Experiences of Perinatal Mental Health Care among Minority Ethnic Women during the COVID-19 Pandemic in London: A Qualitative Study

The impact of the early COVID-19 pandemic on maternal mental health during pregnancy and postpartum

PURPOSE

The aim of this study was to investigate the effects of the COVID-19 pandemic on maternal mental health during pregnancy and the postpartum period.

METHODS

The impact of the COVID-19 pandemic situation during and post pregnancy was addressed on three main factors; maternal mental health, mother-child bonding, and maternal self-confidence. To do this, two different patient cohorts were compared; data from one cohort was collected pre-pandemic, and data was collected from the other cohort at the beginning of the pandemic. Questionnaires were used to collect data regarding depressive symptoms (Edinburgh Postnatal Depression Scale [EPDS]), anxiety (State Trait Anxiety Inventory [STAI]), maternal self-confidence (Lips Maternal Self-Confidence Scale [LMSCS]) and mother-child bonding (Postpartum Bonding Questionnaire [PBQ]).

RESULTS

There were no significant differences in depressive symptoms (EPDS with an average median of 4.00-5.00) or anxiety (STAI with an average median of 29.00-33.00) between the cohorts. However, the quality of postpartum maternal bonding was higher at 3-6 months in the pandemic cohort, which was also influenced by education and the mode and number of births. The maternal self-confidence was lower in the pandemic sample, also depending on the mode of birth delivery.

CONCLUSIONS

In this study, a differential effect of the COVID-19 pandemic on mother-child bonding and maternal self-confidence was observed. The results thereby identified possible protective factors of the pandemic, which could potentially be implemented to improve maternal mental health and bonding to the child under normal circumstances.

Disparities in spatiotemporal clustering of maternal mental health conditions before and during the COVID-19 pandemic

Mounting evidence indicates the worsening of maternal mental health conditions during the COVID-19 pandemic. Mental health conditions are the leading cause of preventable death during the perinatal and postpartum periods. Our study sought to detect space-time patterns in the distribution of maternal mental health conditions in pregnant women before (2016-2019) and during (2020-2021) the COVID-19 pandemic in North Carolina, USA. Using the space-time Poisson model in SaTScan, we performed univariate and multivariate cluster analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), maternal mental disorders of pregnancy (MDP), suicidal thoughts, and suicide attempts during the pre-pandemic and pandemic periods. Clusters were adjusted for age, race, and insurance type. Significant multivariate and univariate PMAD, SMI, and MDP clustering persisted across both periods in North Carolina, while univariate clustering for both suicide outcomes decreased during the pandemic. Local relative risk (RR) for all conditions increased drastically in select locations. The number of zip code tabulation areas (ZCTAs) included in clusters decreased, while the proportion of urban locations included in clusters increased for non-suicide outcomes. Average yearly case counts for all maternal mental health outcomes increased during the pandemic. Results provide contextual and spatial information concerning at-risk maternal populations with a high burden of perinatal mental health disorders before and during the pandemic and emphasize the necessity of urgent and targeted expansion of mental health resources in select communities.

Preliminary findings on the experiences of care for women who suffered early pregnancy losses during the COVID-19 pandemic: a qualitative study

BACKGROUND

Women who suffer an early pregnancy loss require specific clinical care, aftercare, and ongoing support. In the UK, the clinical management of early pregnancy complications, including loss is provided mainly through specialist Early Pregnancy Assessment Units. The COVID-19 pandemic fundamentally changed the way in which maternity and gynaecological care was delivered, as health systems moved to rapidly reconfigure and re-organise services, aiming to reduce the risk and spread of SARS-CoV-2 infection. PUDDLES is an international collaboration investigating the pandemic's impact on care for people who suffered a perinatal bereavement. Presented here are initial qualitative findings undertaken with UK-based women who suffered early pregnancy losses during the pandemic, about how they navigated the healthcare system and its restrictions, and how they were supported.

METHODS

In-keeping with a qualitative research design, in-depth semi-structured interviews were undertaken with an opportunity sample of women (N = 32) who suffered any early pregnancy loss during the COVID-19 pandemic. Data were analysed using a template analysis to understand women's access to services, care, and networks of support, during the pandemic following their pregnancy loss. The thematic template was based on findings from parents who had suffered a late-miscarriage, stillbirth, or neonatal death in the UK, during the pandemic.

RESULTS

All women had experienced reconfigured maternity and early pregnancy services. Data supported themes of: 1) COVID-19 Restrictions as Impractical & Impersonal; 2) Alone, with Only Staff to Support Them; 3) Reduction in Service Provision Leading to Perceived Devaluation in Care; and 4) Seeking Their Own Support. Results suggest access to early pregnancy loss services was reduced and pandemic-related restrictions were often impractical (i.e., restrictions added to burden of accessing or receiving care). Women often reported being isolated and, concerningly, aspects of early pregnancy loss services were reported as sub-optimal.

