Postcode lottery of care

The notion of a postcode lottery of maternity service provision gained traction in the media over the summer of 2020.18 Concerns were reflected in national documents from almost all included organisations, the stakeholder interviews, and reflected in Trust level responses. Variation was justified by some organisations as a reaction to local need, for example: ‘restrictions on other visitors should follow hospital policy and national guidance’ (RCM_7) and ‘all staff should work to the same local policy, to provide a consistent service to women’ (SoR_5). The caveat to most guidance was that any policies needed to be re-addressed in the event of local spikes in COVID-19 cases or following local risk assessment, to ensure a ‘consistent service to women’ (SoR_2):

But it’s guidance, and every hospital will make its own decisions and to a certain extent, they will have to because the physicality, the layout, the facilities that they have in hospitals will differ. You know, there’s not much room in the waiting area if the corridors are very narrow [so] that the people can’t have a two-metre distance. (Stakeholder 20, National charity)

Some Trusts were identified as having ‘gone out of their way to ensure their services remain family-centred’ (BR_14), whereas in others, partners or other companions of choice were unable to attend any antenatal appointments or scans (BR_16). NHS England released guidance in September 2020 intended to assist Trusts to reintroduce access for companions (NHSE_8). Some organisational responses claimed that this led to ‘some Trusts starting to backtrack and reduce restrictions in maternity services’ (BR_17), while other Trusts continued to impose restrictions (BR_18) and often without a clear rationale for these variations:

And that’s the problem. You … because down the street, down the road, you could get a very warm, empathetic ultrasonographer who says, of course, yeah, I realise how difficult it is. You know, it doesn’t take much, and we just have lost it because people are stressed and there’s lots of reasons for it [restricting companions], but it’s just not good enough. (Stakeholder 18, Midwifery—strategic role)

Confusion and stress around ‘rules’

Concern over a lack of clarity in decision-making and changes in policies around companionship/visiting were highlighted. For instance, letters from Birthrights to maternity leads (eg, BR_12; BR_16; BR_19) repeatedly emphasised the need for clear reasons, evidence and justification as to why decisions were being made. Concerns included that Trusts ‘acted too quickly to withdraw services’ and ‘decision-making has not always been proportionate or transparent’ (BR_18). While most Trusts made some reference to infection risk as the rationale for the restrictions, a sizeable minority (9/25) did not. Many Trusts offered no rationale as to why partners could attend some appointments but not others, for example:

One birth partner may attend for the 20-week anomaly scan only. Women to attend all other scan appointments unaccompanied. (South-west 2)

Birthrights and some stakeholders highlighted a failure to communicate local restrictions in a timely manner, compounded by rules changing rapidly and difficulties in communicating these changes widely and consistently to large numbers of healthcare professionals. This confusion about the rules was also compound by changeovers of staff and communication between different teams in some areas—‘there’s been no consultation with sonographers in terms of risk assessments […] or changes in practice’ (Stakeholder 26, Radiographer), and services being provided by staff from outside the maternity team.

While some stakeholders noted that individual Trusts responded to this confusion by using a range of public communications, data from the 25 maternity Trusts found that less than half (10/25) had a consistent message about companionship or visiting across different channels. Parent frustration reported by stakeholders also related to how the rules for companions and visiting seemed at odds with the social distancing rules outside of the hospital context:

In the middle of lockdown, it was ‘we don’t like it, but we know you’re keeping us safe’. Now ‘it’s we don’t like it and I don’t see how you’re keeping us more safe doing this because I can meet my partner in the pub, but he can’t come to my scan. I can do this, but I can’t do that’. Yes. So, it’s more of an angry mood now. (Stakeholder 12, Maternity Voices Partnership)

In some of the documents by Birthrights (eg, BR_14; BR_16) and the Royal College of Midwives (RCM) (ie, RCM_31) they called for the harm caused by restricted access by companions to be properly and transparently considered within the decision-making processes:

We would be grateful if you could publish or send us the risk assessment that quantifies the increased risk of spreading COVID-19 within the unit (despite PPE and other mitigating factors, and the fact that most partners are from the same household) caused by relaxing restrictions, and weigh this against the known harms to pregnant women, birthing people and their families from keeping the current restrictions in place. (BR_16)

