COVID-19 and Decision-Making for Pregnant Women: Taking or Relinquishing Control in Response to a Pandemic.

COVID-19 has uniquely impacted pregnant women. From the initial unknowns about its virulence during pregnancy, to frequent and rapidly changing hospital guidelines for prenatal care and delivery, pregnant women have felt intense uncertainty and, based on recent research, increased anxiety. This study sought to determine the impact COVID-19 had on women's birth plans. Open-ended qualitative responses from an anonymous, online survey of pregnant women in the United States, conducted on April 3-24, 2020, were analyzed using the Attride-Stirling qualitative framework. A conceptual framework for understanding the impact of COVID-19 on women's birth plans was generated. 2,320 pregnant women (mean age 32.7 years, mean weeks pregnant 24.6 weeks) responded to the open-ended prompts, reflecting the following themes: the impact(s) of COVID-19 on pregnant women (including unanticipated changes and uncertainty), the effect of COVID-19 on decision-making (including emotional reactions and subsequent questioning of the healthcare system), and how both of those things led women to either exercise or relinquish their agency related to their birth plan. These findings indicate that the changes and uncertainty surrounding COVID-19 are causing significant challenges for pregnant women, and absent more clarity and more provider-driven support, women seeking to cope are considering changes to their birth plans. Health systems and providers should heed this warning and work to provide pregnant women and their families with more information, support, and collaborative planning to ensure a positive, healthy birth experience, even during a pandemic.

The impact of the emergence of COVID-19 on women's prenatal genetic testing decisions.

OBJECTIVE: We conducted a study to examine the impact of COVID on patients' access and utilization of prenatal genetic screens and diagnostic tests at the onset of the COVID-19 pandemic in the United States. METHODS: We conducted telephone interviews with 40 patients to examine how the pandemic affected prenatal genetic screening and diagnostic testing decisions during the initial months of the pandemic in the United States. An interview guide queried experiences with the ability to access information about prenatal genetic testing options and to utilize the tests when desired. Audio recordings were transcribed and coded using NVivo 12. Analysis was conducted using Grounded Theory. RESULTS: The pandemic did not alter most participants' decisions to undergo prenatal genetic testing. Yet, it did impact how participants viewed the risks and benefits of testing and timing of testing. There was heightened anxiety among those who underwent testing, stemming from the risk of viral exposure and the fear of being alone if pregnancy loss or fetal abnormality was identified at the time of an ultrasound-based procedure. CONCLUSION: The pandemic may impact patients' access and utilization of prenatal genetic tests. More research is needed to determine how best to meet pregnant patients' decision-making needs during this time.

Roles and Experiences of Registered Nurses on Labor and Delivery Units in the United States During the COVID-19 Pandemic.

OBJECTIVE: To examine the roles and experiences of labor and delivery (LD) nurses during the COVID-19 pandemic. DESIGN: Cross-sectional survey. SETTING: Online distribution between the beginning of July and end of August 2020. PARTICIPANTS: LD nurses (N = 757) responded to an open-ended question about changes to their roles during the COVID-19 pandemic as part of a larger national survey. METHODS: We calculated descriptive statistics on respondents' characteristics and their hospitals' characteristics. We applied conventional content analysis to free-text comments. RESULTS: We derived four major categories from the responses: Changes in Roles and Responsibilities, Adaptations to Changes, Psychological Changes, and Perceived Effects on LaborSupport. Nearly half (n = 328) of respondents reported changes in their roles and responsibilities during the COVID-19 pandemic. They described adaptations and responses to these changes and perceived effects on patient care. Infection control policies and practices as well as the stress of a rapidly changing work environment affected the provision of labor support and personal well-being. CONCLUSION: The experiences described by respondents conveyed considerable changes in their roles and subsequent direct and indirect effects on quality of patient care and personal well-being. Policies and practices that can facilitate the ability of LD nurses to safely and securely remain at the bedside and provide high-touch, hands-on labor support are needed. The findings of our study can help facilitate the provision of labor support during times of disruption and foster the resiliency of the nursing workforce.