CONCLUSIONS

These findings provide important insight for the recovery and rebuilding of health services in the post-pandemic period and help us prepare for providing a higher standard of care in the future and through any other health system shocks. Conclusions made can inform future policy and planning to ensure best possible support for women who experience early pregnancy loss.

Freedom for some, but not for Mum: the reproductive injustice associated with pandemic 'Freedom Day' for perinatal women in the United Kingdom

Introduction

Healthcare services for pregnant and postpartum ('perinatal') women were reconfigured significantly at the advent and for the duration of the SARS-CoV-2 pandemic, and despite the United Kingdom announcing 'Freedom Day' on 19 July 2021 (whereafter all legal lockdown-related restrictions were lifted), restrictions to maternity (antenatal, intrapartum, and postnatal) services remained. This study presents data from eight perinatal women about their experiences of psychosocial wellbeing and maternity care in the post-'Freedom Day' epoch.

Methods

Semi-structured interviews were conducted virtually, with data recorded, transcribed, and analysed by hand. Grounded theory analysis was employed with the final theory assessing the reproductive injustice of the pandemic 'Freedom Day'.

Results

Analysing iteratively and inductively led to four emergent themes: 'A Failing System, Failing Women'; 'Harm Caused by a State of Difference'; 'The Privileges (Not Rights) of Reproductive Autonomy, Agency, and Advocacy'; and 'Worried Women and Marginalised Mothers'. Together, these themes form the theory of 'Freedom for some, but not for Mum'.

Discussion

Women experienced a lack of high-quality reliable information about the pandemic, vaccination against the virus, and the changes to, and decision-making surrounding, their perinatal care. Women recognised healthcare professionals and maternity services were stretched and that maternity services were failing but often reported hostility from staff and abandonment at times when they were unsure about how to navigate their care. The most singular injustice was the disparity between women having to accept continuing restrictions to their freedom whilst receiving maternity care and the (reckless) freedom being enacted by the general public.

Oscillating autonomy: a grounded theory study of women's experiences of COVID-19 infection during pregnancy, labour and birth, and the early postnatal period

BACKGROUND

Testing positive for COVID-19 was associated with higher rates of detrimental psycho-social and physical health outcomes. The COVID-19 pandemic caused unprecedented disruption to everyday life. This included major reconfiguration of maternal, child, and perinatal mental health and care services and provision. This study aimed to investigate the experiences of those who tested positive for COVID-19 during pregnancy, labour and birth, or the early postnatal period.

METHODS

National on-line recruitment from across the United Kingdom resulted in sixteen mothers being invited to qualitative semi-structured interviews to understand the experiences of mothers who had been infected by COVID-19 during pregnancy, labour and birth, or the early postnatal period. Interviews were conducted, recorded, and transcribed using video-conferencing software. A Grounded Theory approach was used to analyse the data gathered pertaining to women's experiences of their positive COVID-19 diagnosis during pregnancy, labour and birth, or the early postnatal period.

RESULTS

The theory of 'Oscillating Autonomy - Losing and Seeking to Regain Control by Striving for Agency' was developed, comprising three main themes: 'Anxious Anticipation: The fear of infection was worse than COVID-19 itself'; 'Fluctuating Agency: What changed when COVID-19 took control'; and 'Reclaiming Control: Seeking reassurance during COVID-19 positivity'. Testing positive for COVID-19 whilst pregnant, during labour or birth, or in the early postnatal period was associated with a perceived loss of control. Those who were able to regain that control felt more secure in their situation.

CONCLUSIONS

Support was paramount to manage increased vulnerability, as was reassurance achieved by information seeking and positive action including increased health monitoring and COVID-19 vaccination.

Artificial intelligence in perinatal mental health research: A scoping review

The intersection of Artificial Intelligence (AI) and perinatal mental health research presents promising avenues, yet uncovers significant challenges for innovation. This review explicitly focuses on this multidisciplinary field and undertakes a comprehensive exploration of existing research therein. Through a scoping review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, we searched relevant literature spanning a decade (2013-2023) and selected fourteen studies for our analysis. We first provide an overview of the main AI techniques and their development, including traditional methods across different categories, as well as recent emerging methods in the field. Then, through our analysis of the literature, we summarize the predominant AI and ML techniques adopted and their applications in perinatal mental health studies, such as identifying risk factors, predicting perinatal mental health disorders, voice assistants, and Q&A chatbots. We also discuss existing limitations and potential challenges that hinder AI technologies from improving perinatal mental health outcomes, and suggest several promising directions for future research to meet real needs in the field and facilitate the translation of research into clinical settings.

