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A Mixed-Methods Study of Experiences During Pregnancy Among Black Women During the COVID-19 Pandemic

Dove-Medows, Emily PhD, CNM; Davis, Jean PhD, DNP, EdD, FNP-BC, PHCNS-BC; McCracken, Lindsey BS; Lebo, Lauren RN, BSN; Misra, Dawn P. PhD, MHS; Giurgescu, Carmen PhD, RN, WHNP, FAAN; Kavanaugh, Karen PhD, RN, FAAN

Author Information
The Journal of Perinatal & Neonatal Nursing: April/June 2022 - Volume 36 - Issue 2 - p 161-172
doi: 10.1097/JPN.0000000000000622
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Abstract

In 2019, Black women in the United States gave birth to 15% of infants born in the United States.1 Infants who are born to Black women in the United States have mortality rates that are 2.5 times those of White women.2 Social determinants of health, including exposure to structural racism and racial discrimination, are fundamental causes of this disparity.3 Healthcare in the prenatal, intrapartum, and postpartum periods could ameliorate the impact of such factors. However, too often Black women in the United States experience racism and face disrespect during experiences of healthcare. Emerging evidence suggests that the coronavirus disease-2019 (COVID-19) pandemic worsened these already negative experiences.4–6 The purpose of this study was to use a mixed-methods approach to explore the perspectives of a sample of Black women in the Midwestern United States to learn about their experiences of care in the prenatal, birth, and postpartum periods during the COVID-19 pandemic.

BACKGROUND

In a study with 913 pregnant women (24% Black; 57% White) conducted in April to May 2020, Black women reported higher levels of worries about their birth experience and access to resources including food, medications, and infant items compared with White women.7 Policies changed to limit visitors and, in some cases, labor support individuals (eg, doulas) were banned.8 In a study conducted in the Midwestern United States with 114 women (46 pregnant, 68 postpartum; 19% non-Hispanic Black) between April and May 2020, 51% of the pregnant or recently delivered women expressed concerns about the partner's ability to attend the birth.9 Visitor policies that limit labor support to only 1 person are an example of how Black women are disproportionately negatively impacted, as they are more likely to experience adverse outcomes with less support during labor.5,10

Pregnant women experienced disruptions in prenatal care as a result of the pandemic.8 In-person prenatal care visits became a potential source of exposure to infection for patients and providers leading to the rapid implementation of telehealth for the delivery of prenatal care. One of the main changes to how prenatal care was delivered at the beginning of the pandemic was a switch to a mixture face-to-face and telehealth visits. What this meant for pregnant patients was that they attended some visits in person (every other or second visit, typically) and some using a secure telehealth platform (Google Meeting or other video conference platform). Patients could take vital signs and use a Doppler to assess fetal heart tones during telehealth visits at home. Thus, pregnant women experienced changes in how prenatal care was delivered, with many clinics offering telehealth either over the phone or by video platform. These changes resulted in reductions in visits or opportunities for points of contact including changes to what would otherwise be considered necessary testing and care.11–13 This shift may have exacerbated obstetric racism or it could possibly have buffered Black women from such experiences. In a study conducted in New York in March 2020 (n = 91), 86.9% of patients were satisfied with the telehealth care they received and 78.3% would recommend telehealth visits to others.14 However, only 12% (n = 11) of the sample identified as Black or African American and results were not reported separately by race/ethnicity.

COVID-19 has undeniably placed an inequitable and disproportionate burden on Black women in the United States.6,15,16 More research is needed to understand the impact of the COVID-19 pandemic on Black women who already experience obstetric racism during their pregnancies outside the pandemic.17 To date, the majority of the studies that have reported on healthcare and birth during the COVID-19 pandemic in the United States have been quantitative and most (with the exception of those cited earlier) have included few Black mothers. Such an approach does not incorporate the first-person accounts of Black birthing women who have been most impacted by COVID-19.

METHODS

Design and sample

This is a convergent mixed-methods study18 with participants who were enrolled in the Biosocial Impact on Black Births (BIBB) study (parent study) and were still pregnant during the COVID-19 pandemic. The parent study (BIBB) is a prospective study that examines the role of maternal factors (eg, social stressors) on birth outcomes among Black women. Participants were enrolled in the BIBB study if they self-identified as Black or African American, were 18 to 45 years old, had singleton pregnancies, were less than 30 weeks' gestation, and were able to read and write in English. A subsample of 35 of the 627 BIBB study participants who were still pregnant in May to June 2020 participated in a study focused on the participant's experiences during the COVID-19 pandemic. Of these 35 participants, 33 completed a COVID-19-focused online survey that included questions about prenatal care and birth and only 2 completed a qualitative interview for an in-depth understanding of the participant's experiences during COVID-19. A total of 16 (14 of the 33 and an additional 2 BIBB participants who did not complete the additional online survey prenatally) participated in the interviews. The BIBB survey did not include questions that were on the online survey developed for this study about the impact of COVID-19. Furthermore, the focus on the current analyses was to explore Black women's perspectives on prenatal care, labor, and birth during the COVID-19 pandemic.

