‘There's only so much you can be pushed’: Magnification of the maternity staffing crisis by the 2020/21 COVID‐19 pandemic

Concerns about the impact of staffing shortages and burnout in the maternity workforce on safe and respectful care are long-standing, in the UK and internationally.1, 2 The COVID-19 pandemic has further reduced workforce availability worldwide.3 We explored the impact of the pandemic on maternity staff experience.We thematically analysed in-depth interviews (November 2020–October 2021) with 28 frontline maternity staff and 28 heads of service from seven geographically and demographically diverse NHS Trusts in England, as part of the ASPIRE COVID-19 study.The pandemic magnified existing problems within maternity care. Well established challenges such as short staffing, organisational demands, and barriers to providing relational care were exacerbated by the pandemic, leaving staff emotionally exhausted and unable to carry on. While the service is usually maintained through the goodwill of its workers, this is not sustainable in the long-term or through crisis situations. We identified three sub-themes (Figure 1) that capture changing experiences as the pandemic progressed.A sudden influx of staff and resources early in the pandemic, combined with a sense of camaraderie, public support and professional pride, led to an unexpectedly positive work environment. Despite fears for their own health and worries about taking home the virus to their families, many reported that making huge personal sacrifices was part of being involved in something bigger than themselves.However, these protective factors did not last. Experiences later in the pandemic included poor staff recruitment and retention, deteriorating physical and psychological wellbeing, insufficient staffing and unmanageable workloads. Some described unsafe working practices such as an inability to provide one-to-one care in labour, and excessively long working hours. Many described the emotional distress of working intensively to maintain standards of care but feeling only able to do the ‘bare minimum’. For some, the dissonance between the safe and personalised care they wanted to provide, and the experience of dangerously low levels of staffing, was associated with accounts of significant moral injury and distress.Those interviewed later in 2021 reported increasingly critical staffing shortages. Respondents described compassion fatigue, both towards their colleagues and for those in their care. ‘Exhausted’, ‘broken’, ‘unable to carry on’ or similar terms were used by a majority of participants. Serious concerns were raised about a rising incidence of burnout and breakdown, leading to an exodus of experienced and expert staff. One obstetrician warned of the ‘the biggest midwifery crisis of all time’.Our findings indicate that the COVID-19 pandemic has magnified the existing and escalating maternity staffing crisis in England, impacting on the ability to provide both safe and personalised care. International evidence suggests that maternity services globally face similar challenges.3 Coping mechanisms that usually enabled staff to go ‘above and beyond’ to plug service gaps were breaking down towards the end of the data collection period, reducing the sustainability of all but basic care, and risking the psychological, emotional and physical health of respondents.The impact of sub-optimal staffing on service user safety is increasingly highlighted in maternity safety reviews, which have also recognised that although staff are frequently intensely concerned about staffing ratios, these concerns have been dismissed.4, 5 Addressing insufficient staffing in maternity is a central recommendation of these reviews and can no longer be ignored.There is a unique opportunity for a post-pandemic rebuild of maternity services. This should begin by examining protective factors and organisational and political drivers that sustain psychological and physical staff wellbeing, and optimal service user outcomes and experiences. These include explicit organisational commitment to safe and sustainable staffing, flexible, autonomous practice, and protected time to provide person-centred, relational care. Getting these factors right, may promote sustainable recruitment and retention of professional maternity care staff, both for care under normal circumstances and for future crises

‘There's only so much you can be pushed’: Magnification of the maternity staffing crisis by the 2020/21 COVID‐19 pandemic