'I was scared I will end up in another abortion': a mixed-methods study assessing the impact of COVID-19 pandemic and lockdown on the antenatal care of pregnant women in Puducherry, South India.

BACKGROUND: As a mitigation measure for COVID-19 pandemic, lockdown was implemented in India for a period of 2 months (24 March-31 May 2020). Disruption in antenatal care (ANC) provisions during lockdown is expected due to diversion of public health facilities on pandemic. OBJECTIVE: To assess the proportion of pregnant women who had not completed the ideal number of antenatal visits, availability of iron-folic acid (IFA) supplements and challenges in availing health services during the period of lockdown. METHODS: A concurrent mixed-methods study was conducted among pregnant women in Puducherry, India. Information on obstetric characteristics and details regarding antenatal visits were collected through telephonic interviews. In-depth interviews were conducted to understand the perceived challenges in availing health services during the lockdown period. RESULTS: Out of 150 pregnant women, 62 [41.3%; 95% confidence interval (CI) 33.6-49.3] did not complete the ideal number of visits and 61 (40.7%, 95% CI 32.7-49.0) developed health problems. Out of 44 women who received medical care for health problems, 11 (25%) used teleconsultation. Of all the women, 13 (8.7%, 95% CI 4.9-14.0) had not taken the IFA supplements as prescribed by the health provider. Economic hardship, restricted mobility, lack of information about the health system changes and psychological stress due to the fear of COVID were the challenges in accessing care. CONCLUSIONS: Two out of five pregnant women did not complete the ideal number of visits and developed health problems during the lockdown period.

"Anxious and traumatised": Users' experiences of maternity care in the UK during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic saw universal, radical, and ultra-rapid changes to UK National Health Services (NHS) maternity care. At the onset of the pandemic, NHS maternity services were stripped of many of the features which support woman and family centred care. In anticipation of unknown numbers of pregnant women and maternity staff potentially sick with COVID-19, services were pared back to the minimum level considered to be required to keep women and their babies safe. The aim of this survey was to understand the impact of COVID-19 public health messaging and pandemic-related service changes on users of maternity care in the UK during the pandemic. METHODS: We conducted an online survey to explore user's experiences of COVID-19 public health messaging and 'socially-distanced' maternity care across the UK. The study population consisted of women who had experienced pregnancy after the 11th March 2020 (when the WHO declared a pandemic), whether or not they were still pregnant. We collected data between June and September 2020. We used framework analysis for the free-text data and generated descriptive statistics. FINDINGS: Women were generally happy to adopt a precautionary approach and stringently social distance in the context of a relatively unknown pathogen and in an environment of extreme anxiety and uncertainty, but were acutely aware of the negative impacts. The survey found that the widespread changes to services caused unintended negative consequences including essential clinical care being missed, confusion over advice, and distress and emotional trauma for women. COVID-19 restrictions have resulted in women feeling their antenatal and postnatal care to be inadequate and has also come at great emotional cost to users. Women reported feeling isolated and sad in the postnatal period, but also frustrated and upset by a lack of staff to help them care for their new baby. KEY CONCLUSIONS: With growing evidence of the impact of the virus on pregnant women and an increased understanding of the unintended consequences of unclear public health messaging and overly precautious services, a more nuanced, evidence-based approach to caring for women during a pandemic must be prioritised. IMPLICATIONS FOR PRACTICE: All maternity services should ensure they have clear lines of communication with women to keep them updated on changing care and visiting arrangements. Services should ensure that opportunities to provide safe face-to-face care and access for birth partners and visitors are maximised.

The impact of COVID-19 on prenatal care in the United States: Qualitative analysis from a survey of 2519 pregnant women.

