Strengthening community provision

Further innovation strengthened the provision of both primary and community care. The aim of these innovations was primarily to reduce the volume of patients within hospitals, in order to minimise capacity problems and infection risk for both service users and staff. Examples included the increased use of methods to enable early labour at home after induction of labour , unless there were complications requiring hospital attendance. Women booked for hospital birth were also advised to remain at home during early labour. In the UK, the pre COVID-19 drive for continuity of carer (CoC) continued, although some CoC projects were temporarily discontinued. Some hospital Trusts established new CoC provision during the pandemic.

Comment

The documents we reviewed highlight many innovations in maternity care resulting from the COVID-19 pandemic. Some were completely new; others had previously been used, but were rolled out rapidly as the need arose. In addition to the more familiar technical innovations (e.g., telemedicine), we identified innovations relating to staff wellbeing, resulting in a more resilient maternity care system and in strengthening community care.
The innovations which were implemented during COVID-19, largely to minimise infection risk, may be continued post-pandemic, due to the benefits that have been observed for organisations, staff and service-users. The benefits of fully embracing pre-existing guidelines also became apparent, according to national documents. For example, there was increased encouragement for women to remain at home during early labour, with the support of a midwife, to reduce the impact on hospital capacity as well as minimising infection risk. This guidance was in place pre-pandemic because women who remain at home during early labour have a lower risk of intervention, and support at home during this phase of labour increases maternal satisfaction.4, 5
A resilient maternity care system requires the resources and capacity to cope with largescale stressful events, such as natural disasters and pandemics.6 Some of the innovations we identified are directly linked to short-term challenges, such as the development of escalation plans and digital storage of key documents needed to run a midwifery practice and/or hospital department, in case of major capacity problems. The pandemic also highlighted long-term challenges, such as strengthening the workforce.7 This was particularly apparent with the increased risk of anxiety, stress and burnout as a result of working during COVID-19. These conditions decrease staff quality of life and increase the potential for staff to leave the profession or take early retirement.8 During the pandemic, attempts were made to limit the risk of emotional exhaustion and to increase staff wellbeing, via better rest and break facilities, as well as psychological support. The continuation of these psychological support mechanisms may contribute to a more positive work environment, to lower staff attrition rates, and to improve outcomes for women, birthing people, infants, and families.
All of these innovations (including the roll out of existing practices) have potential ethical, governance, and organisational implications, for maternity care specifically, and for health care in general. In contrast to the idea of careful development and testing of new practices for efficacy, effectiveness, feasibility, acceptability and equity, there was no time for evaluation, and many new practices were implemented almost overnight as solutions and work-arounds to emerging problems.9 This has resulted in a dynamic and creative space that has generated or catalysed valuable new approaches to healthcare. Some of these changes (such as support for staff wellbeing) are self-evidently beneficial. However, the rapid introduction of others (such as telehealth) raises the potential for over-extension of techniques that might not work for all; might not be affordable in the longer-term; could disadvantage some; and that may have longer term adverse effects. It is critical to invest time and resources to find out what works, for whom, in what circumstances and why, and to ensure that the use of new approaches is equitable, acceptable and feasible.9 There are some studies addressing this issue, particularly in relation to telehealth.10Extension of such analyses to other areas of innovation is especially important in a context where pandemic innovations are already becoming normalised in practice, as de-implementation can be more challenging than implementation.11 The time has come to learn which innovations worked best from a service-user, professional and organisational perspective, and to use this knowledge to build infrastructure and practices to enable resilient and sustainable maternity care systems, both for a post-COVID-19 future, and in anticipation of any future health care crisis.