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Pregnancy During the COVID-19 Pandemic: A Nerve Wracking and Isolating Experience for Women and Health Care Providers

By Sharmila Leela Mysore

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Citation

Mysore S. Pregnancy during the COVID-19 pandemic: a nerve wracking and isolating experience for women and health care providers. HPHR. 2021;34

Pregnancy During the COVID-19 Pandemic: A Nerve Wracking and Isolating Experience for Women and Health Care Providers

Abstract

Objective

The objective is to explore the experiences of pregnant women and health care providers during the COVID-19 pandemic.

Design

This is a qualitative study that utilizes semi-structured interviews of 15 total participants. A grounded framework was used to display the data collection and analysis that occurred simultaneously. Data was then developed into analytic codes and refined to thematic categories that were then interpreted into to discoverable outcomes. Social processes that were explored in the data include the mental health outcomes of both pregnant women and health care providers as well as the relationship between clients/patients and health care providers.

Setting

The location is within the United States on a virtual platform where all the interviews were all conducted via Zoom or phone call. Additionally, the analyzing, drafting, and reporting stages were also performed remotely.

Participants

Included are a total of 15 participant respondents including eight pregnant women, four midwives, two obstetrician-gynecologists (OB/Gyns), and one doula. Five out of the eight pregnant women were pregnant at the time and three had given birth during the early months of the pandemic which were no earlier than April of 2020 right when the pandemic was at one of its peaks.

Findings/Key Conclusions

The main findings are that women expressed adverse mental health outcomes from isolation, fear of the unknown and a need for more support. Additionally, health care providers discussed how adapting to the changes of the pandemic has negatively affected their practices and philosophy. This included increased stress due to working in a high-risk environment, and the inability to care for their patients in the wholistic way they were used to.

Implications

The COVID-19 pandemic is observed to be associated with influencing women’s mental health from isolation. Health care providers experience greater stressors due to an overwhelmed health care system. The importance of telemedicine is observed as highly associated with the COVID-19 pandemic.

Grant Acknowledgement

Special thanks to the Tulane University Newcomb-Tulane and Newcomb Institute Grants committee for their generous contribution to this study.

Introduction

Literature Review

The key themes discovered are as follows: significant adverse mental health outcomes in pregnant women during the pandemic; feelings of isolation and separation from family and friends; effects of an overwhelmed health care system; telemedicine as an efficient prenatal care delivery tool; structural inequalities marginalizing women of color.

 

When the COVID-19 pandemic was officially declared a pandemic in March of 2020, major health agencies including the Center for Disease Control and Prevention (CDC) had a vague understanding of how certain vulnerable populations were at risk. Pregnant women have historically been at high risk for major viral disease, one most notoriously is the Zika virus in which microcephaly is a common adverse outcome in newborns. Vertical transmission, high disease severity, known adverse outcomes of COVID-19 infected pregnant women, and protective measures will be discussed in this literature review.

 

The CDC has proclaimed numerous times that there is no data to conclusively prove that pregnant women are affected differently than non-pregnant persons[1]. The CDC has also said, however, that pregnant women are at a greater risk for severe illness should they contract COVID-19, consistent with a pattern of disease that occurred during the SARS and MERS epidemics in 2003 and 2012, respectively[2] The CDC has also released information specific to pregnant women and protective measures that they should take to prevent transmission and infection. These include traditional measures such as wearing a face cloth covering, washing hands after being outside, and quarantining when necessary[3].

 

There is no conclusive evidence to say that vertical transmission of COVID-19 is possible. Vertical transmission occurs when pathogens are passed from mother to fetus in utero[4]. A study conducted in New York City in May, two months after the pandemic was declared, tracked the delivery of 32 newborns from COVID-19 positive mothers[5]. Researchers conducted placental membrane swabs on 11 randomly selected subjects and found three positive samples of COVID-19 virus in the membranes[6] However, they concluded that it was too early to determine that vertical transmission was possible given that all the newborns tested negative for COVID-19[7]. Researchers could not conclude where the viral appearance in the placenta came from but did agree that vertical transmission was not likely. COVID-19 is unlike other viruses such as HIV and Zika which have a high probability of transmission from mother to child. Though vertical transmission of COVID-19 is rare and unlikely to cause problems for infants, pregnant women should remain cautious and take necessary measures to protect themselves[8].

