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Ozgur Karcioglu,
University of Health Sciences,
Türkiye
REVIEWED BY
Céline Miani,
Bielefeld University, Germany
Rizka Ayu Setyani,
Sebelas Maret University, Indonesia
*CORRESPONDENCE
Sergio A. Silverio
Sergio.Silverio@kcl.ac.uk
†
These authors share first authorship
‡
These authors share senior authorship
RECEIVED 25 July 2024
ACCEPTED 11 November 2024
PUBLISHED 28 November 2024
CITATION
Dasgupta T, Bousfield E, Pathak Y, Horgan G,
Peterson L, Mistry HD, Wilson M, Hill M,
Smith V, Boulding H, Sheen KS, Van Citters AD,
Nelson EC, Duncan EL, von Dadelszen P, The
RESILIENT Study Group, Silverio SA and
Magee LA (2024) Healthcare providers’
experiences of maternity care service delivery
during the COVID-19 pandemic in the United
Kingdom: a follow-up systematic review and
qualitative evidence synthesis.
Front. Glob. Womens Health 5:1470674.
doi: 10.3389/fgwh.2024.1470674
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© 2024 Dasgupta, Bousfield, Pathak, Horgan,
Peterson, Mistry, Wilson, Hill, Smith, Boulding,
Sheen, Van Citters, Nelson, Duncan, von
Dadelszen, The RESILIENT Study Group,
Silverio and Magee. This is an open-access
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distribution or reproduction is permitted
which does not comply with these terms.
Healthcare providers’
experiences of maternity care
service delivery during the
COVID-19 pandemic in the
United Kingdom: a follow-up
systematic review and qualitative
evidence synthesis
Tisha Dasgupta1†, Emily Bousfield1,2†, Yosha Pathak3,
Gillian Horgan1, Lili Peterson1,4, Hiten D. Mistry1, Milly Wilson1,
Meg Hill5, Valerie Smith6, Harriet Boulding7, Kayleigh S. Sheen8,9,
Aricca D. Van Citters10, Eugene C. Nelson10, Emma L. Duncan11,
Peter von Dadelszen1, The RESILIENT Study Group12,
Sergio A. Silverio1,13*‡and Laura A. Magee1‡
1
Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s
College London, London, United Kingdom,
2
School of Medicine and Population Health, Faculty of
Health, University of Sheffield, Sheffield, United Kingdom,
3
GKT School of Medical Education, Faculty of
Life Sciences & Medicine, King’s College London, London, United Kingdom,
4
Department of Population
Health Sciences, School of Life Course & Population Sciences, King’s College London, London, United
Kingdom,
5
The RESILIENT Study Patient & Public Involvement & Engagement Advisory Group, United
Kingdom,
6
School of Nursing, Midwifery and Health Systems, College of Health and Agricultural
Sciences, University College Dublin, Dublin, Ireland,
7
The Policy Institute, Faculty of Social Science &
Public Policy, King’s College London, London, United Kingdom,
8
Department of Social Sciences,
College of Health, Science and Society, University of the West of England Bristol, Bristol,
United Kingdom,
9
The RESILIENT Study Technical Advisory Group, United Kingdom,
10
The Dartmouth
Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover,
NH, United States,
11
Department of Twin Research & Genetic Epidemiology, School of Life Course &
Population Sciences, King’s College London, London, United Kingdom,
12
The RESILIENT Study Group,
United Kingdom,
13
School of Psychology, Faculty of Health, Liverpool John Moores University,
Liverpool, United Kingdom
Problem and background: During the COVID-19 pandemic, there was
substantial reconfiguration of maternity care services, affecting both users and
healthcare providers (HCPs), in the United Kingdom (UK) and globally.
Aim: To further our understanding of the impact of maternity service
reconfigurations in the UK, from the perspective of maternity HCPs.
Methods: Scopus, MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane
COVID Study Register were searched for relevant studies reporting qualitative
data from the UK, published in English between 01 June 2021 and 30
September 2023. Qualitative data on HCPs’experiences of maternity care
reconfiguration during the pandemic were extracted from 15 studies. Data
were subjected to thematic synthesis according to key service reconfigurations.
TYPE Review
PUBLISHED 28 November 2024
|
DOI 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 01 frontiersin.org
Results: Nine themes were identified: Care-seeking and Care Experience:
Changes to existing care, Limitations placed on the partner, Mental health and
lack of support networks, and Barriers to successful implementation of
reconfiguration strategies; Virtual Care: Impact on quality of care, Increased
convenience and flexibility, and Digital exclusion; and Ethical Future of
Maternity Care Services: Optimising patient care, and Service users and staff as
the driving force for change. No studies reported on the concepts of Self-
monitoring or COVID-19 vaccination.
Discussion and conclusion: The review findings highlight HCPs’views of the need
for greater inclusion of partners, choice of virtual or in-person care for women and
birthing people; and a need for co-designed services for future policy-making.
KEYWORDS
COVID-19, maternity services, healthcare professionals, systematic review, qualitative
research
1 Introduction
During the COVID-19 pandemic, maternity care was provided
throughout as essential within National Health Service (NHS)
provision (3). Nevertheless, substantial service reconfigurations
were made.
Guidance from the Royal College of Obstetricians and
Gynaecologists [RCOG] and the Royal College of Midwives
[RCM] was published frequently, often updated weekly (1).
Guidance aimed to: prevent transmission of the SARS-CoV-2
virus, adapt services to increased demand in acute care settings,
and respond to heightened maternal vulnerability to severe
COVID-19 associated with pregnancy (1). For women and
birthing people, service reconfigurations included: a shift to
virtual care provision for at least some antenatal care visits (2–5);
fewer antenatal visits (20); alterations in some diagnostic care
pathways (6,7); exclusion of fathers, partners, and non-
gestational parents from many aspects of care (3,8–10); and
restriction on choice of place of birth (11). Other changes to
maternity services included: new satellite ‘Nightingale’hospitals,
reorganisation of existing hospital facilities, redeployment of
maternity staff to other departments, and encouragement of
newly-retired staff to return to work (2,12,13). Throughout the
pandemic, maternity healthcare providers (HCPs) continued to
work in high-risk areas, facing new challenges and rapid changes.
In their qualitative thematic synthesis of global literature,
which included 17 studies published between 01 January 2020
and 13 June 2021, Flaherty et al. explored HCPs’experiences of
providing maternity care during the pandemic, identifying
positive and negative impacts (14). Inconsistencies and recurrent
changes in guidelines left HCPs feeling confused and unable to
provide safe and effective care (14). HCP workload increased,
and as the pandemic continued for longer than anticipated, acute
changes became chronic. Staff burnout became evident, relating
to staff shortages (15), the burden of additional tasks required to
deliver new care practices, and the need for longer antenatal and
postnatal appointments to address pregnant women and birthing
people’s questions and anxiety (14). Simultaneously, maternity
HCPs reported enhanced camaraderie and bonding with
colleagues, which led to a more positive working environment (14).
As the pandemic resolves, HCPs have reflected and considered
the value of pandemic-related changes to maternity care (23). Thus,
we updated the previous relevant systematic review (14), with
literature published to September 2023, to inform future
development and organisation of maternity services.
2 Methods
The review forms part of the RESILIENT study: Post pandemic
planning for maternity care for local, regional, and national
maternity systems across the four nations (NIHR134293) (16).
The review was registered with PROSPERO [CRD42022355948]
(17) and adheres to the PRISMA 2020 statement (18)
(Supplementary Table S1).
