This study analyses the impact of the COVID-19 pandemic on the implementation of quality standards for perinatal care including breastfeeding protection and support [1], in Spanish hospitals committed to BFHI. Our study shows that these practices were restricted during the first months of the pandemic in our country.
Confusion, overload and collapse of the entire hospital system characterised the first weeks of the pandemic [15]. Recommendations rapidly evolved alongside new knowledge and publications about SARS-CoV-2 virus, COVID-19 disease, and therapeutic tools to deal with it. A few weeks after the pandemic had started in China, data showed no evidence of vertical transmission, horizontal transmission risk seemed similar to that of general population, and no severe neonatal cases were reported [16, 17]. Despite this evidence, those for whom the fear of contagion outweighed the risk of loss of breastfeeding or mother-infant separation continued to recommend separation measures and discouraged direct breastfeeding [2, 9]. Meanwhile, based on the primum-non-nocere principle (first, do no harm), WHO and other scientific associations, recommended maintaining the standards of quality and humanisation for perinatal care and protecting breastfeeding considering the unlikely risks of vertical transmission or the neonatal infection through breast milk [3, 4]. In May, when this survey was completed, these recommendations had even greater backing due to the accumulated evidence in the previous months. The morbidity and mortality rates, in newborns and infants, were very low worldwide and no cases of vertical transmission, or via breast milk [17, 18] had been reported. Despite this knowledge, some social networks, press and a great number of scientific publications warned that the right to accompaniment during the labour and delivery process was being withdrawn in worldwide maternity hospitals, immediate skin-to-skin contact and early or direct breastfeeding were not allowed, and mothers and newborns were being separated in a critical period [2, 4].
The survey was launched when the situation in Spain had already substantially improved, hospitals were starting to improve their situation and care could begin to be planned and organised [15]. It was the right time to analyse actions and identify the areas that leave room for improvement. In their study, Perrine et al. involved 1344 of 2018 hospitals in a surveillance network and collected data on care in US maternity wards between July and August 2020 [19]. At that time, the epidemiological situation in the USA was similar to ours in April, but for the accumulated knowledge of the effects of the pandemic in Europe and Asia in the previous months. The proportion of maternity hospitals that stopped assisting women with COVID-19 was higher in Spain (10%) than in the USA (1.5%). Among those centers that maintained assistance, about 20% in both countries advised against mothers practicing immediate skin-to-skin contact. However, in Spain, 32% of the hospitals allowed immediate skin-to-skin without restrictions for women with mild COVID-19, compared to 13% in the USA. Rooming-in was more frequently allowed in Spanish maternity hospitals, where 26% separated mothers with mild COVID-19 from their babies, compared to 43.1% in American hospitals. Rates of early discharge from the maternity ward (before 48 h) were similar, around 75% in both studies. Although, in both countries, maternity hospitals acknowledged that they decreased their breastfeeding support, 78% of the Spanish facilities and 67% of the USA ones reported their support to breastfeeding. Breastfeeding in the first hour of life was allowed in only around one in three women both in Spain (36%) and the USA (33.3%) [19]. A total of 40% of the facilities in Spain, confirmed that they have implemented some strategies to mitigate breastfeeding rate decline. The differences described may be partially explained by the fact that the recommendations of our Ministry of Health and scientific societies were in line with those of the WHO, and that the maternity hospitals included in the Spanish study were also committed to the BFHI.
Our study is the first to analyse the impact of the COVID-19 pandemic on perinatal care in women without COVID-19. Our results show that, although these women, newborns and families, suffered fewer restrictions than those with COVID-19 infection, most of them were separated from their partners during the labour period and, in many cases at the time of delivery, as well.
The degree of commitment to WHO-UNICEF perinatal quality standards, integrated into the BFHI, was associated with increased maintenance of good practices, despite the pandemic. Moreover, we found that it was in the regions where the pandemic hit harder, where women suffered the least restrictions on their rights and where quality practices were most often maintained. Specifically, women in these regions were significantly more often able to have a companion during the labour, delivery and postpartum periods, to practice skin-to-skin contact and to room-in with their babies. The fact that there was a higher level of commitment among hospitals in these regions, reinforces the possibility that BFHI protected families from loss of quality perinatal care, even under very adverse conditions. On the other hand, our data, contrast with those of Parker in the USA, who did not find differences in care related to BFHI practices [20].
It is possible that skin-to-skin contact and breastfeeding in the first hour of life were more frequently restricted in hospitals with more than 1500 deliveries per year. It could be partially explained considering the higher clinical workload suffered by these hospitals. It is possible that smaller hospital suffered less clinical workload and, consequently, they could better reorganise their care strategy. A similar situation has been described in the USA, where restriction of skin-to-sin contact was more frequent in level 3–4 hospitals, although no differences were observed with the other practices [20].
Most of the hospitals in our study, considered that a better provision of resources could have avoided some restrictions. Similarly, professionals participating in the neonatal COVID-19 registry of the Spanish Neonatal Society (SENeo) reported that around 80% of the admissions of neonates born to mothers with COVID-19 infection were associated with more difficulties in the organisation of the hospital for mother-infant rooming-in [21]. This situation has also been described in the USA, where the shortage of protective equipment, material means and human resources significantly affected the quality of care for newborns and families [22].
Restrictions to labour and delivery accompaniment by a person of choice, prohibiting immediate skin-to-skin contact and early or direct breastfeeding, and postnatal separation of mother and infants, have caused to women, newborns and their families high level of distress and anxiety. Consequently, all these disruptions during the COVID-19 pandemic have caused a severe impact on the family and social relationships [23]. It is highly likely that this negative impact could cause serious short- and long-term consequences on women’s mental and physical health [23, 24] and on the development of a secure attachment and bonding [25]. In addition, a negative impact of these restrictions on breastfeeding has also been described, with lower breastfeeding rates observed at discharge, and months later, in mothers who were separated from their newborns [24]. It is important to remember that all these practices are considered quality standards in perinatal care because their protective impact have been measured and demonstrated on maternal and infant health [26]. The evidence accumulated in a pandemic year time shows that good perinatal care practices promoted by the BFHI, such as skin-to-skin contact, immediate breastfeeding and keeping mother and infants together, with adequate prevention measures, do not increase the risk of disease [27, 28]. On the contrary, separating mothers from their infants increase their risk of nosocomial infection [28], while IgA found in the milk of mothers with COVID-19 could provide extra protection for the neonate [29].
The main strength of this study is that it is the first nationwide analysis, in Europe, to measure the variation in maternity care practices, in the first wave of the COVID-19 pandemic. Furthermore, our study examined these variations of care both for women with and without COVID-19. Its main limitation lies in the fact that the survey was conducted among hospitals committed to BFHI and this fact may have led to an underestimation of the impact of the pandemic on some of the studied practices, since these maternity hospitals have implemented them better than the average. We were not able to report on the practices in the other 58 hospitals that did not respond to the survey.
