key: cord-0767896-pv98q927
authors: Altman, Molly R.; Gavin, Amelia R.; Eagen-Torkko, Meghan K.; Kantrowitz-Gordon, Ira; Khosa, Rue M.; Mohammed, Selina A.
title: Where the System Failed: The COVID-19 Pandemic’s Impact on Pregnancy and Birth Care
date: 2021-03-31
journal: Glob Qual Nurs Res
DOI: 10.1177/23333936211006397
sha: 4c2e53d1d58c52f5d2e66b2f80200186d8151efd
doc_id: 767896
cord_uid: pv98q927

The COVID-19 pandemic created a massive shift in health care systems, including within pregnancy and birth care. To explore how experiences of pregnancy and birth were impacted, 15 patient participants and 14 nurse participants were interviewed and transcripts analyzed using critical thematic analysis. Patients highlighted how adaptations to care were inadequate to meet their needs, a desire for support in response to stress, and the impact of COVID on patients’ experiences. Nurses identified how inconsistencies in policies impacted nurses’ ability to care for patients, the impact on nurses from hospital actions, and the impact on patients from hospital actions. Both groups discussed how system changes had disparate impacts on marginalized communities, leading to racially-biased care. This pandemic will continue to have lasting impact on pregnant and birthing families, and the nurses who care for them, and it is imperative that hospitals examine their role and any potential impacts.

The SARS-CoV-19 (COVID-19) viral pandemic created a massive shift in how health care systems interact with patients, staff, and the public. The maternity care system, which encompasses prenatal care, labor and birth care, and postpartum care, has experienced vast changes in structure and interpersonal interactions as an attempt to curb exposure for both patients and staff, specifically with visitor policy changes, COVID testing for patients, and reduced or clustered care (Capanna et al., 2020; Fryer et al., 2020; Peña et al., 2020) . These changes have profoundly affected the experiences of patients interacting with the health care system, as well as the nurses who are caring for them.

The current health care system for pregnancy and birth care is made up of multiple layers of service provision, with transitions in location and personnel from prenatal care to labor and birth, and then to postpartum care. Prenatal care has historically emphasized frequent in-person visits, which became a de facto source of social and emotional support for the pregnant person (Coley et al., 2018; Gregory et al., 2020; Nicoloro-SantaBarbara et al., 2017) . In addition, the labor and birth experience in the hospital setting often serves as the apex, magnifying the impact of nursing care on a person's understanding of and satisfaction with their entire pregnancy experience (Lyndon et al., 2018; Simon et al., 2016) . As with many health-related transitions, pregnancy and birth is primarily a social experience in which care services support not only the medical health and wellbeing of patients but also the development and growth from individual to parent (Hill et al., 2019; Kennedy et al., 2009) . Nurses provide the bulk of this support while patients are in the hospital for birth, which translates as often being the most influential relationship for patients during their perinatal experiences (Edmonds et al., 2017; Lunda et al., 2018; Zielinski et al., 2016) .

Prior to the pandemic, existing issues of racial discrimination, bias, and stigma against pregnant and birthing people of color (predominantly Black people) have been described, both at the individual and structural levels (Altman et al., 2019; Bailey et al., 2017; Chambers et al., 2020; Davis, 2018; Yearby, 2018) . Interactions with health care providers have been shown to have great impact on perceptions of care experience, with intersections of provider power and implicit bias creating loss of agency and trust in the health care system (Altman et al., 2019; Davis, 2018) . Additionally, marginalized communities often have reduced access and options for quality care, which greatly reduces the ability for people of color to find and receive care from providers they trust (Yearby, 2018) . These issues, which lead to disrespectful care, mistreatment, and other sources of harm, may have contributed to the worsening disparities in maternal outcomes (McLemore et al., 2018; Vedam et al., 2019) .