 

Perinatal outcomes of women with COVID-19 infection are a major concern during this pandemic and many studies have been investigating the possibility of high disease severity in pregnant women. In one study conducted in July 2020 in China, researchers analyzed the clinical presentations and signs of coronavirus pneumonia in 15 pregnant women[9]. Coronavirus pneumonia is one of the most severe clinical presentations of COVID-19 infection and even after recovery can leave long lasting damage to the lungs. Pneumonia is one of the leading causes of COVID-19 deaths in the United States currently and is an obvious concern for pregnant women who fear being ventilated during their delivery. This study saw that the most common symptoms of the women who were admitted to the hospital during delivery with COVID-19 pneumonia were fever, fatigue, muscle aches, and diarrhea[10]. Fortunately, researchers saw no evidence of vertical transmission after the delivery and all women were able to delivery naturally. However, the researchers did indicate that pregnant women are especially vulnerable to respiratory pathogens and severe pneumonia because of their immunosuppressive state, making COVID-19 pneumonia a risk that is on many pregnant women’s minds[11]. This can complicate the delivery procedure, because women who are infected are now considered high-risk, and are therefore subject to harsher restrictions during delivery – including the possibility of their newborn being separated from them.

 

Although social distancing and quarantine orders continue to occur throughout the country, the CDC stresses the importance of continuing to attend prenatal and postpartum appointments whether they are conducted via telemedicine or in-person[12]. However, women are understandably concerned about bringing their newborns into a high-risk hospital environment for their postpartum check-ups. Children are one of the lowest affected population groups being severely affected by COVID-19 virus and hospitalization rates for children infected with COVID-19 are low[13]. This is partially since their younger immune systems tend to react less than adult immune systems reducing the likelihood of developing severe disease[14]. Additionally, newborns have not been found to have a high rate of infection during the delivery process as many hospitals have adapted their procedures accordingly[15]. Finally, prevention measures are the same for young children, but newborns should not wear a face cloth covering or face shield[16].

 

Informative technology solutions have the power to create equity in health care and telemedicine is a vital resource that can increase access to medical information and care to ultimately improve overall patient outcomes[17]. This research will be exploring the utilization and efficiency of telemedicine as a part of prenatal care delivery during the pandemic. Telemedicine usage has spiked during the pandemic and is now one of the most sought-after forms of health care delivery in the United States. Telemedicine has been increasingly successful during the widespread stay-at-home, safer-at-home, and social distancing mandates around the country. Telemedicine has provided a replacement for in person visits during the prenatal period while maintaining quality care and satisfaction. Some major benefits include an increased sense of control, lower cost of care, increased high acuity, supportive partnerships, increased patient engagement, and less time away from family and work[18]. Though telemedicine was established before the pandemic was declared, there is now extended access of telemedicine for many populations in need.

 

Finally, telemedicine has proved to be a vital source of care for women of color and women living in low socioeconomic areas. Telemedicine can provide a streamlined access for women living in low socioeconomic areas, particularly rural areas, to doctors, midwives, and doulas[19]. However, barriers such as low health and digital literacy, and lack of technology prevents some women from utilizing telemedicine[20]. Additionally, language barriers make it difficult for some women of color to communicate with their providers over the phone, but telemedicine video services can increase efficacy and care delivery quality[21]. Finally, before the COVID-19 pandemic, Medicare and Medicaid supported policy was absent and only recognized during this emergency[22]. Therefore, it is vital that federal policy is created to make permanent coverage available under these programs so that all women regardless of socioeconomic status may have access to telemedicine.

Statement of Purpose

The qualitative study explores the pregnancy and health care experience of women who were not infected with COVID-19 during the first wave of the pandemic. The main challenges, attitudes, feelings, perceptions, and stress level of pregnant women during the early months of the pandemic will be explored. The study also seeks to examine how health care providers have adapted to the new environment. Finally, a focus on the future impacts of prenatal care and the integration of telemedicine will be presented.

Methods

Recruitment, Eligibility Criteria, and Interview Process

A convenience sample was utilized in which only those who were willing to participate and met the criteria would be contacted and interviewed. A convenience sample occurs when participants are recruited based on immediate availability and eligibility criteria[23]. Participants were then asked to refer the researcher to other potential participants utilizing the snowball sampling method[24]. Five of the participants were pregnant and three of the participants had already given birth by the time of the interview. Eight health care providers were interviewed including five midwives, two OB/Gyns and one doula. All participants were in the United States. In total, 15 participants were interviewed.

 

The eligibility criteria for pregnant women participating in the study included:

  • Pregnant at the time of the recruitment process in August 2020
  • Had given birth after the time of the first declaration of the pandemic in March,
  • Located in the United States,
  • There was no age, gender, race, ethnicity, religion, or socioeconomic limitation.

The eligibility criteria for health care providers included:

  • A midwife, doula, or OB/Gyn currently working on prenatal care during the time of recruitment,
  • Not retired or on leave,
  • Working in the United States.