Measures

Sociodemographic characteristics, prenatal care, changes in birth plan, and worries related to hospitalization were measured via an online survey that also included measures for the BIBB, as noted in Table 1.

Table 1. - Measures
Concept/variable Questionnaire/interview guide
Sociodemographic characteristics Questionnaire: Sociodemographic characteristics (eg, maternal age, level of education, and employment) were collected by self-report survey as part of the BIBB study.
Prenatal care Questionnaire: Are you going to prenatal visits at a doctor, midwife, or nurse practitioner's office? And are you receiving prenatal care by telehealth (video conference)? The response options for these survey questions were yes/no.
Interview: Have you made any changes with your healthcare during pregnancy because of the COVID-19 virus?
Changes in birth plan Questionnaire: Have you had to change your birth plan because of changes in hospital practices? The response options for these survey questions were yes/no.
Interview: Have you made any changes with your plans for the birth because of the COVID-19 virus?
Worries related to hospitalization and birth Questionnaire: How worried are you about: Not having everyone I want with me during labor, Getting the coronavirus (COVID-19) when I give birth in the hospital, and The baby getting the coronavirus (COVID-19) at the hospital after birth. The response options for these questions were a great deal, a lot, a moderate amount, a little, or not at all. Participants were also offered the option for something else (Please describe) with a free-text response box.
Interview: What concerns you about COVID-19 and being pregnant?
Abbreviation: BIBB, Biosocial Impact on Black Births.

Additionally, drawing from recent research, traditional and social media, and the authors' clinical experiences, questions specific to the impact of COVID-19 on the woman's prenatal care, pregnancy, and birth were asked during the qualitative interview and on the survey. These questionnaire items were consistent with other studies that examined similar concepts and were conducted during a similar period and included visitor policies and labor support, introduction of telehealth, and fears of acquiring COVID-19.8,9,12,19,20

Procedures

The study was approved by the institutional review boards at the participating universities and clinical sites. Prior to the pandemic, research staff approached eligible participants in the prenatal clinics and invited them to participate in the BIBB study. After obtaining informed consent, participants completed questionnaires on a tablet computer. Participants received a $30 gift card for completion of the questionnaires. Participants who were still pregnant in May to June 2020 were contacted by text and email to complete an online questionnaire and participate in qualitative interviews focused on experiences during the COVID-19 pandemic. The research staff sent up to 2 reminders 4 days apart for participants who did not complete the questionnaires the first time they were contacted. A subsample of 16 of the 35 participants (46%) participated in recorded qualitative audio interviews conducted by telephone; 14 of these participants also completed the online questionnaire. Of these 14 participants, all but 1 participated in an individual interview within 2 weeks before or after completing the questionnaire. Participants received a $20 gift card for completing the online survey and a $30 gift card for participating in the qualitative interview.

Data management and analysis

Quantitative data

Participants completed the questionnaires using Qualtrics Research Suite, a web-based platform for creating online surveys. Password-protected, customer-controlled survey data were captured in real-time and stored on Qualtrics' secure and Transport Layer Security (TLS) encrypted servers. Data were downloaded as an SPSS 26 data file for analysis.21 Descriptive statistics were used to describe sample characteristics and major variables of the study (eg, prenatal care, birth plan, worries related to hospitalization, and birth).

Qualitative data

Using a process outlined by Braun and Clarke,22 thematic analysis was performed. The audio-recorded interviews were transcribed verbatim and reviewed for accuracy. The BIBB codebook was expanded to include codes related to COVID-19. The interviews were coded by 2 separate team members using NVivo 12 to facilitate data management. Codes were created according to the corresponding question in the interview guide. Four interviews were double coded, and case summaries were created for all 16 participants and entered into a matrix for within and across case review.23 Using NVivo 12, coding queries were then reviewed for all codes relevant to COVID-19 and pregnancy, and any additional missing data were added to this specific COVID-19 matrix. Preliminary themes were discovered using thematic analysis where patterns specific to each question were noted.

A number of strategies to address trustworthiness as originally described by Lincoln and Guba24 and recently presented by Nowell at al25 and Morse26 were included throughout data management and analysis. First, a process of familiarization with the data occurred during transcript verification, the creation of a codebook, coding, and double coding. Codes were checked and confirmed using team consensus. Next, potential codes and themes were considered during the analysis and an audit trail was maintained, as key decisions were made. Discussions with key informants about specific themes were held and then debriefed via member checking to ensure dependability, validity, and cultural rigor.22 Themes were developed and reviewed by team members. The themes were refined further and validated with key informants to ensure cultural rigor. Consensus was reached for all themes.

