Introduction

Perinatal care in Ontario, Canada consists of both regulated health professionals—family physicians, obstetricians (Ob/Gyn), nurses/nurse practitioners, midwives—as well as perinatal support workers such as doulas and lactation consultants [1,2,3]. Prior to the COVID-19 pandemic, between 2017 and 2019, there were approximately 378,000 births per year in Canada, 38% of these in Ontario [4], with most births occurring in hospitals, supported by medical providers [2, 5]. Canadian perinatal care guidelines emphasize evidence-based, family-focused care that prioritizes women’s autonomy and informed decision making [1, 6] – principles of care intrinsic to midwifery practice [5, 7] and high-quality obstetrical care [8]. A holistic, intersectoral and collaborative approach that is both woman- and patient-centered, enable collaborative decision-making between pregnant people, their families and care providers [6, 7, 9, 10].

In early 2020, about 40% of Canada’s COVID-19 hospitalizations occurred in Ontario, causing extraordinary pressure on the healthcare system, and prompting significant societal changes [11]. The province implemented several community public health measures including mandatory masks, physical distancing, and stay-at-home orders, and multiple region-wide shutdowns lasting two or more months in 2020–21 [12]. Ontario’s hospital capacity was exceeded during the first COVID-19 wave, resulting in suspension of elective surgeries, rearrangements of hospital wards for infection control, and redeployment of patients to other facilities [5, 13]. A provincial task force recognized COVID-19-exacerbation of existing service gaps in the Ontario perinatal healthcare system, particularly for Indigenous, and racialized pregnant people, and those living in remote and rural regions of the province [14]. This task force made several recommendations including the prioritization of perinatal patients for essential medications during supply chain issues, special considerations for rural and remote communities such as access to SARS-CoV-2 tests, and access to universal health care for all, including those not already covered by Ontario’s Ontario Health Insurance Plan (OHIP) [14]. Pregnant patients from Ontario and the rest of Canada reported pandemic-related disruptions to their perinatal health services, particularly the introduction of virtual models of care, and restriction of support person(s) related to provincial and federal pandemic recommendations to limit COVID-19 cases [15,16,17].

Ontario’s healthcare system, which serves over 15 million people, was significantly impacted by COVID-19, as described [5, 13, 14]. Recognizing that perinatal providers are essential determinants of the quality of patient care, and facilitate patient decision-making [6, 9, 18], we explored the experiences and perspectives of these providers through key informant interviews, to better understand the impacts of the COVID-19 pandemic on perinatal healthcare in Ontario.

Methods

Design

This study used a woman-centered care lens [7, 9, 10] to evaluate the impacts of the pandemic on pregnant people’s reproductive decision-making and agency. As essential determinants of woman-centered care, health professionals and support workers in the field of perinatal care were interviewed as key informants in this qualitative study. At the time of recruitment/data collection, the fourth COVID-19 wave, driven by the Delta variant emerged in the Fall 2021, followed by the fifth wave, characterized by the highly infectious Omicron variant in December-Winter 2022 [13, 19]. COVID-19 vaccine uptake (2 doses) reached about 80% of eligible Canadians by December 2021, driven in part by vaccine mandates (e.g. employers-government, healthcare, education, travel) [19]. Public health restrictions in Ontario during this time included vaccine-passports for entertainment and restaurant venues, public mask requirements, and capacity and gathering size limits [19].

Participants

Key informants were Ontario Ob/Gyn, midwives and perinatal support workers who were (1) English proficient; (2) had worked in prenatal/maternity care field for at least three years; (3) had worked in perinatal/maternity care specifically during the period of January 2020–2022 in the province of Ontario. Candidates who did not meet these criteria were excluded. Key informants, identified through circulation of a recruitment ad via the health sciences researchers’ professional networks, Facebook, Instagram, and snowball sampling, were invited to participate directly through email or Facebook/Instagram messaging, from August 2021 through January 2022. Recruitment continued until thematic saturation was reached.

Data collection

Building on existing perinatal experiences literature [2, 3, 7] and informed by principles of woman-centered care [7, 9, 10], an interview guide was developed to explore key informants’ COVID-19 experiences and perspectives related to perinatal care, patient decision-making, at-risk communities, and patient-provider rapport (see Supplementary Information). The interview guide included semi-structured questions exploring impacts of the COVID-19 pandemic on (1) participants’ work experiences, (2) perceived patient reproductive decision-making, (3) patient communication- in general, and with minority/marginalized communities, (4) perceived pregnant peoples’ agency in healthcare decisions, including experiences of at-risk patients, and (5) demographics. The interview guide was informally piloted with health sciences graduate students and remained unchanged throughout the formal data collection. Fifteen key informant virtual interviews were conducted from August 2021 to January 2022 by a health sciences graduate student (SS-C), with no prior relationship with participants, until thematic saturation was reached. Online video interviews were captured by audio-recordings and field notes, which were used to produce transcripts.