Concerns about the impact of staffing shortages and burnout in the maternity workforce on safe and respectful care are long-standing, in the UK and internationally.1, 2 The COVID-19 pandemic has further reduced workforce availability worldwide.3 We explored the impact of the pandemic on maternity staff experience.We thematically analysed in-depth interviews (November 2020–October 2021) with 28 frontline maternity staff and 28 heads of service from seven geographically and demographically diverse NHS Trusts in England, as part of the ASPIRE COVID-19 study.The pandemic magnified existing problems within maternity care. Well established challenges such as short staffing, organisational demands, and barriers to providing relational care were exacerbated by the pandemic, leaving staff emotionally exhausted and unable to carry on. While the service is usually maintained through the goodwill of its workers, this is not sustainable in the long-term or through crisis situations. We identified three sub-themes (Figure 1) that capture changing experiences as the pandemic progressed.A sudden influx of staff and resources early in the pandemic, combined with a sense of camaraderie, public support and professional pride, led to an unexpectedly positive work environment. Despite fears for their own health and worries about taking home the virus to their families, many reported that making huge personal sacrifices was part of being involved in something bigger than themselves.However, these protective factors did not last. Experiences later in the pandemic included poor staff recruitment and retention, deteriorating physical and psychological wellbeing, insufficient staffing and unmanageable workloads. Some described unsafe working practices such as an inability to provide one-to-one care in labour, and excessively long working hours. Many described the emotional distress of working intensively to maintain standards of care but feeling only able to do the ‘bare minimum’. For some, the dissonance between the safe and personalised care they wanted to provide, and the experience of dangerously low levels of staffing, was associated with accounts of significant moral injury and distress.Those interviewed later in 2021 reported increasingly critical staffing shortages. Respondents described compassion fatigue, both towards their colleagues and for those in their care. ‘Exhausted’, ‘broken’, ‘unable to carry on’ or similar terms were used by a majority of participants. Serious concerns were raised about a rising incidence of burnout and breakdown, leading to an exodus of experienced and expert staff. One obstetrician warned of the ‘the biggest midwifery crisis of all time’.Our findings indicate that the COVID-19 pandemic has magnified the existing and escalating maternity staffing crisis in England, impacting on the ability to provide both safe and personalised care. International evidence suggests that maternity services globally face similar challenges.3 Coping mechanisms that usually enabled staff to go ‘above and beyond’ to plug service gaps were breaking down towards the end of the data collection period, reducing the sustainability of all but basic care, and risking the psychological, emotional and physical health of respondents.The impact of sub-optimal staffing on service user safety is increasingly highlighted in maternity safety reviews, which have also recognised that although staff are frequently intensely concerned about staffing ratios, these concerns have been dismissed.4, 5 Addressing insufficient staffing in maternity is a central recommendation of these reviews and can no longer be ignored.There is a unique opportunity for a post-pandemic rebuild of maternity services. This should begin by examining protective factors and organisational and political drivers that sustain psychological and physical staff wellbeing, and optimal service user outcomes and experiences. These include explicit organisational commitment to safe and sustainable staffing, flexible, autonomous practice, and protected time to provide person-centred, relational care. Getting these factors right, may promote sustainable recruitment and retention of professional maternity care staff, both for care under normal circumstances and for future crises

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

Objectives: To explore stakeholders’ and national organisational perspectives on companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19, as part of the Achieving Safe and Personalised maternity care In Response to Epidemics (ASPIRE) COVID-19 UK study.Setting: Maternity care provision in England.Participants: Interviews were held with 26 national governmental, professional and service-user organisation leads (July–December 2020). Other data included public-facing outputs logged from 25 maternity Trusts (September/October 2020) and data extracted from 78 documents from eight key governmental, professional and service-user organisations that informed national maternity care guidance and policy (February–December 2020).Results: Six themes emerged: ‘Postcode lottery of care’ highlights variations in companionship and visiting practices between trusts/locations, ‘Confusion and stress around ‘rules’’ relates to a lack of and variable information concerning companionship/visiting, ‘Unintended consequences’ concerns the negative impacts of restricted companionship or visiting on women/birthing people and staff, ‘Need for flexibility’ highlights concerns about applying companionship and visiting policies irrespective of need, ‘‘Acceptable’ time for support’ highlights variations in when and if companionship was ‘allowed’ antenatally and intrapartum and ‘Loss of human rights for gain in infection control’ emphasises how a predominant focus on infection control was at a cost to psychological safety and human rights.Conclusions: Policies concerning companionship and visiting have been inconsistently applied within English maternity services during the COVID-19 pandemic. In some cases, policies were not justified by the level of risk, and were applied indiscriminately regardless of need. There is an urgent need to determine how to sensitively and flexibly balance risks and benefits and optimise outcomes during the current and future crisis situations