Mixed-methods data management and analysis

A mixed-methods matrix was created that contained quantitative survey data and free-text responses from the 16 participants who participated in qualitative interviews and 4 additional participants who provided free-text responses in the questionnaire but had not participated in interviews. Qualitative interview data from the 16 participants specific to prenatal care, preparation for the infant, labor, and birth were then added to this mixed-methods matrix. Thus, data from a total of 20 participants were reviewed for the mixed-methods analysis. The qualitative (interview and free-text responses) and quantitative (demographic and questionnaire) data were compared to note and describe data convergence and divergence for common topics using an integrated mixed-methods analysis. Four team members conducted across-case analysis to identify categories at a descriptive or thematic level and assess for patterns within the categories. A final presentation of themes was named and described while noting convergence and divergence of the data between the qualitative and quantitative data.

RESULTS

Description of the sample

Participants had a mean age of 28.6 ± 4.8 years and a mean gestational age at data collection of 32.0 ± 3.4 weeks when they completed the COVID-19 questionnaire. Most participants were single (54%), had a household income of less than $30 000 (83%), graduated high school or completed GED/technical school (51%), and were employed (54%), as noted in Table 2.

Table 2. - Maternal characteristics (N = 33)a
Variable Mean ± SD
(range)
Maternal age, y (BIBB questionnaire) 28.6 ± 4.8 (20-39)
Gestational age at completion of COVID-19 questionnaire, wk 32.0 ± 3.4 (24-38)
n (%)
Marital and cohabitation status (BIBB questionnaire)
Married to or living with the father of the baby 16 (45.7)
Single 19 (54.3)
Household income prior to the COVID-19 pandemic (BIBB questionnaire)b
<$10 000 15 (42.9)
$10 000-$29 999 14 (40)
≥$30 000 5 (14.3)
Level of education (BIBB questionnaire)
Less than high school 4 (11.4)
High school/GED/technical school 18 (51.4)
Some college or associate degree 13 (37.1)
Employed prior to the COVID-19 pandemic (BIBB questionnaire)
Yes 19 (54.3)
No 16 (45.7)
Employed during the COVID-19 pandemic (COVID-19 questionnaire)
Yes 10 (30)
No 23 (70)
Laid off from the job (COVID-19 questionnaire)
No 18 (55)
Yes 5 (15)
If yes, job loss because of COVID-19
No 2 (40)
Yes 3 (60)
Abbreviation: BIBB, Biosocial Impact on Black Births.
aData are for 33 women who completed the COVID-19 questionnaire. Two women did not complete the COVID-19 questionnaire (all study participants identified as women).
bThe frequency does not add up to 100% due to missing data.

Survey results

All 33 participants who completed the online survey indicated that they continued to attend prenatal care in person for all or some of the visits. Four (12%) reported that they had visits switched to a telehealth modality (video or phone) for some prenatal care. Five (15%) indicated that they had to change birth plans due to COVID-19. Of these 5 participants, one stated that she switched hospitals due to COVID-19. Three of the remaining participants stated that the change in birth plan was related to the number of birth partners allowed to be in attendance, and 1 woman stated that she was considering home birth but had not transferred care to a homebirth provider yet. Twenty-nine participants (88%) reported that they were worried to a certain degree about not having everyone they wanted with them for labor and delivery, as noted in Table 3.

Table 3. - Worries of pregnant women during the COVID-19 pandemica,b
Please let us know how worried you are about the following A great deal
n (%)
A lot
n (%)
A moderate amount
n (%)
A little
n (%)
Not at all
n (%)
Not having everyone I want with me during labor 11 (33.3) 5 (15.2) 7 (21.2) 6 (18.2) 4 (12.1)
Getting the coronavirus (COVID-19) when I give birth in the hospital 11 (33.3) 4 (12.1) 5 (15.2) 6 (18.2) 7 (21.2)
The baby getting the coronavirus (COVID-19) at the hospital after birth 18 (54.5) 2 (6.1) 3 (9.1) 4 (12.) 6 (18.2)
aData are reported for 33 women who completed the COVID-19 questionnaire. Two women did not complete the COVID-19 questionnaire.
bN = 33.

Twenty participants (60.6%) reported that they worried a great deal/a lot about their baby getting coronavirus (COVID-19) at the hospital after birth. Fifteen participants (45.5%) reported that they worried a great deal/a lot about getting coronavirus (COVID-19) themselves during their stay at the hospital.

Mixed-methods results

Interruption of plans

The participants expressed disappointment about disruptions in experiences of pregnancy. These disruptions included the cancellation of planned “rites of passage” like childbirth classes or infant showers, the way that prenatal care was experienced, and changes to who could be present during and after the birth. Two overarching themes developed that related to these disruptions: the loss of pregnancy rites of passage and changes to pregnancy plans.