Each interview lasted between 45 minutes and an hour and no interview extended beyond an hour. Each interview took place via phone or zoom video chat. An audio recorder was used during the interview to ensure efficient transcription occurred. There was only one interview per participant and follow up questions were not needed. After each interview, the recordings were transcribed by hand onto the software used for data analysis. A sample of the interview questions can be found in Appendix A

Demographic Description

Participating pregnant women ranged from various locations around the United States, with four participants from Massachusetts, two participants from California, two from New York, and one from Kentucky. All women were in urban/suburban areas. All women identified as middle to upper middle class. Though specific demographic information was not taken, all women were between the ages of 29 and 44 years old.

 

Three of the midwives work in a birthing center attached to a hospital, and one of the midwives works in a birthing center that runs separately from a hospital. All the midwives work in or just outside of Philadelphia, Pennsylvania. One Ob/GYN works in a county and private hospital in Texas while the other Ob/GYN works in a large, public hospital in Ohio. The doula participant has her own independent practice that is now virtual.

Ethical Considerations

This study was conducted in accordance with the Declaration of Helsinki, and the study protocol was approved by the Tulane Internal Review Board for the local enrollment of 15 total participants in August 2020. All participants gave their informed consent to participate in the study and be recorded prior to the interview. Pregnant women are considered a vulnerable population and proper CITI training took place by the researcher to ensure that this human subject’s research was performed ethically. Risk was minimized as interview questions were surface level, meaning they did not call for the recollection of any personally traumatic events that would induce a mental health burden. All interviews were conducted in English and therefore translation was not required.

 

This author has no conflicts of interest.

Data Analysis

Qualitative data analysis was conducted through a coding software called QDA Miner Lite software. The coding procedure modeled a description-focused process in which codes were applied to relevant information in the data for the purpose of reflecting a description. Codes did not reflect any opinion, judgement or interpretation by the researcher and were categorized based on relevance to the research questions. Each research question contained a multitude of codes in an index. The index was then sorted to combine codes that were similar based on the context of each answer. Finally, each code was transformed into a cluster of represented information that set the foundation of this research study. During this research, all relevant information that was tagged by the codes will be transferred by the researcher into a meaningful translation on the experiences of pregnancy during the COVID-19 pandemic.

Frequency Tables

Table 1: Key Themes from Pregnant Women

 

Themes

Frequency of Mentions

Percentage

Depression/Anxiety

5

62.5%

Fear

7

87.5%

Isolation

6

75%

Lacking support

7

87.5%

Positive perception of telemedicine

Negative perception of telemedicine

5

4

62.5%

50%

 

Table 2: Key Themes from Midwives/Doulas

Themes

Frequency of Mentions

Percentage

Altered relationship with client

5

100%

Feelings of uncertainty/concern

4

80%

Philosophy of empowerment

3

60%

Emphasis on mind/body experience

3

60%

Positive perception of telemedicine

Negative perception of telemedicine

4

2

80%

40%

 

Table 3: Key Themes from OB/Gyns

Themes

Frequency of Mentions

Percentage

Lack of support for clients/patients

2

100%

Lack of support for providers

2

100%

Structural inequalities

2

100%

Stress from working in a high-risk environment

1

100%

Positive outlook on telemedicine

2

100%

Findings

“How are we going to handle it all?”

 – Pregnant Woman

Isolation and quarantine measures that were put in place have caused people around the world to feel lonely, anxious, depressed, and worried. It is evident that isolation because of quarantine requirements is the greatest cause of adverse mental health effects that have drastically changed the experience of pregnancy. On March 19th, 2020 California became the first state to mandate a stay-at-home order in which many other states quickly followed[25]. This issue required all residents to stay at home except in the cases of essential jobs or shopping for essential needs[26]. The pregnant women discussed what it was like learning about how they would have to quarantine and change their entire daily schedule to abide by COVID-19 precautions. This change, although seemingly simple, made the worries of pregnancy even greater and the ability to contact support even harder. For pregnant women, having their partners, family, and friends’ support whether it was virtual, or in-person meant the world to them. Midwives, doulas, and OB/Gyns had to step up their support process for their clients and patients which included education on COVID-19 and how to quell feelings of anxiety and depression.

“People who come to birth center want to feel free.”