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

Objectives: To explore stakeholders’ and national organisational perspectives on companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19, as part of the Achieving Safe and Personalised maternity care In Response to Epidemics (ASPIRE) COVID-19 UK study.Setting: Maternity care provision in England.Participants: Interviews were held with 26 national governmental, professional and service-user organisation leads (July–December 2020). Other data included public-facing outputs logged from 25 maternity Trusts (September/October 2020) and data extracted from 78 documents from eight key governmental, professional and service-user organisations that informed national maternity care guidance and policy (February–December 2020).Results: Six themes emerged: ‘Postcode lottery of care’ highlights variations in companionship and visiting practices between trusts/locations, ‘Confusion and stress around ‘rules’’ relates to a lack of and variable information concerning companionship/visiting, ‘Unintended consequences’ concerns the negative impacts of restricted companionship or visiting on women/birthing people and staff, ‘Need for flexibility’ highlights concerns about applying companionship and visiting policies irrespective of need, ‘‘Acceptable’ time for support’ highlights variations in when and if companionship was ‘allowed’ antenatally and intrapartum and ‘Loss of human rights for gain in infection control’ emphasises how a predominant focus on infection control was at a cost to psychological safety and human rights.Conclusions: Policies concerning companionship and visiting have been inconsistently applied within English maternity services during the COVID-19 pandemic. In some cases, policies were not justified by the level of risk, and were applied indiscriminately regardless of need. There is an urgent need to determine how to sensitively and flexibly balance risks and benefits and optimise outcomes during the current and future crisis situations

Making maternity and neonatal care personalised in the COVID-19 pandemic: Results from the Babies Born Better survey in the UK and the Netherlands

Background The COVID-19 pandemic had a severe impact on women’s birth experiences. To date, there are no studies that use both quantitative and qualitative data to compare women’s birth experiences before and during the pandemic, across more than one country. Aim To examine women’s birth experiences during the COVID-19 pandemic and to compare the experiences of women who gave birth in the United Kingdom (UK) or the Netherlands (NL) either before or during the pandemic. Method This study is based on analyses of quantitative and qualitative data from the online Babies Born Better survey. Responses recorded by women giving birth in the UK and the NL between June and December 2020 have been used, encompassing women who gave birth between 2017 and 2020. Quantitative data were analysed descriptively, and chi-squared tests were performed to compare women who gave birth pre- versus during pandemic and separately by country. Qualitative data was analysed by inductive thematic analysis. Findings Respondents in both the UK and the NL who gave birth during the pandemic were as likely, or, if they had a self-reported above average standard of life, more likely to rate their labour and birth experience positively when compared to women who gave birth pre-pandemic. This was despite the fact that those labouring in the pandemic reported a lack of support and limits placed on freedom of choice. Two potential explanatory themes were identified in the qualitative data: respondents had lower expectations of care during the pandemic, and they appreciated the efforts of staff to give individualised care, despite the rules. Conclusion Our study implies that many women labouring during the COVID-19 pandemic experienced restrictions, but their experience was mitigated by staff actions. However, personalised care should not be maintained by the good will of care providers, but should be a priority in maternity care policy to benefit all service users equitably

Effects of psychotherapy for anxiety in children and adolescents: a meta-analytic review

This paper provides a comprehensive quantitative review of high quality randomized controlled trials of psychological therapies for anxiety disorders in children and young people. Using a systematic search for randomized controlled trials which included a control condition and reported data suitable for meta-analysis, 55 studies were included. Eligible studies were rated for methodological quality and outcome data were extracted and analyzed using standard methods. Trial quality was variable, many studies were underpowered and adverse effects were rarely assessed; however, quality ratings were higher for more recently published studies. Most trials evaluated cognitive behavior therapy or behavior therapy and most recruited both children and adolescents. Psychological therapy for anxiety in children and young people was moderately effective overall, but effect sizes were small to medium when psychological therapy was compared to an active control condition. The effect size for non-CBT interventions was not significant. Parental involvement in therapy was not associated with differential effectiveness. Treatment targeted at specific anxiety disorders, individual psychotherapy, and psychotherapy with older children and adolescents had effect sizes which were larger than effect sizes for treatments targeting a range of anxiety disorders, group psychotherapy, and psychotherapy with younger children. Few studies included an effective follow-up. Future studies should follow CONSORT reporting standards, be adequately powered, and assess follow-up. Research trials are unlikely to address all important clinical questions around treatment delivery. Thus, careful assessment and formulation will remain an essential part of successful psychological treatment for anxiety in children and young people