Antenatal Care During The COVID-19 Pandemic: Couples As Dyads

Written by Rebecca Brown

During the pandemic, many healthcare services have been reduced. One instance of this is the antenatal care of expectant mothers. Ordinarily, partners of pregnant women are permitted to attend appointments. This includes the 12 week scan: typically the first opportunity expectant parents get to see the developing foetus, to discover whether it has a heartbeat and is growing in the right place. This can be very exciting and, if there’s bad news, devastating. It also includes scans in mid pregnancy and (for first-time mothers) at 36 weeks, as well as the entirety of labour.

During the pandemic, many healthcare providers have restricted attendance at antenatal appointments as well as labour and postnatal care. Even when lockdown restrictions were eased, with pubs, zoos and swimming pools re-opening and diners in England being encouraged to Eat Out to Help Out, some hospitals continued to exclude partners from all antenatal appointments and all but the final stage of labour, requiring them to leave shortly after birth. This included cases where mother and newborn had to remain on wards for days following delivery. With covid cases rising, it seems likely that partners will once again be absent from much antenatal, labour, and postnatal care across the country.

This has obviously been challenging for many people, most acutely those who have had to deal with tragic outcomes during pregnancy and labour. A BBC article described the experiences of a number of women who underwent miscarriages during lockdown. Although their experiences differed in numerous ways, a consistent theme of all their stories is the way in which COVID-19 infection control measures prevented ordinary actions of human kindness or support – a hug from a midwife, the reassuring presence of a partner. Occasionally in these stories the rules were broken and an elicit knee pat was delivered. It is clear that the miscarriages these women experienced would have caused them deep distress under any circumstances; it is also clear that the particular ways in which COVID-19 impacted their care exacerbated that distress.

Less emphasised in the BBC article and other discussions of COVID-19-related changes to maternity services, is the suffering of the partners in these stories. One story describes how helpless a partner felt, having to piece together information from his emotional spouse rather than a medical professional: “I’ve got questions that I’ve never been able to ask… I’m involved as well. I’ve just been cast out, cast aside.” This is striking. Whenever a person is struggling with poor health, partners can play an important supporting role, and also suffer themselves. When being given medical information (particularly bad news) people often find it hard to concentrate, retain information and ask relevant questions. For this reason, it can be extremely valuable to have a trusted person present who may be better able to listen and ask questions during consultations, and provide support during and afterwards.

All of this applies to the care of pregnant women and those who experience loss or bad news during their antenatal, birth, and postnatal care. But there is more here too: the partners interviewed in the BBC article, and many more like them, were also prospective parents, not just partners of prospective parents. Although their bodies were not carrying the foetus, the miscarriage was in a very real sense something they were going through as well. Attendance at the appointments where news regarding the health of their future child was delivered was something to which they were entitled.

Attitudes towards partners’ involvement in pregnancy and childbirth have shifted. It is now much more acceptable – and common – for fathers to be present at the birth of their children and to attend antenatal appointments than has historically been the case. Paternal involvement in childcare is also becoming more of an expectation than a surprise. Yet we should not get ahead of ourselves: uptake of shared parental leave in the UK (whereby parents can split the allowance of time away from work after a child is born, some of which is paid) has been low, perhaps as low as 2% of eligible parents (though numbers here are unreliable). During the COVID-19 pandemic, the bulk of additional childcare that parents had to provide when schools and nurseries were closed was undertaken by women. There are many reasons for these asymmetries in childcare, including financial barriers to men taking leave in couples where they are the higher earner. But it is also undoubtedly the case that expectations around fathers’ involvement in the care of their child, both before and after birth, continue to be much lower than the expectations of mothers’ involvement. Could this be influencing the perceived importance of partners’ presence during antenatal care and birth? It is hard to say. But it seems worth acknowledging that the basis for partners’ presence at such moments is not restricted to the support they provide, but their own right to be involved.

In a number of ways, reproduction and fertility is a weird bit of medicine. It challenges our commonplace assumptions about what counts as disease, what counts as a person, what counts as treatment. There is plenty of opportunity for metaphysical debate about the individuation of persons but we can also take a pragmatic approach. The majority of children in the UK are born to couples: ONS data from 2016 found that “84% of babies were registered by parents who were married, in a civil partnership or cohabiting” (ONS 2017). Typically, both parents will be deeply invested in the project of conceiving, incubating and raising a child. The physiological work of gestating the pregnancy happens in the mother’s body, but much else around it is experienced by both parents.

It is not clear, then, that it makes sense to act as if antenatal care (and care during childbirth and postnatally) is exclusively concerned with the mother, whereby partners are involved only insofar as they provide support to the primary care recipient. In some circumstances, it might make more sense to consider care as being delivered to the dyad of the mother+partner (or perhaps the triad of the mother+partner+baby). There is precedent for thinking in terms of dyads (rather than individuals, bound by the skin) as the relevant unit of analysis in research, as well as the target of therapeutic care.

It’s quite possible that partners are actually often more concerned about their capacity to support pregnant and labouring women, rather than the potential philosophical mistake being made in excluding them from antenatal appointments etc. The case for permitting partner attendance at scans, the duration of labour, and during postnatal care might be made on the basis of both the well-being effects (for pregnant women and partners) and a principled judgement that partners are care recipients with a right to be present. Welfarists will think that the well-being based argument should ultimately be decisive (if the COVID-19 infection risks are outweighed by the well-being gains of permitting partners’ presence, then partners ought not to be excluded). But there are plenty of examples where policies are adopted on the basis of principles that aren’t expected to maximise well-being – such as the tradition of medical ethics viewing patient autonomy as trumping what others would judge to be in patients’ best interests when it comes to decision-making.

Many sacrifices have been made in order to reduce the harms of transmission during the COVID-19 pandemic. Yet it is questionable whether some of the demands made of people are justified. During the earliest stages of lockdown, people died in hospital with loved ones absent; people were not allowed to visit elderly mothers, fathers and partners in care homes; attendance at funerals was heavily restricted. Many such policies were changed in recognition of the deep importance of these moments to people’s lives. We should question whether the same compassion and recognition of what matters to people’s lives – what gives them meaning – is being recognised more broadly, and whether excluding partners from antenatal care, particularly in tragic circumstances, is justified by the risks of COVID-19 transmission.