With the pandemic, many systems had to change or adapt care processes in order to help prevent spread of COVID-19. In-person visits changed to virtual, visits that required in-person contact used physical distancing and reduced time face-to-face, and support mechanisms such as childbirth education and group prenatal care were changed to virtual. Family members and friends were often excluded from outpatient and inpatient care, which can have disparate impacts on BIPOC families who already are less safe in the health system (Davis, 2018) . In parallel, the changes enacted by health care systems also significantly impacted nurses who provide care in the hospital setting, potentially causing negative consequences on the quality of care provided (Labrague & De Los Santos, 2020; Pappa et al., 2020) . This study explored how experiences of pregnancy and birth were impacted by the COVID-19 pandemic, both from the patients' and nurses' perspectives in order to understand the multifaceted and intersectional impacts from these adaptations.

Using critical thematic analysis methods (Braun et al., 2014; Lawless & Chen, 2019) , researchers explored experiences of care provision during pregnancy and birth by both patients and nurses during the COVID-19 pandemic between April and August 2020.

An interdisciplinary research team was created for the purposes of this study, including researchers from nursing, midwifery, and social work, and included a community researcher who received training on research conduct and participated in all aspects of the study. Of the six researchers, three identified as Black, Indigenous, or People of Color (BIPOC); five identified as cisgender women and one as a cisgender man. Four of the researchers had expertise in qualitative methods, mainly thematic analysis, critical discourse analysis, constructivist grounded theory, and ethnography. All researchers shared an understanding of the impacts of health disparities, racism and discrimination, critical race theory, and intersectionality, all of which provide the theoretical framework and foundation for positionality for this study.

Two parallel participant groups were recruited between April and August 2020: people who were pregnant or had given birth since March 2020 (patient participants), and registered nurses (RNs) who were currently working as RNs in a perinatal setting (inpatient or outpatient) since March 2020 (nurse participants). No patient nor nurse participant was known to have had a positive COVID-19 diagnosis at the time of interview. Patient participants were restricted to those living in Washington State; however, nurse participants were recruited from across the United States to include more diverse perspectives. Recruitment occurred mainly online using social media, with targeted and snowball recruitment strategies used to assure a diverse sample of participants. Participants were recruited until emerging concepts were ascertained to be fully described and complete.

Due to the COVID-19 pandemic, virtual interviews were conducted by three members of the research team and recorded via the Zoom platform. Interviews lasted approximately 1 hour, were open-ended, and loosely guided by interview prompts when necessary. The introductory prompt asked, "Can you tell us about your experience (during your pregnancy/birth)/(while working) during the COVID-19 pandemic," with additional prompts as necessary to guide conversation. Audio recordings were professionally transcribed, and resulting transcripts were compared to the recording for accuracy and de-identified by the lead researcher. Prior to the recorded interview, verbal consent was obtained after a written information page was provided electronically and reviewed for understanding. Video recordings were kept for future dissemination after explicit verbal consent by participants, with recordings deleted for those who did not consent. Participants were provided a $50 online gift card as compensation for their time. Human subjects approval was obtained through the University of Washington Institutional Review Board.

Researchers employed critical thematic analysis as the dominant methodology for analysis (Braun et al., 2014; Lawless & Chen, 2019) , informed by other interpretive methods such as critical discourse analysis and situational analysis (Clarke, 2003; Powers, 1996) . The lead researcher performed inductive coding on all transcripts to lay a foundation of concepts that emerged from the data, with themes identified for those concepts that were represented by the majority of participants. Concurrently, members of the research team conducted individual interpretive analyses for each transcript using individually-oriented methods (based on expertise). Each transcript was then reviewed and discussed as a team, with an integrative group analysis memo described for each participant which included development of themes from concepts, constructs, and discourses identified by individual team members. Final themes were confirmed by consensus of the entire group, with all discrepancies resolved within the context of each team meeting. Themes created in the group analysis memo were then triangulated with the initial codes pulled from the full set of transcripts, and exemplar quotes identified. Lastly, constructs/themes were then arranged and organized for the purposes of cohesiveness in dissemination.

Strategies for maintaining rigor and reflexivity included frequent team meetings, group memos with a process for reaching consensus on themes and constructs, triangulation, and the use of processes from several qualitative methods to capture multiple perspectives and understandings (Braun et al., 2014; Clarke, 2003; Powers, 1996) . The inclusion of a community member as part of the research team also strengthened the methodological approach, providing avenues for input from those within and caring for the affected communities.