2.1 Inclusion criteria
We followed the SPIDER (Sample, Phenomenon of Interest,
Design, Evaluation, and Research Type) framework used in the
original review (14).
Our sample included maternity HCPs directly involved in
provision of maternity care during the COVID-19 pandemic. A
Abbreviations
CINAHL, cumulative index of nursing and allied health literature; COVID-19, coronavirus disease 2019 caused by the SARS-CoV-2 virus infection; ENTREQ,
enhancing transparency in reporting the synthesis of qualitative research; EMBASE, excerpta medica database; EPPI-Centre, evidence for policy and practice
information and co-ordinating centre; HCP, healthcare provider; HICs, high income countries; LMICs, low- and middle-income countries; MEDLINE, online
counterpart of MEDLARS MEDical literature analysis and retrieval system; NHS, National Health Service; PRISMA, preferred reporting items for systematic
reviews and meta-analyses; RCM, Royal College of Midwives; RCOG, Royal College of Obstetricians and Gynaecologists; RESILIENT: The RESILIENT study,
post pandemic planning for maternity care for local, regional, and national maternity systems across the four nations; SPIDER, sample, phenomenon of interest,
design, evaluation, and research; UK, United Kingdom; WHO, World Health Organization.
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 02 frontiersin.org
range of professions were captured, including, but not limited to
midwifery, nursing, and obstetrics. Whilst we sought studies
published globally, in this review, we have restricted our sample
to UK-based studies (see Search Strategy and Selection section
for further detail). The phenomenon of interest was HCP
experience of maternity care provision during the pandemic,
including all antenatal care (except abortion), labour and
childbirth, and up to six months postpartum. Care in all settings
was considered. Qualitative study designs of interest included:
descriptive, exploratory, and interpretive studies; ethnographic
studies; observational or mixed-methods studies in which
qualitative data had been extracted separately; survey designs
with open-text questions when significant qualitative data had
been collected and formally analysed; linguistic studies; and
studies of public discourse. Only published literature was included.
Literature published between 01 June 2021 and 30 September
2023 [building on the previous review’s(14) search, 01 January
2020 to 13 June 2021] was sought. The search strategy was
restricted to English language.
2.2 Search strategy and selection
Systematic searches were undertaken of the electronic
databases of Scopus, MEDLINE (Online counterpart of
MEDLARS MEDical Literature Analysis and Retrieval System),
EMBASE (Excerpta Medica dataBASE), CINAHL (Cumulative
Index of Nursing and Allied Health Literature), PsycINFO and
the Cochrane COVID Study Register. The search terms and
keywords used in the Flaherty et al. review (14) were adopted
(Supplementary Table S2).
EndNote Reference Manager was used to clean search result
duplicates, and citations were uploaded to the Rayyan web-based
systematic reviewing tool. Team members (TD, LP, GH, MW,
SAS, HDM, PvD, LAM) independently screened each title and
abstract, followed by full-text review. After each screening stage,
disagreements were resolved through discussion with the wider
team. Given the large number of studies meeting inclusion
criteria, and the focus of RESILIENT on maternity care in the
UK, a decision was made prior to data extraction to sub-divide
the review by population of interest (women and birthing people
or HCPs) and geography [UK, other high-income countries
(HICs), or low- and middle-income countries]. The remaining
studies have (19) or will be synthesised separately.
2.3 Data extraction and synthesis
Data were extracted independently by two reviewers (EB, YP)
into a pre-designed Microsoft Excel data extraction sheet, and
checked by wider-team members during regular discussions.
Extracted information included: characteristics of studies (e.g.,
reference, aims, setting, and dates of data collection) and
participants (e.g., number, setting), data collection method,
details of analyses, and themes identified, all taken from the
results sections of included papers. Then, each paper was
imported into NVivo qualitative research software for coding
and synthesis of Discussion sections. Of note, Results sections
were not coded to avoid replicating codes/themes and rendering
logic circular.
In line with the previous reviews (7,14), methodological
quality was assessed independently by two team members (EB,
YP) and checked for correctness by other authors, using an
adapted version of a 12-item EPPI-Centre (Evidence for Policy
and Practice Information and Co-ordinating Centre) tool which
captures information on the reliability and validity of study
methods and reporting, for qualitative evidence synthesis (20).
Data were included for synthesis, regardless of quality, to provide
relevant ‘views/experiences’data. We did, however, interrogate
our final results to ensure that inclusion of low-quality papers, if
any, did not compromise the integrity of resulting themes (that
is, the removal of codes derived from low quality studies was not
found to affect the overall set of derived themes).
Thematic Synthesis (21) was undertaken based on a set of a
priori concepts which address RESILIENT aims: (1) Care-seeking
and care experience, (2) Virtual care, (3) Self-monitoring, (4)
COVID-19 vaccination, and (5) Ethical future of maternity care
services. Extracted data from each study were aligned with one
or more of these key concepts, then data under each concept
were coded, and descriptive themes generated inductively. Data
were synthesised independently by two reviewers (EB, YP), to
ensure cohesion and congruity in coding, with regular discussion
to resolve any conflicts and agree on derived themes.
3 Results
3.1 Search and selection
Figure 1 illustrates the search and selection process (18). The
initial literature search yielded 21,860 records. Records were
removed if they were: duplicates (n= 2,925); ineligible at title/
abstract screening (n= 18,468); could not be retrieved (n= 54); or
were ineligible at full-text review (n= 200; see Figure 1 for
reasons). Thereafter, 215 records met inclusion criteria, of which
15 studies of UK HCPs’experiences of delivering maternity care
during the pandemic are reported here (4,5,22–34).
3.2 Description of included studies
The 15 included studies were exclusively UK-based, apart from
one; this compared care between the UK and the Netherlands (31),
and presented data all together. One study (18) presented data
from maternity and children’s healthcare professionals,
commenting on each set of professionals.
There were 940 participants, with additional unspecified
numbers from 224 maternity units (23,30) and eight maternity
care policy organisations (30). Data collection ranged from
February 2020 to November 2021, extended by 11 months
beyond the original review (14). Study methodology varied:
semi-structured interviews (n=8) (5,22,24–26,28,29,34),
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 03 frontiersin.org
semi-structured interviews alongside analysis of policy and
guidance documents (n=2) (30,31), mixed-method survey with
free-text analysis (n=3) (23,27,32), both interviews and a
mixed-method survey (n=1) (4), and a focus group with
midwives (n=1) (33). For data analysis, most studies utilised
thematic analysis (n=7) (22,25–28,32,33); other methodologies
included: content analyses (n=1) (30), descriptive analysis (n=2),
23,34 framework analyses (n=2) (4,31), or grounded theory
analyses (n=3) (5,24,29). For detailed characteristics of included
studies and their key findings, see Supplementary Table S3.
3.3 Quality assessment
Study quality varied. Eight studies met all 12 quality criteria
(5,22–24,29,31,33,34); two studies met 11/12 criteria (27,30)
FIGURE 1
PRISMA 2020 flow diagram of study selection process.
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 04 frontiersin.org
as they did not actively involve participants in the design and
conduct of the study; one study met 10/12 criteria (4), two
studies met 9/12 criteria (26,28), one study met 8/12 criteria
(25), and one study met 7/12 criteria (32). As such, all studies
were deemed to be of moderate-high quality; for details, see
Supplementary Table S4.
3.4 Synthesis and findings
Our synthesis identified nine themes within three of the five
RESILIENT concepts: care-seeking and care experience, virtual
care, and ethical future of maternity care services (Supplementary
Table S5). No studies reported on the RESILIENT concepts of
self-monitoring or COVID-19 vaccination. Passages of text from
the original discussion sections are presented in Tables 1–3to
support synthesised findings.
