INDIRECT IMPACT OF THE PANDEMIC CAUSED BY COVID-19: CALLING FOR STORIES FROM THE NANN MEMBERS!
From March 24 to April 20, 2020, the first round of global online survey was conducted by the partnership of multiple international groups coordinated by the Institute of Tropical Medicine in Antwerp, Belgium, to explore the indirect impact of the pandemic on maternal and newborn healthcare and on healthcare professionals.1 Their researchers stated on the basis of the previous experience of past major outbreaks: "The Pandemic's indirect effects will likely surpass the direct infection effects on women and newborns." The second round of the survey was completed between July and December 2020, and data for the third round is currently being collected at the time of this writing. Future publications are awaited.
The survey was offered in 12 languages to collect information and to synthesize both the voices and experiences of global frontline healthcare professionals in the early stages of COVD-19 pandemic. Respondents (N = 714) from 81 countries (63% from high-income countries [HICs]) included nurses, midwives, community health workers, physicians, medical students/trainees, and others. Nearly half of the respondents were either nurse or nurse-midwives. A total of 87 participated from North America.
The majority of those responding (90%) reported to have received information regarding COVID-19, including the transmission route, preventive measures, or treatment. One-third reported they were offered simulation exercises. Half of the respondents from low- and middle-income countries (LMICs) and 82% of those from HICs reported that they received updates on guidelines. Most (92%), however, made personal efforts to search for the updated COVID-19 information. Some were concerned about lack of national recommendations as of April 2020.
Respondents reported that various measures were implemented globally in response to the COVID-19 pandemic, including setting up screening policies with signs posted to indicate the methods/locations of screening, or reserving isolation rooms for possible positive cases. Eighty-three percent of the HIC-based respondents reported isolation rooms were available versus 57% for LMIC-based respondents. The ability to order COVID-19 tests for maternity patients prior to the delivery of the neonates was 23% for LMICs versus 61% for HICs. The personal protective equipment (PPE) availabilities were also higher for those in HICs. Regardless of resource differences, both groups reported similarly that they experienced a "somewhat" or "substantially" higher level of stress than usual (91% vs 89%, respectively).
Respondents felt that PPE created barriers in communicating with patients. Facial expressions and human warmth through touch are essential tools to express comfort, sympathy, empathy, or encouragement. Some expressed the sadness for families who lost learning "time" from the nurses or midwives in face-to-face settings. Others voiced worsening challenges due to decrease in available staff members from isolation or quarantine measures. Lockdown measures adopted by countries and cities caused challenges for some professionals and patients, making commuting long distances difficult, challenging patients' access to receive outpatient care. All of these placed an additional burden on the front line with implications for the quality of care. Great concern was expressed regarding the maternal-infant separation when COVID-19-positive mothers were denied skin-to-skin care or direct breastfeeding for their infants. Others reported early discharges postbirth (as early as 6-8 hours) and expressed concerns for mothers and infants going home with insufficient feeding experiences, education, or support. One obstetrical national association in Eastern Europe recommended banning of partners or doulas from attending any births altogether, distressing healthcare professionals. Semaan and colleagues1 discuss extensively with existing evidence that banning visitors, denying family presence, or denying direct breastfeeding all potentially jeopardizes the well-being of the families and infants.
In response to what was occurring, the Academy of Breastfeeding Medicine questioned the practice of separation of infants from COVID-19-positive mothers and emphasized the established breastfeeding benefits for a long-term well-being.2 The American Academy of Pediatrics updated the earlier recommendations and now encourages COVID-19 mothers to continue to breastfeed or room-in with their child with certain precautions, such as performing hand hygiene and wearing a mask while breastfeeding.3
Darcy Mahoney and colleagues4 conducted a US-based survey in late April to examine the impact of restrictions on parental presence in the neonatal intensive care unit (NICU). The authors reported that nearly half of the NICUs that responded (N = 277) had restricted parental entry to NICUs (less restrictions for single-room NICUs), with the majority allowing only one parent at the bedside.4 The overall decrease in NICUs with 24-hour parental presence in response to the pandemic is concerning (83% down to 53%). Parental involvement during medical rounds was also noted to be decreased regardless of single-room or multibed settings, suggesting an increased barrier for family's direct engagement with the care team as well as for opportunities for shared decision-making for their child in the NICU. Nearly half of the responding NICUs experienced reduction in at least one of the critical services including developmental care (occupational/physical/speech therapies), social work, or lactation consultants. The researchers raise concerns about the potential long-term or lifelong ill effects on both infants and their families.
Ahmad and colleagues5 conducted serial surveys to explore the burden of pandemic on NICUs and evolving care practice policies over time. The survey periods were March 26-April 3, April 8-19, May 5-22, and July 13-August 2 (number of participating NICUs at each round: 153, 160, 165, and 148, respectively). This is the only published study at the time of this writing that contains data beyond the early stages of the pandemic. At the time of this study, reported confirmed cases of neonatal COVID-19 were minimal (maximum of 0.4% NICU inpatient population). Various care aspects changed over time. Isolation/separation of infants from COVID-19-positive mothers for 14 days declined from the second round to the fourth round of data collection (from 46% to 20%). There was a gradual increase from the second round to the fourth round in the number of NICUs where COVID-19-positive mothers are allowed to directly breastfeed (17%, 21%, and 47%). The number of cites allowing the infants to room-in with their COVID-19-positive mothers also increased from the second round to the fourth round (from 14% to 50%). These authors also expressed concerns that the indirect effects of COVID-19 may impact bonding and long-term breastfeeding success; thus, both short- and long-term impacts of pandemic-led practice changes must continue to be studied over time.
Neonatal nurses are in a position to recognize the indirect impact of COVID-19 and to advocate for the needs of the vulnerable infants and their families. Some NANN members are implementing innovative strategies to maximize parent-infant time together including encouraging discouraged mothers and fathers who are often not allowed to visit together to find ways to share their time using technologies such as Zoom and serving on the institutional COVID-19 committee to provide a nursing perspective. COVID-19 changed how nurses practice; however, it will not change our commitment to improve the neonatal/family outcomes. Please contact Wakako Eklund at mailto:[email protected] if you have a story to share about special initiatives your unit has undertaken so we can share in a Noteworthy Professional News column later in 2021. We know you make a difference to the infants and families you serve each and every day!
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