The patient participants represented a diverse sample of the population of birthing people in Washington State, with six out of 15 participants self-identifying as Black or African American and one participant self-identifying as transgender. A slight majority of patients (60%) were experiencing their first birth. Out of the 15 total participants, six were pregnant and nine were postpartum at the time of the interview (see Table 1 ). Out of 14 nurse participants, six self-identified as Black, Indigenous, or People of Color (BIPOC), all identified as female, and the average length of experience as a nurse in the perinatal setting was 6 years. Of note, two of the patient participants also identified as nurses, and two of the nurse participants were pregnant at the time of their interviews. These participants were able to choose which perspective they intended to use within the interview (often due to relevance of experience in relation to the pandemic). Patient participants and nurse participants brought different perspectives to how the hospital systems influenced care provision. Patient participants focused upon how adaptations to care structure were inadequate to meet their needs and an expressed desire for additional support and services to respond to stress from COVID-19. Nurse participant themes focused on how inconsistencies in policies and policy implementation impacted nurses' ability to safely care for patients and the impact on nurses from hospital actions. Both nurse and patient participants described the impacts on patients from hospital responses to the pandemic, with overlap between patient and nurse themes related to concerns about infection and exposure risk and consequent impacts on care receipt and provision, as well as noted disparities in care for BIPOC patients.

Patient participants in this study described multiple facets of their care experience during COVID-19 regarding service provision, culminating in the following distinct themes: adaptations to care structure not meeting patient needs and a need for additional support and services in response to stress from COVID.

Adaptations to care structure were inadequate to meet patient needs. Overall, the majority of participants described preferences for in-person visits and interactions over virtual or telehealth visits. There was a lack of connection noted in virtual visits that was missed and considered important in pregnancy and postpartum care. As one pregnant participant shared:

When it comes to like having a visit over the phone it's like, I know that there's nothing wrong right now. I feel fine and I don't really want to have that conversation. I want to be able to actually have a check in and actually have a doctor be able to check everything's fine and make sure the baby's heartbeat is still okay or see how my uterus is measuring and things like that that are more concrete. . . .I see the phone conversation just more being like, "Is everything okay," and me saying "Yes" and then that kind of being it.

Another participant noted how the telehealth visit she had was useless and cost her money, while what she needed was an in-person visit: That lack of connection and hands-on assessment led to feelings of isolation, loneliness, and mistrust among participants. One participant recalled the isolation she felt in relation to her providers due to virtual visits:

Having like Zoom prenatals has been-it's just been a very different experience from what I've had before [. . .] it's kind of been a bit of a lonely pregnancy in that respect.

Tele-health visits were noted to work for some things, such as needing prescriptions or quick evaluations. One participant, who had resources available to support care such as a blood pressure cuff, felt comfortable with telehealth appointments for simple needs: However, many patients shared a need for reassurance and connection from their providers, and tele-health visits did not provide it. One participant shared the comfort in knowing that her provider could take care of whatever need may arise, which was not felt during telehealth visits:

I was only being seen over the phone and I prefer to be seen in person just so that it gives me more, I don't know, I feel like just in case I want to see ultrasound or anything I have that comes up and I want to get checked out, that scares me, that's pretty hard to do over the phone.

Need for additional support and services in response to stress from COVID. Outside of how visits and interactions with providers were conducted, patient participants shared a lack of additional support modalities to compensate for the additional stress felt during this time. Participants wanted to have additional resources provided to help them cope with the changes and resulting isolation, grief, and loss that accompanies the COVID pandemic. Participants described discomfort with the uncertainty of the pandemic and a lack of reassurance from providers, as described by one participant:

We don't talk about how this is affecting us or what it means for the future. It's just they leave you hanging like, "Okay, well I'm guessing everything's okay so I'm just going to walk on out of here." But if you could just say something nice, concise and brief but meaty it would be perfect. "Okay, like hey, I don't know either what we're going to do but we're going to move through this together as best as we can." If they could even just say that, that would be awesome.

