Women's views on the visiting restrictions during COVID-19 in an Irish maternity hospital

The coronavirus (COVID-19) infection, formally known as SARS-CoV-2, was declared a global pandemic by the World Health Organization (WHO) on 11 March 2020. Due to the pandemic, visiting restrictions were implemented in all hospitals throughout Ireland and were recommended by the Institute of Obstetricians and Gynaecologists (2020) and the WHO (2020). Only partners of women in labour were permitted to attend all maternity hospitals in Ireland. No other visiting was permitted; however, exceptions were made for bereaved parents and in extenuating circumstances. At all times throughout the pandemic, women were facilitated to have one nominated person with them in the labour ward and for the birth of their baby, including births by caesarean section. Women had to attend all outpatient visits alone and no visitors were permitted during admission to the antenatal or postnatal wards in this hospital.

While pregnant women do not appear to be more likely to contract COVID-19 than the general population (Royal College of Obstetricians and Gynaecologists, 2020), visiting restrictions were required to protect the safety of mothers, babies and staff working in the hospital (Institute of Obstetricians and Gynaecologists, 2020; WHO, 2020). Furthermore, given space restrictions within the hospital, social distancing would not be possible if partners and children were to attend with women for appointments and visiting women on antenatal and postnatal wards. As COVID-19 is a new virus, there is limited information about the impact of these visiting restrictions. Anecdotal information regarding women's experience of visiting restrictions has been mixed. Some women appear to feel safer knowing there are fewer people in the hospital. On the other hand, women appeared to find it difficult to attend appointments alone and missed having their partner and other family members visit while they were admitted to hospital.

Aims

This study aimed to gain an understanding of women's experiences of visiting restrictions imposed due to COVID-19 and to provide information to inform policy development in relation to visiting.

Methods

This mixed-methods survey study was conducted in a large urban maternity hospital in Ireland, with a birth rate of approximately 9 000 births per year. Ethical approval was granted by the hospital's ethical committee for this evaluation. No ethical issues arose during this study. Women who attended the hospital for outpatient appointments and those who were inpatients on the antenatal or postnatal ward during a two-week period, and were asked to complete an anonymous survey.

The 14-item survey was developed by the management team of the research site. The questions were guided by the data required to inform the assessment and adjustment of the current visiting restrictions, which were put in place as a result of the COVID-19 pandemic. Once the questions were drafted, the survey was reviewed by the hospitals research team, made up of experts in qualitative research and statistics, prior to distribution. The research team assessed the questions to ensure sound comprehension and easy-to-understand response categories. The team then explored the most appropriate data analysis methods for this study and made some minor adjustments to the wording. The final survey consisted of demographic, as well as open- and-closed questions. The three demographic questions, included parity, due date and department in which the survey was completed. The first question asked the participants if they were aware of the visiting restrictions. The remainder 13 questions included a five-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. Of the questions, six out of 13 pertained to women who had their baby and were in the postnatal wards only. All questions gathered information on women's opinions, wishes and attitudes to the current visiting restrictions, such as: ‘the hospital has made adequate preparations for me to feel safe’; ‘I would like my family members to be able to visit me and my baby’.

As there was a need for broad inclusion, convenience sampling was used to recruit participants. All women who attended the antenatal clinics for routine appointments, the fetal assessment unit for routine ultrasound scans, in-patients in the antenatal ward and all mothers in the private, semi-private and public postnatal wards were distributed paper surveys and invited to complete them on-site. Completion of the survey implied consent to participate. The only exclusion criteria included women who had suffered a pregnancy or perinatal loss. Each ward allocated a gatekeeper who was a staff member of that ward and was responsible for the distribution of the surveys. The women were informed that their completion of the survey was voluntary, and that non-completion would not negatively impact them. The survey was anonymous—no identifiable data was requested. Data collection took place in a two-week period in July 2020.