Unintended consequences

Almost all organisations, highlighted that having trusted companions throughout labour and birth is linked to improved outcomes, and a lack of companionship was associated with increased need for pharmacological or other interventions (AIMS_8; BR_23). This included perceived impacts on the labour process due to, for example, (increased) ‘demand for epidurals’ (RCM_8). Alongside the obvious fear and anxiety of infection, organisations and stakeholders highlighted concerns about women/birthing people feeling ‘petrified’ (Stakeholder 15, Midwifery—strategic role) or not accessing maternity care, ‘due to the women’s preferred birth partner not being allowed to accompany her’ (RCM_2). There were also concerns of companions feeling ‘unsupported and uncared for’ (Stakeholder 20, National charity) due to being unable to be with the woman/birthing person when they heard bad news (during ultrasound) or missing the birth due to ‘being told that they should wait in the car park or something’ (Stakeholder 7, Service-user organisation). All but four Trust websites contained messages of empathy regarding the restrictions, sometimes alongside expressions of regret and/or justifications for their necessity: ‘We understand the restrictions we have had in place over recent months have been particularly hard for pregnant women and their families’ (North-west 1). Concerns were also expressed by stakeholders and within documents by Sands and Birthrights, towards women/birthing people who had experienced prior baby loss or who may receive bad news alone during the scan:

Women are being asked to attend scans alone, with many sharing frustrations that they cannot video link to their partners. These very vulnerable women tell us they are concerned about having to attend stressful antenatal appointments and scans alone. While units are being encouraged to consider facilitating women to take a video clip at the end of an appointment, this is reliant on local policies. (Sands_1)

Companionship was noted to have practical as well as emotional implications for women/birthing people. Some of the documents claimed that the absence of companions meant that women/birthing people required more support from maternity care professionals (eg, RCOG/RCM_1 j; NHSE_1) creating additional stress for over stretched services (RCOG/RCM_1 L) and additional potential exposure to COVID-19 infection. Some practitioner respondents also reported that they or their colleagues experienced moral distress when social distancing rules prohibited physical contact with women/birthing people who were alone, or receiving bad news:

All of a sudden it was just women on their own for us. And that was really, really stressful for the women and the staff. And a lot of a lot of my job is giving bad news. And to give that to women that are on their own with no support; you can’t touch them. You can’t hug them. And so that for us is really, really challenging. I think that was probably the most challenging thing. (Stakeholder 24, Sonographer)

Need for flexibility

Concerns discussed within the documents (eg, BR_8; BR_18; RCM_4) and raised by stakeholders related to the blanket adoption of visitation rules across whole hospitals. Some commented that pregnant women/birthing people were a ‘separate population with separate needs’ (Stakeholder 7, Service-user organisation), arguing that visiting rules adopted in other areas of healthcare should not apply to a perinatal population:

So, you know, several heads of midwifery were saying to me, I want to do this, but they won’t let me because they made a decision about what the visiting will look like in this hospital. And they do not see maternity as an exception. And, you know, it is an interesting reflection, isn’t it, that maternity has always been a service that has seen itself as an exception to the health care service in which it sits. (Stakeholder 17, NHS improvement lead)

Responses from organisations, including AIMS, Birthrights and the RCM, argued how there needed to be consideration of women’s/birthing people’s unique situations. Restrictions on companionship were considered to have a disproportionate impact on those who were facing disadvantages, including those for whom English is a second language, those with mental health problems, cognitive impairments, refugee and asylum seekers (AIMS_8; RCM_4; BR_8; BR_18). Only one Trust included a statement on their website about offering personalised (flexible/individualised) care for all women/birthing people, that might not be in line with COVID-19 policies. Five others said that they offered this on a case-by-case basis (often expressed as ‘exceptional circumstances’). One of these referred to Black, Asian and ethnic minority communities along with concerns about greater COVID-19 risks, and three referred to ‘allowing’ women/birthing people to bring a companion if they ‘needed assistance’. In two Trusts, this was explicitly linked to those with disabilities:

Partners and family members will not be allowed to enter the building unless you need support from a carer/relative (eg, if you have a disability and need support). (North-west 2)

Birthrights stipulated how ‘protected characteristics’ under the Equality Act 2010 (eg, physical disability or mental health condition) meant that maternity Trusts were obliged to make reasonable adjustments (eg, BR_15; BR_18). NHS England emphasised the need for ‘essential visitors’ (seen as different to ‘normal visitors’) for those with specific communication or care needs (NHSE_8). AIMS also stressed that on some occasions, on a ‘case-by-case basis’, such as a disability, ‘a second birth partner may be critical to women’s mental well-being or other needs’ (AIMS_2).

