) .

Recognizing the important role of advocacy that support people provide for BIPOC communities is present and confirmed in the existing literature. Racism and discrimination are widely recognized as barriers to pregnancy and birth care in the hospital setting (Alhusen et al., 2016; Altman et al., 2019; Davis, 2018; McLemore et al., 2018) . Forcing patients to choose one person, who often is a partner and not always the primary source for support and advocacy, limits their ability to get what they need from their providers in their care (Simon et al., 2016) . The role of support people is often seen as an essential safety measure, not just a comforting presence, in which the presence of another person may make a significant difference in how the patient experiences their care (Davis, 2018; Wint et al., 2019) . The restriction of visitors likely plays a role in exacerbating disparities in experience of care for BIPOC patients, both through the actual policy itself and through biased enforcement of the policies by nurses and other health care personnel (Niles et al., 2020) . While the perceived benefit from visitor restrictions includes a reduced potential for exposure to the COVID-19 virus, providers and health care systems need to balance the ethical quandary of then increasing risk for perpetuating health disparities, particularly exposure to racism and mistreatment by providers for BIPOC communities (Bruno et al., 2020) .

The parallel structure of exploring experiences of patients and nurses simultaneously was a considerable strength in this study, with the benefit of exploring the relational impacts of visitor policies from multiple perspectives in the hospital setting. Taking into account the mutuality of the shared experience, both nurse and patient experiences bring depth of understanding to the impact on the birthing person and family. We also intentionally interviewed large proportions of BIPOC participants in both groups to assure that our data captured diverse experiences, knowing the impacts of racism on experiences of care, and had a racially diverse research team including community members to support appropriate interpretation of the results. However, several limitations to our study include inability to have in-person interviews due to the pandemic, and the use of Zoom for interviews may have limited the ability for interaction and non-verbal cues. Given the nature of the study, we also do not intend to generalize these results to other settings, but instead hope that these results can be transferrable and may lend meaning and direction for adapting and implementing visitor policies in a culturally appropriate way.

These results from our study examining experiences of pregnancy and birth care during the COVID-19 pandemic highlight the importance of considering impacts from policies and of involving those with lived experience in policy making decisions. Recommendations by participants include recognizing that visitor restrictions enacted for other areas of the hospital do not pertain to perinatal care, and as such should be amended to include the recognition of how critical support is for labouring and birthing people and their birth outcomes (Bohren et al., 2017) . In addition, including BIPOC in policy decisions is required to reduce risk of perpetuating harm through biased policies. While this pandemic is nearing the end, these results can hopefully be used to guide structuring of policy not only for the next pandemic, but also for universal policy development. Mitigating the effects of racism in policies, by including diverse stakeholders in decision-making, should be an inherent part of hospital administration procedures.

In response to the COVID-19 pandemic, hospitals utilized visitor restriction policies to reduce the potential risk for spreading infection for patients under their care. However, as our study depicts, these visitor policies have had a disproportionately harmful effect on BIPOC patients and families, leading to some patients opting to make decisions that increase their physical risks to alleviate their risk of labouring and birthing without desired support. Given the importance of support people for BIPOC patients in mitigating risk of racism and bias in hospital encounters, these policies have had the unintended effect of exacerbating racism in the hospital setting.

The authors acknowledge and thank the participants in this study who shared their experiences in hopes of supporting others during the COVID-19 pandemic. We also thank the regional birth worker communities for supporting development of the purpose and aims of this study.

The authors have no conflicts of interest to disclose.

All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*):

1. substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;

2. drafting the article or revising it critically for important intellectual content.

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.14991.

Molly R. Altman https://orcid.org/0000-0002-0453-0469

Alhusen, J. L., Bower, K. M., Epstein, E., & Sharps, P. (2016). Racial discrimination and adverse birth outcomes: An integrative review. J Midwifery Womens Health, 61 (6), 707-720. https://doi.org/10.1111/jmwh.12490.

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Situational analyses: Grounded theory mapping after the postmodern turn

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Developing a method of critical thematic analysis for qualitative communication inquiry

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