 – Midwife

The midwives and doulas who participated in the study worked at birthing centers that were either attached to a hospital or were close by to one. The birthing center is an organized space where women can give birth and feel liberated in an open environment. Midwives discussed how pregnancy and birth is a natural process that must be embraced with the woman’s needs and vision in mind. A doula and midwife’s responsibility are to educate the mother and the father and to ensure that they are aware of all their options throughout the pregnancy. Although the doula’s role is often different than the midwife, one unique aspect that they share is the importance of the mind-body experience. Empowering their clients through education, physical and emotional practices, and meditation are important to their approach to pregnancy.

“The role of the midwife is to address all issues in the client’s life that might affect their pregnancy. It is often the intersection between medicine and social justice.” 

 – Midwife

Finally, the role of the midwife and doula during the pregnancy is most effective when they can help their client reach an ideal pregnancy given the other potential barriers in their lives. Midwives often take an approach that centers around the woman’s life. Their jobs are not limited to just monitoring the pregnancy, but rather ensuring that their clients achieve the pregnancy they envision without other pressures. To do this, midwives and doulas may act as advocates and confidants that will ensure their clients are listened to and cared for.

“Before breathing heavily [during labor] was okay, now it was a problem.” 

 – Midwife

During the pandemic, health care workers have been impacted extremely quickly and drastically. Their practices, typical approaches to medical care, and outlook on how care will change in the future influences the consequences of this pandemic. Both OB/Gyn’s worked in a hospital setting as a resident practitioner. Both OB/Gyn’s worked in a hospital that was not attached to a birthing center, making their approach to pregnancy different than that of a midwife or doula. Both OB/Gyn’s discussed working night shifts during their residency and mentioned that a typical night consisted of ebbs and flows with rarely any major complications considering most of the women they saw were low risk. While neither OB/Gyn’s discussed a specific philosophy that surrounded their approach to pregnancy, it was clear that the patients’ safety and the security of others around them was at the forefront of their work.

“It was uncomfortable telling our family and friends they couldn’t come by for a while.”

 – Pregnant Woman

The informants who were either pregnant at the time or had just given birth spoke at length about how they expected to spend quality time with their family and friends during their pregnancy. The feeling of isolation and anxiety were thereby even greater when the pandemic hit given that many women had to nearly lock themselves in their houses during the months before their delivery. Another important expectation these participants had was having a personable relationship with their midwife/OB/Gyn. A strong relationship allows these women every opportunity to ask questions, express concerns and feel supported during this exciting and unique time. When the pandemic hit major cities around the United States, many of the women were still well into their pregnancy and had to change their expectations almost immediately. This included telling family and friends that they could not come over and this made many women uncomfortable and upset.

“It is sad and hard to picture that when the pregnancy is over, our new life will not be the same.”

 – Pregnant Woman

Pregnant women ultimately lost the connection they had to the outside world and were mentally and physically locked in for the safety of themselves and their future newborn. Most of the women had toddlers ranging in age from 2-5 years old. It was clear that the difficulties of quarantine were exacerbated by the fact that no one was there to be with their first child to keep them company during the pregnancy. The second time moms shared with me that their first pregnancy experience was especially family oriented. One informant even discussed how it was like a big party in the delivery room and she was showered with gifts and love from her family and friends. This experience, of course, was not the same during this pregnancy given the restrictions hospitals have put in place on visitors. Many of the second time moms discussed how great it felt to go out and do something nice for themselves during their first pregnancy. Freedom was something they were looking forward to for their second pregnancy but was halted due to quarantine measures. Finally, they even expressed sympathy for those going through their first pregnancy during this difficult time. The first-time moms had a greater grasp on how pregnancy should be like, and this knowledge quelled many of their anxieties. While second time moms had a heightened sense of fear because this was not only a new experience, but an unexpectedly stressful one as well due to the pandemic.

“When staff support was lacking, it became more nerve wracking.”

 – OB/Gyn

Mental and physical support during this pandemic has proven to be one of the greatest challenges. For example, both obstetricians discussed the importance of support during labor and delivery and how their companionship with senior doctors and physicians is important. However, when less people can be in a room with a COVID-positive patient, that means the resident is likely on her own. Additionally, the anxious feeling that resources were lacking, including Personal Protective Equipment (PPE), makes for a stressful environment. The informants were concerned about not only the health and safety of their patients, but now more than ever, their health as well. Their exposure to COVID-19 skyrocketed in the hospital environment. When the OB/Gyn’s began to observe a rapidly increasing rate in cases and patients in their hospitals, their reaction was disbelief. As the pandemic progressed, they became and more exhausted, confused, and anxious about the state of both their hospital environment and the world itself. The OB/Gyn’s were and still are aware of their risk of exposure and know that the best way to protect themselves is to wear PPE and sanitize as much as possible as the number of sick women they are seeing increases every day.