Statistical analysis of the data was performed using SPSS (version 24). The typical sequence of analysis was descriptive analysis. Thematic analysis, guided by Attride-Stirling (2001), was used to analyse the detailed free-text comments. Attride-Stirling (2001) developed a series of steps to follow for thematic analysis. These steps were followed in the analysis of this project's data. The method encompassed two phases of analysis. The first consisted of multiple readings of the open-ended answers from the survey, followed by a second stage of considering the dataset, as a whole, and identifying connecting themes. Themes were created when recurring words, phrases or metaphors were used. As a new theme was identified, it was coded as a node. Once all data were coded, the features in the software package NVIVO 12 was used to visually display the themes that were coded. Validation of the themes was achieved through discussion between two members of the research team to confirm findings.

Results

A total of 422 surveys were completed during the study period. As the survey was freely available in all wards and clinics for the two-week data collection period, the response rate was unable to be calculated. In total, 43% (n=183) of mothers were primiparous. In terms of where the surveys were completed, 48.4% (n=194) of women completed the survey in the antenatal clinic, 19% (n=76) were completed in the fetal assessment unit, 7.5% (30) were completed in the antenatal ward and 25.2% (n=101) were completed on the postnatal ward. A total of 21 women did not clarify where they completed the survey. Results of the closed questions are summarised in Table 1. Overall, 89.2% of women somewhat or strongly agreed that the restrictions are a good idea. However, 61.4% of women felt that their partners should be allowed to attend appointments in the scanning department. Although 90.2% of women would have liked their partners to visit them and their baby in the postnatal ward, only 23.8% wanted their children, and only 20.5% wanted other visitors, to visit them in the postnatal ward. Additionally, 83.7% of women enjoyed having alone time with their baby during their postnatal stay at the research site.

A total of 303 women out of the 422 respondents wrote free-text comments. A total of eight basic themes were identified within the data: communication, benefits of restrictions, safety, birth partner support, becoming a mother, mothers need time and space, staff support and easing the restrictions. Women highlighted the need for clear communication and the benefits of the restrictions. Women reported missing their partner at scans and other appointments but were very complimentary about the safety aspect of the restrictions which have been in place to date to protect the women and babies who attend the hospital. Each of the eight themes is explored below, and presented in conjunction with some of the results reported in Table 1.

Communication

The vast majority of women (97.8%) reported that they were aware of the restrictions that were in place at the hospital. A total of 90.7% (n=380) of women reported that the hospital communicated information about the restrictions adequately. Several women also wrote free-text comments in relation to communication from the hospital about the restrictions. Women commented on the high quality of information around the hospital.

‘I like that the reception area at the entrance controls who come in and provides information.’

The website, in particular, was cited as being a significant resource and it was requested that all women be directed to it to gain further knowledge about COVID-19 in pregnancy and other antenatal education, as per the comment below:

‘I have seen new information appearing on your website. It would be helpful to receive emails to let us know about new videos etc have been added.’

Some requests were made for the hospital to improve communication regarding restrictions. Some women explained that they had to go looking for information and requested that text message alerts or letters be sent out to them outlining relevant information, as per the below comment:

‘Letters to expectant parents informing with details of restrictions. I had to Google/check website for updates.’

Benefits of restrictions

Overcrowding, or lack thereof, was a significant theme within the free-text comments. Many women praised the restrictions for reducing the footfall in the hospital, including the wards and the waiting room of the outpatient and scanning departments. Women attributed a more efficient service to the reduction in crowds.

‘Felt appointments moved quicker, less busy waiting room is good.’

Furthermore, the women highlighted that they felt safer with less crowds, to reduce the risk of contracting COVID-19, as per the comment below:

‘It hasn't been crowded which gives a bit of peace of mind during the consultations and time at the waiting room.’

A further key message presented within this theme was the advantage of the COVID-19 restrictions in streamlining the appointments and significantly reducing waiting times for most respondents:

‘Appointments are very quiet, nearly no waiting time, it's not crowded.’