The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives

BACKGROUND

Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these.

AIMS

To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare.

METHOD

A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts.

RESULTS

Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities.

CONCLUSIONS

During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Women's experiences of maternity care in the United Kingdom during the COVID-19 pandemic: A follow-up systematic review and qualitative evidence synthesis

BACKGROUND

Maternity care services in the United Kingdom have undergone drastic changes due to pandemic-related restrictions. Prior research has shown maternity care during the pandemic was negatively experienced by women and led to poor physical and mental health outcomes in pregnancy. A synthesis is required of published research on women's experiences of maternity care during the latter half of the COVID-19 pandemic.

AIM

To update a previous systematic review of maternity care experiences during the pandemic to June 2021, exploring experiences of maternity care specifically within the United Kingdom and how they may have changed, in order to inform future maternity services.

METHODS

A systematic review of qualitative literature was conducted using comprehensive searches of five electronic databases and the Cochrane COVID Study Register, published between 1 June 2021 and 13 October 2022, and further updated to 30 September 2023. Thematic Synthesis was utilised for data synthesis.

FINDINGS

Of 21,860 records identified, 27 studies were identified for inclusion. Findings included 14 descriptive themes across the five core concepts: (1)Care-seeking and experience; (2)Virtual care; (3)Self-monitoring; (4)COVID-19 vaccination; (5)Ethical future of maternity care.

DISCUSSION

Our findings in the UK are consistent with those globally, and extend those of the previous systematic review, particularly about women's perceptions of the COVID-19 vaccine during pregnancy.

CONCLUSION

Our findings suggest the following are important to women for future maternity care: personalisation and inclusiveness; clear and evidence-based communication to facilitate informed decision-making; and achieving balance between social commitments and time spent settling into motherhood.

Utilization of Antenatal Care Services Within the Context of COVID-19, Security Challenges, and an Unstable Healthcare System at Primary Health Care Centers

Background

Utilizing antenatal care (ANC) is vital for maternal and neonatal well-being, especially in low-resource settings with healthcare challenges. Identifying factors impacting antenatal care this context, t of current situation in Sudan is crucial for developing strategies to improve maternal care. This study explores ANC utilization amidst COVID-19, security issues, and healthcare instability in primary health care centers in a resource-constrained environment, aiming to enhance maternal care access and quality.

Methods

This is a mixed-methods study. Quantitative data were collected through a retrospective analysis of ANC attendance records before and during the pandemic. Demographic variables were analyzed for their association with ANC utilization. In-depth interviews were conducted to collect qualitative data from pregnant women and healthcare providers. These interviews focused on capturing the experiences, perceptions, and obstacles associated with antenatal care services during the pandemic and within the healthcare system challenges.

Results

Preliminary quantitative analysis revealed a significant decline in ANC utilization during the pandemic. Fear of COVID-19 infection, disrupted transportation, and resource constraints have emerged as significant barriers to ANC attendance. The qualitative findings highlighted the impact of security challenges on healthcare access and the adaptation strategies employed, including mobile ANC clinics and telehealth consultations.

Conclusion

This study illuminates the intricate landscape of ANC utilization in the face of a pandemic, security instability, and healthcare system vulnerability. Policymakers and stakeholders should collaborate to strengthen healthcare systems and ensure the continued provision of essential maternal health services during challenging times.

A consensus statement on perinatal mental health during the COVID-19 pandemic and recommendations for post-pandemic recovery and re-build

Introduction

The COVID-19 pandemic posed a significant lifecourse rupture, not least to those who had specific physical vulnerabilities to the virus, but also to those who were suffering with mental ill health. Women and birthing people who were pregnant, experienced a perinatal bereavement, or were in the first post-partum year (i.e., perinatal) were exposed to a number of risk factors for mental ill health, including alterations to the way in which their perinatal care was delivered.

Methods

A consensus statement was derived from a cross-disciplinary collaboration of experts, whereby evidence from collaborative work on perinatal mental health during the COVID-19 pandemic was synthesised, and priorities were established as recommendations for research, healthcare practice, and policy.

Results

The synthesis of research focused on the effect of the COVID-19 pandemic on perinatal health outcomes and care practices led to three immediate recommendations: what to retain, what to reinstate, and what to remove from perinatal mental healthcare provision. Longer-term recommendations for action were also made, categorised as follows: Equity and Relational Healthcare; Parity of Esteem in Mental and Physical Healthcare with an Emphasis on Specialist Perinatal Services; and Horizon Scanning for Perinatal Mental Health Research, Policy, & Practice.