The lack of flexibility for highly sensitive events such as experiences of trauma or loss were also highlighted by Birthrights (eg, BR_18) and the RCM (eg, RCM_41). While some incidents of positive practice were identified, stakeholders also shared stories of those whose baby had died in utero being unable to take photographs or spend time with their deceased child:

We had a lot of stories from parents who hadn’t been allowed to take photographs, haven’t had time to sit and hold their baby. And I think all of those were linked to both a lack of space, to lack of bereavement space, but also a lack of staff understanding of how to adapt bereavement care standards. We also saw in this group a lot of problems around not having the partner with them. (Stakeholder 10, National charity)

‘Acceptable’ time for support

Access to and timing of support from companions were issues at key stages during the perinatal journey, and notably during antenatal ultrasound appointments and during early onset of labour. A key area of contention related to women/birthing people having to attend ultrasound scans unaccompanied: a situation described by one of the stakeholders as ‘ludicrous’ (Stakeholder 7, Service-user organisation). Guidance from the Royal College of Obstetrics and Gynaecologists (RCOG) recommended that ‘patients should be asked to attend alone if possible or with a maximum of one partner/visitor’ (RCOG_5), whereas a RCM document stated ‘partners should attend scans unless rooms are too small to socially distance: partners may attend scans virtually’ (RCM_28). However, in contrast to this permission for virtual contact, a joint statement by the Society of Radiographers (SoR), RCOG, RCM and the British Medical Ultrasound Society stated that devices required for remote contact by companions via video/phones are a vehicle for transmission (due to surface contamination), and that recordings would impact on scan time, sonographer concentration and potential detection of fetal abnormalities—although it was acceptable for the woman/birthing person (if in line with local policies) to ‘save a short 10–30 s cine clip of the fetus at the end of selected examinations’ (SoR_11).

Trust data revealed that while most permitted companions at one or both standard ultrasound appointments (12 weeks and 20 weeks), seven (~30%) did not. Four Trusts mentioned video or other means of ‘virtual’ companionship, but usually to specify that videos of scans were not permitted. Only one Trust referred to women/birthing people being able to phone a companion for support if the sonographer were to find ‘important clinical information that your partner needs to be aware of’ (Greater London 2). While many stakeholders were critical of the ultrasound restrictions on the right to be accompanied, one respondent argued the need to highlight that antenatal ultrasound scanning continued, even when ‘other screening programmes went into hibernation’ (Stakeholder 26, Radiographer). Some defended restrictions on women/birthing people being accompanied during scanning, noting that scans often have to take place in areas ‘like a broom cupboard in a very small poorly ventilated space’ (Stakeholder 17, NHS improvement lead) coupled with the restricted time to undertake the examination and sterilising the room and equipment after each appointment. One reported that there had been a ‘downgrading’ of the importance of scans as a medical examination that required focused concentration in challenging situations, during vociferous debate about companion attendance (Stakeholder 26, Radiographer). However, while sonographers may have faced increased risks due to screening large numbers of women/birthing people, the specific rationale for not allowing videos as an alternative was challenged:

You can argue the toss as to whether some of the justifications for not allowing that were real or weren’t real. You know, is there really a risk of infection if you pick up your phone? Really? Maybe some anxiety for sonographers or whoever’s doing the scan. You know, you don’t really want the phone on with a video while you’re doing the scan because who knows, they might use it in some kind of litigation. Who knows? But whatever it was, it really didn’t help. (Stakeholder 20, National charity)

A further area of contention concerned companionship during labour and birth. While organisations such as Birthrights argued for companionship throughout, less than half (9/25) of the Trusts referred to companions of choice attending ‘throughout’ or ‘for the duration’. Three Trusts referred to companionship being permissible only when the woman/birthing person was in ‘established’ or ‘active’ labour (with no details as to how this would be established), and 13 Trusts did not specify the relevant phase of labour. RCM guidance advised that women/birthing people would not be able to have companions present during inductions that took place in a bay or ward (RCM_27). Only six Trusts (25%) indicated that companions could be present during induction of labour, and four allowed companions, but with limitations (either restricted to daytime or if the woman/birthing person needed additional support). About half (12) provided no information, and three explicitly stated that companions were not allowed:

If you are attending for induction of labour please attend alone, your birth partner will join you once you are transferred to the Delivery Suite. (Yorkshire and Humber 1)

Birthrights and AIMS (ie, BR_8; AIMS_5; BR_18; BR_23) also raised concerns about cervical dilatation as the only acceptable indicator of active labour. As this meant that some women/birthing people who may not have wanted (or needed) a vaginal examination felt pressured to accept the procedure if they wanted their chosen companion to be granted access.