As existing support mechanisms such as group prenatal care and childbirth education moved to the virtual space, participants noted that they didn't meet the additional needs for support that the pandemic inflicted upon them, leaving patients feeling unprepared and disconnected. One participant shared how the lack of hands-on education and built-in social support that accompanies childbirth classes interfered in her getting the support she needed in her pregnancy and after her birth:

We signed up on all these online classes but we don't think that [met] 

As patient participants focused on influences related to service provision, nurse participants shared experiences that focused mainly on how system-level changes impacted their ability to care for themselves and their patients. The following themes were identified: inconsistencies in policies and policy implementation impacted nurses' ability to safely care for patients and impacts on nurses from pandemic hospital responses.

Inconsistencies in policies and policy implementation greatly impacted nurses' ability to safely care for patients. Many nurse participants noted that their hospitals or health care systems were vastly unprepared to respond to the COVID-19 pandemic. Even with having one initial patient diagnosed with COVID-19 prior to the first wave of outbreaks, one labor and delivery nurse described a lack of organization and planning on the part of the hospital: I felt like we were totally unprepared for a larger wave of patients. When we just had the one I felt like it went really well, so I was disappointed to see that in the, at least a month, more like six weeks since we'd had just the one COVID patient, that not a lot had been done to prepare in the meantime, both on a national scale and just at our hospital.

Several inpatient nurses noted feeling like hospitals were taking a reactive stance instead of looking ahead. One nurse participant shared:

It just was very-everything's been very reactive the whole time. Which I know, because nobody's ever experienced anything like this but my frustration was like, "Why not be proactive and protect all of us?

Nurse participants across multiple health care systems described having management tell them to NOT wear a mask at the beginning of the pandemic, despite knowledge of airborne or droplet spread of the majority of respiratory viruses. One described her experience having management interfere with her ability to protect herself: I was wearing a mask from day one and I kept getting told by management I wasn't allowed to wear a mask, there was no need to wear a mask and I did anyway.

Even continuing past the initial responses around masking and personal protective equipment (PPE), participants described a shortage of PPE that has adversely affected nurses' ability to stay safe in their work setting, as described by one inpatient nurse about 4 months after the start of the pandemic: In addition, nurse participants described the struggles coping with rapidly changing policies and the inability to feel safe in their work environment. As one nurse described, policies in her labor and delivery unit changed rapidly and were not disseminated in ways that supported transparent communication:

I felt like at times on my shift policies would change literally every 15 to 30 minutes. You do something one way and you get an email within the hour that this now has changed and we're doing this procedure this way and it was just constant like nobody knows what they're doing so it was very stressful.

Nurse participants described the moral distress of seeing their system not following, or delaying policy change towards, national guidelines for infection prevention. One inpatient nurse described feeling unsupported by management when asked about this: Many nurse participants also highlighted the lack of transparency in how their hospitals are responding to COVID, leaving nurses to wonder about risk of exposure and ability to trust the response. One participant described feeling defeated by the lack of support and accountability from her management regarding the risks of exposure as part of her job: I got an email like a month or so ago that a patient who was seen postpartum was presumed negative in our triage but has now tested positive. Nurse participants acknowledged that they were expected to take additional risks that other providers were not, which was interpreted as nurses not being valued as part of the health care team. One participant described an interaction with an anesthesiologist in her unit that highlighted how nurses were not valued and considered expendable in the hierarchy of health care providers:

[The anesthesiologist] is sitting there telling me, "Hey, I don't need to be exposed to this person because she has Covid and there's one of me." I'm thinking, "I understand there's more nurses than you but you're basically saying we're expendable because we're up in her face all the time. We've been in there all night trying to get her comfortable. She's miserable." I don't know, it was just inappropriate and definitely not a great thing to have happen. Impacts on nurses from hospital response. Overwhelmingly, nurse participants described a decreased trust that their workplace would support them and keep them safe while providing care to others. One nurse described a feeling that management wanted them to be thankful for what they are receiving instead of expecting a higher standard:

Nurses described wanting more compassion and respect from hospital administration, with one participant describing a need to be seen as an individual who is being placed at risk:

That just really hit me. I was like, "Okay, well, I'm just a number. I'm not a person. It doesn't matter as long as they have somebody to take care of patients." Yeah, I get that but I guarantee most people are going to value their family and themselves more than a mass majority of patients. So I just think a little compassion can go a long way and there's not a lot of that going around nowadays.