3.5 Concept 1: care-seeking and care
experience
Fourteen studies (4,5,22–34) contributed data to this
concept, with four themes: 1.1 Changes to existing provision of
care, 1.2 Limitations placed on the partner, 1.3 Mental health
and lack of support networks, and 1.4 Barriers to
implementation of reconfiguration strategies (Table 1 for
supportive quotations).
3.5.1 Changes to existing provision of care
Studies described a reduction in midwifery-led care due to
closure of community-based services and a move towards
centralised obstetric-led and hospital-based care (23,28,31,32).
These changes were perceived to cause a reduction in mothers’
and gestational parents’choice in birth planning, as well as
TABLE 1 Concept 1 –care-seeking and care experience.
Themes Quotations
Changes to existing
provision of care
“This was particularly apparent during COVID-19 with conflicts between wards, services and localities. This made it particularly difficult for
staff who were redeployed during the pandemic, who did not always feel included in their new ingroup but were no longer part of their old
ingroup and could be left without clear lines of management support.”Billings et al. PLoS One 2021.
“Some variation can probably be explained by changing national knowledge about the prevalence and impacts of COVID- 19, and by
different levels of exposure to COVID- 19 infection. However, our data suggest that this was not the case where blanket policies were applied
with minimal individual flexibility, or where there was unjustified variation in visiting and companionship rules, coupled with poor and
inconsistent communication.”Thomson et al. BMJ Open 2022.
“Relatively “simple”changes which proved possible during the COVID- 19 pandemic, such as hosting multiple clinics during the same
prenatal visit, offering the choice of virtual care appointments, and allowing women more flexible access to care, created opportunities to
achieve new ways of delivering high- quality care”De Backer et al. Acta Obstetricia et Gynecologica Scandinavica 2022.
“Remote antenatal care can alter how women make judgments about their own care needs, complicating their ability to identify their own
eligibility for health care or to make a claim for attention from the system.”Hinton et al. Health Services Research & Policy 2023.
Limitations placed
on the partner
“In the second wave of the pandemic there continued to be significant impacts on whether partners could attend early labour assessment (not
permitted in 40% of units), be with the woman during labour (not possible in 5% of units) or visit during the womans postnatal stay (not
possible in 43% of units).”Brigante et al. Midwifery 2022.
“Partners may also have to leave the maternity unit shortly after the birth, and women could receive devasting news or have to make life-
changing decisions without the support of their partner.”Hanley et al. Journal of Hospital Infection 2022.
“Mental health care support following a miscarriage or termination or difficult birth was also largely overlooked, particularly when it came to
partners. In fact, the vast majority of partners were not provided with any information or support throughout the perinatal period”Martin-
Key et al. Journal of Medical Internet Research 2021.
Mental health and lack
of support networks
“Staff often did not attend to the state of their own, and their colleagues, mental health, indicative of a lack of awareness of mental health
issues in some physical healthcare settings”Billings et al. PLoS One 2021.
“Medical exceptionalism promotes healthcare as an extraordinarily self-sacrificing profession in which one must discount personal rights and
responsibilities; in our data we saw chronic presenteeism by ethnic minority interviewees, despite risks to their own health.”Silverio et al.
eClinicalMedicine 2022.
Requires attention to the potential moral distress of maternity care staff (and healthcare staff in general, including ultra sonographers). These
professionals are faced with the stress of having to balance these two imperatives with real people, in intensely emotional real time, repeatedly
day in and day out, and at times with insufficient PPE equipment available, at a time when they too could be pregnant at risk of exposure to
infection, or fearful of infecting others”Thomson et al. BMJ Open 2022.
“Others who endorsed these concerns regarding the inconsistent application of care provision, explained there could be adverse psycho-
social, emotional, and physical health consequences for women and for their healthcare providers”Silverio et al. BMC Pregnancy and
Childbirth 2023.
Barriers to implementation
of reconfiguration strategies
“Un(der)- preparedness and flourishing”, demonstrating fractured and fragmented services, addressed the pervasive narratives that services
(and staff) were under- prepared at best, and un- prepared at worst, to cope with the magnitude of the COVID-19 health system shock”De
Backer et al. Acta Obstetricia et Gynecologica Scandinavica 2022.
“This was difficult due to staffing pressures, already present prior to the pandemic, which worsened due to additional tasks and a reduced
workforce.”Jones et al. BMJ Open 2022.
“It lacks plasticity, rendering it inflexible to change, and instead of facing racial and ethnic disparity head-on, it “papers over the cracks”. This
is perhaps unsurprising of a system which works at “full-tilt”, 100% of the time.”Silverio et al. eClinicalMedicine 2022.
“Especially problematic in situations where clinicians are having to rely more on service users when it comes to noticing and reporting
symptoms, and where they do not always have ready access to complete records.”Hinton et al. Health Services Research & Policy 2023.
“Most staff commented how the service was not ready to be challenged by such a significant shock, and unprepared, such as with regards to
digital technology.”Silverio et al. BMC Pregnancy Childbirth 2023.
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TABLE 2 Concept 2 –virtual care.
Themes Quotations
Impact on quality of care “Remote consultations may also reshape the nature and quality of the relationships between maternity service users and staff, and impact on
how clinicians evaluate and make judgements about care needs. Our study suggests that continuity of care, already problematic prepandemic,
may be even more challenging to achieve remotely, despite its known benefits.”Hinton et al. Health Services Research & Policy 2023.
“Concerns about safety, effectiveness and person- centredness, linked to the risk that absence of in- person contact might undermine the
quality of interactions and hinder safeguarding and recognition of other safety issues.”Hinton et al. BMJ Quality & Safety 2022.
“PHCPs also highlighted concerns that remote assessments could not provide the same level of detail as face-to-face assessments, which may
lead to misdiagnosis”Moltrecht et al. BMC Health Services Research 2022.
Increased convenience and
flexibility
“Although participants valued the potential convenience and flexibility offered by remote care, what may appear to be efficiency gains may
also involve hidden burdens leading to invisible work and compensatory labour”Hinton et al. BMJ Quality & Safety 2022.
“A variable impact of virtual care on patient experience is in-line with other research, suggesting virtual care was enjoyed by some”Silverio
et al. BMC Pregnancy and Childbirth 2023.
“PHCPs also reported some positive aspects of the use of telemedicine including parents being easier to reach at times and an increase in the
frequency of contacts with service users”Moltrecht et al. BMC Health Services Research 2022.
“Although face-to-face groups were seen as ideal, online delivery offered opportunities to break down barriers such as geography and
childcare, whilst appearing to retain many of the benefits such as peer support and enhanced information-sharing.”Wiseman et al. Midwifery
2022.
“There was also much concern about the potential for negative impacts of remote care on equality and inclusion, especially given disparities
in digital access and variation in maternity outcomes linked to structural inequalities”Hinton et al. BMJ Quality & Safety 2022.
“PHCPs also identified internet and mobile data charges as a significant barrier to many young parents ability to engage with telemedicine.”
Moltrechet et al. BMC Health Services Research 2022.
Digital exclusion “There was also much concern about the potential for negative impacts of remote care on equality and inclusion, especially given disparities
in digital access and variation in maternity outcomes linked to structural inequalities”Hinton et al. BMJ Quality & Safety 2022.
“PHCPs also identified internet and mobile data charges as a significant barrier to many young parents ability to engage with telemedicine.”