“In medicine, you see a lot of different attitudes surrounding COVID-19 around you. It’s frustrating when people don’t take the pandemic seriously.” 

 – OB/Gyn

Both OB/Gyns described that their hospitals tested all labor patients upon arrival and even advised their patients to be tested well beforehand – though this was not guaranteed. While partners were not tested, they were screened for symptoms and a fever; making it easy to determine if they were allowed in the delivery room or not – a frightening feeling for the women giving birth. However, testing presented its own set of challenges. One Ob/GYN discussed how many of the symptoms of COVID-19 are like the common cold or flu, making it more likely that a partner would not be allowed in the room even if they were technically negative. In addition, if a woman were to go into labor and needed to give birth immediately, she would still have to wait for the COVID test to come back causing potential risk for delivery complications. Many hospitals have pre-scheduled COVID-19 screenings and tests 24-48 hours before delivery, with additional screenings on the day of deliver[27]. If a patient does test positive upon arrival, testing for partners may be arranged but support persons are no longer allowed in the waiting room at that point[28]. Finally, while it is difficult to wear a mask during delivery, each hospital decides the best method for mitigating transmission during delivery[29].

“There’s so much you can’t control when you’re pregnant”

 – Pregnant Woman

When the COVID-19 pandemic began many women felt they knew very little about how this virus was different. Several women heard the horrors of labor and delivery and how it was more intense if you test positive. For the few informants who were seeing a midwife and/or doula, all of them had planned what their relationship with their midwife would look like. Though many visits ended up being virtual, women felt that in-person might have been better. For some, it was even more frustrating when they would be looking forward to an in-person visit and would get notified last minute that it had to be virtual since their providers were still figuring out how to adjust procedures. However, all the women did feel that their provider made a valuable effort to ensure their expectations were met. The seriousness of testing positive became very real, and women did everything they could to protect themselves. They began staying indoors and only seeing family members that lived in their households. Some women even deliberately said that they locked themselves in their houses for months out of fear and uncertainty. Women were also concerned that they were immunosuppressed and thereby more likely to experience severe symptoms and consequences.

“The need for human connection is so great. I’ve never felt this level of anxiety and frustration before.”

 – Pregnant Woman

Of the eight women that were interviewed during or after their pregnancy, more than 50% of them were seeing an OB/Gyn for their prenatal care. All the women who were seeing an OB/Gyn, explained how they were asked to continue to come for in-person visits as the pandemic progressed. Although they were asked to wear masks and not bring any family members, this still created a heightened sense of tension and fear. The most frightening aspect, of course, was the possibility of their newborn being taken away if they tested positive. Those who delivered during the pandemic either in a birthing center or hospital had a good understanding of what the procedure would look like beforehand. Knowledge about the delivery procedures was not as high for the women delivering in the hospital. On average, 94.8% of women give birth in a hospital setting, while a small percentage choose to deliver in a birthing center[30]. This changed drastically during the pandemic as several factors advanced the shift from hospitals to home and birthing centers. These factors include worries of exposure in a hospital environment, fear of separation from infant due to exposure or infection, and anxiety regarding the possibility of not having a support person during delivery. On the other hand, fee waivers permitting those with Medicare and Medicaid insurance to receive reimbursements have been allowed[31]. This creates more opportunity for women to choose a birthing center, but midwives still have concern that these new clients have limited understanding of what this experience will be like.

“I needed to have more confidence and independence when senior residents and attending [physicians] couldn’t be there.”

 – Pregnant Woman

Delivery itself was challenging for the Ob/Gyns because even though the protocol was relatively the same if the patient tested positive, there was a heightened sense of difficulty during the process. Laboring patients always needs extra hands-on help, and when the doctors are not able to physically help their patients, it can make it difficult especially when less assistance is in the room.

“Wearing such heavy PPE can be disorienting when everything is fogging up and hot in the gown and masks. This is supposed to be an intimate and supportive delivery which is hard to do now.”

 – Midwife

All midwives that were interviewed described that they wore full PPE during delivery and screened both partners and clients for symptoms upon arrival. This changed not only the timing of the prenatal and delivery process, but also the essential practice of how midwives approach pregnancy in general. As described earlier, midwives see birth as an intimate and physically natural process (like OB/Gyn’s). Therefore, the midwife informants described how wearing full PPE and having no family support around made the delivery process frightening and uncomfortable for both the client and the midwife herself.

“It took a while to get used to the fact that I couldn’t be as hands-on and personal at this time.”

