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\begin{document}

\title{The United Kingdom and the Netherlands maternity care responses to
COVID-19: a comparative study~~~~}



\author[1]{Lauri van den Berg}%
\author[2]{Marie-Clare Balaam}%
\author[2]{Rebecca Nowland}%
\author[2]{Gill Moncrieff}%
\author[2]{Anastasia Topalidou}%
\author[3]{Suzanne Thompson}%
\author[2]{Gill Thomson}%
\author[1]{Ank de Jonge}%
\author[2]{Soo Downe}%
\affil[1]{Amsterdam UMC }%
\affil[2]{University of Central Lancashire}%
\affil[3]{Zuyd University}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Background:} The national health care response to coronavirus
(COVID-19) has varied between countries. The United Kingdom (UK) and the
Netherlands (NL) have comparable maternity and neonatal care systems,
and experienced similar numbers of COVID-19 infections, but had
different organisational responses to the pandemic. Understanding why
and how similarities and differences occurred in these two contexts
could inform optimal care in normal circumstances, and during future
crises.~\textbf{Aim:} To compare the UK and Dutch COVID-19 maternity and
neonatal care responses in three key domains: choice of birthplace,
companionship, and families in vulnerable situations.~\textbf{Method:} A
multi-method study, including documentary analysis of national
organisation policy and guidance on COVID-19, and interviews with
national and regional stakeholders.~\textbf{Findings:} Both countries
had an infection control focus, with less emphasis on the impact of
restrictions. Differences included care providers' fear of contracting
COVID-19; the extent to which personalised care was embedded in the care
system before the pandemic; and how far multidisciplinary collaboration
and service-user involvement were prioritised.~\textbf{Conclusion:} We
recommend that countries should 1) make a systematic plan for crisis
decision-making before a serious event occurs, and that this must
include authentic service-user involvement, multidisciplinary
collaboration, and protection of staff wellbeing 2) integrate women's
and families' values into the maternity and neonatal care system,
ensuring equitable inclusion of the most vulnerable and 3) strengthen
community provision to ensure system wide resilience to future shocks
from pandemics, or other unexpected large-scale events.%
\end{abstract}%



\sloppy




Lauri M.M. van den Berg\textsuperscript{1}, Marie-Clare
Balaam\textsuperscript{2}, Rebecca Nowland\textsuperscript{2}, Gill
Moncrieff \textsuperscript{2}, Anastasia Topalidou\textsuperscript{2},
Suzanne Thompson\textsuperscript{1,3}, Gill Thomson\textsuperscript{2},
Ank de Jonge\textsuperscript{4}, Soo Downe\textsuperscript{2},
ASPIRE-COVID19 Collaborative Group (details below)

\textbf{Affiliations}

\textsuperscript{1} Amsterdam University Medical Centre, Vrije
Universiteit Amsterdam, Department of Midwifery Science, AVAG/Amsterdam
Public Health, The Netherlands

\textsuperscript{2} School of Community Health and Midwifery, Faculty of
Health and Care, University of Central Lancashire, UK.

\textsuperscript{3} Research Centre of Midwifery Science Maastricht,
Zuyd University, The Netherlands

\textsuperscript{4} Amsterdam University Medical Centre, Vrije
Universiteit Amsterdam, Department of Midwifery Science, AVAG/Amsterdam
Reproduction and Development , The Netherlands

\textbf{ASPIRE-COVID19 Collaborative Group}

\emph{Co-investigators}

Soo Downe; University of Central Lancashire, George Ellison; University
of Central Lancashire, Alan Fenton; Newcastle upon Tyne Hospitals NHS
Foundation Trust, Alexander Heazell; University of Manchester, Ank de
Jonge; Amsterdam University Medical Center, Carol Kingdon; University of
Central Lancashire, Zoe Matthews; University of Southampton, Alexandra
Severns; NHS England and NHS Improvement North West, Gill Thomson;
University of Central Lancashire, Anastasia Topalidou; University of
Central Lancashire, Alison Wright; Royal Free Teaching Hospital in
London

\emph{Research Staff}

Naseerah Akooji; University of Central Lancashire, Marie-Clare Balaam;
University of Central Lancashire, Jo Cull; University Of Central
Lancashire, Lauri van den Berg; Amsterdam University Medical Center,
Nicola Crossland; University of Central Lancashire, Claire Feeley;
University of Central Lancashire, Beata Franso; Amsterdam University
Medical Center, Steph Heys; University of Central Lancashire, Gill
Moncrief; University of Central Lancashire, Rebecca Nowland; University
of Central Lancashire, Arni Sarian; University of Central Lancashire

\emph{Steering committee}

Maria Booker; Birthrights, Jane Sandall; Kings College London, Jim
Thornton (chair); The University of Nottingham, Tisian Lynskey-Wilkie;
University of Central Lancashire, Vanessa Wilson; East Lancashire
Hospitals NHS Trust