OBJECTIVE: To explore if and how women perceived their prenatal care to have changed as a result of COVID-19 and the impact of those changes on pregnant women. DESIGN: Qualitative analysis of open-ended prompts included as part of an anonymous, online, cross-sectional survey of pregnant women in the United States. SETTING: Online survey with participants from 47 states within the U.S. PARTICIPANTS: Self-identified pregnant women recruited through Facebook, Twitter, and other online sources. MEASUREMENTS AND FINDINGS: An anonymous, online survey of pregnant women (distributed April 3 - 24, 2020) included an open-ended prompt asking women to tell us how COVID-19 had affected their prenatal care. Open-ended narrative responses were downloaded into Excel and coded using the Attride-Sterling Framework. 2519 pregnant women from 47 states responded to the survey, 88.4% of whom had at least one previous birth. Mean age was 32.7 years, mean weeks pregnant was 24.3 weeks, and mean number of prenatal visits at the point of the survey was 6.5. Predominant themes of the open narratives included COVID-19's role in creating structural changes within the healthcare system (reported spontaneously by 2075 respondents), behavioral changes among both pregnant women and their providers (reported by 429 respondents), and emotional consequences for women who were pregnant (reported by 503 respondents) during the pandemic. Changes resulting from COVID-19 varied widely by provider, and women's perceptions of the impact on quality of care ranged from perceiving care as extremely compromised to perceiving it to be improved as a result of the pandemic. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Women who are pregnant during the COVID-19 pandemic have faced enormous upheaval as hospitals and healthcare providers have struggled to meet the simultaneous and often competing demands of infection prevention, pandemic preparedness, high patient volumes of extremely sick patients, and the needs of 'non-urgent' pregnant patients. In some settings, women described very few changes, whereas others reported radical changes implemented seemingly overnight. While infection rates may drive variable responses, these inconsistencies raise important questions regarding the need for local, state, national, or even global recommendations for the care of pregnant women during a global pandemic such as COVID-19.

Knowledge, attitudes, practices, and influencing factors of anxiety among pregnant women in Wuhan during the outbreak of COVID-19: a cross-sectional study.

BACKGROUND: Prenatal anxiety has been a significant public health issue globally, leading to adverse health outcomes for mothers and children. The study aimed to evaluate the sociodemographic characteristics, knowledge, attitudes, and practices (KAP), and anxiety level of pregnant women during the coronavirus disease 2019 (COVID-19) epidemic in Wuhan and investigate the influencing factors for prenatal anxiety in this specific context. METHODS: Pregnant subjects' KAP towards COVID-19 and their sociodemographics and pregnancy information were collected using questionnaires. The Zung Self-Rating Anxiety Scale (SAS) was used to assess anxiety status. Factors associated with the level of prenatal anxiety were analyzed by Pearson's chi-square test and multivariable logistic regression analyses. RESULTS: The prenatal anxiety prevalence in this population was 20.8%. The mean score of knowledge was 13.2 ± 1.1 on a 0 ~ 14 scale. The attitudes and practices data showed that 580/ 817 (71.0%) were very concerned about the news of COVID-19, 455/817 (55.7%) considered the official media to be the most reliable information source for COVID-19, and 681/817 (83.4%) were anxious about the possibility of being infected by COVID-19. However, only 83/817 (10.2%) worried about contracting COVID-19 infection through the ultrasound transducer during a routing morphology scan. About two-thirds 528/817 (64.6%) delayed or canceled the antenatal visits. Approximately half of them 410/817 (50.2%) used two kinds of personal protection equipments (PPEs) during hospital visits. Logistic regression analysis revealed that the influential factors for prenatal anxiety included previous children in the family, knowledge score, media trust, worry of contracting the COVID-19 infection and worry about getting infected with COVID-19 from the ultrasound probe antenatal care (ANC) schedule. CONCLUSION: Prenatal anxiety was prevalent among pregnant women in Wuhan during the outbreak of COVID-19. The current findings identified factors associated with the level of prenatal anxiety that could be targeted for psychological care.

Pregnant women's concerns and antenatal care during COVID-19 lock-down of the Danish society.

