Labouring alone: How some maternity services failed pregnant women in the Covid-19 age

Pubs and offices may have reopened, but in some NHS trusts the strictest pandemic restrictions on maternity wards were still in place this month.

In June, when lockdown constraints were starting to ease – the reopening of shops and zoos, the introduction of social “bubbles” – Ruth, 29 and pregnant with her second child, went to Peterborough City Hospital in labour.

Although society was tentatively opening up, the hospital was sticking to strict coronavirus rules. At first, she was in labour alone, her husband waiting outside the door of the ward. Birth partners were only allowed in during more advanced stages of labour.

Ruth’s husband was allowed in some 20 minutes before their daughter was born at 6.40am that Friday morning. By 11am, he was asked to leave. Like a number of hospitals in the UK, no visitors – not even birth partners – were allowed on the postnatal ward.

Not long after Ruth’s husband left, her baby began struggling to breathe: chest pulled in, nostrils flaring. Staff put the newborn on antibiotics, so Ruth stayed on the ward for another two days. She didn’t see any family or friends, not her husband or two-year-old daughter, until she left on Sunday evening. 

“At night it was probably the worst,” she told me over the phone while feeding her then 10-week old daughter. “We were on a ward of, like, four babies that all woke up at different points, and because she had breathing difficulties and they were worried about her, I found it really hard to sleep. If I had my husband there just to take her for half an hour, I could have slept. When we had our first he obviously stayed all the time.”

Across the UK, as the months of lockdown dragged, pregnant women and their families were met with an anxiety-inducing postcode lottery of changes to maternity care. With each trust using its own interpretation of national guidelines from the NHS, Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG), restrictions varied. Women were limited to one birth partner. There were limits on accompanying women during labour and some places cut access to services such as home births.

Like much of the NHS, many trusts used virtual appointments for some antenatal care.

In the worst cases, says Maria Booker, programmes director of the charity Birthrights, these rules remained what they were at the height of the pandemic: partners kept out until “established labour”, prohibited from staying after birth, and not allowed to antenatal scans.

Women have gone unaccompanied for inductions and to pre-C-section operation prep. They have also had to receive bad news on their own.

Recovering alone from a “smooth” birth is hard enough, but it is even worse after a traumatic one – all the while dealing with staff who are under pressure in a pandemic and wearing full PPE.

Even though the government had been urging people to “Eat Out to Help Out” all August, some trusts were still not allowing visitors on to wards or at antenatal scans as late as this month. NHS England only issued guidance to encourage trusts to “reintroduce access for partners, visitors and other supporters of pregnant women” on 8 September. The move followed calls for guidelines from charities like Birthrights. The charity said England was lagging behind the devolved nations, where there was political direction to remove restrictions from June or July.

The #ButNotMaternity campaign, and a 386,000-signature strong petition (at the time of writing) to the Health Secretary Matt Hancock and the NHS, added to the public pressure.

On the day the new guidance was published, the RCM and RCOG released a statement criticising NHS England for the delay, saying it was “dragging its feet”.

The CEO of RCM, Gill Walton, said: “The RCM and RCOG worked together to support NHS England to complete draft guidance in early August, yet here we are, over a month on, with still no publication.”

Now, as Boris Johnson once again tightens Covid-19 measures, and with local lockdowns looking likely, there are concerns that lessons won’t be learned from this mass experiment in maternity service provision during a crisis.

In 2015, a National Maternity Review led by the Conservative peer Julia Cumberlege resulted in the Better Births policy, now in its fifth year, which sets a vision for maternity services across England to become“safer and more personalised”. The Morecambe Bay Investigation, concluded that year, found that serious failures of care at Furness General Hospital led to the deaths of 11 babies and one mother.

Soo Downe, a midwife and professor in midwifery studies at the University of Central Lancashire, is leading an ESRC-funded study to find out how these two strands were safeguarded during the pandemic.

“The idea is to look at a range of different hospitals, hospital trusts, and community services to say: what was the most effective way of responding to the crisis to ensure safety and personalisation so that women got choices?” she tells me.