Safety

A total of 97.6% (406 out of 416) of women agreed that the hospital made adequate preparations for them to feel safe. Furthermore, only 6.93% (n=29) of women disagreed with the statement that the restrictions are a good thing (see Figure 1). Strengthening these findings were comments from women agreeing with the restrictions which have been put into place:

‘Overall, I agree with all the measures.’

Figure 1. Response to ‘Overall, I think the visiting restrictions are a good thing’.

A small number of women, however, requested the restrictions be lifted, or partially lifted.

‘My partner and I have been through a long process to have this baby. Not having him here at all has been awful for both of us.’

Even though women displayed their desire to have their birthing partner with them, several women displayed their understanding of the reasons for the restrictions:

‘The good outweigh the difficulties. I feel safer with restrictions in place.’

Birthing partner support

As discussed, most women reported that the restrictions are a good thing and several advantages were cited about the restrictions. However, the vast majority of the 262 women who responded with a comment about the negative consequences of the restrictions cited not having their partner with them as the main negative consequence. Additionally, only 4.5% (n=5) of the women in the postnatal ward disagreed with wanting their partner to be able to visit them and their baby. With regard to the question, women were asked about whether they miss their partner at the antenatal visits, 65.08% (n=272) of women did somewhat, or strongly, agree with this.

When comparing answers to this question between primiparous women and multiparous women, a larger percentage of primiparous women missed having their partner at the antenatal visits (75.4%) compared to multiparous women (57.6%). Primiparous women were also more inclined to make comments in their open answers about being affected by the restrictions, with several women mentioning the fact that this was their first baby when describing the negative affect the restrictions had on them:

‘Not being able to share the moment with my partner. This is our first child and we both are quite nervous. I am dreading not having his support the entire time I am in the hospital having our baby.’

When women were asked if they felt that their partners should be able to attend appointments in the scanning department, 61.3% (n=257) strongly, or somewhat, agreed and 23.39% (n=98) strongly or somewhat disagreed. Additionally, several comments were made requesting that partners be allowed to attend the 20-week anomaly scan:

‘It has made the pregnancy very lonely! I feel overwhelmed, being the only one being told information. I think dads should be allowed come to scanning appointment and unlimited visits when baby comes.’

Some women gave examples of the importance of partner support during scans in exceptional circumstances, such as receiving information about fetal anomalies:

‘When I attended for my scan, I was anxious because early scan discovered chromosomal abnormality and I was having follow-up scan. I was very anxious about receiving any bad news all by myself.’

Most women (86.5%) reported wanting their partner to be able to visit them on the antenatal ward. Several women commented on the support women require during long stays in the antenatal ward. The support required during early labour in the antenatal ward, when women are in pain, was also described as difficult without their partner.

‘Most difficult part was being in (the antenatal ward) for two hours on my own having labour pains but I was reunited with my husband two hours later.’

Becoming a mother

Several positive consequences of the restrictions have emerged, besides the obvious safety factor. ‘Becoming a mother’ was a key theme within the free-text data. The restrictions allowed for less ‘traffic’ on the wards and women valued the time they had to become independent with baby care and receive help and advice from midwives:

‘As much as I felt sad on Friday night after delivery that my partner could not return, I'm now glad of the days of my time to adjust to motherhood. I learnt so much from nurses and got my time to sort myself out and learn how to look after baby without external pressures, totally benefitted me.’

Time to bond with the baby on the postnatal ward was also highlighted by the women and this extra bonding time was attributed, by some, to the reduced number of visitors on the ward, as per the comment below:

‘The one-on-one time has been nice for bonding. The midwives and other staff have been very helpful and supportive.’

The above comment about bonding with, and becoming independent with, the baby strengthens the finding in relation to the question the women were asked about whether they have enjoyed having alone time with their baby. In total, only 5.4% (n=6) disagreeing somewhat, or strongly that they enjoyed having alone time with their baby.