INTRODUCTION: Pandemics are known to cause stress and anxiety in pregnant women. During the coronavirus disease 2019 (COVID-19) lockdown of the Danish society, pregnant women were considered to be at increased risk, and access to antenatal care changed. METHODS: On 8 April 2020A, a questionnaire was sent to 332 pregnant women previously sampled by general practitioners in two Danish regions. The women were contacted via secured e-mail (e-Boks), and questionnaires were returned until 6 May. RESULTS: The questionnaire was returned by 257 women (77%). More than half believed that they were at a high risk of infection with COVID-19, and a third of the women were concerned about the risk of serious disease - especially for their unborn child. Almost 90% isolated at home most of the time. The majority were worried about possible consequences of the pandemic for antenatal care, but very few had actually missed a scheduled preventive consultation with their general practitioner, and only 15% had missed an appointment with their midwife. The majority of the women preferred normal consultations and found no added safety in shifting the consultation from the normal clinical setting. CONCLUSIONS: The COVID-19 pandemic and lockdown have had a major impact on Danish pregnant women. Even so, concerns were more focused on access to care than on the risk of COVID-19 infection. Contacts with the antenatal healthcare system have only been moderately affected. FUNDING: TRYG Foundation and KEU, Region Copenhagen. TRIAL REGISTRATION: not relevant.

The German version of the pandemic-related pregnancy stress scale: A validation study.

OBJECTIVE: The consequences of the COVID-19 pandemic may lead to exceptional stress in pregnant women. In order to evaluate stress levels of pregnant woman in this difficult time, the Pandemic-Related Pregnancy Scale (PREPS) was introduced in the US. The present study introduces and validates the German version of the PREPS. STUDY DESIGN: In total, 1364 German-speaking pregnant women from Germany and Switzerland took part in this online cohort study and completed the PREPS as well as gave information on sociodemographic, obstetric and other psychological factors. RESULTS: A confirmatory factor analysis of the PREPS showed very good psychometric values and confirmed the structure of the original questionnaire. The PREPS comprises three dimensions: Infection Stress (5 items), Preparedness Stress (7 items) and Positive Appraisal (3 items). Furthermore, correlations between the PREPS and other psychological factors such as Pregnancy Specific Stress and Fear of Childbirth highlight convergent validity. The sensitivity of the questionnaire was demonstrated by its associations with several obstetric and COVID-19 related factors. CONCLUSION: The German PREPS showed good psychometric properties and is a useful instrument for future studies which aim to investigate the impact of pandemic-related stress on birth outcomes and postpartum factors.

Effect of COVID-19 on delivery plans and postnatal depression scores of pregnant women.

INTRODUCTION: Owing to the coronavirus disease 2019 outbreak Hong Kong hospitals have suspended visiting periods and made mask wearing mandatory. In obstetrics, companionship during childbirth has been suspended and prenatal exercises, antenatal talks, hospital tours, and postnatal classes have been cancelled. The aim of the present study was to investigate the effects of these restrictive measures on delivery plans and risks of postpartum depression. METHODS: We compared pregnancy data and the Edinburgh Postpartum Depression Scale (EPDS) scores of women who delivered between the pre-alert period (1 Jan 2019 to 4 Jan 2020) and post-alert period (5 Jan 2020 to 30 Apr 2020) in a tertiary university public hospital in Hong Kong. Screening for postpartum depression was performed routinely using the EPDS questionnaire 1 day and within 1 week after delivery. RESULTS: There was a 13.1% reduction in the number of deliveries between 1 January and 30 April from 1144 in 2019 to 994 in 2020. The EPDS scores were available for 4357 out of 4531 deliveries (96.2%). A significantly higher proportion of women had EPDS scores of ≥10 1 day after delivery in the post-alert group than the pre-alert group (14.4% vs 11.9%; P<0.05). More women used pethidine (6.2% vs 4.6%) and fewer used a birthing ball (8.5% vs 12.4%) for pain relief during labour in the post-alert group. CONCLUSIONS: Pregnant women reported more depressive symptoms in the postpartum period following the alert announcement regarding coronavirus infection in Hong Kong. This was coupled with a drop in the delivery rate at our public hospital. Suspension of childbirth companionship might have altered the methods of intrapartum pain relief and the overall pregnancy experience.