Part of the study involves monitoring constant updates to maternity services by tracking changes on trust websites and on social media. It is clear that there has been a mixed response across the UK, she says.

Different trusts have restricted or permitted companions for women at antenatal scans, labour, birth and on postnatal and neonatal wards to varying degrees. In July some places were only allowing birth partners to visit for one specified hour each day, but many trusts had reinstated home birth. The study will be looking at the variation, and how it can be minimised in future.

It is also possible that some mothers and their families saw a positive side to these arrangements. Birte Harlev-Lam, executive director for professional leadership at the RCM told Spotlight that “some of our members have found that breastfeeding rates have improved as a result of visiting restrictions, as women have had more time to work with midwives and maternity support workers. They’ve also noted how women have supported each other on postnatal wards. That’s not to diminish the role of partners.”

Outside of her study, Downe notes some examples of good practice. This includes Chelsea and Westminster Hospital NHS Foundation Trust, for its “very creative” use of private ambulances to keep home birth provision open, and a two-year-old continuity of care scheme in Warwick, which may have helped the hospital to minimise closing services.

The NHS did not respond to Spotlight’s requests for data on how many trusts have been imposing which restrictions.

“I think women are feeling really frustrated and starting to get cross and anxious about why their needs aren’t being prioritised,” says Booker. “The issue is that it has been left to the discretion of trusts, and they are taking a different view of it.”

In some hospitals, midwifery units may have felt restricted by wider trust policy and restoring visitor access might not have been a priority; for some it might even have made things easier.

“Trusts can’t reduce the amount of women they see,” Booker says. “Some do genuinely have issues with their estates [when it comes to social distancing], but have they looked at all possible solutions?”

Between June and August, Birthrights received a growing rate of queries to its advice line from people worried about restrictions. The charity has also picked up concern about postnatal care being cut, with an increase in virtual meetings. The worry is that temporary changes will become the norm.

What has been made clear is that birth partners are not mere visitors, and shouldn’t be treated as dispensable. Why have women have been allowed to go to the pub, but not allowed to have apartner with them on the ward? “Partners  have a real stake in the care of their baby,” says Booker.

The restriction on companionship for antenatal scans is particularly distressing for parents who have previously lost a baby, says Clea Harmer, the chief executive of Sands, a stillbirth and neonatal death charity. According to Sands, one in four pregnancies ends in miscarriage, and in the UK every day 14 babies are stillborn or die within 28 days of being born.

The stress of attending scans and appointments alone has been the main issue Harmer has found among bereaved parents during the pandemic.

“It is devastating to receive the news that your baby has died in any circumstance, but to be on your own and without a partner is not something that we should be putting any mother through,” she says.

This highly sensitive area of care has been hard for both families and healthcare professionals during the pandemic. Aside from problematic social distancing protocols, Harmer also highlights the challenge of providing compassionate care while in full PPE, the closing of bereavement suites – where parents whose child have died are able to spend time and make memories with their baby – because of Covid-19 restrictions, and the redeployment of some specialised staff.

“That’s been really challenging for those healthcare professionals left in positions of providing care but they haven’t yet had the training,” says Harmer.

She also worries that the government’s “stay at home” messaging puts women at risk, as some parents had been taking it very literally, even when they were worried about fetal movements or a newborn’s health. When Sands raised this – because parents were flagging it as an issue on the charity’s helpline – the NHS updated its messaging to encourage parents to come to hospital with concerns, says Harmer.

St George’s Hospital in London recorded a four-fold increase in stillbirths during the pandemic, though this has not been the case across the country.

The period since lockdown has taken a toll on the mental health of pregnant women and new mothers in general, according to research by the Universityn of Liverpool and King’s College London. Preliminary findings from the first wave of their research, conducted from mid-April to mid-May and under review at a journal, “are quite shocking”, says the University of Liverpool’s Vicky Fallon.

Respondents to their online survey suggested a spike in clinically relevant depression and anxiety rates in new mothers were related to psychological changes as a result of social distancing measures. “The results are absolutely striking,” she says. “We’ve never seen anything like it in all our years of research in this area.”