\emph{Stakeholder Group}

Rebecca Abe and Tinuke Awe; FivexMore, Toyin Adeyinka; MVP BAME group,
Ruth Bender-Atik; The Miscarriage Association, Lia Brigante; RCM,
Rebecca Brione; Birthrights, Franka Cad\selectlanguage{ngerman}ée; International Confederation
of Midwives (ICM), Elizabeth Duff; Expert, postnatal care, Tim Draycott;
Royal College of Obstetricians and Gynaecologists (RCOG), Duncan Fisher;
Fathers included/Family included/ the Family Initiative, Annie Francis;
Neighbourhood Midwives, Arie Franx; Erasmus MC, Lucy Frith; University
of Liverpool, Louise Griew; National Maternity Voices, Clea Harmer;
SANDS, Caroline Homer; Burnet Institute, Australia, Marian Knight;
National Perinatal Epidemiology Unit (NPEU), Amali Lokugamage;
University College London, Amanda Mansfield; London Ambulance Service
Trust, Neil Marlow; University College London, Trixie Mcaree; NHS
England, David Monteith; Grace in Action, Keith Reed; Twins Trust, Yana
Richens; UCL \& City University, Lucia Rocca-Ihenacho; Midwifery Unit
Network, Mary Ross-Davie; RCM Scotland, Seana Talbot; BirthWise NI,
Myles Taylor; British Maternal and Fetal Medicine Society, Maureen
Treadwell; Birth Trauma Association

\par\null

\section*{1. Introduction}

{\label{906853}}

The World Health Organization (WHO) considers respectful maternity care
(RMC) to be based on the principles of universal human rights {[}1{]}.
The WHO define RMC as ``care organised for and provided to all women in
a manner that maintains their dignity, privacy and confidentiality,
ensures freedom from harm and mistreatment, and enables informed choice
and continuous support during labour and childbirth'' {[}1{]}. In the
United Kingdom (UK), the National Health Service (NHS) England Better
Births maternity review emphasises the need for both safety and
personalisation in maternity and neonatal care {[}2{]}. Safe care is
more than good perinatal outcomes: it also includes the importance of
women having choices and making decisions based around their personal
circumstances, values, social norms, and needs {[}2{]}.

The coronavirus (COVID-19) pandemic has impacted health care capacity
worldwide, including maternity and neonatal care. At the beginning of
the pandemic, there was uncertainty about the effect of COVID-19
infections on perinatal health outcomes, and actions were taken to
protect pregnant women and babies {[}3, 4{]}. Changes in maternity care
provision were made to reduce infection rates and to protect maternity
and neonatal care capacity {[}5{]}. These changes included switching to
online and telephone consultations, limiting birth partner
companionship, and ensuring extra hygiene precautions during
breastfeeding for COVID-19 positive mothers {[}5{]}. While it can be
considered acceptable to limit some rights to contribute to security,
safety, and emergency resource management {[}6{]}, some of the changes
have raised fierce opposition {[}7{]}. Complaints have been made about
restrictions in women's birth choices, and about women being alone
during labour or while attending potentially highly sensitive
appointments (i.e. anomaly scans). For some, this has been seen as a
direct violation of women's rights {[}8{]}.

The UK and the Netherlands (NL) are European countries with similar
social structures and norms, comparable maternity care systems, and, by
population size, experienced similar numbers of COVID-19 infections. In
principle, therefore, they should not differ drastically in the way they
balance human rights in the areas of safety and personalisation in
maternity care {[}9{]}. However, key differences in maternity and
neonatal services organisation have been noted, particularly in terms of
rules about companionship during labour and birth, and accessibility to
community maternity care provision {[}5{]}.

This paper reports on the findings from a multi-method study that was
undertaken to compare the UK and Dutch COVID-19 maternity and neonatal
care responses. We considered that an understanding of why and how
similarities and differences occurred in similar health and social
contexts could help inform how to optimise maternity and neonatal care
in future, both in normal circumstances, and during future crises.
Therefore, our research question was: how and why did maternity and
neonatal care policies adapt to the COVID-19 pandemic in the UK and the
NL?

\section*{2. Methods}

{\label{485218}}

\textbf{2.1 Study design}

This study was undertaken as part of the Achieving Safe and Personalised
maternity care In Response to Epidemics (ASPIRE-COVID19) project
designed to determine `what works' in providing care for mothers,
babies, and families during and after a pandemic {[}10{]}.

One of the work packages of the ASPIRE study comprised a comparison
between the UK and the NL maternity care responses, including
documentary analysis of public maternity care organisational documents
that influenced national maternity care policy and interviews with
national maternity care stakeholders. Three domains are reported in this
paper, because they emerged during the study as areas where there were
evident differences between the two countries. These domains were choice
of birthplace, companionship during the perinatal period, and the extent
to which women and families in vulnerable situations had been
considered. A modified ``Framework Method'', with a combined inductive
and deductive approach was used to examine similarities and differences
in policy in these areas, and, more importantly, to identify drivers
that might explain these similarities and differences {[}11{]}.

\textbf{2.2. Data collection}

\emph{2.2.1. Document collection}

\emph{}National (UK and NL) and international public maternity care
documents (i.e., guidelines, protocols, and position papers) were
prospectively collected from maternity care and service-user
organisations between February 2020 and December 2020 (Table 1). Our
initial plan was to collect documents until September 2020, however, due
to the second wave of COVID-19, we felt it would be beneficial to
continue data collection, which then ended in December 2020. We chose to
focus on fifteen key organisations from September 2020 onwards, due to
resource limitations. The fifteen organisations were identified to be
those which had been the most influential on maternity service provision
during the first wave of the pandemic. The list of key organisations was
agreed with the ASPIRE Collaborative Group, comprising stakeholders from
professional, service user, and policy backgrounds.