Discussion

The evidence base on the effect of the pandemic on perinatal mental health is growing. This consensus statement synthesises said evidence and makes recommendations for a post-pandemic recovery and re-build of perinatal mental health services and care provision.

Exploring access and engagement with Improving Access to Psychological Therapies (IAPT) services, before, during, and after the COVID-19 lockdown: A service evaluation in the Northwest of England

The purpose of this study was to compare clients' prevalence and explore the characteristics that predicted access and engagement with IAPT treatment before, during, and after Lockdown.

We conducted a retrospective observational service evaluation, using routinely collected IAPT data from n = 13,019 clients who entered treatment between March and September in 2019, 2020, and 2021. Chi-square and multiple logistic regression were used to explore associations and potential predictors of access and engagement with IAPT treatment.

The number of people accessing and engaging with IAPT treatment was significantly higher after lockdown compared to before. Unemployed clients were less likely to access treatment during and after lockdown. Yet, perinatal clients and people from a black ethnic background were more likely to access treatment during lockdown. Being young and being unemployed were predictors of treatment disengagement across all three time points, whereas perinatal clients were less likely to engage only before and during lockdown. Clients who were not prescribed medication and clients with a long-term condition were more likely to engage during lockdown.

The demonstrated changes in access and engagement with IAPT treatment after the introduction of remote therapy urges the services to further consider the individual needs of specific client groups.

Inside the 'imperfect mosaic': Minority ethnic women's qualitative experiences of race and ethnicity during pregnancy, childbirth, and maternity care in the United Kingdom

BACKGROUND

Persistent, high rates of maternal mortality amongst ethnic minorities is one of the UK's starkest examples of racial disparity. With greater risks of adverse outcomes during maternity care, ethnic minority women are subjected to embedded, structural and systemic discrimination throughout the healthcare service.

METHODS

Fourteen semi-structured interviews were undertaken with minority ethnic women who had recent experience of UK maternity care. Data pertaining to ethnicity and race were subject to iterative, inductive coding, and constant comparison through Grounded Theory Analysis to test a previously established theory: The 'Imperfect Mosaic'.

ANALYSIS & FINDINGS

A related theory emerged, comprising four themes: 'Stopping Short of Agentic Birth'; 'Silenced and Stigmatised through Tick-Box Care'; 'Anticipating Discrimination and the Need for Advocacy'; and 'Navigating Cultural Differences'. The new theory: Inside the 'Imperfect Mosaic', demonstrates experiences of those who received maternity care which directly mirrors experiences of those who provide care, as seen in the previous theory we set-out to test. However, the current theory is based on more traditional and familiar notions of racial discrimination, rather than the nuanced, subtleties of socio-demographic-based micro-aggressions experienced by healthcare professionals.

CONCLUSIONS

Our findings suggest the need for the following actions: Prioritisation of bodily autonomy and agency in perinatal physical and mental healthcare; expand awareness of social and cultural issues (i.e., moral injury; cultural safety) within the NHS; and undertake diversity training and support, and follow-up of translation of the training into practice, across (maternal) health services.

A longitudinal qualitative study of women's experiences of postnatal care following hypertensive disorders of pregnancy

PROBLEM

There has been little focus on women's views of care and recovery following pregnancy complicated by hypertensive disorders of pregnancy [HDP] despite long-term implications for maternal health.

BACKGROUND

Increasingly in clinical research, areas of interest include the extent to which women are involved in postnatal care planning, perceived value of routine postnatal contacts, lifestyle behaviour advice, and extent to which ongoing concerns about HDP could be discussed with healthcare professionals.

AIM

This study explored women's experiences of birth-recovery up to 12 months following HDP.

METHODS

A longitudinal qualitative study using semi-structured interviews at four and 12 months postpartum. Twenty-four women who each had a form of HDP, were recruited using a maximum variation, purposive sampling strategy from four National Health Service maternity units in London, 21 of whom were interviewed at both time points. Data were collected and analysed by timepoint following a recurrent, cross-sectional cohort approach using template analysis methodology.

FINDINGS

Four main themes and ten sub-themes were identified. Main themes included: assumptions about blood pressure; perinatal experiences; postnatal care pathways; and managing complex health conditions.

DISCUSSION

Postnatal care needs to be tailored to women's individual needs following HDP, with ongoing review by relevant clinicians during and beyond the first six weeks. Many women with HDP have ongoing information needs about hypertensive status, treatment and prognoses, and future birth planning.

CONCLUSION

Policy makers, health providers and funders cannot continue to ignore the need to ensure postnatal services meet the needs of women who have experienced medically complex pregnancies.

