Providing Perinatal Care in Canada during the COVID-19 Pandemic: Lessons Learned from an Ongoing Qualitative Study
Kathleen Rice, PhD, Assistant Professor at the Department of Family Medicine, McGill University
and Tier II Canada Research Chair in the Medical Anthropology of Primary Care
“[My partner] had to leave four hours after I delivered. It was terrifying. I've never had a baby before, and I had the whole night and then the whole next day to take care of a newborn by myself after having a hard labour and delivery. I was there alone; I was on pain medication. It was not set up to help women at all. It was more helpful for the staff than it was for the parent. I felt like I was put in a room with a baby, and I was forgotten about. Any time a nurse came in my room, they were hung up on trying to get baby on the boob. My baby was born with a posterior tongue tie so she could not latch. And I had other concerns other than just breastfeeding, like, my God! I think that there needed to be more compassion, especially where I was alone without my support person. I felt, not by [my partner], but by our healthcare system during this time, I felt abandoned and forgotten about.”
The quote above was provided by “Amanda,” a first-time mother from St John’s, Newfoundland, as part of my ongoing qualitative research into perinatal care in Canada during the COVID-19 pandemic. It speaks to many of the challenges that have been related to me by people who have participated in the study since I began this research in July 2020. Although there is limited space here to discuss this research in detail, my aim in this blog post is to provide an overview of the project, to share some emergent findings that I see as the most urgent, and to offer my recommendations for how these concerns can be addressed.
Firstly, however, some context:
I returned to work from maternity leave in June 2020, meaning I was embedded in a network of pregnant people and new parents. I had witnessed first-hand the challenges that they faced during the pandemic, as healthcare for themselves and their newborns shifted online at the same time that social supports available to them decreased dramatically. Moreover, I am a medical anthropologist and professor of family medicine research whose work has long focused on gender, power, and on the effects of health policies and guidelines on both healthcare practice and on the experiences of people who are affected by those guidelines and policies. By turning a critical eye to healthcare practice, I question – and often critique – the “common-sense” logics that underpin healthcare policies, especially where those logics cause unintended harm. I think many readers might relate to this approach because with COVID-19, we have all experienced the exceptionally swift implementation of constantly changing policies aimed at infection control and have witnessed – if not experienced ourselves – the unintended impacts of those policies (e.g., mental health crises) on many domains of life. The intersection of the personal and professional thus set the stage for my current research. I started with nearly 70 interviews with people across Canada who have been pregnant and given birth during the COVID-19 pandemic. More recently, I have expanded the scope of my investigation to look at the experiences of healthcare providers, including obstetricians, family doctors, nurses, midwives, and doulas.
Pregnancy and childbirth occupy a strange conceptual space within healthcare systems. In Canada, as in many countries, the vast majority of births take place in hospital settings, and most people feel that monitoring and ready access to medical technology is the only safe way to give birth. This message has been disseminated widely even in world regions that lack the material and human resources necessary to ensure that hospital births are, indeed, safe (see e.g., Strong 2021). Yet, pregnancy and childbirth are also normal, natural processes. Pregnant people are not inherently sick, and pregnancy is not a pathology, however, since most births take place in hospitals, pregnant people go where sick people go and are cared for by people who are trained to treat and manage disease, and perinatal care has been subject to intense pressures to limit traffic into and out of hospitals and clinics in the interest of infection control. Limiting the presence of support persons (partners, mothers, doulas) at appointments and during labour and delivery has been a key method of achieving this, alongside a scaling-back of in-person prenatal and postnatal care. These policies privilege infection control over the support and companionship that is known to be important to birthing people (McCourt 2017) and to lead to better birth outcomes (Hodnett et al. 2013); (Indeed, for groups that face systemic discrimination within the healthcare system, such as Black and Indigenous women, the presence of culturally safe support persons can be lifesaving [Davis 2019; Kolahdooz et al., 2016]).
In broad strokes, I have found that the perinatal care that is being provided in Canada during the pandemic is biomedical, largely shorn of comfort, care, and support. Across the country this has entailed limiting the number of support persons present during labour and delivery, and in some places, requiring that individual to leave the hospital shortly after birth and not return. It has entailed a massive clawing-back of postpartum care of all kinds, as well as a removal of breastfeeding supports. In particular, it has entailed excluding partners – usually fathers – from most aspects of perinatal care. While some birthing people are doing fine, first-time parents and those with complicated deliveries and/or pre-existing mental health struggles have suffered as a consequence of these policies. Furthermore, I have found that some obstetricians are reaching for medical technologies – interventions, much as induction of labour and elective cesarian section – as a response to pandemic stresses (for related emergent findings from Europe, see ECDP 2020). For example, some pregnant people have been anxious to deliver quickly out of fear that the pandemic may escalate in severity to the point that their partner will be banned completely from the labour and delivery – as happened briefly at one Montreal hospital – and are being offered inductions or elective c-sections as a solution to these fears.
A lot more could be said about this, and I have many findings that I have not touched on here due to lack of space. For now, I’ll conclude by articulating what I see as the most pressing lessons to be taken from the research that I have done so far. Firstly, I emphasize that policies which restrict the presence of support persons in hospital and at home during the postpartum period are harmful. To address this, I recommend that pregnant women be encouraged to plan for additional postpartum support, rather than telling them that they must eschew all contact outside their household. Secondly, it is apparent that a support person must be permitted to remain with the postpartum person for their entire hospital stay, especially for medically complicated deliveries. Finally, additional breastfeeding supports are needed, and this cannot consist solely of online support.
More broadly, as with other domains of care – for instance, long-term care, – the impact of the COVID-19 pandemic on perinatal care in Canada provides an opportunity to address systemic problems in the way in which care has long been organized. Many of the problems that I have identified through this research could be addressed, for instance, by increasing the capacity for out-of-hospital births and perinatal care, and for decentering excessive monitoring and intervention as integral to perinatal care for uncomplicated births. Indeed, doing so would put Canada more in line with other countries with similar healthcare systems, such as the UK and the Netherlands, both of which have more comprehensive midwifery systems than Canada, and have continued to emphasize that during the pandemic continuity of care and safe birth are easier to provide outside the hospital in the case of uncomplicated births (Coxon et al. 2020).
About the Author
Kathleen (Kate) Rice is a medical anthropologist and Assistant Professor in the Department of Family Medicine at McGill University, where she holds the Tier II Canada Research Chair in the Medical Anthropology of Primary Care. She uses ethnography to explore the underlying discourses, ideologies, and taken-for granted practice that shape healthcare in areas where current practices are suboptimal. Grounding her analyses in everyday practices of care provision allows her to identify inadequacies in the logics of health policy, practice, and training. Driven by a commitment to improved healthcare delivery, Kate’s work aims to improve the health of marginalized populations, both in Canada and in a global health context. Her areas of research expertise include gendered, generational, and interprofessional power in clinical and community settings, rural and remote health, pregnancy and birth, chronic pain, human rights and subjectivity, and clinical translation both in South Africa and Canada. Kate’s current research looks at pregnancy and birth in Canada during the COVID-19 pandemic, with particular focus on the increased use of interventions.
Department of Family Medicine, McGill University
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