Loss of pregnancy rites of passage

Several participants discussed the cancellation of infant showers as a major disruption of pregnancy plans, noted in Table 4.

Table 4. - Prenatal care, plans, and rites of passage: Quantitative and qualitative data (n = 20)
Participant PNC in officeaQuantity PNC via telehealthb,c Change in birth planc,d Worry about support person (not enough support people)c,e Showers/prenatal classes/loss of rites of passagec
Quality
Quantity Quality Quantity Quality Quantity Quality
1 Yes No No data No No data A great deal No data Stressed due to cancelling shower
2 Yes No No data No No data A little No data No data
3 Yes No No data No No data A lot No visitors as well as her children No data
4 Yes No Monitoring BP at home No Considered home birth A great deal No data No data
5 N/A N/A No data N/A No data N/A No data Registry instead of a shower
6 Yes No No data No No data A great deal FOB only not mom like for prior births No data
7 N/A N/A Attending all appointments N/A No data N/A FOB only, facetime mom and sister No data
8 Yes Yes Cannot see MD in person due to childcare Yes Only allowed 1 person A great deal Had to choose between mom and boyfriend Cancelled shower; prenatal classes cancelled
9 Yes No No data No Has anxiety wearing a mask during labor Not at all Waiting to see if husband can be in delivery room No data
10 Yes Yes No data No No data A great deal Hopes she can have FOB and mom or grandma Had to skip shower
11 Yes No Afraid she will forget to ask doctors questions Yes Wants to do a home birth but hopes it is not too late to switch A great deal No data No data
12 Yes No No data No Considered a home birth A moderate amount No hugs, kisses, face-to-face interactions No data
13 Yes No Appointments over the phone No Plans home birth A moderate amount No data Lamaze and parenting classes not available
14 Yes No No data No No change in birth plans A little Disappointed people will not be able to visit Not able to attend pregnancy classes
15 Yes No Teleconference visits No Considering home birth so not alone Not at all No data Has to go to appointments alone
16 Yes Yes No changes No No data A lot No data No data
17 Yes No No data No No data A moderate amount No data No data
18 Yes Yes No data Yes Only allowed 1 person A great deal No data No data
19 Yes No No data Yes Changed hospitals due to quarantine handling A great deal No data No data
20 Yes No No data Yes Only 1 person allowed A moderate amount No data No data
Abbreviations: BP, blood pressure; FOB, father of baby; PNC, prenatal care; N/A, not available.
aQuestionniare item: Are you going to prenatal visits at a doctor, midwife, or nurse practitioner's office? (yes vs no).
bQuestionnaire item: Are you receiving prenatal care by telehealth (video conference)? (yes vs no).
cQualitative data from text responses and qualitative interviews.
dQuestionnaire item: Have you had to change your birth plan because of changes in hospital practices?
eQuestionniare item: Please tell us how worried you are about the following: Not having everyone I want with me during labor (not at all to a great deal).

The participants also mourned the loss of other rites of passage like childbirth preparation classes that they had hoped to experience with partners. One participant reported that she was watching YouTube videos because the childbirth classes were cancelled.

The participants described this loss of rituals not only in terms of general infant preparation, but also in terms of how the infant shower represented the opportunity to celebrate the new infant, and mourning that this was no longer possible. One participant responded:

Participant (P): You know, I couldn't even have a baby shower because of everything.

Interviewer (I): Were you planning on one and did you have to make it like a virtual one or did you just cancel it completely?

P: I just canceled it completely.

The participants also discussed the overall loss of a normal first pregnancy and all of the experiences that a first-time mother would experience during normal circumstances. One participant noted:

I kind of wish it was back to normal because it's my first baby I kind of wanted to experience everything like ... how it be regularly. But I can't.

This loss included prenatal care appointments being switched to telehealth telephone or computer formats, the impersonal nature of mask wearing during interactions with providers, or the limitation of visitors during prenatal care visits. Even though 1 participant indicated on the survey that she attended all prenatal visits, during the interview, this woman, who had a history of heart palpitations, stated that she had to miss visits because she could not bring her nephew whom she was caring for to the clinic. One additional participant who did not complete the questionnaire but participated in the interview reported having telephone visits with her provider rather than in-person appointments. Participants described how experiences like having a partner listen to the infant's heartbeat during appointments were missed.

Changes to birth plans

The participants described several changes to overall pregnancy plans during the interviews. Even those participants who indicated on the questionnaire that they did not change plans described in the interview that they wanted to change plans. These changes included the way that birth would be experienced, worries about their inpatient stay, and isolation after the infant is born.

