Our definition of the two main topics was reconfirmed as we continued our review. For the first topic (the structural and organizational challenges posed by the pandemic and adjustments made by maternity staff), we defined five subtopics: a) staff shortage and restructuring; b) personal protective equipment and tests; c) switching to virtual communication; d) dealing with maternity patients who tested positive for SARS-CoV-2; and, e) excluding accompanying persons. For the second topic, we described the subjective effects of the crisis on the mental health of maternity staff. For an overview of the main topics and the subtopics, see Fig. 2.

Fig. 2

Main topic: Structural and organizational challenges

Staff shortage and restructuring

After Covid-19 was declared a pandemic, lockdown in most countries soon led to staff shortages on obstetrical wards. Maternity staff with parental duties had to coordinate the care for their children when schools and kindergartens closed [5, 17,18,19]. Hospitals needed to arrange flexible duty rosters [20]. In New York, a physician described her attempt to balance her need to protect her own family against the needs of pregnant women who required continuous support at births, abortion appointments, prenatal examinations, and during medical treatment [19]. In Germany, midwives were not initially included in essential professions, so they were not provided with emergency childcare [17]. Maternity staff with underlying conditions and pregnant professional staff had to undergo a risk assessment before they could go back to work [5, 20]. Infected staff and staff in quarantine made the staff shortage in the UK worse. After the national call for self-isolation in the UK in March 2020, staff dropped out when they were infected and also as a precautionary measure after they came in contact with a Covid-19 patient [20]. In New York, a general 14-day quarantine was imposed on all staff members who spent longer than 10 minutes within 2 meters of a Covid-19-positive patient [21]. This strict regulation was later mitigated after wearing protective masks was required [21].

In New York there were reports that the health system would be massively restructured during the pandemic [5]. Maternity staff was assembled into new teams and they needed new instructions to make it easier to work together under pressure, placing high demands on maternity staff to be adaptive and flexible [5]. In Germany, to address the shortage, the German Midwives Association linked its website to an internet platform connecting voluntary helpers with hospitals [17]. Across Europe, retired staff were called back, school and university students were contracted for paid internships [18, 20] and, in the public health system, the hiring dates for newly-qualified obstetricians were advanced (especially for office work and organizational tasks) [18].

The approach was inconsistent across countries. In some countries, maternity hospitals were closed because emergency services lacked capacity for transfers. In others, maternity hospitals were kept open so pregnant women did not have to go to general hospitals [22]. The Netherlands made an official recommendation to give birth at home to reduce the number of people present at the birth [18]. In New York, an obstetrical ward was moved to a building far from the main building as a precaution [23], even though it took more time for consultants to get there and sometimes women had to be moved to the main building [23].

Cohorts formed in delivery rooms, while teams working on the wards or with outpatients were separated [19, 24]. Waiting areas were reorganized to reduce the risk of infecting patients and staff [4, 25]. In France, a gynecological and obstetrics area was turned into a Covid-19 ward [4] and in Italy maternity wards were designated as centers to which infected (or presumed infected) pregnant women must be admitted [26]. In many places, women who were required to go to hospital for examination or women who presented themselves at hospital were usually checked, via questionnaires or email, for potential symptoms before they entered the hospital [4, 21, 24, 26, 27]. There was a shortage of protective clothing and in a pandemic wave up to 11-26% of healthcare staff in European countries tested positive for Covid-19. Midwives were among the dead in the UK and Italy [18].

Personal protective equipment and tests

A complete set of protective clothing against contamination with Sars-CoV-2 consists of a respiratory mask (FFP2 or N95), a protective overall with hood, gloves, and protective goggles [5, 20, 26, 28,29,30,31]. Even in Europe protective clothing was not available everywhere [5, 25, 32]. Hospital wards treating Covid-19 positive patients were prioritized but initially delivery rooms were not [33]. By mid-March 2020, only 74.9% of outpatient midwives in France (n=1,136) had masks, 61.6% of these midwives had hand sanitizers for the patients, 15.6% had protective overalls, and 7.8% had goggles [34]. The lack of protective clothing made maternity staff and patients feel insecure, creating uncertainty and fear of infection [20, 33]. Midwives want to use protective clothing responsibly, and to know that they are taking care of themselves and the women in their charge, in the hospital and during home visits [20].