A framework of key safety and personalisation criteria was developed
based on the expert opinion of the ASPIRE Collaborative Group
(Supplementary File 1). Data were then extracted and mapped to the
framework. From the 391 collected documents, 246 had data of interest
for this analysis. In this manuscript the documents are indicated with
the organisation name and document number (e.g., organisation\_document
number).

\par\null

\subsubsection*{Table 1 Organisations that documents were collected
(abbreviation). * = key organisation, data from Sept
2020.}

{\label{261096}}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=1.00\columnwidth]{figures/Screen-Shot-2021-11-29-at-2-05-22-PM/Screen-Shot-2021-11-29-at-2-05-22-PM}

\end{center}
\end{figure}

\emph{2.2.2. Stakeholder Interviews}

\emph{}We conducted semi-structured in-depth interviews with national
and regional level stakeholders (professionals, service user
organisation representatives, policy makers) in the interviewees' native
language (English or Dutch). We used an interview guide with a focus on
personalisation and safety in maternal and neonatal care during the
pandemic (Supplementary File 2).

Thirty-nine national and regional maternity care stakeholders were
purposively selected and invited to ensure that there was representation
from all key maternity and service-user organisations involved in
national maternity and neonatal policy during the pandemic in the UK and
NL. Twenty-six participants from the UK and thirteen from the NL were
interviewed (Table 2). More stakeholders were interviewed in the UK than
in the NL, since the UK has more service-user organisations than the NL
and we wanted to make sure we had representation of all devolved nations
(Scotland, Wales, Northern Ireland). The interviews were held from July
2020 to December 2020 and were video- or audio-recorded in Microsoft
Teams and transcribed using Sonix (Sonix Inc., San Francisco, CA) and
MaxQDA software (v18.2.5) and were subject to post-transcription manual
checks and editing. Interviews were undertaken by four researchers in
the UK and two researchers in NL. All interviewers were experienced
qualitative researchers and most of them had experience of undertaking
research in maternity and/or neonatal care.

\par\null

\subsubsection*{Table 2 Interview
participants}

{\label{945245}}\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=1.00\columnwidth]{figures/Screen-Shot-2021-11-29-at-2-06-26-PM/Screen-Shot-2021-11-29-at-2-06-26-PM}

\end{center}
\end{figure}



2.3 Data analysis

The documents were first analysed by three members of the research team
(two in the UK, one in NL) using the safety and personalisation
checklist previously described (Supplementary File 1). Relevant data
segments were extracted and recorded in excel files. Analytical
frameworks were established for each domain through repeated and
extensive discussion by the three researchers, and then reviewed by all
authors.

The interviews were transcribed and anonymised and then subjected to
open coding supported by the MAXQDA software package (v18.2.5) by two
members of the research team (one UK, one NL). Open coding was conducted
in the native language by English or Dutch speaking researchers. Codes
were grouped together into categories across the open coding for each
country to develop a framework through discussion.

The documentary and interview analytical frameworks were interpreted
together within each domain to explore relationships within and between
the categories. This led to explanation of the policy drivers in both
countries. Differences in opinion in the research team were resolved
with mutual agreement. The research team consisted of nine women from a
range of academic and clinical backgrounds including midwifery,
psychology, and sociology.

\section*{3. Findings}

{\label{797465}}

In the first paragraph we present the similarities and differences in
maternity care policy between the UK and NL during the COVID-19 pandemic
for each of the chosen domains. This paragraph has a documentary focus.
The second paragraph describes the policy drivers behind these
similarities and differences and is more interview-based.

\textbf{3.1 Similarities and differences between the British and Dutch
maternity care response during the COVID-19 pandemic}

\emph{3.1.1. Choice of birthplace}

Organisations in both countries adjusted their advice for the choice of
birthplace according to whether the woman giving birth was suspected of
being positive for COVID-19 (Table 3). The most striking difference
between the UK and the NL was the provision of home birth services.
Although most guidance advised that the provision of home birth and
midwifery-led choices should continue, a Royal College of Midwives (RCM)
survey of the heads and directors of midwifery reported that 32\% of
services had stopped or restricted home births in the UK (RCM\_33). Home
birth services were discontinued in some UK regions, mainly due to
(anticipated or actual) staff shortages in hospitals and ambulance
services (RCOG\_2a, \_11). Conversely, in the NL, women who were
considered to be low-risk were initially advised not to give birth at
the hospital to reduce the potential impact on hospital capacity
(KNOV\_1, 22 March 2020). However, this advice was withdrawn within a
month (24 April 2020), as it became clear that there were no actual
capacity issues due to COVID-19.

\par\null

\subsubsection*{Table 3 Choice of
birthplace}

{\label{334834}}\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=1.00\columnwidth]{figures/Screen-Shot-2021-11-29-at-2-09-00-PM/Screen-Shot-2021-11-29-at-2-09-00-PM}

\end{center}
\end{figure}

In preparation for the second wave of the pandemic, several UK
organisations published statements about the importance of the choice of
birthplace (RCM\_30; RCOG\_15). Many advantages to keeping place of
birth choices unrestricted were emphasised and included reducing the
risk of infection for women and babies (ICM\_1; RCOG\_2; AIMS\_1) and
the reduced pressure on already overstretched hospitals (RCOG\_2a;
AIMS\_2; NHS\_1).