Moltrechet et al. BMC Health Services Research 2022.
“Women may not know what is expected of them in antenatal care and where socially disadvantaged women may lack knowledge or
resources for digital technology, delays, and poor quality care may result.”Hinton et al. Health Services Research & Policy 2023.
TABLE 3 Concept 3—building an ethical future for maternity care.
Themes Quotations
Optimising patient care “Relatively “simple”changes which proved possible during the COVID- 19 pandemic, such as hosting multiple clinics during the same
prenatal visit, offering the choice of virtual care appointments, and allowing women more flexible access to care, created opportunities to
achieve new ways of delivering high- quality care”De Backer et al. Acta Obstetricia et Gynecologica Scandinavica 2022.
“Optimising remote care for the future will require investment in high quality technology infrastructure, human resources and digital literacy
skills and in codesigning pathways, work systems, workflows and processes to support efficiency and convenience for both service users and
healthcare professionals.”Hinton et al. BMJ Quality & Safety 2022.
“Policy and practice should consider whether the increased responsibilisation implied by remote antenatal care is suitable for all and ensure
adequate alternative services are provided.”Hinton et al. Health Services Research & Policy 2023.
“When issuing guidance and its updates, consideration is needed of the balance required of the need for up-to-date information, with both
the need for clear, consistent messaging (particularly when time is short) and the time required to implement change. Following a more
reflective process should help to sustain high-quality care, and improve staff morale throughout health system shocks”Silverio et al. BMC
Pregnancy and Childbirth 2023.
“Our study highlighted challenges to remote consulting unique to the perinatal period. Face-to-face assessment is necessary in high-risk cases
as highlighted by the recent confidential enquiry of maternal deaths in the UK during the first 3 months of the pandemic, which included
four suicides and two domestic homicides”Wilson et al. Archives of Womens Mental Health 2021.
“It is time to capitalise on these learnings, so that staff providing care do not feel burdened by providing care they believe to be sub-optimal,
are motivated by innovation, and avoid feeling like they are in a “parrotocratic”situation whereby they are simply repeating policy handed
down to them by senior Trust and Governmental sources, for whom they are expected to be an obedient mouthpiece.”Silverio et al. BMC
Pregnancy and Childbirth 2023.
Service users and staff as the
driving force for change
“Consultation and co-production with frontline staff is going to be essential in establishing systems of support which are likely to be most
effective, acceptable, and sustainable.”Billings et al. PLoS One 2021.
“Remote antenatal care services should be optimised for equality, inclusion and diversityand, critically, co-designed with maternity service users
and representation from minoritised and marginalised groups to achieve this goal.”Hinton et al. Health Services Research & Policy 2023.
“Staff wish to be engaged in care policy and planning as well as delivery, including in the process of rapid change which must be implemented
at pace (i.e., re-development, re-organisation, and re-deployment)”Silverio et al. BMC Pregnancy and Childbirth 2023.
“Our study emphasises that any lasting shift to remote provision will need to be highly attentive to designing care pathways so that they
facilitate successful relationships between people who are pregnant and those who are caring for them”Hinton et al. BMJ Quality &
Safety 2022
“Staff often have valid concerns, and they must feel able to express them through existing institutional feedback mechanisms that are
meaningful, timely, and most importantly, fair.”Silverio et al. eClinicalMedicine 2022
“The pandemic brings into sharp focus the fundamental and underpinning ethical dilemma between social actions that ensure the greatest
benefit for the population as a whole, and the individual human rights of each person within that population. Resolving this potential conflict
of ethical imperatives depends on an open and informed debate about rights and consequences.”Thomson et al. BMJ Open 2022.
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emotional distress (22,26,31,32). There were challenges in
providing care, given rapid changes to protocols, lack of adequate
guidance for staff regarding implementation (5,23,25), and less
time allotted for discussion of care plans (23,24,26,30,34).
However, one study found evidence of some positive effects: staff
adapted rapidly, particularly in later lockdowns (11).
3.5.2 Limitations placed on the partner
Studies showed distinct variation between hospitals in
visitation rights and involvement of fathers, partners, and non-
gestational parents during care appointments and birth (23,25–
27,30,31). Exclusion of these individuals was perceived as
having negative and adverse effects on women and birthing
people’s healthcare experiences and emotional state. One study
described how paternal mental health was often unaddressed
when poor maternal or neonatal outcomes occurred (27).
3.5.3 Mental health and lack of support networks
Nine contributing studies (5,22,24–28,32) outlined the
impact of reconfigurations on staff mental health, independent of
fathers’, partners’, and non-gestational parents’involvement
described above. Some staff described a negative impact on
morale because they could not provide the standard of care and
enhanced support that their service-users deserved (22,24–28,
32). Particular concerns were raised about a lack of guidance for
staff about how they could address service-users’perinatal mental
health (27,30,32). Importantly, several studies described HCPs
selflessly prioritising the physical and mental health of women
and birthing people over their own (22,26,30).
3.5.4 Barriers to implementation of
reconfiguration strategies
Data from nine studies (5,23,24,26,28,29,31,33,34),
illustrated how challenges for staff were exacerbated by the
pandemic, rather than created anew (24,26,29,33). The
“unrealistic work pressures”(24), highlighted across studies, were
attributed to increased work demands, reduced staffing, finite
resources, and limited guidance on how to adjust practice and
cope with difficulties (24,26). These made it difficult for staff to
adapt to new and ever-changing policies, impeding successful
implementation of reconfiguration strategies.
3.6 Concept 2: virtual care
Nine studies (4,5,23,25,27,28,32–34) contributed data to
this concept, describing how some maternity care changed from
in-person to virtual, by telephone or video-conference. Three
themes were identified: 2.1 Impact on quality of care, 2.2
Increased convenience and flexibility, and 2.3 Digital exclusion
(Table 2 for supportive quotations).
3.6.1 Impact on quality of care
In seven studies (4,5,23,25,27,28,34), concerns were raised
about potential harmful consequences of virtual (vs. in-person)
delivery on quality of care. HCPs felt positive and trusting
patient-provider relationships were harder to establish during
virtual care (23,27,28,34). Patient safety was questioned with
particular reference to mental health assessments; HCPs felt
sensitive information might be less likely to be divulged by
service-users over telephone or video calls. Additionally, concerns
were expressed for children’s welfare in the absence of a full
assessment of home circumstances or domestic violence (4,25,28).
3.6.2 Increased convenience and flexibility
In contrast, the shift to virtual care had some benefits. Some
HCPs commented on being able to provide greater continuity of
care, and more frequent contact with service-users (28).
3.6.3 Digital exclusion
HCPs perceived the main barrier service-users faced accessing
virtual maternity care was their limited access to the internet and/
or electronic devices (including smartphones) (4,25,27,28,34),
as well as limited technology skills and English-language skills
(25,27). Also, HCPs described their own difficulties with access,
such as lack of compatible software resources on home devices,
and unsuitable home-working environments which hindered
hybrid-working (4,5,25,27,28). Others suggested the transition
to virtual care required additional work and time to
operationalise (4,5).
3.7 Concept 3: ethical future of maternity
care services
All fifteen studies (4,5,22–34) provided data for this concept,
describing how maternity services should be built back in a fairer
and ethical way, to prevent further exacerbation of health
inequities. This concept was coded into two themes: 3.1
Optimising patient care, and 3.2 Service users and staff as the
driving force for change (Table 3 for supportive quotations).