Women's experiences of specialist perinatal mental health services: a qualitative evidence synthesis

PURPOSE

Specialist perinatal mental health services identify and treat women experiencing mental health conditions during pregnancy and up to one year post birth. There is limited knowledge about women's experiences of care from specialist services. Evaluation and optimisation of service delivery requires knowledge of women's care experiences. This review aimed to systematically identify, appraise, and synthesise qualitative evidence exploring women's experiences of specialist perinatal mental health services.

METHODS

A systematic literature search of five databases: Medline (OVID), EMBASE (Elsevier), PsycINFO (EBSCO), CINAHL (EBSCO) and Scopus (Elsevier), grey literature searching, and backward citation, identified a total of 1035 papers of which sixteen met inclusion criteria. Methodological quality of the included studies was assessed using the Critical Appraisal Skills Program (CASP) tool.

RESULTS

Thematic synthesis identified three themes: connected relationships; new beginnings; and meaningful service delivery. Findings identified that relationships developed with clinicians were significant to women and their experience of care. Women valued continuity of care from dedicated non-judgemental clinicians. Peer support from other mothers was perceived as meaningful to women. Through service interventions women gained new insights into their infant's needs and grew in confidence as a mother.

CONCLUSIONS

Women require provision of flexible and accessible specialist services with clinicians who are sensitive to their individual psychosocial needs and preferences. Examining discharge practices and continuing care needs is essential to ensure the best outcomes for women and their families.

The antenatal psychological experiences of women during two phases of the COVID-19 pandemic: A recurrent, cross-sectional, thematic analysis

Initial COVID-19-related social distancing restrictions, imposed in the UK in March 2020, and the subsequent lifting of restrictions in May 2020 caused antenatal disruption and stress which exceeded expected vulnerabilities associated with this lifecourse transition. The current study aimed to explore the antenatal psychological experiences of women during different phases of pandemic-related lockdown restrictions in the UK. Semi-structured interviews were held with 24 women about their antenatal experiences: twelve were interviewed after the initial lockdown restrictions (Timepoint 1; T1), and a separate twelve women were interviewed after the subsequent lifting of those restrictions (Timepoint 2; T2). Interviews were transcribed and a recurrent, cross-sectional thematic analysis was conducted. Two themes were identified for each timepoint, and each theme contained sub-themes. T1 themes were: 'A Mindful Pregnancy' and 'It's a Grieving Process', and T2 themes were: 'Coping with Lockdown Restrictions' and 'Robbed of Our Pregnancy'. COVID-19 related social distancing restrictions had an adverse effect on women's mental health during the antenatal period. Feeling trapped, anxious, and abandoned were common at both timepoints. Actively encouraging conversations about mental wellbeing during routine care and adopting a prevention opposed to cure attitude toward implementing additional support provisions may serve to improve antenatal psychological wellbeing during health crises.

Reflective, pragmatic, and reactive decision-making by maternity service providers during the SARS-CoV-2 pandemic health system shock: a qualitative, grounded theory analysis

BACKGROUND

Pregnant and postpartum women were identified as having particular vulnerability to severe symptomatology of SARS-CoV-2 infection, so maternity services significantly reconfigured their care provision. We examined the experiences and perceptions of maternity care staff who provided care during the pandemic in South London, United Kingdom - a region of high ethnic diversity with varied levels of social complexity.

METHODS

We conducted a qualitative interview study, as part of a service evaluation between August and November 2020, using in-depth, semi-structured interviews with a range of staff (N = 29) working in maternity services. Data were analysed using Grounded Theory analysis appropriate to cross-disciplinary health research.

ANALYSIS & FINDINGS

Maternity healthcare professionals provided their views, experiences, and perceptions of delivering care during the pandemic. Analysis rendered three emergent themes regarding decision-making during reconfigured maternity service provision, organised into pathways: 1) 'Reflective decision-making'; 2) 'Pragmatic decision-making'; and 3) 'Reactive decision-making'. Whilst pragmatic decision-making was found to disrupt care, reactive-decision-making was perceived to devalue the care offered and provided. Alternatively, reflective decision-making, despite the difficult working conditions of the pandemic, was seen to benefit services, with regards to care of high-quality, sustainability of staff, and innovation within the service.

CONCLUSIONS

Decision-making within maternity care was found to take three forms - where at best changes to services could be innovative, at worst they could cause devaluation in care being delivered, and more often than not, these changes were disruptive. With regard to positive changes, healthcare providers identified staff empowerment, flexible working patterns (both for themselves and collectively as teams), personalised care delivery, and change-making in general, as key areas to capitalise on current and ongoing innovations borne out of the pandemic. Key learnings included a focus on care-related, meaningful listening and engagement of staff at all levels, in order to drive forward high-quality care and avoid care disruption and devaluation.