 – Doula

Since doulas are not considered essential health workers, their presence in the delivery ward was not permitted. During the interview, the doula described how this changed her practice immensely and that her role as a voice for the mother had to be entirely virtual. When she began to see the rise in cases of COVID-19 and increase in restrictions around the country, she understood why hospitals were overwhelmed and she could not be essential. However, her overall reaction to COVID-19 was frustration and uncertainty as many other health care providers felt and still feel. This can be especially impactful on women of color because an already overwhelmed hospital that refuses to allow doulas to assist women during delivery drastically reduces necessary mental and emotional support for women. Women of color, who already face higher levels of stress, anxiety, and depression during pregnancy, are now being deprived of an important support system that marginalizes them further[32].

“Having to go to all the appointments by myself [because partners were not allowed to attend] was stressful and he missed out on those important moments.”

 – Pregnant Woman

During delivery, partners are not allowed to leave and re-enter the hospital, making it difficult for the partners themselves take breaks, fetch important resources like food and nourishment, or even just take a shower. Visiting hours in the hospital are also minimal and restrictive. Therefore, a woman’s family members are not typically allowed to visit after delivery, and this is especially true in the public clinics versus the private hospitals. Waiting rooms are suspended, partners are not allowed at check-ups and in some hospitals, women must wear a mask while breastfeeding their newborns. All these restrictions have created an alienating environment for the woman, her partner/family, and her newborn.

“I was not fearful right away because we didn’t even know enough to be fearful. But then came quarantine and a phase of disappointment for things that were planned and now cancelled.”

 – Pregnant Woman

Those who became pregnant early in the pandemic described how the sudden changes that were brought about because of quarantine had caused more anxiety than ever before. They felt they had to fight isolation physically and mentally during quarantine. They were forced to give up the human connection to others and it was even more stressful during prenatal appointments. When partners could not be there, it was up to the women to make important decisions on their own during their pregnant. This was not foreseen and ultimately caused their partners to be significantly less involved during the pregnancy. Although partners were not included in the scope of this study, it was evident that they felt extremely limited and concerned whenever they could not accompany their partners for prenatal visits.

“We develop a mindset that is confident, affirming, and positive. However, I am not able to be there in person during the delivery, I want my clients to be prepared visually on what their options are.”

 – Doula

Fear of COVID-19 itself contributed a high amount of anxiety and depression for women as well. The doula informant described how she upped the number of virtual videos and advice she gave to her clients on how to ask their health care provider questions. She spoke about how it was important to show them that they were being listened to, that they were cared for, and that they could get additional help if they needed. Midwives and doulas were now acting as both a health care provider and educator more than they ever had before. They encouraged women to limit contact with others, find ways to support themselves to combat feelings of isolation, and make their homes as comfortable as possible. Many women tried to stay positive, but hearing about cases rising, women getting their newborns taken away from them, and high levels of exposure in hospitals elevated fear to the maximum. The postpartum expectations of being able to celebrate their newborn baby to their family and friends also made the informants sad and defeated. This was a huge life changing moment for these women, and it had to be celebrated practically alone.

“Labor and delivery experiences is much different if you test positive, that feels risky mentally, and spiritually.” 

 – Pregnant Woman

A major underlying contribution to negative mental health outcomes in pregnant women is the fear of a hospital environment. Women are too scared to come in for their appointments out of fear of exposure. When the initial spike of COVID-19 hit major cities such as New York City, a wave of pregnant women who were planning hospital deliveries switched to birthing centers. This was because they feared the hospital environment for high levels of exposure, knew their partners would not be allowed in during delivery, and concerned their newborns might be taken away from them. Therefore, this tremendous number of women shifting from hospital to home births or midwifery practices created a shift in delivery experiences. Women, who had no knowledge or education regarding a midwifery practice, were now seeing midwives exclusively and doctors virtually. It was evident to the midwives that it would take a long time to restore women’s faith in the hospital environment after this experience.

“Everything is just changing so much, I’m ready for it to stop.”

 – OB/Gyn

Many of the OB/Gyns felt like they were unsure how prenatal care would change in the future, stating that before the pandemic the situation was ideal. They are yearning for things to go back to normal and to not worry about high levels of exposure to this virus at their workplace. Midwives and doulas also felt uncertainty that things might never go back to normal. They especially felt that women would be reluctant to give birth in a hospital setting for a while. The midwives and doulas had to adapt their practices to be almost entirely virtual and this set up is something they do not believe will decrease in the future. Some midwives also had realizations of the importance of PPE and how wearing a mask and full PPE during delivery will probably remain. Finally, doulas and midwives discussed that women will likely have less prenatal care visits entirely and will turn to telemedicine for appointments that are not physical examinations of tests.

“It was a relief to have appointments with my midwife through telemedicine postpartum.”