3.7.1 Optimising patient care
Hybrid care delivery was described by HCPs as giving mothers
and gestational parents the opportunity to choose face-to-face
appointments should they wish (24,25,32), increasing their
autonomy and potentially, their satisfaction with care (4). To
facilitate a move to hybrid delivery, HCPs emphasised the need
for adequate technology and for digital inequities to be
addressed, to prevent exclusion of certain groups (service-users
and staff) (27,28,34). Nevertheless, HCPs emphasised the need
to retain in-person care for high-risk and vulnerable women and
birthing people, such as those with complex medical, physical, or
social needs (5,32).
3.7.2 Service-users and staff as the driving force
for change
Finally, to build an ethical future of maternity care services, HCPs
reported it was crucial to involve staff and service-users in policy-
making, particularly through collaboration which considered local
context and its challenges and opportunities. Input from those with
lived experience of maternity care was seen as vital to ensure service
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Frontiers in Global Women’s Health 07 frontiersin.org
delivery kept their needs and values at the forefront (4,27,31,34).
Involvement and consideration of at-risk and vulnerable
populations was emphasised, particularly in times of crisis (5,31).
4 Discussion
4.1 Main findings
This systematic review of 15 qualitative studies (4,5,22–34)of
HCPs’experiences of providing maternity care during the
COVID-19 pandemic in the UK, builds on a previous qualitative
evidence synthesis (14).
Key findings included reduction in provision of community
midwifery services leading to perceived loss of autonomy for
women and birthing people, challenges with providing good
quality care, and inadequate guidance and support for staff
regarding protocol changes and safety measures. Altered care-
provision and limitations placed on the role of fathers, partners,
and non-gestational parents during appointments and birth were
perceived by HCPs to be detrimental for women’s emotional and
physical wellbeing. Staff reported loss of morale, unrealistic work
pressures, and reduced staffing—making it difficult to
successfully implement reconfiguration strategies.
Studies evaluating experiences of virtual care highlighted
HCPs’concerns about care quality, compared to in-person care,
especially for high-risk and vulnerable groups. Participants felt
that comprehensive mental health and wellbeing assessments
cannot be completed virtually, potentially jeopardising women
and birthing peoples’safety, and leaving staff feeling they were
unable to fulfil their duty of care. Access to digital devices and
reliable internet connectivity were highlighted as problematic.
However, HCPs expressed that virtual care increased convenience
and flexibility, and some HCPs found it easier to provide
continuity of care and more frequent contact with women and
birthing parents.
HCPs perceive an ethical future for maternity care services in the
UK to include: personalisation of care to suit individuals’needs, the
offer of in-person care when necessary, and the offer of hybrid care
for others who prefer to avoid coming to hospital. The synthesis
emphasised the importance of a co-designed and collaborative
approach to designing future maternity care, by including both
service-users and HCPs in the decision-making process.
4.2 Interpretation
To our knowledge, this is the only UK-focused systematic
review of HCPs’qualitative experiences of delivering maternity
care during all three COVID-19 pandemic lockdowns.
We add 15 UK publications (4,5,22–34) to the single
UK study included in the previous qualitative thematic synthesis
by Flaherty et al. (14), comprehensively enhancing our
understanding of the impact of the COVID-19 pandemic on UK
HCPs’experiences of providing care during an unprecedented
health system shock. Adhering to the aims of RESILIENT, data
were synthesised according to our five pre-defined concepts;
however, our findings resonate with those of HCPs
internationally. The six themes identified in Flaherty et al.’s
review drawing on the global literature align primarily with our
core concepts of Care-seeking and care experience: altered
maternity care, altered care structures and provision, capacity to
provide care, professional and personal impact, professional
impact, and personal burden (14). We expand, by adding themes
related to virtual care and, importantly, HCPs’views on an
ethical future for UK maternity care services (7). However, no
data were found to align with the RESILIENT concepts of Self-
monitoring or Vaccination.
Our findings align with those of service-users and specific
groups of HCPs studied by other researchers. An online survey
of parents in Northern England found a reduction in women
and birthing people’s choices and autonomy over their care
(particularly with respect to birth-planning), which jeopardised
their overall satisfaction and wellbeing (35). Others reported how
it was difficult for HCPs to work in ways which incorporated
infection control measures, whilst meeting the needs of women
and birthing people, particularly given restricted personal
engagement and the ability to provide supportive touch (36,37).
The negative consequences of restrictions placed on fathers’,
partners’, and non-gestational parents’involvement have been
echoed in several other works (6,38,39), including potentially
reducing these individuals’ability to bond with their baby, and
to offer support to the mother or gestational parent (40)
Akeyfinding of our review was the challenge faced by staff in
fulfilling their duty of care, in the face of staff shortages and limited
resources. This issue has been recognised and debated by the UK
Government (41). Staff surveys in the global setting have
attributed staff shortages to heightened stress levels and burn-out
(42). Several studies document an increase in depression, anxiety,
and stress among HCPs during the pandemic, along with post-
traumatic stress symptoms (43,44).
Our findings that staff had concerns about developing trusting
and meaningful relationships with women and birthing people
through telephone or video consultation was echoed by service-
users, who felt virtual antenatal consultations provided
impersonal care and had a negative impact on how much
information women and birthing people chose to disclose to
their HCP (45). Workforce surveys and those from the UK’s
communications regulator have associated digital poverty
during the COVID-19 pandemic with disabilities and lower
socioeconomic background and housing tenure (46). An
extensive narrative review of telemedicine in the United States of
America emphasised the need for equitable access to digital
technology, as well as its potential (47). With a global shift to
virtual care delivery in a post-pandemic world, it is crucial to
carefully consider the ramifications of using digital technology
for groups that are already marginalised and prone to digital
exclusion (34). It is crucial to understand the multilayered
aspects involved in the adoption and implementation of this
technology, from the perspective of all stakeholders, and it
should not replace traditional face-to-face care, but rather
complement it (51,52). Finally, the strong desire of women and
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Frontiers in Global Women’s Health 08 frontiersin.org
birthing people to have a model of maternity care that supports
women-led decision making (48) speaks to the collaborative
working and co-design expressed by HCPs in the literature
we reviewed.
Although the roll-out of the COVID-19 vaccination program
began in the UK in December 2020, and management of routine
self-monitoring of symptoms for pregnancy complications (such
as gestational diabetes and hypertension) were major maternity
service reconfigurations during the pandemic, the paucity of
literature reporting HCPs’views on these concepts may indicate
that staff did not perceive them to have had a major impact on
their day-to-day lives, or that this was not a research priority in
studies with HCPs. Other research with service users has shown
self-monitoring of symptoms during pregnancy to be associated
with implementation and resourcing issues (49). Within the
RESILIENT programme of work, we have found in interviews
with HCPs, policymakers, women, and partners that vaccination,
particularly mandatory vaccination programs for staff was a
contentious issue (50). We would endorse future research to
confirm these findings within other contexts.
4.3 Strengths and limitations
This review benefits from robust data extraction and
synthesis, with all studies screened for inclusion independently
by at least two authors; while data extraction, quality-assessment,
and synthesis were conducted independently by two authors. We
evaluated HCPs’experiences of care provision over all three
pandemic lockdowns in the UK. Importantly, we gathered
information on how HCPs believed maternity care can be
improved in the future, and their emphasis that these should be
informed by their own experiences. Given the sheer volume of
literature published in the last three years about the impact
of the pandemic on experiences of maternity care, and the focus
of RESILIENT on the pandemic in the UK, we limited the
scope of this review to UK studies only. Nevertheless, Flaherty
et al. (14) reported similar views of HCPs in their review of
global literature; with no thematic differences between HICs and
LMICs, and we plan to complete the additional RESILIENT
study systematic reviews in describing longer-term experiences
internationally, imminently. Whilst we can take these findings
from the UK as a critical case (53) from which we can
extrapolate to other settings we realise they may not be
wholly generalisable to HCPs’experiences in other parts of the
world, particularly where the system is not modelled on being
‘free-at-point-of-use’. Future publications of the RESILIENT
study as well as other research should focus on comparing
experiential literature between different healthcare settings.