The participants described several worries about their inpatient stay on the labor and delivery unit. Many participants were worried about the limitation on support persons at the birth, which was often restricted to only 1 designated person for the entire hospital stay, as noted in Table 4. During the interview, several participants discussed a desire to change their place of birth due to hospital policies and restrictions during COVID-19 even when they did not indicate so on the questionnaire. A few of these participants desired a home birth but did not make any changes. Others described seeking out alternatives to hospitals such as home birth, but none of the participants had a concrete plan for this nor had any transferred prenatal care to a home birth provider at the time of the interview. One participant commented:

Uh ... uh, right now, I'm, I'm planning on doing a water birth, but I haven't really talked to anybody ... this would be my second time meeting with, um, the lady for the water birth, but we haven't went over a plan yet.

Several participants, including 1 who did not believe there was a pandemic, planned for a home birth because of COVID-19 restrictions on people in attendance.

I've already planned for that. I already told the doctors, too, a couple months ago. I said, as soon as it came out, I said, “If you guys make it to where I have to be by myself in the hospital, I'm not going to be here.”

Even those participants who did not report any worry in the questionnaire described concerns during the interviews about having to be alone or worry about having a partner who was not well equipped to solely provide the emotional and physical support that the participant would need during birth. Having to choose between 2 family members contributed to this worry. One, who was experiencing her first pregnancy and talked about other lost rites of passage, said that she had to choose between her boyfriend and her mother, a hard decision especially because it was her boyfriend's first child. Participants who were used to having more than 1 support person wondered what birth would be like. Another participant explained her anticipated change in support roles:

I was gonna have my ... daughter's father be there as well as my mom, but they going to limit it to just one person and one person only the whole time that you're at the hospital ... cause she more so was like my support coach with the breathing and rubbing my back ... So, it's gonna be way different.

Some participants worried about the physicality of giving birth while wearing a mask. One explained:

I've been having like anxiety about if I'm going to have to have on a mask when I'm pushing the baby out or whatever, ‘cause it's hard to breathe in those, you know?

Worry about preterm birth and a subsequent neonatal intensive care unit (NICU) stay was also a concern. One participant worried that the father of her infant would not be with her and the infant in the NICU due to COVID-19 restrictions:

I was asking like if my child had to come in here, would me and her dad be able to come? And it would only be able to be one of us. So, I know that can be pretty scary, especially around this time of what's going on.

The participants also expressed concern about isolation during the postpartum period right after birth and outside the hospital. One described the isolation and separation due to COVID-19 visitor restrictions:

My two-year-old ... he's not used to being away from me...so I mean like how's he gonna handle three days without seeing me? ... Plus I'll be by myself for three days, so ... I mean you got the staff, but it's not—it's not your family.

Participants also voiced concern about feeling isolated during the postpartum period as a result of having to be home alone with the infant without the full range of support from family and friends. One described these feelings:

That one hug, that one kiss on the forehead, that one pat on the back from a family member to tell you that it's going to be okay and you feel it. And it just heals everything overall. So, I think it may impact a lot of pregnancies. I think ... postpartum depression rates will probably skyrocket because everyone's isolated and you're stuck in the house with your children and you can't get out, you know, if you're stuck. You, you don't want to do any harm to your kids and you don't want to, you know, ignore them or have a mental breakdown, but I really feel like the, the rate of it is going to skyrocket. Because we're all trapped in a way, you know, trapped in one area.

Some participants noted difficulty negotiating the balance between limiting the spread of COVID-19 and needing help and rest immediately after giving birth. They expressed feeling torn between wanting family and loved ones to be with them postpartum and wanting both their newborns and older or more vulnerable family members to stay safe.

Fears of acquiring COVID-19

Many participants described concerns about being exposed to the disease and either contracting the disease themselves or infants getting COVID-19. Most of these participants feared that their infant would acquire COVID-19 and several of them immediately expressed this concern when initially asked about any worries related to the virus. One participant was concerned about her infant and her other child. She stated that she feared:

exposure to my children, you know, I have a 16-month old and then bringing home a newborn whose, you know, immune system is brand new ... just the unknown of what can happen is pretty scary in pregnancy

Another described the emotional toll on pregnant women:

If a pregnant person catches the COVID-19 then, of course, that would be extra stressful because she'll be sick and, you know, worried about her life and the life of her child and wondering if it will pass on to the next baby... emotionally like that's a big toll on a woman even to think about, you know, her baby being at risk.

Many of the participants feared the possible effects of COVID-19 on themselves. The participants were afraid of the potential exposure during their hospital stay from healthcare personnel, roommates, or others who might have asymptomatic COVID-19. Even though several indicated on the questionnaire that they only worried a little, they talked about their worries during the interview; one was concerned enough to talk to her physician about it. She said:

You don't know who's been around who. You don't know, you know, who you going to be in the room with that maybe been around somebody.

