Discussion
This cohort studied was reflective of the routine perinatal population
that would attend our tertiary maternity unit normally. Notably, the
proportion of non-Caucasian ethnic groups in the COVID-19 group was
significantly higher. This reflects a national and international pattern
whereby BAME populations, including the pregnant women within these
cohorts, are seemingly more at risk of contracting
COVID-194. The majority in both cohorts were in a
partnership/co-habiting or married, had secondary or higher level of
education, were coping or comfortable financially and reported a
baseline good to very good level of health.
The impact of COVID-19 on anxiety and depression globally is a growing
concern 22. Pregnant women and their partners across
the world have had to frequently adjust to the developing situation,
with reports globally of increased anxiety in comparison to pre-pandemic
levels17,23,24. Similarly, other reports have shown
increased emotional eating among pregnant women during the
pandemic25, and increased depression and anxiety in
women and their husbands26. In assessing the HRQoL
amongst women routinely attending for antenatal, delivery and postnatal
maternity services, we found no significant difference between COVID and
Non-COVID cohorts of women in relation to their mental health and
psychological wellbeing. Both groups reported similar psychological
wellbeing scores by two validated measures, SF-12 and CORE-OM, and those
scores correlated closely (-0.787, 95% CI [-0.9171 to -0.5067],
p<0.0001), reassuring their validity. A similar study in the
UK was a pilot case-control comparison and reported no difference in
anxiety between prenatal women with or without COVID-19
infection27. This study had smaller matched sample,
and used different validated tools to assess anxiety and health. It
found that rather than COVID-19 infection status, sociodemographic
influences during the pandemic might have a greater impact on mental
health among perinatal women27. Despite some
literature reporting anxiety in perinatal women with COVID-19 during the
pandemic, our data shows no different in the COVID and non-COVID-19
cohorts, which may suggest that the anxiety and mental health
consequences seen during the COVID-19 pandemic are a product of the
cultural and social environment rather than the SARS-CoV-2 infection
itself.
Our data demonstrates there was a significantly higher physical burden
for women who had COVID during the pandemic period. They reported higher
levels of fatigue, pains, aches, shortness of breath and an impact of
their ability to function day to day (Table 2). Many common gestational
signs and symptoms of pregnancy such as physiological dyspnoea, altered
pulmonary function, congestion, and fatigue are also the clinical
manifestations of COVID-1928–30, and we may have been
underestimating the physical and physiological impact among the COVID
cohort of women. It is unclear how the precise pathophysiology of
COVID-19 in pregnancy can both be less severe generally amongst a
pregnant cohort, but also be very severe among those women who have
acute severe respiratory failure7,13,18. Some
hypotheses include the protective hormonal environment attenuating
severity during pregnancy, similar to hormonal effects shown in
influenza infections among pregnant cohorts31. Another
hypothesis is the combination of the immunological response to viral
pathogens transitioning to a T-helper 2 milieu which favours
anti-inflammatory cytokine expression and may reduce the severity of
COVID-19 amongst pregnant women8. In spite of these
hypotheses, much remains unknown, but our COVID cohort of pregnant women
certainly felt an acute physical burden on their functional day-to-day
capacity to be physically active.
The format of healthcare delivery in hospitals and healthcare settings
has seen significant changes in an attempt to ameliorate the spread of
COVID-19 and the risk to patients and healthcare workers. The healthcare
environment has similarly adapted and re-developed to meet new emerging
requirements to ensure safe and high quality care18.
Hospitals worldwide, including our site, have prepared to face severe
disruptions to routine protocols and procedures32.
Similar to affected units globally, our site created a dedicated task
force to ensure specific protocols were developed and applied across the
tertiary unit; new ER triage protocols, patient isolation rooms, visitor
restrictions, COVID-19 delivery and theatre practices were implemented
as per the latest government guidance. Dedicated COVID-19 theatre
measures were engaged and staff received up to date hospital
developments as well as training in personal protective equipment,
patient and self-management32,33. Collaboration and
hospital multidisciplinary team work is notably at the core of
successfully managing the pandemic and any subsequent
resurgence32,34.The positive consequences of these
proactive measures are clearly seen in the QoC results (Table 3). No
differences were seen in the medical care received, the identity
oriented approach of care, and the socio-cultural approaches to care in
either COVID or non-COVID cohorts. The COVID cohort was significantly
happier with the element of care received, specifically the physical
technical domain, though both COVID and non-COVID groups had very
positive results in this domain. The possible rationale for the COVID
cohort expressing significantly more satisfaction in relation to
nutrition received, equipment provided in the room and hospital, and the
quality of the hospital bed (4.11 vs 3.4, 95% CI [-1.18 to -0.24],
p<0.003) possibly is as a result of the required isolation
measures due to their COVID positive status. These women will have
received single rooms, with en-suite bathrooms, better sleep, more
focussed targeted postnatal care to minimise visits in and out of their
rooms, and as such may have felt there was greater care, provision and
quality given to them than they originally may have expected. The
overall positive responses between both groups across a broad range of
quality assessments from outpatient, inpatient, emergency room, medical
and nursing care, to the quality of the hospital environment is very
reassuring. Our results reinforce that a high level of care can be
delivered and patient satisfaction can be maintained even while
following stringent COVID-19 isolation and infection control management
protocols.
The limitations of this study include the small sample number, the
single centre studied, the bias associated with patient’s self-selecting
for future research, self-reporting results and variability between
stages of pregnancy that each of the participants were at when surveyed.
Similarly, the full maternal medical records were not accessed and as a
result relevant history was excluded from the study. Future studies
might look to power results with larger sample numbers, though post-hoc
power analysis of our significant differences between cohorts was well
powered, there is a risk of type two error in our results that were
non-significant.
The management of COVID-19 in a pregnant women remains an evolving
challenge for obstetricians and physicians. It is imperative that
pregnant women receive the specialist holistic care during this time.
There is real risk of increased maternal, fetal and pregnancy
complications among labouring and pregnant women who lack support, and
the literature supports proactively encouraging social connections
during pregnancy35. Approaches used in previous
worldwide crises and pandemics can be used, and specific strategies
targeting maternal isolation or maternal stress such as psychological
first aid and effective risk communication can reduce risk to women and
their infants17,36. As the sequelae of the pandemic
unfold, and as further surges arise, the care provided needs to focus on
the added physical burden suffered by pregnant women who have contracted
COVID-19, as well as psychological, emotional and mental health supports
that too often are forgotten when other health crises
present37,38. Additionally, maternity units must
continue to meet the required demands for the expected quality of care,
that we have shown is achievable, when caring for women, infants and
their families during this ongoing pandemic.