Finally, although our search strategy for the population of
interest included a range of professional roles within maternity
care, it may not represent the whole maternity workforce in the
UK, particularly as specific social determinants (such as gender,
ethnicity, or geographic location of individual Trusts) were not
considered. This work would be complemented by further local
and context-specific research.
5 Conclusion
Based on our synthesis of HCPs’experiences of providing
maternity care during COVID-19 in the UK, we make the
following practical recommendations:
1. Maternity services should be optimised by providing more
choice in care delivery. Pandemic preparedness plans for
maternity care should prevent extensive centralisation of
maternity care services and removal of services such as home
births, along with ensuring that harsh restrictions are not
place on birth partners.
2. Future maternity services should be co-designed with staff and
service-users, to reflect their collective experiences and
understanding of the context in which they provide and
receive care, respectively. Taking into account staff
experiences in designing services has the potential to improve
workplace wellbeing and maternity staff retention, thereby
positively affecting women’s maternity care experience.
Patient and public involvement and
engagement
This systematic review was periodically reviewed by the Patient
and Public Involvement and Engagement (PPIE) group of the
wider RESILIENT Study which comprises 15 participants. The
group was involved throughout, from conception of the project
and research questions, through to checking findings for
relevance. Meetings were held three times per year, were well-
attended (with at least 8/15 members present at each), and had
good representation of birthing and non-birthing parents,
healthcare workers, and community support, from multiple
ethnic backgrounds, birth histories, and living in different parts
of the UK. Each meeting allowed for in-depth discussion and
reflection of the work by the wider PPIE team, with suggested
changes incorporated. Additionally, one member of the PPIE
team was part of the smaller authorship team of this paper and
reviewed and edited this manuscript in detail.
Author Contributions
TD: Conceptualization, Data curation, Formal Analysis,
Investigation, Methodology, Project administration, Resources,
Software, Visualization, Writing –original draft. EB: Data
curation, Formal Analysis, Investigation, Visualization, Writing –
original draft. YP: Data curation, Formal Analysis, Investigation,
Writing –review & editing. GH: Data curation, Formal Analysis,
Investigation, Methodology, Project administration, Resources,
Software, Writing –review & editing. LP: Conceptualization,
Data curation, Investigation, Project administration, Software,
Writing –review & editing. HDM: Conceptualization,
Investigation, Project administration, Resources, Software,
Validation, Writing –review & editing. MW: Investigation,
Writing –review & editing. MH: Validation, Writing –review &
editing. VS: Conceptualization, Resources, Methodology, Writing –
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 09 frontiersin.org
review & editing. HB: Conceptualization, Funding acquisition,
Validation, Writing –review & editing. KSS: Conceptualization,
Validation, Writing –review & editing. ADVC: Conceptualization,
Funding acquisition, Validation, Writing –review & editing. ECN:
Conceptualization, Validation, Writing –review & editing.
ELD: Funding acquisition, Validation, Writing –review & editing.
PvD: Conceptualization, Funding acquisition, Investigation,
Validation, Writing –review & editing. SAS: Conceptualization,
Funding acquisition, Resources, Validation, Writing –review &
editing. LAM: Conceptualization, Funding acquisition, Investigation,
Project administration, Resources, Supervision, Validation,
Visualization, Writing –review & editing.
The RESILIENT Study Group
consists of:
Chief Investigator: Prof. Laura A. Magee (King’s College
London); and Co-Investigators: Prof. Debra E. Bick (The
University of Warwick), Dr. Harriet Boulding (King’s College
London), Dr. Kathryn Dalrymple (King’s College London), Ms.
Tisha Dasgupta (King’s College London), Prof. Emma L. Duncan
(King’s College London), Dr. Abigail Easter (King’s College
London), Prof. Julia Fox-Rushby (King’s College London), Miss.
Gillian Horgan (King’s College London), Prof. Asma Khalil
(St. George’s University Hospitals NHS Foundation Trust &
Liverpool Women’s NHS Foundation Trust), Ms. Alice
McGreevy (King’s College London), Dr. Hiten D. Mistry (King’s
College London), Prof. Eugene C. Nelson (Dartmouth College),
Prof. Lucilla Poston (King’s College London), Mr. Paul Seed
(King’s College London), Sergio A. Silverio (King’s College
London & University of Liverpool), Dr. Marina Soley-Bori
(King’s College London), Dr. Florence Tydeman (King’s College
London), Ms. Aricca D. Van Citters (Dartmouth College),
Dr. Sara L. White (King’s College London), Prof. Ingrid Wolfe
(King’s College London), Prof. Yanzhong Wang (King’s College
London), & Prof. Peter von Dadelszen (King’s College London).
Funding
The author(s) declare financial support was received for the
research, authorship, and/or publication of this article. The
RESILIENT Study was funded by the National Institute of
Health and Care Research [NIHR] Health Services & Delivery
Research programme (ref:-NIHR134293) awarded to LAM, SS,
HB, ADVC, ELD, PvD, & Members of The RESILIENT Study
Group. TD is in receipt of a Health Practices, Innovation &
Implementation [HPII] Doctoral Fellowship (ref:- ES/P00703/1),
funded by the Economic & Social Research Council [ESRC] as
part of the London Interdisciplinary Social Science Doctoral
Training Partnership [LISS DTP]. The funders had no role in the
work or write-up associated with this manuscript.
Acknowledgments
We would like to extend our thanks to all members of The
RESILIENT Study Group, The RESILIENT Study Patient &
Public Involvement & Engagement Advisory Group, and The
RESILIENT Study Technical Advisory Group for their assistance
with reviewing the results of this review on an ongoing basis.
Conflict of interest
Three studies included in the qualitative evidence synthesis
were authored by at least one member of the review team (SAS,
LAM, or the wider RESILIENT Study Group). However, data
extraction, quality assessment, and synthesis of these papers were
not conducted by any of the authors, rather by TD, EB, and YP
who have no competing interests. The RESILIENT Study has
been adopted by the National Institute for Health and Care
Research Applied Research Collaboration South London [NIHR
ARC South London] at King’s College Hospital NHS Foundation
Trust. The views expressed are those of the authors and not
necessarily those of the NIHR or the Department of Health and
Social Care.
The remaining authors declare that the research was conducted
in the absence of any commercial or financial relationships that
could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board
member of Frontiers, at the time of submission. This had no
impact on the peer review process and the final decision.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fgwh.2024.
1470674/full#supplementary-material
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 10 frontiersin.org
References
1. Royal College of Obstetricians & Gynaecologists and Royal College of Midwives.
Information for Healthcare Professionals Coronavirus (COVID-19) Infection in
Pregnancy. London: Royal College of Obstetricians & Gynaecologists (2020).