Addressing Disparities in Prenatal Care via Telehealth During COVID-19: Prenatal Satisfaction Survey in East Harlem.

OBJECTIVE: In the setting of an inner city, safety net hospital, patient satisfaction with prenatal care conducted via telehealth was compared with in-person visits at the height of the novel coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Through this cross-sectional study, patients were identified who received at least one televisit and one in-person visit during the COVID-19 pandemic. The Short Assessment of Patient Satisfaction (SAPS) survey was used to measure patient satisfaction. Surveys pertaining to in-person and televisits were conducted at the end of a telephone encounter, and overall satisfaction scores were documented. Patients were excluded if they received in-person or virtual care only and not both. The SAPS score correlated with the degree of patient satisfaction. RESULTS: A total of 140 patients were identified who received both virtual and in-person prenatal care from March 1, 2020 to May 1, 2020. One hundred and four patients (74%) agreed to be surveyed: 77 (74%) self-identified as Hispanic and 56 (54%) stated that their primary language was Spanish. The overall median satisfaction score for televisits and in-person visits was 20 (interquartile range [IQR]: 20, 25) and 24 (IQR: 22, 26) (p = 0.008, Z score = 2.651). In patients who self-identified as Hispanic or identified their primary language as Spanish, there was no statistically significant difference in their satisfaction scores. CONCLUSION: While there were lower scores in patient satisfaction for televisits in every category, there were no clinically significant differences since all medians were in the "satisfied" range. By lowering patient exposure to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), especially for those at risk for reduced access to care and higher COVID-19 cases by zip code, telehealth allowed for appropriate continuation of satisfactory prenatal care with no impact on patient perceived satisfaction of care. KEY POINTS: · Telehealth allowed for continuation of satisfactory prenatal care in Hispanic patients.. · Hispanic patients are at risk for reduced access to care.. · Telehealth was a useful tool for achieving patient-perceived satisfactory care..

Pregnant Women's Reports of the Impact of COVID-19 on Pregnancy, Prenatal Care, and Infant Feeding Plans.

PURPOSE: The aim of this study is to describe how the COVID-19 (coronavirus) pandemic has affected pregnancy, prenatal maternity care practices, and infant feeding plans among pregnant persons in the United States. STUDY DESIGN: Cross-sectional descriptive study using an app-based survey. METHODS: A link to the survey was sent via email to users of the Ovia Pregnancy app on May 20, 2020 and was open for 1 week. Participants were asked to complete the survey as it applied to their pregnancy, breastfeeding, and maternity care received during the COVID-19 pandemic, beginning approximately February 2020 through the time of the survey. There were 258 respondents who completed the survey. RESULTS: The majority (96.4%; n = 251) of pregnant women felt they received safe prenatal care during this time period. Slightly less 86.3% (n = 215) felt they received adequate prenatal care during this time period. 14.2% (n = 33) reported changing or considering changing the location where they planned to give birth due to COVID-19. Of those who reported they had begun purchasing items for their baby, 52.7% reported that the COVID-19 pandemic has affected their ability to get items they need for their baby. CLINICAL IMPLICATIONS: Although it is imperative to implement policies that reduce risk of transmission of COVID-19 to pregnant women and health care providers, it is necessary for health care providers and policy makers to listen to the collective voices of women during pregnancy about how COVID-19 has affected their birth and infant feeding plans and their perception of changes in prenatal care.

Prenatal anxiety and obstetric decisions among pregnant women in Wuhan and Chongqing during the COVID-19 outbreak: a cross-sectional study.