In both countries, concerns were expressed that COVID measures may have
influenced choices around place of birth, such as Dutch hospitals not
allowing primary care midwives to be present at medium risk births, for
example when a woman has a postpartum haemorrhage after a previous
birth, leading women to choose home birth while this was not their first
choice (GB\_3). In the UK, some of the documents described a potential
rise in the number of unassisted births, with several organisations
implying that the restrictions on birth place choices were a potential
cause (RCM\_2; AIMS\_2, \_5; BR\_1).

\begin{quote}
\emph{`Closure of services, so women haven't had choices. Yeah, and
might have ended up making choices like to freebirth that they wouldn't
otherwise.' (UK stakeholder 5, National Maternity Voices Partnerships)}
\end{quote}

\emph{3.1.2. Companionship}

In both countries, the initial response was to limit companionship for
women during the antenatal, natal, and post-partum periods. Many
organisations in the UK and NL recommended no companionship during
antenatal check-ups (KNOV\_1; BEN\_01; NVOG\_4; CPZ\_7; ISUOG\_6;
SoR\_11; NHSE\_1; RCOG\_1c; RCM\_8). In the early days of the pandemic
there was some guidance in the NL documentation to make exceptions to
companionship restrictions in the antenatal period (CPZ\_7).

\begin{quote}
\emph{`Pregnant women can face difficult and emotional decisions. In
such situations, it is realistic that health care providers deviate from
this advice' {[}no companionship during antenatal check-ups{]}' (Dutch
College for Perinatal Care, CPZ\_7, 27 March 2020).}
\end{quote}

There were differences between UK and NL policies for companionship
throughout childbirth. In the NL, only one person could be present, but
this could be throughout labour and birth (KNOV\_1, \_4). In the UK, in
the early phases of the pandemic, recommendations were that birth
companions were not allowed during early labour in spontaneous birth or
during the early phase of induction of birth (RCM\_8, \_28; AIMS\_8).
When the woman was in established labour, only one birth companion was
allowed to be present (RCOG\_1g). The documentary evidence we reviewed
did not advise on how established labour should be confirmed, but there
are reports that this requirement may have led to unwanted vaginal
examinations (AIMS\_5; BR\_8\_18\_23). In the UK, concerns were
expressed that an unintended consequence of the restrictions on
companionship was that some women chose an unassisted birth (AIMS\_2,

\begin{quote}
\emph{`Restrictions imposed by the majority of trusts (86\%) have meant
many women are alone in hospital during early labour which can last
hours or even days. Although all trust policies allowed birth partners
to attend once labour is established, the unpredictable nature of birth
has meant that in some circumstances women have given birth alone'
(Association for Improvements in the Maternity Services, AIMS\_8).}
\end{quote}

When the first COVID-19 wave had passed its peak, various service-user
organisations in both countries began lobbying for companionship rules
to be relaxed. In the UK, the focus was on companionship during early
labour, while in the NL, the concern was focused on enabling the
presence of a second companion (AIMS\_2; BR\_1, \_14; NBvD\_3; GB\_2).
The pressure resulting from these efforts led to restrictions slowly
being relaxed.

\begin{quote}
\emph{`Especially in a clinical setting, where there are often unknown
caregivers, a trusted person is so incredibly important. For these
women, it is important that they are seen and heard during birth, with
an extra person of their own choice. This allows a good start for them
now and for the future of the baby that they are bringing into the
world. For some women, this will be a doula, midwife or birth
photographer, or their mother; for others, a trainee care provider is
welcome.' (The Birth Movement, GB\_2, 22 May 2020).}
\end{quote}

In the UK, companionship on the post-partum ward was limited; in some
hospitals, visitors on the post-partum ward were not permitted, while in
others, visitors were restricted to a specific timeslot (AIMS\_6;
NHSE\_8; BR\_1, \_8, \_16, \_17, \_23; SANDS\_1; RCM\_7, \_28). In the
NL, there was no national guidance about post-partum companionship
restrictions in hospital. However, interviewees suggested that in many
Dutch hospitals, only the woman's partner could visit the post-partum
ward but without being restricted to a timeslot. Furthermore, there was
national guidance restricting visitors to all Dutch homes. This impacted
on the presence of maternity care assistants and family (BO\_1;
KNOV\_31). From 11 May 2020, women that had just given birth could
appoint one family member to visit them during the first week
postpartum; during the second COVID-19 wave, the number of visitors was
linked to national or regional infection rates (KCKZ\_4, \_13; BO\_4;
KNOV\_44). In the UK, rules about companionship in the home were limited
in maternity care organisation documents, but rules regarding home
visits were linked to nationwide lockdown measures, leading to fewer
physical visits from maternity care professionals (RCM\_15).

At the beginning of the pandemic, guidelines were published which
advised that newborn babies should be separated from COVID-positive
parents (NVK\_05; BAPM\_3). Moreover, in both countries from May 2020
onward, increased attention was placed on whether parents (not
necessarily infected with COVID-19) were seen as visitors to the
neonatal ward, thereby limiting their visiting hours (GB\_1; ICM\_1,
policy due to increased focus on the negative impact of limited
parent-infant (KNOV\_15; BAPM\_5, \_6, \_7; RCOG\_9, \_2a; SCOT\_3).

\begin{quote}
\emph{`Neonatal services present a unique situation in terms of
``visitors'' and it is essential that the mother and her partner are
never considered to be visitors within the neonatal unit -- they are
partners in their baby's care, and their presence should be encouraged'
(British Association of Perinatal Medicine, BAPM\_5, 6 May 2020).}
\end{quote}

\emph{3.1.3. Women and families in vulnerable situations}

In the documents published during the first weeks of the pandemic, there
was almost no mention of women and families in vulnerable situations in
either country. From the end of March 2020, the attention on women and
families in vulnerable situations increased, especially in service-user
organisation outputs.