Another's concerns again centered around the impact on the infant:

I don't want the baby to catch the coronavirus ... When they're first born, they don't really have an immune system ... I understand that there are like procedures, you know, medical instruments ... I guess because I have to work a lot in the environment, so I see what the environment is ... I don't know if I wanna be on the receiving end of that.

The fears even extended to the short time spent in a hospital setting during the pandemic. One participant said:

... It's all over the news everywhere, so it's pretty scary because thinking like, uh, I could go to the hospital for a check-up and come out with something that's potentially life-threatening.

DISCUSSION

Black women and families have been disproportionately affected by COVID-19,27 and this study helps illuminate some of the ways that pregnant, Black women experienced this impact. Participants in this sample described losses and worries about pregnancies that were due to COVID-19-related changes and restrictions. Frequently, they expressed disappointment about the loss or restructuring of infant showers, which represented a ceremonial celebration and tradition for pregnant Black women. Infant showers were opportunities to gather with loved ones and prepare for the arrival of an infant, a major life milestone. Some participants in the study also expressed feelings of loss over not being able to participate in childbirth classes and experiences. Similarly, Ahlers-Schmidt and colleagues9 found pregnant women reported cancellation of showers during the pandemic as well as a lack of childbirth preparation classes.

Changes to prenatal, intrapartum, and postpartum care during the COVID-19 pandemic represented challenges for the participants in the sample. Participants may have had to choose between caring for children (now home from school due to the pandemic) or other caregiving responsibilities and attending in-person appointments with limits to those accompanying them. A large study that included pregnant participants (n = 1829) reported that 10% of that sample used telehealth at some point during the pregnancy, which is consistent with our findings (12%).28 Changes to prenatal care delivery with telehealth and other remote modalities presented a problem for both personal and practical reasons. While telehealth can increase access to care, more work is needed to explore how telehealth may impact people who have historically been marginalized or underserved in healthcare.29 Women may also hesitate to express concerns during telehealth visits due to a lack of privacy with a virtual visit occurring at home. This is important for pregnant Black women because the exchange of information is key to respectful care and shared decision-making during pregnancy.30

Concerns about inpatient experiences were also particularly relevant to participants. Most participants were concerned about contracting COVID-19 through hospital exposure and feared its effects on themselves and, even more so, their infant. This finding is consistent with those of Salehi et al20 and Kumari et al,19 who both reported that participants in their studies expressed fear around contracting COVID-19. The study participants described concerns about pregnancy and pregnancy outcomes that Black women experience more than White women including preterm birth and having an infant stay in the NICU. While there are several factors that support these inequities, Black women also experience obstetric racism during encounters on labor and delivery units themselves. Given these vast differences in birth outcomes and that COVID-19 has disproportionately impacted Black people in the United States, it is not surprising that the participants voiced concerns about inpatient experiences during the pandemic.

Participants expressed concern about the availability of birth partners during hospitalization. Although many women prefer to have their infant's father or partner present at birth, there are also roles for other support people that women find important during birth. Participants in this study expressed difficulty in having to choose just one support person to be present. In a large study that included questionnaire and open-ended questions, Gildner and Thayer31 reported concerns about birth plan changes among participants. Their study showed that 367/592 (62%) of the participants expected to have fewer support people present at the birth.31 The qualitative findings were similar, with participants stating concerns about who can accompany them and for how long.31 While this is consistent with our findings, one major difference is that the sample of that study included predominately White participants (85.9%). One way partners and visitors support women during labor and postpartum period is to act as advocates. Black women may experience a loss in agency during their intrapartum or immediate postpartum stay due to limitations to visitor or birth partner support. Emotional support and physical comfort have been associated with better birth outcomes for Black women.32,33 Removing this critical aspect of birth was a particular point of difficulty for the participants. Participants also reported concerns over not allowing home visitors after the birth, which is consistent with other studies, although more work is needed to understand this aspect of the COVID-19 postpartum experience.9 The study participants expressed conflicted feelings about balancing the need for postpartum support with maintaining COVID-19 precaution protocols.

Like many pregnant women during the pandemic, decisions around place of birth were considered by several participants in the sample.34 With hospitals representing the “front line” in the COVID-19 pandemic, many of the participants did not want to associate birth with the physicality of the hospital. Homebirth, or community-based birth, was considered as an alternative to hospital birth by many participants in the sample. Overall rates of community-based birth are lower for Black women, but this is not because they feel that this setting is less safe.35 However, limits to scope of practice and lack of collaborative practice for community-based providers in both states where the study took place reduced access to community-based birth options. Increased access to equitable birth settings for pregnant women would present an opportunity to address birth equity for marginalized and minoritized individuals.36 Expansion of scope of practice for out-of-hospital providers including certified nurse-midwives, certified midwives, and certified professional midwives and Medicaid reimbursement for community-based births would increase access to community-based birth and provide an important option during a pandemic.

