Post-pandemic planning for maternity care for local, regional, and national maternity systems across the four nations: a mixed-methods study.

Background: During the COVID-19 pandemic, significant reconfigurations were made to maternity care, to deliver this essential service while minimising the risk of infection for pregnant/post partum women and their infants, initially considered to be more vulnerable.

Design: This mixed-methods study had three work packages. Work package 1 used quantitative methods to analyse pregnancy outcomes over time, considering service reconfiguration and inequalities, using routinely collected maternity and offspring data from three diverse South London trusts. Work package 2 involved in-depth interviews with a diverse sample of pregnant/post partum women, partners, healthcare professionals and policy-makers, and used thematic framework analysis. Systematic reviews were undertaken of women's experiences of receiving maternity care during the pandemic, and healthcare professionals' experiences of providing that care. Questionnaires (October-December 2021 and August-September 2022) were administered nationally via the King's College London COVID Symptom Study Biobank, to evaluate vaccine uptake among women who were planning pregnancy, pregnant or post partum. Work package 3 engaged stakeholders within maternity systems through regional Listening Events and a national Policy Lab.

Results: Among women of reproductive age (8 December 2020-15 February 2021), older age, white ethnicity and a lack of social deprivation were associated with higher vaccine uptake, although ethnicity exerted the strongest effect (Office for National Statistics data). Across pre-pandemic, pandemic with and pandemic without lockdowns, pregnancy outcomes, over time, largely followed pre-pandemic trends (record linkage, South London). However, virtual antenatal care in the second and third trimesters was associated with an excess of adverse pregnancy outcomes (and increased costs).

Work package 2: Our systematic reviews of experiences of receiving (by women) or delivering (by healthcare professionals) maternity care during the pandemic identified the need for personalised care adapted to service users and communities, including those who are marginalised, and including provision of information; and co-design and coproduction of services with service users and staff, to reflect their collective lived experiences. This has the potential to improve workplace well-being for maternity care staff and facilitate inclusive and equitable care for service users. Interviews about COVID-19 vaccination in pregnancy identified a legacy of mistrust, lack of information, and confusing guidance that contributed to vaccine hesitancy for pregnant women during the pandemic. In our national survey, women of reproductive age (including pregnant/post partum women) reported being promptly vaccinated, but with angst and despite having received misinformation and discouragement from some healthcare professionals.

Work package 3: Our programme's findings, published literature and Listening Event discussions led us to focus our Policy Lab on how coproduction can be used in local health systems to substantially improve maternity care over the next 2 years. Participants identified barriers to success, set out their vision for what could be achieved and suggested possible actions to progress improvement at a local level.

Study limitations: In our analysis of data for women of reproductive age (from the Office for National Statistics), we lacked data on other potential determinants of vaccination (such as previous COVID-19 or comorbidities). For analysis of pregnancy outcomes (work package 1), limitations include that our study population was only from South London, however diverse, and we did not adjust fully for multiple analyses; however, we consider that our results reflect a coherent pattern of the main processes operating. For our trajectories of virtual antenatal care analysis, a limitation is that those women assigned to the same trajectory are assumed to follow the same pattern of virtual antenatal care. Also, we defined virtual antenatal care as an appointment that was missing blood pressure, dipstick proteinuria and fetal heart rate (after 16 weeks'), without mention of self-monitoring of these parameters at home; however, if blood pressure had been recorded in the observations as part of 'at-home' monitoring during the COVID-19 pandemic, we will have underestimated the prevalence of virtual antenatal care. For our national survey, our participants were not diverse, reflecting the general demographic of ZOE (ZOE Limited, London, UK) app users, limiting generalisability of our findings. For our systematic reviews, we included only English-language papers, but our focus was on studies of the United Kingdom population which are highly likely to be published in English; regardless, no studies for this review were excluded based on language.

Future work: Maternity care is currently in crisis in the United Kingdom. Adopting a maternity system through partnership between those receiving and delivering maternity care could provide solutions necessary to 'build back better', for now and for future health system shocks.

Conclusions: Our findings suggest that maternity care provision, although altered substantially, largely preserved pregnancy outcomes, although experiences of care receipt and delivery were poorer. Costs may have been lower because less care was sought, although virtual (vs. face-to-face) care was more expensive. There is evidence to suggest that the current context of maternity care is of a demoralised and depleted workforce. Implementing a coproduction learning health system could offer needed solutions to improve maternity care delivery, experiences of care and workplace culture, building resilience to withstand future health system shocks.

Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR134293.