On 22 March 2020, the Dutch organisation Birth Movement published an
ethical statement about maternity care during the COVID-19 pandemic, in
which they encouraged healthcare professionals to continue to consider
exceptions in certain situations; for example, if a pregnant woman had
different needs because she was anxious after a previous traumatic birth
or a previous stillbirth (GB\_1). In response, several professional
organisations started to offer advice specifically relating to families
in vulnerable situations, e.g., the Royal Dutch Organisation of Midwives
published a document on 1 April 2020 in which the objectives of
post-partum care during COVID-19 included `coping with how birth went,
pay attention to the transition to parenthood' (KNOV\_14). In the UK
there were similar changes: service user organisations emphasised the
need to consider women and families in vulnerable situations following
which some professional organisations adjusted their policies.

\begin{quote}
\emph{`To prevent avoidable suffering -- in some cases tragedy -- and
reduce the huge economic burden on society, the mental health of
pregnant women and new mums needs to be given equal priority to physical
health, including by mums and families themselves' (Maternal Mental
Health Alliance, MMHA\_1, 5 May 2020).}

\emph{`Women with known psycho-social vulnerabilities, operative birth,
preterm/low birth weight baby and/or other medical or neonatal
complexities need to be prioritised for face-to-face care' (Royal
College of Midwives, RCM\_14, 20 May 2020).}
\end{quote}

In June 2020, a study was published that demonstrated that in the UK,
women from `black or minority ethnic groups' were significantly more
likely to be admitted to the hospital with COVID-19 than other women
{[}4{]}. In response to this, several UK documents were produced which
emphasised that women from black or ethnic minority communities were
more vulnerable to COVID-19 infection, were more likely to be
hospitalised for COVID-19, and had an increased risk of adverse
perinatal outcomes during the COVID-19 pandemic (BR\_10, \_18; MBRR\_1;
NHSE\_5, \_12; NHSR\_1; RCM\_2, \_3, \_5, \_6, \_13, \_14, \_16, \_17,
clarifying the increased risk for women from minority ethnic
backgrounds, many of these documents also provided recommendations for
practice, such as to lower the threshold for admission for women from
these groups where necessary (RCM\_1, \_32, \_37; NHSE\_5).

In the NL, no data were published about the percentage of women with a
Black or other minority background that were hospitalised with COVID-19.
In NL documents, there was some emphasis on the increased vulnerability
of migrant women, asylum seekers, and women with Dutch as a second
language during the COVID-19 pandemic (NVOG\_1; KNOV\_30), but less
attention was placed on vulnerable women in NL documents, compared to
those from the UK.

\textbf{3.2 Policy drivers behind the British and Dutch maternity care
response during the COVID-19 pandemic}

\emph{3.2.1. Focus on infection control}

According to stakeholders in both countries, at the beginning of the
COVID-19 pandemic, there was a strong focus on reducing infection rates.
Several interviewees indicated that this was due to strong societal
pressure to \emph{`flatten the (epidemic) curve'} and uncertainty
relating to the risks posed by COVID-19 to pregnant women and babies,
particularly at the beginning of the pandemic. There was also fear
amongst policymakers and healthcare providers regarding capacity within
the healthcare system (i.e., staff and beds), due to the strain on
resources relating to COVID-19 infections. These factors were perceived
to have influenced the introduction of strict measures in maternity care
during the early days of the pandemic.

\begin{quote}
\emph{`The RCM, in normal circumstances, takes the clear position that
women should be given the full range of birthplace options, with
evidence-based guidance to aid their decision-making and that midwives
should staff women and not buildings. However, the current crisis
requires those leading and managing services to make difficult decisions
to ensure the safety of pregnant women, their babies and the staff
supporting them' (UK Royal College of Midwives, RCM\_23, March 2020).}
\end{quote}

As the pandemic progressed, more information became available that
suggested that pregnant women and babies were not at serious risk of
severe COVID-19 complications (though this situation has changed with
the advent of the delta variant, that arrived after the end of the data
collection period for this paper) {[}12{]}. However, maternity and
neonatal care remained focused on infection control, especially in the
UK, largely due to the fear of staff becoming infected with COVID-19.
This fear was exacerbated by a shortage of personal protective equipment
(PPE) in the healthcare sector.

\begin{quote}
\emph{`But that's the message I'm hearing back and back from the trust,
is that we only just kept our home birth services staffed and staff was
super worried about going into people's homes and we had to put a lot of
restrictions on to make them feel safer.' (UK stakeholder 12, Maternity
Voices Partnership)}
\end{quote}

This contrasted to the situation in the NL, where, according to the
interviewees, there was a shortage of PPE but there was little fear
amongst maternity care providers of becoming infected.

\begin{quote}
\emph{`I didn't experience that the midwives were so scared of becoming
infected. Of course, there were a few, but most of the measures were
taken to prevent a shortage of midwives {[}if they had to go on sick
leave because of COVID-19 infection{]}' (NL stakeholder 7, Royal Dutch
Organisation of Midwives).}
\end{quote}