Protective clothing became available very late for midwives in Germany [28] and the Netherlands who were not attached to a hospital [5, 18]. Protective clothing was not always distributed to them and sometimes they had to procure it themselves [17]. Midwives working outside hospitals received no standardized instructions [28] and did not have clear responsibilities [17].

Fear and worry also inspired support, help, and solidarity. Midwives spoke of receiving masks as gifts from nail design studios and veterinary practices [5] or of being given disinfectant by a company that could spare it [28, 32]. By mid-June 2020 in France, midwives working outside hospitals were eligible for six masks a week [34]. Some hospitals developed effective methods of recycling protective material [35].

In the hospitals, (video) courses instructed staff about implementing hygiene rules and correctly using protective clothing [5]. They also developed simulation exercises for time-critical emergencies [24]. So-called “dofficers” were made responsible for ensuring staff adhered to the rules and hospitals installed mirrors so staff could check to see if protective clothing fitted properly [5, 35]. Protective clothing makes the environment safer for both hospital patients and maternity staff [21]. Although protective clothing greatly increased safety, gowning up was time-consuming and staff feared they would not be able to react quickly enough in an emergency [33].

Even though the number of positive Covid-19 women in hospitals increased, the USA did not set hygiene standards specifically for the pandemic and standards varied within the country [29]. Since protective clothing was hard to procure, respiratory mask use increased only slightly over time; they were not worn at every birth [5, 29, 31], perhaps because communal facility budgets were tight and the materials were hard to access [29]. Repeated changes and restrictions unsettled maternity staff, who were not sure if protective clothing would prevent them or their families and colleagues from contracting Covid-19 [5]. In some European countries the maternity staff had to work without protective clothing [5, 32]. In some maternity hospitals, a midwife was only allowed to wear a respiratory mask during the birth [33], and in other hospitals complete protective clothing was compulsory at every birth, for self-protection and to protect the newborn child [5, 21]. A survey of 301 hospitals in 48 US states revealed that only 33% required complete protective clothing at each vaginal birth of asymptomatic women and 38% at caesarean sections [31].

Midwives also found that protective clothing made personal contact with women more difficult because the masks and goggles did not allow facial expressions [33] and their charges could not recognize a “comforting smile.” Communication in the “new normal” had to be readjusted accordingly [20, 36].

Testing is another important protection measure that, at first, was done only for symptomatic female patients or those in contact with infected persons [26]. Later, many hospitals began testing every woman who visited the hospital [4, 5, 21, 24, 29, 30]. There were 1,344 maternity hospitals in the USA: 90.2% had adequate testing capacities; 84.3% tested all pregnant women [30]. Later on, rules about wearing protective clothing depended on the results of PCR tests and symptoms indicating an infection with Covid-19, and took into account the lack of protective clothing or the discomfort of staff who wore it [21, 35, 37]. Insufficient protective clothing and inadequate testing capacity posed particular challenges to communal hospitals [29, 31, 36].

Baumann indicated hygiene rules were generally not practicable for home visits [34], which encouraged the adoption of video calls/telemedicine because it eliminated infection risk [38].

Changing to virtual communication

Using online media prevents infections and reduces the need for protective clothing and Covid-19 tests [38, 39]. In large and small maternity hospitals, virtual meetings with pregnant women and women in childbed are increasing [24, 36, 40, 41].

The need to work from home when possible to avoid contacts spurred the development and improvement of platforms for virtual medical staff meetings. These platforms were widely accepted by maternity staff, who ideally received training to use it effectively [42]. As early as March 2020, hospitals in New York established procedures to schedule daily or weekly virtual staff meetings [21, 36]. Yates et al. described daily virtual meetings of 150-200 employees at a time [36]. Maternity staff used these platforms to share information and experiences with Covid-19 patients and update recommendations for action, and they also used them to discuss personal matters. These regular meetings were well accepted overall and created community feeling and raised team spirit [5, 36].

Hotlines and virtual support were set up to reach many women easily via video call [21, 36]. In the outpatient sector, home visits grew shorter and the time between visits lengthened [28, 39]. Maternity staff also contacted women via telephone [21, 25, 28] and preferred video calls [18,19,20,21, 33, 34, 37, 38, 40, 43]. Midwives thus kept in touch with the patients regularly, even if they lacked protective clothing and tests and felt they were able to reduce the anxiety and stress of women and their families [34]. To ensure women received proper care, maternity staff produced videos about preparing for birth and situations that might arise giving birth and streamed courses during video conferences [4, 37, 42, 44]. Midwives were greatly praised by women and were proud of their quick adjustment to new circumstances [41, 43, 44].