Many nurse participants noted feeling expendable or disposable by hospital administration, leading to low morale and mistrust. As one participant shared: I think a lot of nurses feel disposable. We worked really, really hard keeping up with the changes, trying to keep ourselves safe, trying to keep our patients safe and then fighting to protect ourselves and then having-then we would have coworkers who you notice trends that they're calling out sick a lot and you're wondering, "Is this food poisoning (laughs)," or is this something else? Is it COVID or not? And the hospitals have sent many emails that people are not required to share if they are positive, which is really hard, especially because we cannot properly social distance on our unit.

Nurse participants felt that they were sacrificing themselves for their patients, putting themselves and their families at risk at the expense of the need to provide care. One inpatient nurse shared her experience balancing the risks she takes at work with the resultant risks to her family: Several nurse participants described work-arounds that they created in order to protect themselves from ineffective response or policies. One nurse participant decided to change up the reporting structure between shifts to reduce crowding: Another nurse participant stepped in to train the other nurses on proper techniques for using PPE:

Despite a loss of trust in their workplaces and a need for more recognition and compassion from hospital administration, nurse participants described a dedication to maintaining quality care and agency in changing systems to make themselves and their patients safer.

Aside from responses to structural changes within the health care system, both nurse and patient participants noted that individual health care experiences were impacted by the COVID-19 pandemic. Specifically, participants described both changes in care related to perceived exposure risk and changes in care related to racism and discrimination.

Changes in care from perceived exposure risk. Many patient participants noted a change in the care they received due to perception that their providers were treating them as potential vector for COVID exposure. In particular, one participant noted feeling like that treatment led to less compassionate care:

The nurse who roomed me seemed like extremely put off by my temperature being like 99.7, as I was like crying hysterically (laughs) and she was like, "Oh my god, you have a fever!" and I'm like, "No, I don't. That's not actually a fever." It was clear that people were very suddenly concerned that there was some kind of risk of exposure from their patients. [. . .] 

Participants noted fewer interactions with nurses in the hospital, which translated for them to feeling less cared for during their stay. One patient participant described feeling like her support disappeared after her birth:

People were there [in labor] to support me and to make sure I was okay and then I felt like postpartum everyone disappeared. [. . .] I left as soon as I could but like people were forgetting my medication, no one came in to make sure that I had like a peri-bottle or extra pads. I had fundal check for a little while but it was like very clear that [. . .] the nurses were trying to limit exposure.

A Black patient participant even noted feeling like she stopped receiving care postpartum:

Nobody came in our room and checked on us for hours. I think that lady told them, "Just leave them in there. Like don't go help them. Don't go do anything." Nobody came in there for hours. This happened in the morning. Nobody came to check on us, nobody came to ask did I need any medication or anything. So we were like, okay, well when is somebody going to come? All that stopped. We stopped getting care. That wasn't okay.

Relatedly, nurse participants shared examples of how they felt that their care provision suffered due to the enacted changes by their workplace in response to COVID, leading to poor patient experiences. Nurse participants noted that the structural changes, mainly how administration controlled their work environment, influenced how they could provide care. One nurse described an experience realizing her care was suboptimal due to her supervisor restricting her access to PPE after reading about her previous patient's experience:

I read [the online news story] and I said, "Why is that name so familiar." Then it just dinged. It dawned on me. I said, "That was me. This was my patient. She gave an interview regarding my care." That stung because I remember going to my manager's room that day and asking for more supplies so that I could go into the room more frequently without having to break the gowns and reuse the gowns and she said, "You use what you have and I'm not giving you anything else.

Another nurse described her perception that policies were driving a change in how nurses cared for patients:

. . . the message with those patients has been to try and limit contact, which is sad. Like they're already limited in support and then you're wanting us as their nurse who's trying to fill in that support gap to limit our contact with them as well.

While nurse participants described having some agency in how they structure their day, the limits on material resources and through policy impacted how they could provide care.