According to a number of the interviewees, the negative impact of
restrictions on women was justified by the need to reduce the spread of
infection. However, others indicated that the restrictions were not
proportionate and that more attention should have been placed on women's
experiences and psychological wellbeing.

\begin{quote}
\emph{`So it {[}perinatal experience{]} is a really crucial life event.
And however difficult the circumstances, the wishes and the needs and
the sort of thoughts and everything else to do, the women should remain
paramount.' (UK stakeholder 18, Independent Midwifery Advisor)}
\end{quote}

\emph{3.2.2. Facilitators and barriers for personalised care}

In both countries, as the pandemic continued, there was more discussion
in documents and also reflected by interviewees about the balance
between safety and personalisation. However, depending on different
facilitators and barriers for personalised care, the results of this
balancing process differed. Some interviewees reported that in countries
and regions with more embedded personalised care, such as continuous
choice for and access to home birth services, it was easier to uphold
these services.

\begin{quote}
\emph{`We must continue to protect and guard the physiology {[}of
pregnancy and birth{]} as much as possible' (Royal Dutch Organisation of
Midwives, KNOV\_1, 22 March 2020).`But it seems to me. And with my
cynical hat on, a lot of trusts went great, we don't have to provide
home births anymore and it was used as an excuse. And what always
happens is that is that the sort of the wagons are circled around the
labour ward. All the other options are dropped. And that has a really
detrimental impact in so many ways (UK stakeholder 18, Independent
Midwifery Advisor)}
\end{quote}

Many interviewees felt that making exceptions to the rules for specific
needs or to enhance equity was important in principle, but that this was
particularly difficult to do in practice during the pandemic.
Respondents felt that pregnant women could not ask for exceptions to be
made for them, because they respected the rules, and because health care
providers were seen as heroes during the COVID-19 pandemic. Several
Dutch participants indicated that they thought it was difficult for
health care providers to make exceptions, due to the sense of unity
among health care providers. The national policy of the professional
organisations was also aimed at preserving unity among maternity care
providers. According to some Dutch interviewees, this sense of unity
limited maternity care providers in making decisions on whether to make
a special case for any specific individual.

\begin{quote}
\emph{`We {[}maternity care providers{]} are not going to make an
exception for you. We need to be consistent. Maternity care providers
who made an exception did so under conditions of strict secrecy' (NL
stakeholder 3, The Birth Movement)}
\end{quote}

In the UK there were issues regarding making exceptions as well.
According to the UK interviewees, this was mainly due to advice provided
in national guidance, which devolved decisions to individual regions,
Trusts, and units, which were then made dependent on local resources,
capacity, and infection levels.

\begin{quote}
\emph{`And I think there is a bit of a vacuum because there isn't strong
guidance from the centre, but that Trusts should be looking at relaxing
those restrictions and maternity services. So, I guess that's just left
to the local dynamics.' (UK stakeholder 7, Birthrights)}
\end{quote}

The lobbying of service user organisations may have had an effect on the
increased emphasis on personalised care in the UK in the public and
policy agenda that informed and influenced policy at local and national
level. There are more service user organisations in the UK than in the
NL, and service user organisations in the UK are more formalised. This
may have been beneficial for women and families in vulnerable
situations.

\begin{quote}
\emph{`The personalisation of care must remain a priority during this
period. We suggest that Trusts should be advised to consider individual
requests for support to birth at home, for example, on a case-by-case
basis, bearing in mind the needs of the woman (including her mental
health needs) as well as what can be done to mitigate staffing
constraints.' (Association for Improvements in the Maternity Services,
AIMS\_2, 9 April 2020)}
\end{quote}

\emph{3.2.3. Learning how to work together during a time of crisis}

The interviewees indicated that the unexpectedness of the COVID-19
pandemic caused tension and stress because there did not appear to be a
clear plan of action, at least in the early stages. On the other hand,
some interviewees felt that the acute crisis caused by COVID-19 created
a sense of a common purpose. Action had to be taken quickly and health
care workers pulled together to make it happen. In both countries, there
was multidisciplinary collaboration before the pandemic, but the
response at the beginning of the pandemic was to issue monodisciplinary
guidelines. According to the interviewees, and based on the guidelines
collected (such as the RCM/RCOG joint guidelines), as the pandemic
progressed, it became evident that multidisciplinary collaboration was
required to ensure policy alignment, prevent delay in care, and provide
coordinated information to service users and the media; both at the care
provider and stakeholder level.

\begin{quote}
\emph{`So, if you look at the collaboration, there were some incidents
in the beginning. Parties were still communicating a certain message
from their own sector. And later on in the process, things got better
and better: there was more of a joint effort' (NL stakeholder 11,
College of Perinatal Care).}
\end{quote}

According to the interviewees, one of the important factors about
working together during a crisis is the ability to understand each
other's interests, opinions, and expertise. The interviewees indicated
that when the importance of collaboration became widely felt among all
professional groups within maternity care, respect for each other's
expertise and perspective developed. Although some experienced or
witnessed some friction in collaboration, many Dutch interviewees seemed
proud of the collaboration in maternity and neonatal care,

\begin{quote}
\emph{`Well, one party reported to the press on how they were going to
do it, but then it was totally out of sync with the rest, which created
a bit of a disagreement' (NL stakeholder 6, Ministry of Health, Welfare
and Sport).}
\end{quote}

