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.