Mixing home visits and online advice made daily work much easier for freelance midwives [43]. A female gynecologist in New York spoke of the intimacy and connectedness she felt during video calls that took place in women’s homes [19]. Teubner suggested continuing to provide online advice in the future [43], although digital presence could never replace personal visits [17]. A New York study found that 73.8% of women wanted to continue meeting via video call after the pandemic but 56% of the maternity staff did not want to continue the video meetings, though women cancelled far fewer video consultations than they cancelled office visits before the pandemic [40]. Another New York study found 92% of respondents thought telehealth technologies could guarantee adequate care. Though only 45% of them had taken advantage of existing telehealth technologies before the pandemic, 89% wanted to continue to use the technology after the pandemic [45]. Virtual meetings also enabled maternity staff to care for women who would not have otherwise had contact with a midwife because of barriers like travel time or other time limitations, health restrictions, or lack of available childcare [40, 41, 44, 46]. In Germany, there have been reports that laws are changing medical billing options for digital care; midwives could not bill for this before the pandemic [17, 28].

Dealing with women with positive SARS-CoV-2 test results

Ideally, women with positive Covid-19 test results or symptoms and uncertain infection status [46] would not enter hospitals or would be limited to short stays [33]. But women who give birth or have to go to the clinic because of complications may be exposed to infected women, so clinics had to do some restructuring. In the hospitals, separate areas, some with low pressure rooms [24, 27], were set up for infected women [4, 5, 21, 25]. Wards were closed down and some obstetrical units were moved to other buildings [20]. It was necessary to balance the requirement to separate infected and uninfected patients and staff with the urgent need to free as many beds as possible for intensive care patients [21, 23]. Obstetric wards were equipped with signal lamps, non-essential furniture was removed, and one-way routes marked out. Some of the hardware for central cardiotocography monitoring was installed after a delay [5, 20]. Contact between hospital staff and infected women was kept to a minimum [26]. Some staff used the phone or other communication routes to contact women in the hospital [24].

In addition to organizational restructuring, the pandemic also led to changes in the birthing process. Several sources reported that recommendations shortening the length of Covid-19-positive women’s stays after birth had everywhere raised the number of induced labors and cesarean sections [27, 33, 42]. A New York source reported that maternity staff would perform cesarean sections on Covid-19- positive women in critical condition starting in the 24th week of pregnancy, and in the 28th week if the baby were in a critical condition [27]. Another report found that even a serious illness of the expectant mother in itself does not constitute an indication for c-section [24].

Postnatal care and interaction with newborns also spurred changes. As a precautionary measure, health care systems began avoiding evidence-based practices that strongly benefit mother and child. In the USA, 14% of 1,344 maternity hospitals advised against skin-to-skin contact after birth and 6.5% of hospitals forbade it [30]. Italy also advised against skin-to-skin contact at first [26]. In May 2020, four maternity hospitals in New York, where the Covid-19 rate was between 8% and 46% positive for women giving birth, transferred the infants of infected women directly to the intensive care unit [27] where they could be observed [33]. A Coxon et al. editorial claimed European hospitals were doing this too. At first, women were advised not to breastfeed [18, 33], but this advice was later mitigated [18]. Mothers in poor health were advised to pump their breastmilk into bottles [18, 26, 30] or told to wear a respiratory mask while breast-feeding, and to protect their infant from infection by following the hygiene rules [18, 24, 26]. In France, women who asked for breastfeeding support or who had other complaints (including psychological symptoms) were only offered telephone or video-call service [4]. Perrine et al. reported that women in 17.9% of American maternity hospitals seldom received support when breastfeeding [30]. Maternity staff felt burdened by the need to act contrary to evidence-based breastfeeding support [30]. Throughout the world there were reports that hospitals prematurely discharged women who had given birth [4, 24, 30, 35], even when maternity staff had reduced home visits or where postpartum visits were uncommon [4, 33, 42].

These changes and challenges directly affected the staff. A qualitative survey of fourteen midwives in Spain identified factors that posed barriers to creating a safe, respectful environment for women who had or were suspected of having Covid-19 while giving birth. They described the chaos caused at the start of the pandemic, which disrupted organization, coordination and management. They spoke of constantly changing guidelines, heavier workloads, lack of access to proper protective clothing during births, and changes in their roles as midwives. The midwives reported changes ranging from emotional support despite minimized physical contact (due to excluded companions) to dehumanization [47].