According to some interviewees in both countries, service user
participation was missed out on many levels, including developing
guidelines, implementing policy, and providing feedback on practice. The
longer the crisis went on, the more service user participation took
place. However, some interviewees considered the amount of participation
to be insufficient to provide women with a real voice in decision-making
about balancing their safety and other rights.

\begin{quote}
\emph{`It was a such a technical discussion about how to reduce COVID-19
{[}infection rates{]} and the social aspect and the impact was
forgotten. That would perhaps be my main recommendation. Why aren't
there women, pregnant women, people who don't come from healthcare at
the table? They were just not asked.' (NL stakeholder 3, The Birth
Movement)}
\end{quote}

\section*{4. Discussion}

{\label{873074}}

This study examined the similarities and differences in maternity and
neonatal care policy during the COVID-19 pandemic between two European
countries, the UK and the NL, and stakeholder views about the drivers
behind these policies. The focus on infection control in both countries
meant that little attention was paid to the impact of restrictions by
policy makers. Furthermore, it was difficult for care providers to make
exceptions for women and families in vulnerable situations. The most
striking differences between the UK and the NL related to birth place
choices for women and companionship during birth. Differences in policy
during COVID-19 between the two countries seemed to be influenced to a
greater or lesser degree by differences in the extent of fear of
maternity care providers contracting COVID-19, the degree to which
community based care is normative, the extent to which personalised care
was embedded in the maternity care system, and the involvement of
service user organisations in policy making.

\textbf{4.1. Interpretation}

One of the main findings of this study is that the focus on infection
control significantly restricted the choices and rights of women and
their partners/families over the perinatal period in order to achieve
the lowest possible risk of infection {[}8, 13{]}. Restricting women's
rights in an attempt to prevent risk, with little attention paid to the
short and long-term effects on women's psychological wellbeing, has been
argued to generate greater harm than benefit {[}14, 15{]}. For example,
it appears that separation of parents and new-borns may have negatively
influenced breastfeeding success, with negative emotional and health
implications {[}16-18{]}. Furthermore, restricting companionship during
antenatal ultrasounds can negatively influence the transition of
partners becoming parents {[}19{]}. However, the present study suggests
that it was difficult during a time of uncertainty (e.g., during an
international crisis) to weigh up the short-term and long-term risks,
especially as there was a lack of information relating to the risk posed
by COVID-19 infection, particularly at the beginning of the pandemic.

Measures taken to reduce infection during COVID-19 had a significant
impact on maternity and neonatal care for all who experienced it.
However, there may have been a particularly adverse impact for women and
families in vulnerable situations. In the UK, there was an
overrepresentation of pregnant Black and minority ethnic women admitted
to hospital with severe COVID-19 infection {[}4{]}. Moreover, based on
the views of national level stakeholders, the restrictions that were
introduced seemed to affect vulnerable women more than the general
population. For example, when women with low health literacy or with
communication difficulties were not allowed to be accompanied by a
companion during prenatal visits, the consequences were likely to be
greater than for those with better communication capacity {[}14{]}. Some
of the measures taken to prevent infection created inequities in
maternity care, and, potentially, increased risks for some {[}14{]}. It
is critical that measures taken to prevent one kind of harm in some
groups should not increase the risk of harm in other groups, or in other
outcomes {[}20{]}.

Our findings highlight that service user (organisation) involvement in
decision-making and in the process of influencing policy is vital for a
functioning maternity and neonatal care system during a time of crisis.
In both countries, service user organisations played a key role in
advocating for all women and parents, including those with additional
needs or vulnerabilities. The documentary review highlights that service
user organisations put topics such as making exceptions for bereaved
families on the agenda of professional organisations. In the last few
decades, there has been increased attention placed on service user
(organisation) involvement in guidelines and research, which can
contribute to making policy more service-user centred, leading to a more
meaningful outcome for service users {[}21{]}. However, it has been
suggested that during the pandemic, service user involvement was
initially seen as a non-essential and time-consuming element of
guideline development {[}22{]}. This focus in the early days of the
pandemic was confirmed by some of the stakeholders interviewed in this
study. Genuine service user involvement requires a cultural change in
the production of healthcare guidelines during crises such as pandemics,
to ensure that women, birthing people, parents, and service user
organisations are seen as partners in decision-making and that women's
and families' needs are at the centre of decision-making, especially
when critical situations demand rapid responses that may result in
knee-jerk reactions from professionals and policy makers.

Finally, this study illustrates that local norms and values in the
maternity care system become magnified during times of crisis. For
example, in some regions, it was easier to maintain services for home
birth than in others. Home birth services were maintained in the NL but
stopped in 32\% of UK regions. The NL has a long tradition of home
births, unlike the UK {[}23{]}. The decision to rapidly revert to
institution-based care in many UK settings might be reflective of a
dominant belief about the intrinsic safety of hospitals, even when they
may be a vector for infection, in line with wider UK rhetoric relating
to safety in maternity care {[}24{]}. This was despite the fact that
choice of birthplace and other personalisation issues are embedded
within UK maternity policy {[}25{]}. Given the contrasting move towards
maintaining or even increasing home birth in NL, as well as in some
regions of the UK, it may be that maintaining the capacity to offer a
range of choices to parents during a pandemic or similar crisis is
related to the prior organisation, beliefs and values of the maternity
care system, as much as with guidelines issued by national bodies.