Adapting and scaling a digital health intervention to improve maternal and child health among ethnic minority women in Vietnam amid the COVID-19 context: the dMOM project protocol

BACKGROUND

Due to interconnected structural determinants including low maternal health knowledge, economic marginalization and remoteness from low-capacity health centres, ethnic minority women (EMW) in remote areas of Vietnam face severe maternal, newborn and child health (MNCH) inequities. As ethnic minorities represent 15% of the total Vietnamese population, these disparities are significant. 'mMOM' - a pilot mobile health intervention using SMS to improve MNCH outcomes among EMW in northern Vietnam - was implemented from 2013-2016 with promising results. Despite mMOM's findings, and despite exacerbated MNCH inequities and digital health approaches becoming even more salient amid COVID-19, mobile health has not yet been scaled to address MNCH among EMW.

OBJECTIVE

To describe the protocol for adapting, expanding, and exponentially scaling the mMOM intervention qualitatively through adding COVID-19-related MNCH guidance and novel technological components (mobile app, artificial intelligence chatbots); and quantitatively through expanding over a broader geographical area reaching exponentially more participants, within the evolving COVID-19 pandemic and post-pandemic context.

METHODS

dMOM will be conducted in 4 phases. 1) Drawing on a review of international literature and government guidelines on MNCH amid COVID-19, mMOM project components will be updated to respond to COVID-19 and the post-pandemic context, and expanded to include a mobile app and artificial intelligence chatbots to more deeply engage participants. 2) Using an intersectionality lens and participatory action research approach, a scoping study and rapid ethnographic fieldwork will explore EMW's unmet MNCH needs; acceptability and accessibility of digital health; technical capacity of commune health centres; gendered power dynamics and cultural, geographical, and social determinants impacting health outcomes; and multilevel impacts of COVID-19. Findings will be applied to further refine the intervention. 3) dMOM will be implemented and incrementally scaled across 71 project communes. 4) dMOM will be evaluated to assess whether SMS delivery or mobile app delivery engenders better MNCH outcomes among EMW. Documentation of lessons learned and dMOM models will be shared with Vietnam's Ministry of Health for adoption and further scaling up.

RESULTS

The dMOM study was funded by IDRC in November 2021, co-facilitated by the Ministry of Health, and is being co-implemented by provincial health departments in two mountainous provinces. Phase 1 (literature review; updating, adapting, and expanding intervention components) was initiated in May 2022, and phase 2 (scoping study and rapid ethnographic fieldwork) is planned to begin in December 2022. The entire study is expected to be complete in June 2025.

CONCLUSIONS

The dMOM research outcomes will generate important empirical evidence on the effectiveness of leveraging digital health to address intractable MNCH inequities among EMW in low resource settings in Vietnam, and provide critical information on the processes of adapting mobile health interventions to respond to COVID-19 and other future pandemics. Finally, dMOM activities, models and findings will inform a national-scale intervention led by the Ministry of Health.

CLINICALTRIAL

INTERNATIONAL REGISTERED REPORT

PRR1-10.2196/44720.

"There's very little that you can do other than refer them to the doctor if you think they've got postnatal depression": Scoping the potential for perinatal mental health care by community pharmacists

BACKGROUND

Twenty percent of women in the UK develop perinatal mental health (PMH) problems, which have widespread effects on maternal and child health. Community pharmacists are ideally placed to identify PMH problems and refer to other trained healthcare professionals.

OBJECTIVE

This study explored community pharmacists' attitudes, current counselling practices, and barriers to providing mental health advice to perinatal women.

METHODS

A qualitative focus group study was performed virtually with community pharmacists (n = 11), working in urban settings across London. A topic guide was used to cover current counselling practice, barriers to and confidence in counselling women, and thoughts on potential pharmacist-led perinatal mental health services. The focus groups were recorded, transcribed, and analysed using thematic analysis.

RESULTS

Three themes were identified: Doing Mental Health Care; Willing, but Unable; and Introspection and reflection, which were related through a central organising concept of 'Perinatal mental health care as a new frontier for community pharmacy'. It was found that while community pharmacists provide mental health advice to perinatal women and their partners, they lacked confidence, which was related to a lack of knowledge and inadequate training opportunities. Organisational barriers were identified including a lack of a formal referral pathway to existing mental health services and other trained healthcare professionals. Perceptions of opportunities and recommendations for service improvement and change were also garnered.

