On 12 January 2020, the World Health Organization (WHO) confirmed that a novel coronavirus, a new strain of coronavirus known as severe acute respiratory syndrome (SARS-COV-2) causing COVID-19, had caused a respiratory illness in a cluster of people in Wuhan, Hubei Province, China in December 2019. The earliest documented transmission of COVID-19 within the UK appeared on 28 February 2020; all of the cases detected previously had been infected abroad (BBC News, 2020a). By 1 March 2020, cases had been detected in England, Wales, Northern Ireland and Scotland. This led to UK Prime Minister Boris Johnson to announce that ‘non-essential’ travel and contact with others, as well as suggesting people should avoid pubs, clubs and theatres, and work from home if possible. Pregnant women, people over the age of 70 and those with certain health conditions were urged to consider the advice ‘particularly important’, as they were considered ‘vulnerable’ and were asked to self-isolate (BBC News, 2020b)
It was unclear at the time why pregnant women were included in this ‘vulnerable group’. Professor Chris Whitty, England's chief medical officer, said that including pregnant women in this group was a ‘precautionary measure’ as experts are ‘early in [their] understanding of this virus’ (Sun, 2020). Although based on the evidence we have so far, pregnant women were no more likely to contract coronavirus than the general population. What we do know is that pregnancy in a small proportion of women can alter how the body handles severe viral infections. We also know that some viral infections are worse in pregnant women. To date, there is no evidence that pregnant women who contract coronavirus are more at risk of serious complications than any other healthy individuals but the amount of evidence available is still quite limited.
In response to the inclusion of pregnant women in this ‘vulnerable group’, the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM) rapidly produced clinical guidance for doctors, midwives and those providing care for pregnant women (RCOG and RCM, 2020). The priorities identified were twofold: reducing the transmission of COVID-19 to pregnant women; the provision of safe care to women with suspected/confirmed COVID-19. As the evidence emerges, the care and management of pregnant women during the pandemic is subject to weekly changes and clinical guidance being produced rapidly. During a 10-day period, guidance was updated four times (RCOG and RCM, 2020). Maternity units in England have responded at pace, reviewing and amending current maternity guidelines and policies in response to the national guidance (RCOG and RCM, 2020). The main priority for all maternity units in the UK is to reduce the spread of COVID-19 and ensure the safety of staff and women by reducing social contact in line with current government recommendations of social distancing and social isolation. One way to achieve this is to reduce the current recommended number of antenatal and postnatal appointments, and to review how and where antenatal appointments are delivered. Changing from face-to-face appointments to ‘virtual’ appointments conducted online or via the telephone: ‘Units should rapidly seek to adopt teleconferencing and videoconferencing capability, and consider which appointments can be conducted remotely’ (RCOG and RCM, 2020).
The most recent guidance at the time of writing proposes an adjusted schedule of antenatal contacts with a minimum of six antenatal contacts for low-risk women (RCOG and RCM, 2020). Current antenatal guidance is not based on evidence but largely on expert opinion with nine antenatal appointments for low-risk primigravida and seven for multigravida (National Institute for Health and Care Excellence, 2010). Table 1 provides an example of how the proposed changes could be implemented in a hospital and community setting. For women who have a booking appointment at the hospital, the antenatal booking appointment is planned to coincide with the first ultrasound scan appointment. For women who reside within the local area, the antenatal booking is conducted over the telephone with the community midwife, and the ultrasound scan is confirmed. When the woman attends the hospital for her ultrasound scan, the community midwife will attend the scan and meet the woman, taking and recording baseline observations including blood tests, domestic violence and perinatal mental health screening. Women are asked to attend this and all face-to-face appointments on their own.
| Visit | Who | What | Modifications | |
|---|---|---|---|---|
| 1 | Booking visit (hospital) | All women |
|
Virtual booking where possible, or one-stop visit, with dating scan and all testing in maternity unit |
| Booking (community) | All local women |
|
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| 1+ | Dating scan | All women |
|
|
| 16 weeks | All women |
|
Virtual appointment/telephone appointment | |
| 2 | 18−20+6 weeks | All women |
|
Maternity unit or community unit with ultrasound facilities |
| 25 weeks low-risk women | Primigravida women |
|
Telephone Appointment | |
| * | 25 weeks mental health and/safeguarding identified | Primigradiva; multigravida |
|
Face-to-face |
| 3 | 28 weeks | All women |
|
Hospital face-to face; community midwives will see women in antenatal clinic |
| 31 weeks | Nulliparous women |
|
||
| 4 | 32 weeks | All women |
|
|
| 5 | 36 weeks | All women |
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Maintain appointments. If need to reschedule due to illness/quarantine, see or contact all women within 3 weeks of previous contact |
| 38 weeks | Nulliparous women only |
|
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| 6 | 40 weeks | All women |
|
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| 40+10−12 days Locally agreed protocol | All women |
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The scheduled 16-week antenatal appointment is a telephone appointment; women are sent a text message informing them of the changes. The next appointment is the anomaly scan. As women no longer have a face-to-face appointment at 16 weeks, blood pressure and urinalysis are taken and recorded at this appointment. If the woman is over 20 weeks, a Mat B1 maternity exemption certificate is issued. There is evidence that due to imposed social isolation during the COVID-19 pandemic, there is an increase in the number of reported cases of domestic violence (Godin, 2020; Women's Aid, 2020). According to one report, the number of domestic violence cases reported to a police station in Jingzhou, a city in Hubei Province, tripled in February 2020, compared to the same period in 2019 (Allen-Ebrahimian, 2020). In the UK, it is reported that the number of deaths from domestic violence had doubled since the COVID-19 pandemic (Grierson, 2020). Due to this increase in domestic violence, it is recommended that the face-to-face appointment at 25 weeks for any women deemed at risk is retained. This will provide women with the opportunity to be seen alone with the midwife and give a safe space for her to disclose any issues. The next change is to the 31-week antenatal appointment for primigravida, which is replaced by a 32-week appointment for both primigravid and multigravida women. The 34-week appointment is no longer required and the 36- and 40-week appointment is retained for both primigravid and multigravida women.
These changes are having an impact on the number of women attending hospital with less women wishing to attend for a face-to-face appointment. This is impacting on where and how antenatal care is being delivered in the 21st century. Midwives are rising to this challenge in positive innovative ways, as face-to-face antenatal classes are replaced by Youtube antenatal classes. In addition, women who attend ultrasound scans at 20 weeks are offered a ‘gender reveal’ where they are provided with a sealed envelope containing the gender of their baby and they can open it with their partner and family present. Maternity units are adjusting to new ways of working while maintaining high standards of practice and without compromising safe care for all pregnant women.