\textbf{4.2. Strengths and limitations of this study}

To our knowledge, this is the first study that compares maternity care
policy and its drivers during the COVID-19 pandemic between two
different high-income countries. The multi-method approach that was used
enabled us to identify similarities and differences in maternity care
policy and their drivers within both the documentary analysis and
interviews.

A limitation of this study is that we may have missed certain published
policy documents over the period of our data collection. However, the
in-depth interviews provided additional information that suggested this
was unlikely. Having five interviewers may have led to variations in the
kind of data collected, but the team approach meant that participants
could be interviewed in their own language, and a detailed
semi-structured guide was used to minimise any nuanced differences
between interviewer style. Extensive discussion between the interviewers
took place regularly, and a joint coding framework between the countries
was established.

\textbf{4.3. Recommendations for policy and practice}

Based on our data, we propose three recommendations for maternity care
practice to plan for and manage a future crisis such as a pandemic.
These recommendations reinforce new NHS England policy documents on
post-pandemic preparedness {[}26-28{]}.

First, a systematic if-then plan for making decisions during times of
crisis should be created and stress-tested at all levels of the health
care organisation in advance of any such event. Special attention should
be placed on optimising multidisciplinary collaboration and staff
wellbeing, and including meaningful and proportionate service-user
involvement in every phase of decision-making

Second, care provision should be closely and effectively tailored to
service-user values in all maternity and neonatal care systems to ensure
service changes during times of crisis automatically take service user
values into account, including those who are most vulnerable, to
minimise the risk of over-applying blanket risk-reduction or rescue
policies, and to permit staff to make exceptions where this is likely to
reduce psychological as well as physical harms.

Third, effective and accessible community provision should be the norm
for as many maternity services as possible, to ensure provision is more
resilient to future system-wide shocks, especially when these threaten
the availability of centralised services.

\section*{5. Conclusions}

{\label{468479}}

This study identified similarities and differences in maternity and
neonatal care policy in the UK and the NL in three key domains: choice
of birthplace; companionship; and attention to women from disadvantaged
and ethnic minority background. Based on the included national
guidelines and policy analysis, and interviews with national
stakeholders, both countries had an infection control focus. The
differences between the two countries appear to have been influenced by
factors such as the fear of providers contracting COVID-19, how
personalised care was embedded in the maternity care system, and the
extent to which multidisciplinary collaboration and service-user
involvement were prioritised. We recommend that countries should: 1)
make a systematic plan for decision-making and the protection of staff
and service user wellbeing during times of crisis, including
service-user involvement and multidisciplinary collaboration; 2)
integrate women's and families' values into the maternity and neonatal
care system, including the most vulnerable and 3) strengthen community
provision to ensure system wide resilience to future shocks from
pandemics or other unexpected events.

\section*{Acknowledgments}

{\label{250158}}

\textbf{CRediT authorship contribution statement}

\textbf{Lauri van den Berg:} Conceptualisation, Methodology,
Investigation, Formal analysis, Data Curation, Writing - Original
Draft.\textbf{Marie-Clare Balaam:} Conceptualisation, Methodology,
Investigation, Formal analysis, Writing - Review \&
Editing.\textbf{Rebecca Nowland:} Conceptualisation, Methodology,
Investigation, Formal analysis, Data Curation, Writing - Review \&
Editing.\textbf{Gill Moncrieff:} Methodology, Investigation, Formal
analysis, Data Curation, Writing - Review \& Editing. \textbf{Anastasia
Topalidou:} Conceptualisation, Methodology, Data Curation, Review \&
Editing, Funding acquisition. \textbf{Suzanne Thompson:} Investigation,
Writing - Review \& Editing. \textbf{Gill Thomson:} Conceptualisation,
Methodology, Investigation, Formal analysis, Writing - Review \&
Editing, Supervision, Funding acquisition. \textbf{Soo
Downe:}Conceptualisation, Methodology, Writing - Review \& Editing,
Supervision, Project administration, Funding acquisition. \textbf{Ank de
Jonge:} Conceptualisation, Methodology, Writing - Review \& Editing,
Supervision, Funding acquisition. \emph{All authors read and approved
the final manuscript.}

\textbf{Ethical statement}

In the Netherlands the study was submitted to the Medical Ethics Review
Committee of the VU University Medical Centre (reference number
2020.255). No ethical approval was needed, since the Medical Research
Involving Human Subjects Act did not apply on this study, as there was
no infringement of the physical and/or psychological integrity of the
participants.

In the United Kingdom the study was submitted to University of Central
Lancashire (UCLan) Committee for Ethics and Integrity (Health Review
Panel), which approved this study (HEALTH\_0079).

Written informed consent was obtained from all subjects involved in the
study.

\textbf{Funding}

This research is funded by the Economic and Social Research Council
(ESRC), as part of UK Research and Innovation's rapid response to
COVID-19 {[}grant number ES/V004581/1{]}. Full details of the main study
are available via ResearchRegistry (researchregistry5911) and via UKRI
Gateway (https://gtr.ukri.org/projects?ref=ES\%2FV004581\%2F1)

\textbf{Conflict of interest}

None declared

\textbf{Acknowledgements}

We would like to sincerely thank all the stakeholders who participated
in the interviews of this study. Furthermore, the authors would like to
thank the ASPIRE-COVID19 collaborative group for their input.

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{\label{388640}}

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