There were examples of innovation to try to support companionship. Some Trusts initiated or extended the provision of labour induction in community settings or in private hospital rooms (rather than multi-occupancy early labour wards) to prevent separation of women/birthing people from their companions (RCM_8; RCM_27). Some stakeholders also referred to more flexible approaches to induction such as companions being able to ‘come and settle them [women] in’ and to use ‘Facetime to be with their partner all the time’ (Stakeholder 21, Midwife—national role).

Loss of human rights for gain in infection control

There was some evidence from stakeholders that hospital decision-makers in some settings believed that companionship during the maternity episode should not be prioritised over visiting rights in other areas where attendance of close family members would usually be seen as a critical human need and right: especially when someone was dying in hospital:

So, it was interesting and when I would speak to the head of midwifery, sometimes it felt like they were saying, you know, well, everyone’s got to make … sacrifices. And there are people dying alone in hospital. There are people suffering terribly alone in hospital, unable to have visitors … . [while] there were women saying, you know, it’s my right to have a companion it’s your job to provide care for me. So, it felt at times like each group with their own concerns was unable to think about or found it difficult to take on board the concerns of the other group. (Stakeholder 17, NHS improvement lead)

The underlying principle within most of the guidance reviewed was that ‘safety’ was primarily conceptualised as the prevention of transmission of infection, for women/birthing people, companions and staff. NHS England documents referred to minimising ‘control risks working with your IPC [Infection, Prevention & Control] leads, while still allowing the maximum possible safe access’ (ie, NHSE_9). The RCOG/RCM also noted the need to minimise the number of attendees, but acknowledged that one person could be there for antenatal visits should a woman/birthing person choose this:

You will be asked to come alone to clinical appointments or keep the number of people with you to one (including midwifery visits in your home). This will include being asked not to bring your children with you to appointments. This is important to protect maternity staff, other women and babies, and you and your family from the risk of infection. (RCOG/RCM_1g)

Birthrights was one of the key organisations to recommend that notions of safety might also include emotional and psychosocial risks of women/birthing people being unattended (eg, BR_17; BR_16; BR_19; BR_18)—‘The damage caused by ongoing restrictions needs to be weighed up against the requirements of infection control’ (BR_19). Several of their documents (eg, BR_18; BR_19) claimed that routinely restricting companions was a violation of women’s/birthing people’s (and companions) human rights. Despite this, stakeholders stated that, in practice, human rights and choices around companionship did not feature as part of the decision-making processes:

And I think we’ve spent the last, you know, however, many years banging on about the fact we want to give women choice and rights and sharing that discourse and encouraging women to become empowered. And then COVID-19 comes along and we just say, no, no, we’re not doing that. (Stakeholder 17, NHS improvement lead)

The RCM (RCM_41) stated that their ‘greatest concern’ was ‘safety being sacrificed in favour of popularity’, which seemed to imply that companionship or visiting should not outweigh the need to prevent infection of its ‘members’ and of ‘women and families’. SoR also highlighted that its guidance had ‘risk assessments’ at its core (SoR_6). The guidance did not preclude ‘people being accompanied’, but that it ‘must only happen if the safety of the patient and sonographer is not compromised’ (SoR_8). However, others argued that day to day decision-making was based around a belief about safety that was limited: ‘because it’s not just about the physical self, it’s about [the] psychological self’ (Stakeholder 14, Midwife—national role):

But I think safety generally is an interesting thing because … You know, so many different things affect safety don’t they, so something like being able to have your partner with you might not be seen as a primary thing affecting safety in comparison with protecting against COVID-19, but actually if it impacts on someone’s mental health in either the partner or the mother, that does have an effect on safety. (Stakeholder 5, Maternity Voices Partnership)