47% of pregnant women had at least one medical appointment cancelled during COVID-19

The COVID-19 pandemic and the general lockdown of Catalonia's population began just over three years ago, in March 2020. One of the groups whose professional care was affected during the public health emergency was pregnant women. Changes to tests, appointments and courses during their pregnancy were frequent, and online appointments became common. These women's right to be accompanied by a person of their choice whenever they wished was seriously compromised, not only during their appointments and tests related to their pregnancy, but also when they were giving birth, especially during the first state of alert. This is highlighted in the last four reports published in three languages, in the project "Sexual and reproductive rights in the pandemic: maternity and COVID-19 in Catalonia", produced by the Inclusive Societies, Policies and Communities (SoPCI) research group and the UNESCO Women, Development and Cultures Chair at the University of Vic – Central University of Catalonia (UVic-UCC).
 

Around three out of ten pregnant women had at least one clinical test cancelled due to the pandemic, and the O'Sullivan test (which identifies the risk of gestational diabetes) was the specific procedure which was subject to the most cancellations. Only a minority of the women (6.3%) decided not to attend an appointment or clinical test during pregnancy due to fear of infection by COVID-19. In other words, almost nine out of ten of the pregnant women chose to go to their appointments during the pandemic regardless, which shows how important they considered them, regardless of the risk of infection. According to the study, the experience of the tests being cancelled was not a positive one for most of the women, and it created feelings of uncertainty (33%), indignation (32%), frustration (30%) and resignation (27%). However, a large proportion of the women (58%) chose not to seek alternatives when their pregnancy monitoring tests were cancelled.
 

Fewer appointments and a shift online
 

Cancellations of the pregnant women's appointments were quite common during the first few months of COVID-19: 47% of the women - almost five out of ten - had at least one face-to-face appointment cancelled. This percentage increased to 58% among women who were not expecting their first child, while among those experiencing their first pregnancy it was 38%. High-risk women who were more likely to have complications had fewer appointments cancelled (45% of the total cancelled appointments) than medium-risk pregnancies. In the different health systems, 60% of women had at least one face-to-face appointment cancelled during their pregnancy in public health hospitals and centres, while the cancellation rate in private centres was 22%.
 

Face-to-face appointments were changed to online appointments to reduce the risk of infection and ease the pressure on health systems, and this change affected 91.2% of the women. As with the cancellation of tests, this change led to feelings of uncertainty (45%), resignation (32%) and powerlessness (29%), among other emotions. Sandra Ezquerra, the coordinator of the SoPCI research group and director of the UNESCO Women, Development and Cultures Chair, says that "although online healthcare may be important in regions where access is difficult, and in situations where the patients have high-risk pregnancies, it should not replace face-to-face care under any circumstances." And she adds that "online appointments and tests must be considered as complements to face-to-face meetings, rather than substitutes." Most of the women were also unable to take part in face-to-face antenatal groups or courses, and their search for alternatives to the cancelled sessions was subject to their purchasing power. 
 

Less support during their pregnancy
 

The right of pregnant women to be accompanied by the person of their choice whenever they wished was seriously compromised during the pandemic. Visits to emergency rooms and tests (excluding ultrasounds) had the worst rates for support. However, the mothers were able to have a companion to a greater extent in face-to-face antenatal courses or groups: 51% always went with a companion. The other situation in which the mothers were able to be accompanied more often was when they were receiving bad news. In this case, 33% of the women were always able to have someone with them. However, almost six out of ten pregnant women were alone when they received bad news related to their pregnancy during the pandemic.
 

In face-to-face appointments, the rate of accompaniment at all times fell from 94% before the pandemic to 20% during COVID-19. In ultrasound tests, this constant accompaniment declined from 92.6% to 28.5%, and the accompaniment in the emergency ward fell by 60 percentage points. Ezquerra argues that "health protection due to the COVID-19 pandemic must not overlook guarantees of the rights of women and babies."
Women were more likely to be accompanied at all times during tests and face-to-face appointments in the private sector, especially during ultrasounds (in 39% of cases in the private system, compared to 23% of cases in the public system). 
 

Births in greater solitude
 

During the first state of alert, and in half of the cases as a result of the measures applied to prevent infections by COVID-19, the number of women accompanied by a person of their choice during childbirth fell from 86% to 74.6%. In other words, one in four women were not accompanied continuously by someone close to them while they were giving birth.
 

The way their delivery concluded was a determining factor, as women who underwent caesarean deliveries were less likely to be accompanied. Only 37% of the women were always accompanied by a person of their choice, while 17% of those involved in medicalised births were not accompanied at any time. There are no significant differences according to the type of health system: in public hospitals, 81.5% of the women were always accompanied, while in the private system the figure was 78.6%.
 

Cancelled post-partum appointments 
 

Care for mothers during the post-partum period was also affected by the pandemic. Nearly three in ten women had at least one post-partum follow-up appointment cancelled. Only 6.3% of the women were able to participate in face-to-face post-partum and breastfeeding courses or groups, while 72% did not have the opportunity to do so at their health centre, as the course or group was cancelled due to the pandemic. Most cancellations of face-to-face post-partum appointments occurred in the public health system, but the public health system also provided the most opportunities to replace them with online appointments. Seven out of ten women treated by the public system had face-to-face post-partum appointments which were replaced by online appointments. In the private system, five out of ten women's appointments were replaced by an online appointment. 
 

Cancellation rates of in-person post-partum appointments were almost identical for mothers expecting their first child and other expectant mothers. However, being unable to participate in any face-to-face or online post-partum and breastfeeding support courses or groups had a particularly negative impact on first-time mothers, who presented much more negative feelings of powerlessness and resignation. "Follow-up in the post-partum period is subject to much less social attention than pregnancy and childbirth. That was already the case before the pandemic and it continued during the pandemic, despite the fact that a physical examination for women in the post-partum period is essential, and online care is no substitute," argues Sandra Ezquerra.
 

A comprehensive study
 

This research aimed to determine the impact of the management of the COVID-19 pandemic on healthcare and support services for maternity in Catalonia. The research was carried out based on data collected from a survey of women who were pregnant between 1 January and 2018 and the end of September 2021, with a target group (women with an experience after 13 March 2020) and a control group (women with an experience prior to that date). 
 

The data was collected in July, August and September 2021. A total of 2,600 responses were obtained, of which 2,070 were considered valid (1,862 in the target group and 208 in the control group). The members of the research team were Sandra Ezquerra, Montse Fernández, Christel Keller, Michelle Borges, Marta Benet and Louise Bia. 
 

The reports published as a result of the research are: Impact of the pandemic on childbirth care for women testing positive for COVID-19 (May 2022), Impact of the COVID-19 pandemic on accompaniment during childbirth (July 2022), Impact of the pandemic on support during pregnancy care (February 2023), Impact of the COVID-19 pandemic on healthcare during pregnancy (February 2023)  and Impact of the COVID-19 pandemic on healthcare during the post-partum period (March 2023).