 – Pregnant Woman

Most health care providers interviewed believe telemedicine has promising benefits. Some positives include that it cuts down on transportation and time for women and feels more relaxed and informative than an in-person visit. Working women do not have to take off time from work or family to go to their prenatal care appointments, and do not have to pay the same high in-person costs. Some negatives are the fact that it just simply does not equate to an in-person visit. The providers felt that it was hard to identify signs of normal development in the newborn and their patients over a computer screen. Additionally, it is possible that it will completely diminish the empowering and wholesome philosophy that midwives and doulas express so much if it were to be the only mode of health care delivery. However, the doula participant still has faith that she will be able to create a positive relationship with her client despite a virtual platform. The pregnant women discussed how they were happy to not have to enter the hospital environment and feel exposed during their prenatal care appointments. Telemedicine minimizes travel, can ease information access, streamline education, and even provide opportunities for pregnant women to meet other pregnant women safely.

“I hope that the way some of these discrepancies caused by racism have been brought to light will mean there will be some policy and structural changes to the way we deliver health care to help ameliorate some of those inequities.”

 – Midwife

A study conducted in 2021 on mental outcomes of women of color who are pregnant during the pandemic found that black women are more likely to experience worries regarding financial burden, possible infection, and death from COVID-19 than white women[33]. This indicates a higher level of stress that is present amongst black women who already are more likely to have preterm birth, preeclampsia, maternal morbidity, and other complications than white women[34]. The health care providers described the impact this pandemic has had on minorities, especially black and brown women. They could clearly see how pregnant women of color in county clinics were visibly more affected than affluent white women in private hospitals. One Ob/Gyn saw just how great the divide was between hospitals based on socioeconomic status, race, class, income etc. She described how county hospitals are seeing a higher rate of COVID-19 cases among women of color but are lacking the necessary resources to assist pregnant women during delivery. One midwife is seeing firsthand how a lack of access to basic societal needs such as adequate housing, health insurance and transportation has created barriers for women of color to protect themselves from COVID-19. Additionally, she described how discrimination against Asian-Americans has risen too. Racial injustice can put a heavy toll on a pregnant woman on top of the stress they already experience because of their pregnancy. Finally, although telemedicine has proven to be a viable health care service during the pandemic, immigrant women are missing out on the vital translation services that are now limited both in the hospital and virtually. 

Discussion

Implications

One commonality amongst the pregnant women informants was that they were crushed to find out all the plans they made to celebrate their pregnancy were cancelled. The feeling of telling family and friends they could not live these vital moments together hurt their spirit. The only solace was knowing that a beautiful moment was ahead, but how would they deal with it afterwards? Another commonality was that the pregnant women and the health care providers discussed their worries of whether their lives would be normal and free again. This fear is exacerbated by the fact that they are preparing to bring their newborns into a world that is both chaotic and uncertain – something for which no one knows how to prepare. This challenge is both unsettling and frustrating given that many of the informants believed the pandemic would not be a concern for much longer than a few months. Normalcy, to the health care providers meant being able to deliver high quality care that encompassed both a whole-health philosophy and an emotionally positive experience for patients/clients. Normalcy is the ability to practice prenatal care delivery in a way patients and clients feel safe and secure both in their bodies, and the environment they are bringing their child into. Therefore, it is evident that the informants were struggling to stay optimistic that this exciting and incredible moment would not be outweighed by the continuation of this global pandemic. A commonality amongst all health care providers was they were not prepared for the mass amounts of patients that would be filling their rooms all because of one deadly disease. Not only has it reduced resources, but it has also forced other forms of care to be put on hold – such as reproductive care. This delay and reduction of resources to essential care burdens both the health care providers and the patients. Midwives and doulas have also been dealing with the increased number of clients who fear the hospital environment.

Limitations

A disadvantage of this study was the homogeneity across participants. Given that all the pregnant women informants identified as middle class excluded important information about the effect the pandemic has on those in different socioeconomic levels. Inclusion of an immigrant woman would have heightened the diversity in responses. A disadvantage of convenience sampling includes susceptibility to volunteer bias which is when those who volunteer to participate are not representative of the focus population[35]. Additionally, with snow-ball sampling, inferences and conclusions made regarding the outcome of a population are limited, though this was not the intended outcome of the study and thereby unnecessary[36]. Another limitation includes the small scope of informants. A larger number of participants would have increased the range of responses entirely. Additionally, the inclusion of partners and family members could have added to the variety in responses among mental health impacts. This might have increased the number of informants who believe that adverse mental health impacts are a major consequence of this pandemic.