2. Jardine J, Relph S, Magee LA, von Dadelszen P, Morris E, Ross-Davie M, et al.
Maternity services in the UK during the coronavirus disease 2019 pandemic: a
national survey of modifications to standard care. BJOG. (2021) 128(5):880–9.
doi: 10.1111/1471-0528.16547
3. Silverio SA, Backer KD, Easter A, von Dadelszen P, Magee LA, Sandall J.
Women’s experiences of maternity service reconfiguration during the COVID-19
pandemic: a qualitative investigation. Midwifery. (2021) 102:103116. doi: 10.1016/j.
midw.2021.103116
4. Hinton L, Dakin FH, Kuberska K, Boydell N, Willars J, Draycott T, et al. Quality
framework for remote antenatal care: qualitative study with women, healthcare
professionals and system-level stakeholders. BMJ Qual Saf. (2022) 33(5):1–13.
doi: 10.1136/bmjqs-2021-014329
5. Silverio SA, De Backer K, Brown JM, Easter A, Khazaezadeh N, Rajasingam D,
et al. Reflective, pragmatic, and reactive decision-making by maternity service
providers during the SARS-CoV-2 pandemic health system shock: a qualitative,
grounded theory analysis. BMC Pregnancy Childbirth. (2023) 23(1):1–15. doi: 10.
1186/s12884-023-05641-2
6. Silverio SA, Easter A, Storey C, JurkovićD, Sandall J. PUDDLES Global
Collaboration. Preliminary findings on the experiences of care for parents who
suffered perinatal bereavement during the COVID-19 pandemic. BMC Pregnancy
Childbirth. (2021) 21(1):840. doi: 10.1186/s12884-021-04292-5
7. George-Carey R, Memtsa M, Kent-Nye FE, Magee LA, Oza M, Burgess K, et al.
Women’s experiences of early pregnancy loss services during the pandemic: a
qualitative investigation. Women Birth. (2024) 37(2):394–402. doi: 10.1016/j.wombi.
2023.12.004
8. Montgomery E, De Backer K, Easter A, Magee LA, Sandall J, Silverio SA.
Navigating uncertainty alone: a grounded theory analysis of women’s psycho-social
experiences of pregnancy and childbirth during the COVID-19 pandemic in
London. Women Birth. (2023) 36(1):e106–17. doi: 10.1016/j.wombi.2022.05.002
9. Greenfield M, Darwin Z. LGBTQ+ new and expectant parents’experiences of
perinatal services during the UK’sfirst COVID-19 lockdown. Birth. (2024) 51
(1):134–43. doi: 10.1111/birt.12780
10. Keely A, Greenfield M, Darwin Z. “We should be working together, and it felt
like they disrupted that”: pregnant women and partners’experiences of maternity care
in the first UK COVID-19 pandemic lockdown. Int J Environ Res Public Health.
(2023) 20(4):1–15. doi: 10.3390/ijerph20043382
11. Greenfield M, Payne-Gifford S, McKenzie G. Between a rock and a hard place:
considering “freebirth”during COVID-19. Front Glob Womens Health. (2021)
2:603744. doi: 10.3389/fgwh.2021.603744
12. Kasaven LS, Raynaud I, Jalmbrant M, Joash K, Jones BP. The impact of the
COVID-19 pandemic on perinatal services and maternal mental health in the UK.
BJPsych Open. (2023) 9(1):1–6. doi: 10.1192/bjo.2022.632
13. National Heal th Service. Supporting Pregnant Women Using Maternity
Services During the Coronavirus Pandemic: Actions for NHS Providers Executive
Summary. London: NHS England (2020).
14. Flaherty SJ, Delaney H, Matvienko-Sikar K, Smith V. Maternity care during
COVID-19: a qualitative evidence synthesis of women’s and maternity care
providers’views and experiences. BMC Pregnancy Childbirth. (2022) 22(438):1–32.
doi: 10.1186/s12884-022-04724-w
15. British Medical Association. Delivery of Healthcare During the Pandemic BMA
Covid Review 3. London: British Medical Association (2022).
16. RESILIENT. School of Life Course & Population Sciences. London: King’s College
London (2021). Available online at: https://www.kcl.ac.uk/slcps/our-departments/
resilient (cited September 15, 2023).
17. Dasgupta T, Peterson L, Silverio SA, Easter A, Boulding H, Mistry H, et al. Post-
pandemic Planning for Maternity Care for Local, Regional, and National Maternity
Systems Across the Four Nations. York: PROSPERO (2022). Available online at:
https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=355948 (cited
March 07, 2024).
18. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD,
et al. The PRISMA 2020 statement: an updated guideline for reporting systematic
reviews. BMJ. (2021) 10(1):1–9. doi: 10.1136/bmj.n71
19. Dasgupta T, Horgan G, Peterson L, Mistry HD, Balls E, Wilson M, et al. Women
and birth women’s experiences of maternity care in the United Kingdom during the
COVID-19 pandemic: a follow-up systematic review and qualitative evidence
synthesis. Women Birth. (2024) 37(3):101588. doi: 10.1016/j.wombi.2024.02.004
20. Thomas J, Sutcliffe K, Harden A, Oakley A, Oliver S, Rees R, et al. Children and
Healthy Eating: A Systematic Review of Barriers and Facilitators. York: The University
of York (2003). Available online at: https://www.ncbi.nlm.nih.gov/books/NBK70020/
(cited June 12, 2023).
21. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research
in systematic reviews. BMC Med Res Methodol. (2008) 8:1–10. doi: 10.1186/1471-
2288-8-45
22. Billings J, Seif NA, Hegarty S, Ondruskova T, Soulios E, Bloomfield M, et al.
What support do frontline workers want? A qualitative study of health and social
care workers’experiences and views of psychosocial support during the COVID-19
pandemic. PLoS One. (2021) 16(9):e0256454. doi: 10.1371/journal.pone.0256454
23. Brigante L, Morelli A, Jokinen M, Plachcinski R, Rowe R. Impact of the COVID-
19 pandemic on midwifery-led service provision in the United Kingdom in 2020–21:
findings of three national surveys. Midwifery. (2022) 112:103390. doi: 10.1016/j.midw.
2022.103390
24. De Backer K, Brown JM, Easter A, Khazaezadeh N, Rajasingam D, Sandall J, et al.
Precarity and preparedness during the SARS-CoV-2 pandemic: a qualitative service
evaluation of maternity healthcare professionals. Acta Obstet Gynecol Scand.(2022)
101(11):1227–37. doi: 10.1111/aogs.14438
25. Hanley SJ, Jones AB, Oberman J, Baxter E, Sharkey D, Gray J, et al.
Implementation of public health England infection prevention and control guidance
in maternity units in response to the COVID-19 pandemic. J Hosp Infect. (2022)
129:219. doi: 10.1016/j.jhin.2022.04.018
26. Jones IHM, Thompson A, Dunlop CL, Wilson A. Midwives’and maternity
support workers’perceptions of the impact of the first year of the COVID-19
pandemic on respectful maternity care in a diverse region of the UK: a qualitative
study. BMJ Open. (2022) 12(9):e064731. doi: 10.1136/bmjopen-2022-064731
27. Martin-Key NA, Spadaro B, Schei TS, Bahn S. Proof-of-concept support for the
development and implementation of a digital assessment for perinatal mental health:
mixed methods study. J Med Internet Res. (2021) 23(6):1–17. doi: 10.2196/27132
28. Moltrecht B, de Cassan S, Rapa E, Hanna JR, Law C, Dalton LJ. Challenges and
opportunities for perinatal health services in the COVID-19 pandemic: a qualitative
study with perinatal healthcare professionals. BMC Health Serv Res. (2022) 22
(1):1026. doi: 10.1186/s12913-022-08427-y
29. Silverio SA, De Backer K, Dasgupta T, Torres O, Easter A, Khazaezadeh N, et al.
On race and ethnicity during a global pandemic: an ‘imperfect mosaic’of maternal
and child health services in ethnically-diverse South London, United Kingdom.