OBJECTIVES: To investigate the mental status of pregnant women and to determine their obstetric decisions during the COVID-19 outbreak. DESIGN: Cross-sectional study. SETTING: Two cities in China--Wuhan (epicentre) and Chongqing (a less affected city). POPULATION: A total of 1947 pregnant women. METHODS: We collected demographic, pregnancy and epidemic information from our pregnant subjects, along with their attitudes towards COVID-19 (using a self-constructed five-point scale). The Self-Rating Anxiety Scale (SAS) was used to assess anxiety status. Obstetric decision-making was also evaluated. The differences between cities in all of the above factors were compared and the factors that influenced anxiety levels were identified by multivariable analysis. MAIN OUTCOME MEASURES: Anxiety status and its influencing factors. Obstetric decision-making. RESULTS: Differences were observed between cities in some background characteristics and women's attitudes towards COVID-19 in Wuhan were more extreme. More women in Wuhan felt anxious (24.5 versus 10.4%). Factors that influenced anxiety also included household income, subjective symptom and attitudes. Overall, obstetric decisions also revealed city-based differences; these decisions mainly concerned hospital preference, time of prenatal care or delivery, mode of delivery and infant feeding. CONCLUSIONS: The outbreak aggravated prenatal anxiety and the associated factors could be targets for psychological care. In parallel, key obstetric decision-making changed, emphasising the need for pertinent professional advice. Special support is essential for pregnant mothers during epidemics. TWEETABLE ABSTRACT: The COVID-19 outbreak increased pregnant women's anxiety and affected their decision-making.

Explaining the experience of prenatal care and investigating the association between psychological factors with self-care in pregnant women during COVID-19 pandemic: a mixed method study protocol.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel global public health emergency. Prenatal care (PNC) providing institutes should identify the needs and demands of pregnant women by optimizing the means of PNC services during the COVID-19 pandemic. The present study aims to: a) explain prenatal care experiences; b) assess the factors affecting self-care, and c) present a prenatal care guideline and Strategies to improve the PNC. METHODS: This mixed-methods study with a sequential explanatory design consists of three phases. The first phase is a qualitative study exploring the prenatal care experiences among pregnant women. In this phase, the subjects will be selected through purposive sampling; moreover, in-depth individual interviewing will be used for data collection. Finally, the conventional content analysis approach will be employed for data analysis. The second phase is quantitative and will be used as a cross-sectional approach for assessing the association between psychological factors of self-care. In this regard, a multistage cluster sampling method will be used to select 215 subjects who will be visited in health care centers of Tabriz, Iran. The third phase will be focusing on developing a prenatal care guideline and Strategies, using the qualitative and quantitative results of the previous phases, a review of the related literature, and the nominal group technique will be performed among experts. DISCUSSION: The present research is the first study to investigate the prenatal care experiences and factors influencing self-care among pregnant women during COVID-19 pandemic. For the purposes of the study, a mixed-methods approach will be used which aims to develop strategies for improving health care services. It is hoped that the strategy proposed in the current study could lead to improvements in this regard. ETHICAL CODE: IR.TBZMED.REC.1399.003.

Making the most of the first prenatal visit: The challenge of expanding prenatal genetic testing options and limited clinical encounter time.

OBJECTIVE: Advances in prenatal genetics place additional challenges as patients must receive information about a growing array of screening and testing options. This raises concerns about how to achieve a shared decision-making process that prepares patients to make an informed decision about their choices about prenatal genetic screening and testing options, calling for a reconsideration of how healthcare providers approach the first prenatal visit. METHODS: We conducted interviews with 40 pregnant women to identify components of decision-making regarding prenatal genetic screens and tests at this visit. Analysis was approached using grounded theory. RESULTS: Participants brought distinct notions of risk to the visit, including skewed perceptions of baseline risk for a fetal genetic condition and the implications of screening and testing. Participants were very concerned about financial considerations associated with these options, ranking out-of-pocket costs on par with medical considerations. Participants noted diverging priorities at the first visit from those of their healthcare provider, leading to barriers to shared decision-making regarding screening and testing during this visit. CONCLUSION: Research is needed to determine how to restructure the initiation of prenatal care in a way that best positions patients to make informed decisions about prenatal genetic screens and tests.