Changes in care related to racism and discrimination. Participants of color, in particular, noted incidents of disrespectful care and described how the racism that normally exists within the health care system was magnified due to the pandemic. One Black patient participant described the complex interplay in the effects of both racism and pandemic response:

Being of color, you already kind of deal with the standoffish approach from certain people and so like [. . .] Another Black patient participant, who was also a nurse, described how her educational privilege didn't protect her from experiencing racism during the pandemic: Similar to patient experiences of how changes in care disparately affected BIPOC individuals, nurse participants also noted the impacts of racially biased care on patients. One Black nurse described an encounter she witnessed with an obstetrical resident physician:

Recently we had an example where a couple was in triage and there was this kind of stressful situation and they needed to talk to her about possible induction and so a second year resident went in to go talk to her about the need for induction and instead of including the father in the conversation or even introducing herself, she went in, completely turned her back on the dad, started having the conversation with the mom, didn't acknowledge his presence at all and then later on when she was confronted about it, she said she was tired. My thing is this, is that I've been there 10 years and I have never seen that with any Caucasian couple or really anyone else for that matter but in particular, yeah.

Nurses also saw racism through neglectful actions with patients from marginalized communities. One nurse who worked in a high-risk antepartum unit, in which patients can stay for extended periods of time, described how preference was given to White patients for flexibility and accommodation:

We have people who don't speak English as a first language, [. . .] and they just sit in their room by themselves, without their kids, without their family [. . .] because they know they can only have one visitor a day and they follow the rules and now, you know, the squeaky, the person who already has a visitor and is now asking for more, you're going to give it to that person and of course it just feels like it's a white woman who is getting this. That person was also moved to a larger room. It's like of all the patients we have on here, why is it that this patient got the larger room? Do you know what I mean? Why did we accommodate that?

The repeated instances of racism and discrimination described by both patient and nurse participants highlight the pervasive nature of systemic racism within the health care system, present before the pandemic and exacerbated due to the pandemic.

The health care system surrounding pregnancy and birth, which historically has relied on in-person care and multiple avenues of social support, fell short of expectations during this pandemic. Both patient and nurse participants highlighted several changes enacted in response to COVID-19 that adversely affected their care or ability to provide that care. The psychological impacts from those changes were significant and included loneliness, isolation, and mistrust from patients and mistrust and low morale from nurses. Importantly, both nurses and patients described how COVID amplified racially biased and disrespectful care experiences for Black women and birthing people. The inclusion of both patients and nurses in this analysis provided a deeper understanding of the impacts of systems-level changes due to COVID-19, and allowed for clearer perspectives on possible avenues for change.

In addition to existing systems not meeting patient needs, there has been an overall lack of provision of additional support mechanisms to mitigate the significant psychological effects from fear, stress, loss, and isolation that COVID has presented for both patients and nurses. Participants noted how simple reassurance from, and connection with, providers could have had vast influences on their ability to cope with the changes due to the pandemic. From the nurse perspective, participants highlighted how the response from the health care system, which relies on policies and procedures for nurses to function safely in the hospital setting, and the policy roll-out related to the pandemic, was notably inadequate, leading to a collective mistrust of management and administration. Many nurses felt unsafe and unsupported, which had a direct effect on patient care experiences.

Numerous articles have been written since the COVID-19 pandemic began in the United States around the impacts of the pandemic on maternal health care, particularly around disparities in health care and treatment (Minkoff, 2020; Niles et al., 2020) . While the responses to COVID from the health care system are noted to miss the mark for most patients, Black patient participants described a care system that amplified disparities through disrespectful individual interactions as well as through lack of culturally appropriate policies. Even pre-pandemic, hospitals were common locations for BIPOC patients to experience racism and discrimination, both in the form of individual interactions with providers as well as within larger structures such as drug testing policies and insurance acceptance (Altman et al., 2019; McLemore et al., 2018; Roberts & Nuru-Jeter, 2012) . The pandemic brought forth further amplification of these issues as well as adding in new struggles, as seen mainly within patient-provider interactions. As the pandemic continues on, there is a great need to focus on how policies and changes enacted at the health care system level affect marginalized communities (Davis-Floyd et al., 2020; Niles et al., 2020) .

