key: cord-0755871-prd34ilb
authors: Szabo, Rebecca A.; Wilson, Alyce N.; Homer, Caroline; Vasilevski, Vidanka; Sweet, Linda; Wynter, Karen; Hauck, Yvonne; Kuliukas, Lesley; Bradfield, Zoe
title: Covid‐19 changes to maternity care: Experiences of Australian doctors
date: 2021-02-06
journal: Aust N Z J Obstet Gynaecol
DOI: 10.1111/ajo.13307
sha: 0702d67e0297343846726ce2fa1e08a027fccec4
doc_id: 755871
cord_uid: prd34ilb

BACKGROUND: The COVID‐19 pandemic meant rapid changes to Australian maternity services. All maternity services have undertaken significant changes in relation to policies, service delivery and practices and increased use of personal protective equipment. AIMS: The aim of this study was to explore and describe doctors’ experiences of providing maternity care during the COVID‐19 pandemic in Australia. METHODS: A national online survey followed by semi‐structured interviews with a cohort of participants was conducted during the first wave of the COVID‐19 pandemic in Australia (May–June 2020). Participants were recruited through social media networks. Eighty‐six doctors completed the survey, and eight were interviewed. RESULTS: Almost all doctors reported rapid development of new guidelines and major changes to health service delivery. Professional colleges were the main source of new information about COVID‐19. Most (89%) doctors felt sufficiently informed to care for women with COVID‐19. Less than half of doctors felt changes would be temporary. Doctors described workforce disruptions with associated personal and professional impacts. The ability to access and process up‐to‐date, evidence‐based information was perceived as important. Doctors acknowledged that altered models of care had increased pregnant women’s anxiety and uncertainty. All doctors described silver linings from sector changes. CONCLUSIONS: This study provides unique insights into doctors’ experiences of providing maternity care during the COVID‐19 pandemic in Australia. Findings have immediate relevance to the maternity sector now and into the future. Lessons learnt provide an opportunity to reshape the maternity sector to better prepare for future public health crises.

The COVID-19 pandemic has significantly impacted all countries globally, even those with a proportionally small number of cases like Australia. Since the World Health Organization declared the pandemic on 11 March 2020 1 there have been rapid and significant changes to maternity service delivery in Australia. This has meant that changes that are likely to have impacted all stakeholders of maternity services, including doctors, have been put in place.

Changes to maternity service provision have largely encompassed reducing face-to-face contact and increasing infection prevention and control in healthcare settings. Many health appointments have moved to being provided by telehealth or delivered in ways to limit face-to-face contact. 2 The number of support people at clinic visits and during labour and birth has been limited, and siblings and other family members have been prohibited from visiting mothers in hospital. In some settings, access to waterbirth and use of nitrous oxide for pain management in labour have been altered. 3, 4 In addition, there has been increased and up-to-date use of personal protective equipment (PPE). There have also been changes in non-clinical activities, including reduced to no in-person meetings, training and teaching sessions and informal gatherings and face-to-face networking. 5 The aim of this study was to explore and describe medical practitioners' experiences of providing maternity care at the beginning of the COVID-19 pandemic in Australia. This is one cohort of a wider national Australian study exploring the experiences of those providing and receiving maternity care during the COVID-19 pandemic.

A national study of doctors involved in maternity care in Australia was conducted using an online survey followed by semi-structured interviews with a cohort of participants. The study was initiated during the first wave of the COVID-19 pandemic in Australia 

The novel, global nature and scale of the COVID-19 pandemic meant that no instrument existed to allow collection of data from the relevant stakeholders in these circumstances. Thus, a study-specific survey was developed. The survey was divided into three sections, collecting relevant demographics, cohort-specific descriptive data and information about experiences using Likert scales. The survey was kept intentionally succinct and was able to be completed within 15 min.

The online survey was hosted on the coordinating university's Qualtrics account. All surveys were accessed via an anonymous generic link. The commencement of the survey was taken as implicit consent. At the conclusion of the online survey, participants were able to provide their name and email address to register their interest for participating in an interview. These contact details were removed before analysis.

The survey data were analysed using the software package SPSS and are reported as descriptive statistics.