Conclusion

When thinking about how people around the world are adapting to the pandemic, it is important to consider populations who are vulnerable. Pregnant women are under a period of immunosuppression that makes them more susceptible to severe disease. These women are facing unique psychological issues that were unpredictable. I recognize here the importance of highlighting how this population has been impacted by the burdens of the pandemic specifically the inability to experience a family-centered and celebrated pregnancy. It also includes a reduced capacity for health care providers to delivery optimistic prenatal care given the overwhelmed health care system.

 

In the United States, the average number of prenatal care visits is 14, while in other countries it is usually 7-8[37]. The normalization of telemedicine might contribute to the reduction of visits that would lead to lower costs for patients[38]. This could be done by grouping vaccinations, screenings, and tests into a smaller number of in-person prenatal care visits[39]. High risk women could have a more individualized plan for how many visits and follow up visits they would need that would include virtual visits to reduce socioeconomic barriers to accessing care[40]. Setting up online groups where pregnant women can meet other pregnant women and share their experiences would provide extra support as well[41]. All of this would contribute to the reduction of time away from work and family life by making access to high-quality care faster and more convenient for patients no matter where they are located. Additionally, enhancing methods to improve the relationship between health care providers and clients/patients would greatly reduce the adverse psychological consequences. The women who had a close and intimate relationship with their provider showed a great command and overall positive outlook on their pregnancy. Finally, a stronger focus on mental health for both pregnant women and health care providers must be present during times of emergency. These negative mental health outcomes result from an overwhelmed health care system, isolation, and uncertainty. By utilizing tools such as teletherapy and the philosophy of empowerment during practice, both women and their providers will feel confident and excited to journey through pregnancy.

Areas for Further Research

Further research is recommended to continue the exploration of the impact of telemedicine and how it may be further integrated into the U.S. health care systems, so that there can be a wider range of access among patients. Telemedicine has proven to be a prominent facilitator of health care delivery during this pandemic and must be continued even in times of non-emergency. Telemedicine’s positive associations not only include easier access to general prenatal care but also increased ability to speak with midwives, doulas, therapists and Ob/Gyns. It also provides women with vital information on the progress of their pregnancy so they can ask questions and learn about their pregnancy. Finally, it is evident that telemedicine creates opportunities for women living in rural communities to achieve the same level of care as those who live near their providers. Therefore, the United States must seriously consider the positive associations of telemedicine and continue offering widespread coverage of it even in non-emergency times.

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Acknowledgements

Special thanks to the Tulane University Newcomb-Tulane and Newcomb Institute Grants committee for their generous contribution to this study. I am grateful for the guidance and supervision from the professors at the Tulane University School of Public Health and Tropical Medicine, with special thanks to Professor Francoise Grossmann who mentored me throughout the planning, research, analyzing, and drafting stages of this study. Francoise Grossmann is an accomplished public health researcher and professor who has taught me the importance of qualitative research and advocacy in the face of obstacles.

Appendix A: Sample Questions

Appendix A: Sample Questions Pregnant Women/Women who have given birth:

  1. Can you describe your ideal pregnancy experience and what your expectations are for care during your pregnancy?
  2. Can you tell me a bit about your understanding of the COVID-19 pandemic?
  3. What is your experience like when you are attending prenatal care visits?
  4. What major changes have you noticed during your visits
  5. How has your relationship with your midwife/doctor been?
  6. How have these changes made you feel in terms of: Scale of 1-10?
  7. What kind of support are you receiving?
  8. What perceptions or beliefs do you have about COVID-19
  9. What is your perception of your risk? Postpartum?
  10. How has this experience been different from previous experiences?
  11. What is your understanding of telemedicine/telehealth? Have you ever used it? Why or why not?

Healthcare Providers:

  1. How have your roles and responsibilities changed because of the COVID-19 pandemic?
  2. What are some challenges you have faced?
  3. What is your understanding of telemedicine/telehealth? Do you recommend pregnant women use it? Why or why not?
  4. What changes have you seen in access to health care for pregnant women?
  5. What restrictive policies are currently in place at your practice?
  6. What types of concerns are coming from your clients
  7. How have you handled them?
  8. How has your experience with delivery changed?
  9. How do you see prenatal care changing in the future after this pandemic?
  10. What is your understanding of telemedicine/telehealth? Have you ever used it? Why or why not?

About the Author

Sharmila Leela Mysore

Sharmila Leela Mysore is a member of the Tulane University Class of 2021 studying public health and cognitive studies. She was raised in Wayland, Massachusetts and now resides in New Orleans, Louisiana where she first became inspired to study maternal and child health. Sharmila’s unwavering determination to seek answers to global public health issues has just begun.