Nurses and others who care for pregnant women during the COVID-19 pandemic must recognize this and other losses and changes that pregnant Black women have been forced to make. Providing extra support and points of contact, even if not face-to-face, can help lessen feelings of isolation during the pandemic and can also offer more explanation for rapidly changing policies and procedures. This increased engagement between clinicians and pregnant women and families may help facilitate understanding about the policies and help shape shared decision-making around how they may be applied. Recognizing the deep impact that labor support has for Black women may also help shape hospital visitor policies and nurses can advocate for policies that reflect these experiences. Doing so may deepen the understanding of the intersection of how hospital and clinic policy has an impact on the experiences of pregnant women.

LIMITATIONS

The small sample included only participants from 2 states in the Midwestern United States. Their experiences during the pandemic may not reflect those of pregnant women in general. Interviews for this study were conducted by interviewers who were not matched for race due to study staff. Responses may have been influenced as participants may have felt more comfortable speaking about COVID-19-related pregnancy issues with a race-concordant interviewer. Data collection was restricted to telephone only rather than in-person interviews. This method of data collection can impact on relationship building, which is important for conducting research interviews. Due to the rapidity of the pandemic, the questionnaire items addressing COVID-19 were developed by the study team and reliability and validity for these items were not available.

CONCLUSION

The COVID-19 pandemic has shaped experiences of pregnancy for Black women in the United States. The birth of one's child is an experience that is not easily forgotten by those who undergo it. Some of the changes described here such as visitor policies and their effect on support may have a lasting impact on those memories. More work is needed to investigate the multiple dimensions of how the COVID-19 pandemic has disproportionately impacted Black women.