The research team contacted individuals by email who had indicated their willingness to be interviewed after the completion of the survey. The invitation email included an offer to participate in a one-on-one interview and a participant information form. If the individual replied and confirmed consent to be interviewed, a convenient date and time were arranged. Verbal consent was also obtained and recorded at the beginning of each interview.

Semi-structured interviews were conducted by a single interviewer with each participant. The interviews were audio-recorded with consent using the mobile app RecUp (Irradiated Software, LLC©2017) or Zoom. A professional transcription service transcribed the interviews verbatim for analysis.

Interview transcripts were analysed using a thematic analysis approach informed by Braun and Clarke. 6 The lead researchers (R.A.S., A.N.W. and C.H.) read and coded the interview transcripts separately using an inductive, data-driven approach. They then compared results and agreed on final codes, categories and themes until saturation was reached. Further participants would have been invited to undertake an interview if saturation was not reached.

In total, 86 doctors responded to the survey. Most were based in the most populous states in Australia (New South Wales, Victoria and Queensland), almost all had English as a first language and three-quarters were Australian born. The majority of respondents were women (86%), aged 50 years or younger (84%), worked exclusively or mostly in the public sector (57%) and resided or worked in urban areas (67%). Most respondents were working in either specialist obstetrics or general practice obstetrics, and almost three-quarters (72%) had between 1 and 15 years of experience providing maternity care. Over 40% of respondents had been tested for COVID-19 at least once (Table 1) .

A small proportion (5%) had resumed work in maternity care in response to the call for more healthcare workers due to COVID-19, although more than one-third (34%) had been asked to work outside of maternity care. One in five respondents reported that they were working more or longer shifts since the pandemic began, but most reported no changes in workload ( Table 2 ).

The way care was provided had changed considerably (Table 2) . Almost all (95%) reported that their respective health services had developed new guidelines, and more than two-thirds (68%) moved all or most consultations to telephone or video. Of those working in private or billable sectors, more than three-quarters (78%) had been impacted by changes to their billing processes ( Table 2) .

The most frequent means to obtain information about COVID-19 were professional colleges (36%), followed by the individual's maternity service (17%). Two-thirds (66%) reported feeling knowledgeable and well informed to care for a woman with COVID-19.

Regarding maternity care in the future, less than half (42%) felt that the change would be temporary and then clinical practice would revert to normal, but almost one-quarter (23%) were unsure (Table 2) .

Ten survey respondents agreed to be interviewed. Two were subsequently unavailable. Interviews were analysed and recorded and ceased when no new themes were emerging. A total of eight participants were interviewed. The demographical characteristics of interviewees broadly reflected the overall survey sample (Fig. 1) .

We present the responses here under themed and subthemed headings, with example participant responses provided in Table 3 . We found emerging patterns from all experts regardless of geographical location or years of experience.

Eight main themes were identified, and subthemes were also explored. While there was some overlap or interconnectedness between themes, each was quite distinct. The dominant themes were "It was awful and we hardly saw each other; it was really lonely. I literally went into work and saw my patients and came home again and wasn't having any social interaction with anybody; yeah it was awful." "On the home front, I just had a VCE boy who was pretty unimpressed with the whole thing and a university boy for whom it was quite a thing transitioning in his studies, but for him socially, his whole social world completely contracted and he found that very difficult."

Professional impact Impact within work environment, job satisfaction, impact on training, impact on continuing professional development "It was incredibly busy. I didn't sleep very much and I felt like I was an intern again." "In a roundabout way, it has been quite an exciting time to be a doctor in a sort of 'call to arms' kind of way."

Workforce impact Changes to workforce, impact on rosters, cohorting of staff, availability of cover, impact within the workforce "We saw this enormous panic throughout the whole department, and there was this huge surge of anxiety, huge panic, which was really challenging at the beginning and then what our service did was essentially froze all of our outpatient care for a week, so everything got cancelled and we spent a week or two planning COVID care." "In our rooms we went into a split roster, so our reception staff split their week into two halves and we did as well in the rooms, so there were just literally two ships in the night, didn't talk to each other, just kept to ourselves, so the idea was if one half went down, the other half could take over."