Women were also asked if they received enough support in relation to feeding their baby. A total of 89.3% (n=100) of women agreed, somewhat or strongly, with this statement with only 1.8% (n=2) of women somewhat disagreeing and no-one strongly disagreeing with this statement. Improving the chances of breastfeeding more successfully also emerged as a benefit to the restrictions, displayed in the free-text comments:

‘It is a lot quieter, more time to adjust and try to get a hang of breastfeeding without an audience.’

Mothers need time and space

The respondents were asked would they like other family members to visit them on the postnatal wards. There were mixed responses in the closed question. The theme of visitors was, however, prominent in the free-text comments. Several women valued the opportunity to get more rest as a result of less visitors on the postnatal ward.

‘The wards have been quieter, and it has allowed more time to rest and spend with baby.’

The privacy the women received on the wards, as a result of reduced visitors, was also expressed as women felt they were able to move around the wards more freely, as per the below comment:

‘Women can walk around freely without fear of someone staring at them if they were walking funny or carrying maternity pads, catheters etc. Less noise. Great time for mummy and baby.’

Several women were happy to have a reason to not have their own ‘unwanted’ visitors arriving into the postnatal wards and valued not having to make excuses to family members to not visit.

‘Have enjoyed the quiet time and don't feel undue pressure to have visitors—third baby and family can assume it's okay to visit and it's hard to say no.’

Women valued the peaceful, calm atmosphere around the hospital and, in particular, the postnatal ward:

‘It's quite calm, can't imagine how disturbing visitors would be—prefer it like this.’

When women were asked to provide feedback as to whether their other children should be allowed in the hospital, just less than half of the women (48.6%) strongly, or somewhat, disagreed. Furthermore, several advantages of children not being in the waiting rooms and wards as a result of the restrictions were highlighted:

‘Safer environment, feel as less people and children in clinics when waiting. Staff super helpful and even more understanding then usual.’

Staff support during COVID-19

In terms of the support the women received from the staff, 94.7% (n=106) of women strongly or somewhat, agreed with the statement that they received enough support from staff after their baby was born with only 0.9% (N=1) stating that she somewhat disagreed with this statement. In addition, a significant number of acknowledgements were made about the support and help women received from staff:

‘Staff have been very helpful and attentive, especially in terms of helping me establish breastfeeding. They have been patient and encouraging in helping get the baby latched and find a position that suits us. Holding my baby and allowing me to use the bathroom has been invaluable.’

Only 19 women in this study reported requiring isolation for suspected or confirmed SARS-CoV-2. The comments made by these women about the experience of being in the isolation ward were highly positive and mainly described the ‘great’, ‘excellent’ and ‘amazing’ care they received from the staff during this time. One example of these comments are below:

‘Excellent. Staff were most helpful, understanding and had plenty of time to assist. The ward was not too busy as there were less people/visitors within.’

A few women found the experience stressful, with one woman describing lack of information about what was happening and one requesting COVID-19 tests be performed earlier:

‘Upsetting-it wasn't explained to me and I got conflicting advice as to what I could/couldn't do.’

‘Care was excellent. The wait was too long in labour. COVID test should be done at the beginning. It would have made things a lot less stressful.’

Easing restrictions

Women, in general, agreed with the restrictions and even women who missed having their partner with them stated that they understood the rationale and need for the restrictions.

‘Not seeing my husband, very little time spent with him post-birth as had to go to theatre after but all understandably so.’

Women, however, missed having their partner on the postnatal ward for short periods daily to help with the baby. The most common recommendation was for restrictions to be lifted, or eased, to allow partners into the postnatal ward for short periods of time during the day to give the mother a break and to assist in baby care:

‘Tough not getting a break by day to rest, shower, eat, go to the toilet etc. Miss sharing the first precious days with husband/family.’