CONCLUSION

This study demonstrates community pharmacists have a potential role within community mental healthcare in identification of PMH problems and providing appropriate advice and support. Upskilling community pharmacists in mental health should be considered to increase knowledge and confidence while formal referral pathways to other trained healthcare professionals and existing services should be established and made available to pharmacists.

Navigating uncertainty alone: A grounded theory analysis of women's psycho-social experiences of pregnancy and childbirth during the COVID-19 pandemic in London

PROBLEM

Maternity care underwent substantial reconfiguration in the United Kingdom during the COVID-19 pandemic.

BACKGROUND

COVID-19 posed an unprecedented public health crisis, risking population health and causing a significant health system shock.

AIM

To explore the psycho-social experiences of women who received maternity care and gave birth in South London during the first 'lockdown'.

METHODS

We recruited women (N = 23) to semi-structured interviews, conducted virtually. Data were recorded, transcribed, and analysed by hand. A Classical Grounded Theory Analysis was followed including line-by-line coding, focused coding, development of super-categories followed by themes, and finally the generation of a theory.

FINDINGS

Iterative and inductive analysis generated six emergent themes, sorted into three dyadic pairs: 1 & 2: Lack of relational care vs. Good practice persisting during the pandemic; 3 & 4: Denying the embodied experience of pregnancy and birth vs. Trying to keep everyone safe; and 5 & 6: Removed from support network vs. Importance of being at home as a family. Together, these themes interact to form the theory: 'Navigating uncertainty alone'.

DISCUSSION

Women's pregnancy and childbirth journeys during the pandemic were reported as having positive and negative experiences which would counteract one-another. Lack of relational care, denial of embodied experiences, and removal from support networks were counterbalanced by good practice which persisted, understanding staff were trying to keep everyone safe, and renewed importance in the family unit.

CONCLUSION

Pregnancy can be an uncertain time for women. This was compounded by having to navigate their maternity journey alone during the COVID-19 pandemic.

The impact of the COVID-19 pandemic on stress and other psychological factors in pregnant women giving birth during the first wave of the pandemic

BACKGROUND

The onset of mental illness such as depression and anxiety disorders in pregnancy and postpartum period is common. The coronavirus induced disease 2019 (COVID-19) pandemic and the resulting public policy responses represent an exceptional situation worldwide and there are hints for adverse psychosocial impact, hence, the study of psychological effects of the pandemic in women during hospitalization for delivery and in the postpartum period is highly relevant.

METHODS

Patients who gave birth during the first wave of the COVID-19 pandemic in Germany (March to June 2020) at the Department of Obstetrics and Gynecology, University of Würzburg, Germany, were recruited at hospital admission for delivery. Biosamples were collected for analysis of SARS-CoV-2 infection and various stress hormones and interleukin-6 (IL-6). In addition to sociodemographic and medical obstetric data, survey questionnaires in relation to concerns about and fear of COVID-19, depression, stress, anxiety, loneliness, maternal self-efficacy and the mother-child bonding were administered at T1 (delivery stay) and T2 (3-6 months postpartum).

RESULTS

In total, all 94 recruited patients had a moderate concern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at T1 with a significant rise at T2. This concern correlated with low to low-medium general psychosocial stress levels and stress symptoms, and the women showed a significant increase of active coping from T1 to T2. Anxiety levels were low and the Edinburgh Postnatal Depression Scale showed a medium score of 5 with a significant (T1), but only week correlation with the concerns about SARS-CoV-2. In contrast to the overall good maternal bonding without correlation to SARS-CoV-2 concern, the maternal self-efficiency correlated negatively with the obstetric impairment caused by the COVID-19 pandemic.

CONCLUSION

Obstetric patients` concerns regarding SARS-CoV-2 and the accompanying pandemic increased during the course of the pandemic correlating positively with stress and depression. Of note is the increase in active coping over time and the overall good mother-child-bonding. Maternal self-efficacy was affected in part by the restrictions of the pandemic. Clinical trial registration DRKS00022506.

Precarity and preparedness during the SARS-CoV-2 pandemic: A qualitative service evaluation of maternity healthcare professionals

Introduction

The SARS‐CoV‐2 pandemic has devastated populations, posing unprecedented challenges for healthcare services, staff and service‐users. In the UK, rapid reconfiguration of maternity healthcare service provision changed the landscape of antenatal, intrapartum and postnatal care. This study aimed to explore the experiences of maternity services staff who provided maternity care during the SARS‐CoV‐2 pandemic to inform future improvements in care.