References

1. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2019. Natl Vital Stat Rep. 2021;70(2):1–51.
2. Murphy SL, Xu J, Kochanek KD, Arias E, Tejada-Vera B. Deaths: final data for 2018. Natl Vital Stat Rep. 2021;69(13):1–83.
3. Misra DP, Slaughter-Acey J, Giurgescu C, Sealy-Jefferson S, Nowak A. Why do Black women experience higher rates of preterm birth? Curr Epidemiol Rep. 2017;4(2):83–97. doi:10.1007/s40471-017-0102-3.
4. Altman MR, Gavin AR, Eagen-Torkko MK, Kantrowitz-Gordon I, Khosa RM, Mohammed SA. Where the system failed: the COVID-19 pandemic's impact on pregnancy and birth care. Glob Qual Nurs Res. 2021;8:233339362110063. doi:10.1177/23333936211006397.
5. Altman MR, Eagen-Torkko MK, Mohammed SA, Kantrowitz-Gordon I, Khosa RM, Gavin AR. The impact of COVID-19 visitor policy restrictions on birthing communities of colour [published online ahead of print July 30, 2021]. J Adv Nurs. doi:10.1111/jan.14991.
6. Onwuzurike C, Diouf K, Meadows AR, Nour NM. Racial and ethnic disparities in severity of COVID-19 disease in pregnancy in the United States. Int J Gynecol Obstet. 2020;151(2):293–295. doi:10.1002/ijgo.13333.
7. Gur RE, White LK, Waller R, et al. The disproportionate burden of the COVID-19 pandemic among pregnant Black women. Psychiatry Res. 2020;293:113475. doi:10.1016/j.psychres.2020.113475.
8. Burgess A, Breman RB, Bradley D, Dada S, Burcher P. Pregnant Women's reports of the impact of COVID-19 on pregnancy, prenatal care, and infant feeding plans. MCN Am J Matern Child Nurs. 2021;46(1):21–29. doi:10.1097/NMC.0000000000000673.
9. Ahlers-Schmidt CR, Hervey AM, Neil T, Kuhlmann S, Kuhlmann Z. Concerns of women regarding pregnancy and childbirth during the COVID-19 pandemic. Patient Educ Couns. 2020;103(12):2578–2582. doi:10.1016/j.pec.2020.09.031.
10. Norton A, Wilson T, Geller G, Gross MS. Impact of hospital visitor restrictions on racial disparities in obstetrics. Health Equity. 2020;4(1):505–508. doi:10.1089/heq.2020.0073.
11. Boelig RC, Saccone G, Bellussi F, Berghella V. MFM guidance for COVID-19. Am J Obstet Gynecol MFM. 2020;2(2):100106. doi:10.1016/j.ajogmf.2020.100106.
12. Gribble K, Marinelli KA, Tomori C, Gross MS. Implications of the COVID-19 pandemic response for breastfeeding, maternal caregiving capacity and infant mental health. J Hum Lact. 2020;36(4):591–603. doi:10.1177/0890334420949514.
13. Javaid S, Barringer S, Compton SD, Kaselitz E, Muzik M, Moyer CA. The impact of COVID-19 on prenatal care in the United States: qualitative analysis from a survey of 2519 pregnant women. Midwifery. 2021;98:102991. doi:10.1016/j.midw.2021.102991.
14. Jeganathan S, Prasannan L, Blitz MJ, Vohra N, Rochelson B, Meirowitz N. Adherence and acceptability of telehealth appointments for high-risk obstetrical patients during the coronavirus disease 2019 pandemic. Am J Obstet Gynecol MFM. 2020;2(4):100233. doi:10.1016/j.ajogmf.2020.100233.
15. Niles PM, Asiodu IV, Crear-Perry J, et al. Reflecting on equity in perinatal care during a pandemic. Health Equity. 2020;4(1):330–333. doi:10.1089/heq.2020.0022.
16. Ogunwole SM, Bennett WL, Williams AN, Bower KM. Community-based doulas and covid-19: addressing structural and institutional barriers to maternal health equity. Perspect Sex Reprod Health. 2020;52(4):199–204. doi:10.1363/psrh.12169.
17. Davis D-A. Obstetric racism: the racial politics of pregnancy, labor, and birthing. Med Anthropol. 2019;38(7):560–573. doi:10.1080/01459740.2018.1549389.
18. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Thousand Oaks, CA: Sage; 2018.
19. Kumari A, Ranjan P, Sharma KA, et al. Impact of COVID-19 on psychosocial functioning of peripartum women: a qualitative study comprising focus group discussions and in-depth interviews. Int J Gynecol Obstet. 2021;152(3):321–327. doi:10.1002/ijgo.13524.
20. Salehi L, Rahimzadeh M, Molaei E, Zaheri H, Esmaelzadeh-Saeieh S. The relationship among fear and anxiety of COVID-19, pregnancy experience, and mental health disorder in pregnant women: a structural equation model. Brain Behav. 2020;10(11):e01835. doi:10.1002/brb3.1835.
21. IBM Corp. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp; 2019.
22. Braun V, Clarke V. Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern-based qualitative analytic approaches. Couns Psychother Res. 2021;21(1):37–47. doi:10.1002/capr.12360.
23. Ayres L, Kavanaugh K, Knafl KA. Within-case and across-case approaches to qualitative data analysis. Qual Health Res. 2003;13(6):871–883. doi:10.1177/1049732303013006008.
24. Lincoln YS, Guba EG. Naturalistic Inquiry. Thousand Oaks, CA: Sage; 1985.
25. Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis: striving to meet the trustworthiness criteria. Int J Qual Methods. 2017;16(1):160940691773384. doi:10.1177/1609406917733847.
26. Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25(9):1212–1222. doi:10.1177/1049732315588501.
27. Centers for Disease Control and Prevention. COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker. Published March 28, 2020. Accessed September 28, 2021.
28. Bradley D, Blaine A, Shah N, Mehrotra A, Gupta R, Wolfberg A. Patient experience of obstetric care during the COVID-19 pandemic: preliminary results from a recurring national survey. J Patient Exp. 2020;7(5):653–656. doi:10.1177/2374373520964045.
29. Fryer K, Delgado A, Foti T, Reid CN, Marshall J. Implementation of obstetric telehealth during covid-19 and beyond. Matern Child Health J. 2020;24(9):1104–1110. doi:10.1007/s10995-020-02967-7.
30. Altman MR, Oseguera T, McLemore MR, Kantrowitz-Gordon I, Franck LS, Lyndon A. Information and power: women of color's experiences interacting with health care providers in pregnancy and birth. Soc Sci Med. 2019;238:112491. doi:10.1016/j.socscimed.2019.112491.
31. Gildner TE, Thayer ZM. Birth plan alterations among American women in response to COVID-19. Health Expect. 2020;23(4):969–971. doi:10.1111/hex.13077.
32. Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013;103(4):e113–e121. doi:10.2105/AJPH.2012.301201.
33. Thomas M-P, Ammann G, Brazier E, Noyes P, Maybank A. Doula services within a Healthy Start Program: increasing access for an underserved population. Matern Child Health J. 2017;21(S1):59–64. doi:10.1007/s10995-017-2402-0.
34. Davis-Floyd R, Gutschow K, Schwartz DA. Pregnancy, birth and the COVID-19 pandemic in the United States. Med Anthropol. 2020;39(5):413–427. doi:10.1080/01459740.2020.1761804.
35. Sperlich M, Gabriel C, Seng J. Where do you feel safest? Demographic factors and place of birth. J Midwifery Womens Health. 2017;62(1):88–92. doi:10.1111/jmwh.12498.
36. Tilden EL, Phillippi JC, Snowden JM. COVID-19 and perinatal care: facing challenges, seizing opportunities. J Midwifery Womens Health. 2021;66(1):10–13. doi:10.1111/jmwh.13193.
Keywords:

Black women; COVID-19; mixed methods; pregnancy

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