Case-by-case easing of the restrictions was recommended in situations where there were extenuating circumstances. It was recommended that partners be allowed onto the wards for long-stay patients, or appointments, at times when women or babies experienced complications.

‘Attending appointments alone can be difficult. History of stillbirth so appointments make me nervous. Attended A+E last week and being alone was very hard.’

Additionally, women who had caesarean births felt more debilitated in terms of pain and movement, postnatally, and therefore requested that women who have this type of birth receive extra assistance and that their birthing partner is in a position to provide this if the restrictions are eased:

‘I had a c-section and find it very difficult to move. Some partner support would be good. It's also scary to be on your own.’

Women who suffer from anxiety reported their increased anxiousness that the restrictions caused them:

‘For partners, husbands to come for support, especially those with mental health problems who struggle being on your own or has severe anxiety about having to do appointments and that on your own.’

Discussion

Women who participated in this study were very complimentary about the safety aspect of the restrictions, with 97% of women agreeing that the hospital made adequate preparations to make them feel safe. The support of a partner during labour, birth and in the postnatal period have been found to be of vital importance to new mothers and this is supported by the finding of previous studies (Cuijlits et al, 2019; Thompson et al, 2019; Jago et al, 2020). The support of a partner has been found to assist in bonding (Cuijlits et al, 2019) and in the establishment of breastfeeding (Abbass-Dick et al, 2015; Ogbo et al, 2020).

This study also highlights the vital role of a woman's partner. Women were very positive about the support received from staff after the birth of their baby and many highlighted that time for bonding one-to-one with their baby was very beneficial. However, women miss having their partner for support during scans and to help them for a while every day after the baby is born. Women request the presence of their partners more so in situations such as a woman who suffers from mental health issues, when there are complications and after a caesarean birth. Throughout the restrictions exceptions were made in individual cases and birthing parents were facilitated to be present while the women were in the labour ward and for the birth of the baby. Women have valued the peaceful waiting rooms, the streamlined appointment times and the private, quieter postnatal wards. While there is limited data in relation to visiting restrictions during COVID-19 in international literature, the results of this study mirror findings from an older study in relation to visiting policies. Soltani et al (2008) found a wide variety in women's opinion about visiting policies but that the majority of women in their study would like open visiting for their partner.

COVID-19 social distancing requirements have added to the challenges for wards and clinics due to inadequate space and infrastructure. The research site is adopting a phased approach to the reintroduction of visiting. Given the vital role of the woman's partner, and is response to the recommendations provided by this study, they will be prioritised and permitted to visit the postnatal wards daily before any other visitors. The hospital has improved communication about visiting restrictions and the website is being updated continuously. Further research is required to gain a deeper understanding of mothers' and fathers' experience of giving birth during the COVID-19 pandemic and in relation to the impact of visiting restrictions on fathers. In particular, qualitative research is required to further understand parents' experience of giving birth during a pandemic.

This study highlights both the benefits and difficulties associated with the visiting restrictions imposed due to COVID-19. Women expressed a strong desire to have their partner present for appointments and during their postnatal hospital stay. Women valued the time alone with their baby and highlighted the importance of this. While women were clear they wanted their partner to be allowed to visit, they didn't request an open visiting policy for other family members. The information gained from this study can be used to inform visiting policies in maternity hospitals in the future.

Key points

• Due to the coronavirus infection, visitors to the maternity hospital were restricted and only partners of women in labour were permitted to attend the hospital
• This study highlights both the benefits and difficulties associated with the visiting restrictions imposed due to COVID-19
• Women miss having their partner for support during scans and to help after the baby is born
• Women felt safe and valued the support received from hospital staff

CPD reflective questions

• How has COVID-19 visiting restrictions impacted your own practice?
• How can you better support women in relation to visiting restrictions?
• When COVID-19 restrictions are lifted, what do you think is the ideal policy for visitors?