EClinicalMedicine. (2022) 48:101433. doi: 10.1016/j.eclinm.2022.101433
30. Thomson G, Balaam MC, Harris RN, Crossland N, Moncrieff G, Heys S, et al.
Companionship for women/birthing people using antenatal and intrapartum care in
England during COVID-19: a mixed-methods analysis of national and
organisational responses and perspectives. BMJ Open. (2022) 12(1):e051965. doi: 10.
1136/bmjopen-2021-051965
31. van den Berg LMM, Balaam M-C, Nowland R, Moncrieff G, Topalidou A,
Thompson S, et al. The United Kingdom and The Netherlands maternity care
responses to COVID-19: a comparative study. Women Birth. (2022) 36:127–35.
doi: 10.1016/j.wombi.2022.03.010
32. Wilson CA, Dalton-Locke C, Johnson S, Simpson A, Oram S, Howard LM.
Challenges and opportunities of the COVID-19 pandemic for perinatal mental
health care: a mixed-methods study of mental health care staff. Arch Womens Ment
Health. (2021) 24(5):749–57. doi: 10.1007/s00737-021-01108-5
33. Wiseman O, Emmett L, Hickford G, Knight M, Lazar J, Yuill C, et al. The
challenges and opportunities for implementing group antenatal care (‘pregnancy
circles’) as part of standard NHS maternity care: a co-designed qualitative study.
Midwifery. (2022) 109:103333. doi: 10.1016/j.midw.2022.103333
34. Hinton L, Kuberska K, Dakin F, Boydell N, Martin G, Draycott T, et al. A
qualitative study of the dynamics of access to remote antenatal care through the
lens of candidacy. J Health Serv Res Policy. (2023) 28(4):222–32. doi: 10.1177/
13558196231165361
35. Stacey T, Darwin Z, Keely A, Smith A, Farmer D, Heighway K. Experiences of
maternity care during the COVID-19 pandemic in the north of England. Br
J Midwifery. (2021) 29(9):516–23. doi: 10.12968/bjom.2021.29.9.516
36. O’Connell M, Crowther S, Ravaldi C, Homer C. Midwives in a pandemic: a call
for solidarity and compassion. Women Birth. (2020) 33(3):205. doi: 10.1016/j.wombi.
2020.03.008
37. Horsch A, Lalor J, Downe S. Moral and mental health challenges faced by
maternity staff during the COVID-19 pandemic. Psychol Trauma. (2020) 12:S141–2.
doi: 10.1037/tra0000629
38. Andrews K, Ayers S, Williams LR. The experience of fathers during the COVID-
19 UK maternity care restrictions. Midwifery. (2022) 113:103434. doi: 10.1016/j.midw.
2022.103434
39. Fumagalli S, Ornaghi S, Borrelli S, Vergani P, Nespoli A. The experiences of
childbearing women who tested positive to COVID-19 during the pandemic in
northern Italy. Women Birth. (2022) 35(3):242–53. doi: 10.1016/j.wombi.2021.01.001
40. Vasilevski V, Sweet L, Bradfield Z, Wilson AN, Hauck Y, Kuliukas L, et al.
Receiving maternity care during the COVID-19 pandemic: experiences of women’s
partners and support persons. Women Birth. (2022) 35(3):298. doi: 10.1016/j.
wombi.2021.04.012
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 11 frontiersin.org
41. Waitzman E. Staff Shortages in the NHS and Social Care Sectors. London: House
of Lords Library (2022). Available online at: https://lordslibrary.parliament.uk/staff-
shortages-in-the-nhs-and-social-care-sectors/ (cited March 07, 2024).
42. Semaan A, Audet C, Huysmans E, Afolabi B, Assarag B, Banke-Thomas A, et al.
Voices from the frontline: findings from a thematic analysis of a rapid online global
survey of maternal and newborn health professionals facing the COVID-19
pandemic. BMJ Glob Health. (2020) 5(6):e002967. doi: 10.1136/bmjgh-2020-002967
43. Schm itt N, Mattern E, Cignacco E, Selige r G, König-Bachmann M,
Striebich S, et al. Effects of the COVID-19 pandemic on maternity staff in
2020 –a scopin g review. BMC Health Serv Res. (2021) 21(1):1364. doi: 10.
1186/s12913-021-07377-1
44. Slade P, Balling K, Sheen K, Goodfellow L, Rymer J, Spiby H, et al. Work-related
post-traumatic stress symptoms in obstetricians and gynaecologists: findings from
INDIGO, a mixed-methods study with a cross-sectional survey and in-depth
interviews. BJOG. (2020) 127(5):600–8. doi: 10.1111/1471-0528.16076
45. Karavadra B, Stockl A, Prosser-Snelling E, Simpson P, Morris E. Women’s
perceptions of COVID-19 and their healthcare experiences: a qualitative thematic
analysis of a national survey of pregnant women in the United Kingdom. BMC
Pregnancy Childbirth. (2020) 20(1):1–8. doi: 10.1186/s12884-020-03283-2
46. Dafoulas G, Ueno A. Digital Poverty in the UK: Analysisof Secondary Data.London:
The British Academy (2022). Available online at: https://www.thebritishacademy.ac.uk/
publications/digital-poverty-in-the-uk-analysis-of-secondary-data/ (cited March 06,
2024).
47. Kern-Goldberger AR, Srinivas SK. Telemedicine in obstetrics. Clin Perinatol.
(2020) 47(4):743–57. doi: 10.1016/j.clp.2020.08.007
48. Vedam S, Stoll K, McRae DN, Korchinski M, Velasquez R, Wang J, et al. Patient-
led decision making: measuring autonomy and respect in Canadian maternity care.
Patient Educ Couns. (2019) 102(3):586–94. doi: 10.1016/j.pec.2018.10.023
49. Wilson H, Tucker KL, Chisholm A, Hodgkinson J, Lavallee L, Mackillop L, et al.
Self-monitoring of blood pressure in pregnancy: a mixed methods evaluation of a
national roll-out in the context of a pandemic. Pregnancy Hypertens. (2022) 30:7.
doi: 10.1016/j.preghy.2022.07.006
50. Dasgupta T, Easter A, Boulding H, Sutedja T, Khalil A, Mistry H, et al. Post-
pandemic maternity care planning for vaccination: a qualitative study of
the experiences of women, partners, health care professionals, and policy makers in the
United Kingdom. Vaccines. (2024) 12(9):1042–16. doi: 10.3390/vaccines12091042
51. Binsar F, Hamsal M, Ediansyah E. Paradoxes in Telemedicine Services: Analysis
of Challenges and Opportunities for the Future of Digital Health—a Systematic
Literature Review. Preprints (2024). doi: 10.20944/preprints202409.0879.v1
52. Petretto DR, Carrogu GP, Gaviano L, Berti R, Pinna M, Petretto AD, et al.
Telemedicine, e-health, and digital health equity: a scoping review. Clin Pract
Epidemiol Ment Health. (2024) 20:e17450179279732. doi: 10.2174/
0117450179279732231211110248
53. Farrugia B. WASP (write a scientific paper): sampling in qualitative research.
Early Hum Dev. (2019) 133:69–71. doi: 10.1016/j.earlhumdev.2019.03.016
Dasgupta et al. 10.3389/fgwh.2024.1470674
Frontiers in Global Women’s Health 12 frontiersin.org