The apparent value placed on frontline workers such as nurses was also highlighted in this study in descriptions of the apparent disregard by management for nurses' safety and wellbeing within the systems of care. Nurse participants described feeling de-valued and expendable, which then impacted morale and moral distress in having to balance the risks of COVID-19 versus the need to care for patients. There is growing literature around how frontline workers' health and well-being has been repeatedly undervalued during the pandemic, leading to increased burnout and the perpetuation of trauma to a woman-dominant profession such as nursing (Bahn et al., 2020; Clavijo, 2020; Thomason & Macias-Alonso, 2020) . Considering the impacts to the nursing workforce from the COVID-19 pandemic, both in terms of those leaving the field and those getting ill, there needs to be critical reflection by hospital management about how they can better support those workers who are being asked to risk their lives to keep their institutions functioning.

This study also illuminated how both nurses and patients have great mental health needs that are not currently being addressed in many settings, as indicated by feelings of isolation and disconnect from patients, and feelings of burnout and moral distress by nurses. Increasing mental health assessment, support, and services for both patients and nurses could help improve a person's state of wellbeing amidst crisis. Evidence is clearly illuminating a mental health crisis that was caused by the pandemic for both patients and health care workers (Ayaz et al., 2020; Berthelot et al., 2020; Pappa et al., 2020) , and health care systems should be instituting additional measures and supports to help those affected.

Another action distilled from this study was to increase the transparency, communication, and reassurance around policy changes and provide support that mitigates the potential impacts of those changes. Nurses needed transparency in knowing why policies are changing and how to mitigate potential impacts from those changes. Patients needed to understand those policies that affect them and receive reassurance from providers to mitigate some of the uncertainty around what to expect. Levels of stress and anxiety on both patients and nurses are high in response to the pandemic (Berthelot et al., 2020; Labrague & De Los Santos, 2020) , and there is a need for clear, organized, and transparent communication at all levels: patient, nurse, and management.

This study should be viewed within the setting of several limitations. Given the need to physically distance during the pandemic, all interviews were conducted via a virtual online platform (Zoom), which may have limited the non-verbal and conversational quality of the interviews. Additionally, as with most qualitative research, these results are not generalizable and are meant to illuminate depth of perspective, and therefore different settings may yield different perspectives. However, the vast changes related to COVID-19 on hospital systems have likely been similar across the United States due to national and professional guidelines that have been enacted in the United States. In addition, demographic information outside of racial, sexual, and gender identities, such as socioeconomic status, was not captured in this study, which may have influenced perspectives of those who participated. The rapidly changing nature of the pandemic also may limit the relevance of the identified themes as systems and structures changed notably through different phases, and so results need to be interpreted within that context. This study also held many strengths, as seen in the diverse population of participants in both the patient and nurse groups, allowing for non-dominant perspectives to surface within the interviews and analyses. This study illuminated multiple recommendations for care improvement, coming from both the patient and nurse perspectives. Future research should include a deeper qualitative exploration as to the relational dynamics in place within the health care system, particularly between nurses and management.

While the COVID-19 pandemic has tested the U.S. hospital systems in many ways, there is considerable impact being felt by both patients and nurses in the context of hospital pregnancy and birth care. As highlighted by participants in this study, the systems in place did not adequately support patients or the nurses caring for them, and efforts are needed to make sure that changes at the systems levels have the health and wellbeing of both patients and nurses in mind. All system changes should be tailored to address the needs of pregnancy and birth care and to assure that the impacts from these changes are equitable (Shorey & Chan, 2020) . This pandemic will continue to have lasting impact on pregnant and birthing families, and the nurses who care for them, and it is imperative that hospitals examine their role and any potential impacts.

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

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded through the University of Washington School of Nursing, Seattle (Altman).

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

Molly R. Altman, PhD, CNM, MPH (she/her) is an assistant professor in the School of Nursing at the University of Washington. Her research focuses upon patient-provider interactions and racism, bias, and discrimination for marginalized communities during pregnancy and birth.