Exclusion of accompanying persons

Around the world, maternity caregivers began limiting the number of people at a birth. Usually only one accompanying person was permitted during clinical puerperium and to attend the birth [33]. Sometimes women in labor were allowed companionship only after dilation and partners might be allowed to stay only an hour after the birth, depending on the hospital [18, 19, 21, 24, 48, 49]. The partners of pregnant women were sometimes forbidden from attending prenatal appointments and ultrasound scans [18, 20]. Midwives across Europe were torn between continuing to offer partner-oriented care, protecting themselves from the virus, and protecting their own family members [18]. For example, a maternity hospital in France generally allowed one accompanying person during labor if that person wore a respiratory mask and gloves, but they allowed no visitors in the maternity ward (fathers could view newborn babies and mothers through a window) [4]. Italy and Japan usually excluded accompanying persons [26, 42], though hospital stays in Japan normally lasted 5-7 days [42]. Germany also implemented versions of these recommendations [17, 48]. There, women “voted with their feet” and sought out maternity hospitals that allowed an accompanying person [17], which caused some hospitals to quickly ease their restrictions soon [17]. Maternity staff advocated for allowing an accompanying person in the delivery room [19], but even when partners were permitted to attend, they sometimes had to look after their other children [20].

Maternity staff had to learn to cope with women’s anxiety and loneliness [42]. Separation was described as an important issue overall. This included the feelings maternity staff had about separating women giving birth from their families, and their attempts to compensate for that, and midwives’ own isolation from colleagues and friends, from women with whom they were prevented from having a prenatal relationship [20]. Maternity staff worried about the long-term consequences of this isolation [33]. For example, a female gynecologist was disgusted that her professional association recommended excluding partners and doulas during birth [33]. After the first peak, in the Netherlands maternity staff quickly returned to in-person meetings and partners were again allowed to attend ultrasound scans [18].

Over the course of 2020, bans on visits were eased as respiratory masks, PCR tests, and quick tests became more available [27] but practices varied. Some maternity hospitals in New York checked accompanying persons for clinical symptoms [27] and barred anyone with a ≥38°C temperature or other potential Covid-19 symptoms [21, 27, 35]. Some hospitals allowed people who had tested positive for Covid-19 a week before, did not have a temperature within the last 72 hours to attend a birth [21]. In the Netherlands, partners Covid-19 symptoms could accompany woman if they donned respiratory masks and kept their distance [18]. In Poland, Wegrzynowska et al. reported that partners with negative test results could accompany women, but the tests were expensive and difficult to procure [49].

Main topic: subjective effects

During the pandemic crisis, maternity staff were often outside their “comfort zone” and felt that the pressures of providing normal care while coping with the pandemic placed them under strain [50]. In the midst of changing guidelines and protocols, maternity staff needs to calm upset patients and their relatives, adding additional stress [50]. Dethier & Abernathy spoke of “maintaining certainty in the most uncertain of times” [51]. Though hospitals recruited extra staff and shortening visiting hours in maternity hospitals, work load increased [50].

In cross-sectional studies carried out via an online survey with maternity staff during the Covid-19 pandemic increased anxiety and depression values predominated [7, 52,53,54,55,56,57,58,59]. Holton et al. reported that, in Australia, midwives had higher anxiety, depression and stress values than physicians and allied health staff [56]. A survey in Ireland [55] found that female professional staff were more anxious, and younger staff and administrative staff were both more anxious and more depressed. Bender et al. retrospectively compared anxiety values and job dissatisfaction during the Covid-19 pandemic to the same values before the pandemic [54]. Shah et al. compared the anxiety and depression of maternity staff to that of the general population [57]. These studies showed maternity staff had worse mental health scores than the reference. Fear of infection and concern about passing the virus on to family members increased the anxiety of maternity staff [7, 52, 53, 57, 58]. Midwives who did not work in hospitals feared passing the virus to their patients when they made home visits [28]. According to Holton et al., there was a continuing association between higher levels of anxiety, depression and stress and less clinical experience, poorer health, and more worries about Covid-19 [56]. Shah et al. found that continually changing guidelines and rapidly changing conditions caused higher anxiety and depression values [57]. In Turkey, Yörük & Güler found depression risk was 1.92 times higher among midwives than nurses [59].