Impact on women Uncertainty, access to care, model of care, isolation, education, partner and support people "There was the anxiety for my patients …. What was interesting was that they wanted to see me, and they wanted a face to face and they wanted reassurance. For example, they wanted their partner at the delivery and that you know things weren't going to change, and some of them also wanted to know they weren't going to get COVID, which was a tricky one to answer of course." "There was a lot of anxiety around COVID, and I guess pregnancy is a time when there's a lot of anxiety anyway, because you are worrying about you know what might go wrong and all of those things and then throwing in COVID which was an unknown …. I was seeing a lot of people who were asking even before pregnancy, had wanted to have a pregnancy, but then they were anxious about trying because of COVID and what that might mean, so there was a lot of discussion about, 'Is this the time to try and get pregnant or not?' " Information Information sharing, knowledge acquisition "RANZCOG were right on the front foot, providing us with information that was evidence based, and I was able to then circulate that to my patients by email, and a lot of them have commented on how useful that's been." "We got to this stage where we were having all of these meetings and calling meetings and just this enormous flood of emails."

Communication of health services with staff, communication of government, communication with patients Clear guidance versus avalanche of information, confusion and difficult timing Virtual methods and telecommunication "I think it was confusing for the GPs, especially those who shared care with you know two or three hospitals. If you only ever worked with one hospital, I think it's easier, because you took in their process and the thing is the rules kept changing as we learnt more and more and so it was about how they kept up to date and I think some of the GPs …." "It was confusing, because there were different things and it changed so frequently, and that was the thing with me managing the COVID. You know the guidelines for COVID sometimes changed every day, so you were just having to constantly know update and that's hard if you are in a busy general practice managing other things besides pregnancy care."

System and model of care changes Changes in antenatal, labour and postnatal care Private versus public, large system versus agility of smaller systems Links to community care, ie, maternal and child health nurse "So much changed -you can have one support person in both, you can have your visit to postnatal which was the same person that was there at birth, so very significant changes really quickly into the ways that women accessed our care and the ways we provided it." "It was much more spaced, so although we had fewer doctors in the clinic, the women were more spaced, so we were seeing them within 10-15 min of them arriving. They were having longer appointments, all of the issues that they had were being addressed because they were truly the women who needed medical care, not this whole volume of people who came in with a question that was really easy to answer." Interestingly while this was a snapshot at the beginning of the first wave in Australia, over 40% of respondents had already been tested for COVID-19 at least once (Table 1) "I think there's been some significant improvements, and I'm hoping some of those will stay. One thing I would say is shutting down the postnatal ward and only having the partners; midwives have got more time to spend with the women. Women quite like it; they don't have to think about, 'Oh gosh, I can't put the baby on the breast now, because 'Uncle Harry' is coming to visit' so it's really been a positive there." "I think lots of the changes will prove to be better in the end, but the other thing we noticed, the midwives here noticed is that when we didn't have people traipsing through our wards into our four-bedded rooms, women are finding it easier to feed babies, because the person opposite's 'uncle Trevor' is not sitting in the room, so I strongly suspect that with the more opening up, we probably won't open up our postnatal ward quite as much as it was previously." This snapshot has shown inconsistent and constantly changing information contributing to uncertainty and is an important improvement area for future; and silver linings were observed;

these are useful to know and amplify. We need to be aware of lessons learned and continue to be prepared across all of healthcare, including maternity services.

The impacts of COVID-19 are significant and go well beyond the clinical impacts on individuals. Additional research building on this work may provide an opportunity to further explore and amplify the silver linings identified for maternity care and better prepare for future COVID-19 waves, pandemics and other potential future public health challenges.

Timeline of WHO's Response to COVID-19. Geneva: World Health Organization

Available from URL: https://ranzc og.edu. au/state ments -guide lines/ covid -19-state ment 4. Department of Health and Human Services. Maternity and Neonatal Care during Coronavirus (COVID-19). Melbourne: Government of Victoria

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We acknowledge all the participants and their teams as well as the women and babies they have and continue to care for during the pandemic.

Internal funding from the Burnet Institute funded transcriptions.