Fallon and colleagues didn’t specifically ask about maternity service restrictions, but the results highlight how vulnerable women and their families have been since lockdown.

Early on, the government advised pregnant women to shield at home, so many who gave birth in May or June had spent a long period of isolation.

Fallon says prenatal depression and anxiety affect things “as short-term as birth outcomes but as long-term as behavioural outcome in adolescence. In the postnatal period, we know that maternal mood has effects on social, emotional and behavioural outcomes in children.”

Lauren, 30, from the Isle of Wight, has been taking anxiety medication since returning from hospital in May. After a traumatic birth – the baby was breech, and Lauren was rushed into an emergency C-section – she then spent two days alone in hospital, groggy from anaesthetic and hardly able to move after surgery. Her husband and daughter were not allowed to visit her.

“I hated being in there,” she tells me. After 48 hours, “I was insisting that they let me go, even though not 48 hours earlier I’d had quite major surgery. I thought: if I stay, I’m just going to have a breakdown. I don’t have anyone to help me.”

When she got home, she had a panic attack. “I just don’t think I really was able to process properly what had happened to me. I just got home and I thought you know, I just, I can’t, I couldn’t do it… So I ended up having to go on anxiety medication just to help get over the experience.”

One senior NHS manager, who used to be a midwife herself, and prefers to remain nameless, had her third child by elective caesarean this summer. “I think this is the biggest mishandling of the pandemic,” she says. “It has not been women-focused.”

She is particularly concerned about the impact restrictions have had on women undergoing caesareans, and says they have received less equitable treatment over this period than normal deliveries, because they had less time with partners. “It gave me real anxiety,” she says, “the idea that [her husband] wasn’t going to see his son for two or three days” after the birth. She has written to the office of the Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, to the head of midwifery at her hospital, and to the patient safety minister Nadine Dorries to raise these concerns.

“We all want to see services return to as normal as possible, as soon as possible,” says the RCM’s Harlev-Lam.“Trusts don’t make decisions to adapt services, such as restricting partners, lightly. They are making these decisions based on their local circumstances, such as transmission rates and the facilities they have available.” Maternity staff were concerned regarding restrictions, she says, but “safe maternity care was not impacted and that’s what is paramount”.

Penny Snowden, deputy chief nurse for North West Anglia NHS Foundation Trust, which includes Peterborough City Hospital, said: “At the beginning of the pandemic the trust implemented visiting restrictions in line with national guidance  to protect our patients, visitors and staff from the spread of Covid-19.

“We continuously reviewed this decision as the pandemic progressed and were one of the first trusts to allow partners to attend antenatal scans and introduce structured visiting times, when we felt it was safe to do so. We understand the emotional distress that the restrictions caused women and their partners. Our staff have provided emotional support to women and their babies, but we know this isn’t the same as having their partner with them during this time.

“The safety of our patients, visitors and staff has and continues to be our number one priority. We will continue to review restrictions and make adjustments where possible, while ensuring we can keep everyone safe.”

Clea Harmer welcomes the 8 September guidance, but worries local implementation won’t be swift to follow. “We… would urge hospitals to implement them on a local level as soon as possible, as we are hearing all too often of the distress it is causing to women not to be able to have their partners with them.”

Meanwhile, for women like Ruth, the period following the trauma of birth, arriving straight after those long months at home during lockdown, has also been changed as a result of Covid-19.

“It just feels a lot like pregnant people and babies have almost been forgotten a little bit. There’s stuff opening back up, now there’s some local baby groups that opened up recently, but I’ve just felt quite missed really. I’ve been quite lonely this time.”

An NHS spokesperson said: “The NHS continued to deliver safely 1,800 babies every day during the pandemic, and while it is understandable that the pandemic has caused expectant mums increased anxiety, the important changes to maternity services – backed by the Royal College of Midwives - were made to keep women and their families safe.

“Now we have moved past the peak of the pandemic and after extensive engagement with the various professional bodies involved, new guidance has been issued to all maternity units so partners can attend antenatal and postnatal clinics safely, in addition to attending labour which they have been able to do throughout the pandemic.” 

This article originally appears in an upcoming Spotlight supplement on healthcare