A study by Uzun et al. supported the trend of higher anxiety and more depression, but when they compared physicians, midwives and nurses by age and gender, results were not significant [60]. A newspaper article from Ireland about a large online survey of midwives and nurses concluded that most participants thought pandemic harmed mental health [61]. Fear of contagion was justified because maternity staff who had trouble procuring protective clothing were infected twice as often as those with regular access to protective gear [61]. One of their greatest fears was giving the virus to family members. Several surveys and reports found that staff members isolated themselves from their families to prevent contagion [19, 53]. The British study ‘Impact of COVID-19 on the nursing and midwifery workforce’ (ICON), which was mentioned in an editorial [62], also noted how afraid nurses and midwives were of infecting family members. Of the midwives and nurses in the UK, only 1% used the online mental health forum provided by the National Health Service (NHS), perhaps because they could not muster sufficient mental capacity to reflect on their own psychological well-being [61].

A qualitative study of 14 midwives in Spain [47] who looked after women with a suspected or confirmed Covid-19 infection while they gave birth also found that the midwives were afraid they would pass the virus. They too report fear and uncertainty in situations which the midwives had to cope with suddenly on their own, about the discomfort of the protective clothing and about the lack of knowledge and support. Some of the midwives felt they could not provide the women in their care the birth experience wanted to offer them. Other midwives felt good about their work and did everything they could to create a positive, anxiety-free atmosphere [47].

Semaan et al.’s large global study show obstetricians and midwives were under more stress during the pandemic than before because staff was short (either through infection or quarantine) and their workload was higher, schedules changed frequently, and they were exhausted [33]. Kiefer et al. found that the likelihood of post-traumatic stress symptoms increased, especially in women, those who had previous traumatic experiences, and those with higher Covid-19 risk and anxiety scores [63].

Nevertheless, certain factors protect against poor mental health, including routine testing [54], protective equipment, training in managing Covid-19 [7] as well as higher resilience value [59]. Rochelson and Campbell noted that staff were less afraid of contracting Covid-19 after general testing became available in April 2020, both for standard and quick tests [5, 21].

In several studies, the negative effect of the pandemic on mental health was offset by the positive effects of the pandemic. Most of the maternity staff interviewed by Aksoy & Koçak were proud to work in the health sector [52]. Bahal et al. reported that most of them thought better of their profession and felt they were taking adequate care of mothers and newborn children [53]. Danvers & Dolan wrote that, in the face of an unknown virus, staff found working in the “familiar territory of labour and delivery” to be reassuring [19]. We also found these positive effects reflected in experiential reports. In Germany, despite changed working conditions, scarce protective equipment, and many other concerns, maternity staff felt a wave of solidarity and mutual support [28]. Fewer visitors on hospital wards fostered closer relationships between women giving birth and the person who accompanied them, and women had fewer problems breastfeeding [64]. A Letter to the Editor [65] about a small Australian pilot study that conducted semi-structured interviews with 12 physicians captured a strong sense of unit cohesiveness and reliance on collegial relationships to deal with the challenges posed by the pandemic. Staff in New York felt similarly [5, 19, 36].

Ethical dilemmas were the topic of two reviewed commentaries (one peer review [51] and one review by a journal editor [66]). Horsch et al. spoke of “moral injury” caused to staff who were forced by pandemic conditions to act against evidence, professional recommendations, or their ethical and moral values and beliefs [66]. When employees felt they were treated inhumanely it could deaden their sense of ethical and moral obligations; they might disassociate themselves as an act of self-preservation. Dethier & Abernathy described the crisis as a “heart-breaking new reality”, in which one had to work against one’s beliefs while dressed in protective clothing, e.g., separating newborns from their mothers [51]. Excluding the accompanying persons who were women’s sole support while giving birth could cause emotional overload even in experienced personnel [50]. Green et al. also discussed the maternity staff’s views on excluding accompanying persons. This created more pressure on the staff to provide emotional support that had earlier been provided by family members or doulas [67]. Risk of secondary stress from exposure to the others’ traumatic also increased [50].

Finally, some health care professionals faced danger. A peer-reviewed editorial [67] from the USA reported that medical staff around the world had been victims of violent attacks because they were seen as carriers of the disease.

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