Material and methods

A qualitative interview service evaluation was undertaken at a single maternity service in an NHS Trust, South London. Respondents (n = 29) were recruited using a critical case purposeful sample of maternity services staff. Interviews were conducted using video‐conferencing software, and were transcribed and analyzed using Grounded Theory Analysis appropriate for cross‐disciplinary health research. The focus of analysis was on staff experiences of delivering maternity services and care during the SARS‐CoV‐2 pandemic.

Results

A theory of “Precarity and Preparedness” was developed, comprising three main emergent themes: “Endemic precarity: A health system under pressure”; “A top‐down approach to managing the health system shock”; and “From un(der)‐prepared to future flourishing”.

Conclusions

Maternity services in the UK were under significant strain and were inherently precarious. This was exacerbated by the SARS‐CoV‐2 pandemic, which saw further disruption to service provision, fragmentation of care and pre‐existing staff shortages. Positive changes are required to improve staff retention and team cohesion, and ensure patient‐centered care remains at the heart of maternity care.

Mothers and Babies Online Course: Participant Characteristics and Behaviors in a Web-Based Prevention of Postpartum Depression Intervention

Despite the availability of evidence-based postpartum depression (PPD) prevention and treatment interventions, perinatal persons continue to suffer. eHealth and mHealth tools to address mental health issues have grown exponentially, especially given the ubiquity of technology and the increased demand for telemental health resources. The Mothers and Babies Online Course (eMB), an 8-lesson prevention of PPD intervention, was digitally adapted to expand the reach of evidence-based interventions to perinatal persons with limited access to maternal mental health resources. This report describes the characteristics, behaviors, and feedback provided by users of the updated eMB website. Two hundred eight predominantly English-speaking U.S. residents enrolled in the eMB. Thirty-seven percent were either pregnant (n = 38) or postpartum (n = 39) women interested in learning skills to manage changes in their mood during and after pregnancy; 63% were health providers (n = 131) interested in learning how to support their patient communities. Seventy-six percent (n = 159) viewed at least one of the eight eMB lessons, with 50.9% exclusively viewing Lesson 1. Few (4.4%) viewed all eight lessons. The lessons were rated favorably on usefulness and understanding. Perinatal women engaged with interactive content at higher rates than health providers. Examining user behaviors and feedback is an essential developmental step before empirically testing the efficacy of digital tools. Future iterations of the eMB will incorporate these preliminary findings to provide perinatal persons with accessible web-based interventions that will hopefully reduce the incidence and negative consequences of postpartum depression.

On race and ethnicity during a global pandemic: An 'imperfect mosaic' of maternal and child health services in ethnically-diverse South London, United Kingdom

Background

The SARS-CoV-2 pandemic has brought racial and ethnic inequity into sharp focus, as Black, Asian, and Minority Ethnic people were reported to have greater clinical vulnerability. During the pandemic, priority was given to ongoing, reconfigured maternity and children's healthcare. This study aimed to understand the intersection between race and ethnicity, and healthcare provision amongst maternity and children's healthcare professionals, during the SARS-CoV-2 pandemic.

Methods

A qualitative study consisting of semi-structured interviews (N = 53) was undertaken with maternity (n = 29; August-November 2020) and children's (n = 24; June-July 2021) healthcare professionals from an NHS Trust in ethnically-diverse South London, UK. Data pertinent to ethnicity and race were subject to Grounded Theory Analysis, whereby data was subjected to iterative coding and interpretive analysis. Using this methodology, data are compared between transcripts to generate lower and higher order codes, before super-categories are formed, which are finally worked into themes. The inter-relationship between these themes is interpreted as a final theory.

Findings

Grounded Theory Analysis led to the theory: An 'Imperfect Mosaic', comprising four themes: (1) 'A System Set in Plaster'; (2) 'The Marginalised Majority'; (3) 'Self-Discharging Responsibility for Change-Making'; and (4) 'Slow Progress, Not No Progress'. The NHS was observed to be brittle, lacking plasticity to deliver change at pace. Overt racism based on skin colour has been replaced by micro-aggressions between in-groups and out-groups, defined not just by ethnicity, but by other social determinants. Contemporaneously, responsibility for health, wellbeing, and psychological safety in the workplace is discharged to, and accepted by, the individual.

Interpretation

Our findings suggest three practicable solutions: (1) Representation of marginalised groups at all NHS levels; (2) Engagement in cultural humility which extends to other social factors; and (3) Collective action at system and individual levels, including prioritising equity over simplistic notions of equality.

Funding

This service evaluation was supported by the King's College London King's Together Rapid COVID-19 Call, successfully awarded to Laura A. Magee, Sergio A. Silverio, Abigail Easter, & colleagues (reference:- 204823/Z/16/Z), as part of a rapid response call for research proposals. The King's Together Fund is a Wellcome Trust funded initiative.