Data analysis

Interview transcripts were subject to qualitative data analysis using NVivo™ (Version 1.7.1; QSR International, Lumivero, Denver, Colorado, USA) to generate preliminary codes. Codes emerged inductively and deductively, using the frame of the interview guide, and were then organized into major themes, subthemes and minor themes by thematic content analysis [20]. Major themes represented dominant, recurring concepts expressed throughout the interviews, with subthemes further describing a specific element of a major theme. Minor themes represented divergent concepts expressed by a minority of participants. Preliminary coding was performed individually (SS-C, KPP), followed by integration and identification of themes by team consensus.

Ethics

The study details, benefits and risks of participation were provided to key informants, who provided informed consent to participate. Permission to conduct this study was obtained from the University of Ottawa Office of Research Ethics and Integrity (REB file number H-05–21-6902).

Results

Demographics

Participants included healthcare providers (Ob/Gyn, nurses, midwives), allied health professionals (social worker, massage therapist) – both groups regulated in Ontario – and perinatal care support workers (doulas, lactation consultant). Participants primarily practiced in Eastern Ontario, and the majority identified as women (Table 1).

Table 1 Demographics of maternity care providers
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We have presented our findings as major themes with associated subthemes, and divergent minor themes. Four major themes were identified: (1) Impacts of COVID-19 on perinatal care providers; (2) Providers’ perceived impacts of COVID-19 on pregnant people; (3) Vaccine discourse, and (4) Virtual pregnancy care.

Theme 1. Impacts of COVID-19 on perinatal providers

The COVID-19 pandemic directly impacted the personal experiences and wellbeing of perinatal providers. Further, pandemic-related changes to the healthcare system created both challenges as well as opportunities for perinatal providers and their interactions with patients. Three subthemes psychosocial stress; healthcare system barriers; healthcare system opportunities emerged. Psychosocial stress comprised concerns related to providers' fears and concerns about COVID-19 personal exposure and related health impacts, stress related to scientific uncertainties about the pandemic and increased workload (Table 2). Primary health care providers working in hospitals especially experienced work-related stress associated with hospital policies and personal risk of infection. The subtheme healthcare system barriers related to providers’ perceptions of changing hospital policies, insufficient human health resources, supply chain shortages and other infrastructure concerns. For some hospital-based providers, the pandemic fostered healthcare system opportunities, which enabled rapid implementation of new policies, and fostered new professional challenges and collaboration.

Table 2 Major theme: impacts of COVID-19 on perinatal providers
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Theme 2. Providers’ perceived impacts of COVID-19 on pregnant people

Perinatal care providers openly discussed their perspectives of the effects of COVID-19 on their patients’ pregnancy experiences and challenges. Providers’ perceived impacts of COVID-19 on pregnant people were categorized into three subthemes: patient psychosocial stress, amplification of existing healthcare barriers, and influences on reproductive decision-making (Table 3). The subtheme patient psychosocial stress described providers’ perceptions of patient anxiety and fears around COVID-19 infection coupled with associated isolation, and loneliness. Further, patients expressed to their perinatal providers their sense of loss related to the pandemic-related disruption of their anticipated pregnancy experience. Both perinatal support workers and allied health professionals reported occasions when they assumed social and emotional support roles (minor theme) for their distressed patients. Amplification of existing healthcare barriers described our perinatal providers’ awareness that their patients’ lacked access to care and support during the COVID-19 pandemic. Existing barriers such as lack of childcare, financial strain, and geographical or travel limitations were perceived to be further magnified in the context of pandemic-related reductions/cancellations in perinatal support services. Finally, providers considered COVID-19 and related hospital policies among the influences on reproductive decision-making. Patient distress, anxiety and desire for labor and delivery (L&D) support companion(s) were believed to influence both care decisions and choice of provider.

Table 3 Major theme: providers’ perceived impacts of COVID-19 on pregnant people
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Theme 3. COVID-19 vaccine discourse

The introduction of COVID-19 vaccines and related hospital policies created new challenges for providers and their patients, captured as two subthemes: provider empathy, and vaccines and patient family dynamics (Table 4). The subtheme provider empathy described providers’ compassion regarding the challenges presented by COVID-19 vaccines and related decisions faced by their patients, recognizing that hospital policies in particular, were sometimes causes of conflict. The subtheme, vaccines and patient family dynamics, described providers’ recognition that within patients’ families, differing views about COVID-19 vaccinations presented significant challenges. Physician-respondents in particular expressed frustration and concern about patient vaccine hesitancy, captured as a minor theme. COVID-19-related misinformation was identified as a second minor theme limited to Ob/Gyn, nurse and midwifery-respondents. Ob/Gyn in particular attributed vaccine hesitancy to COVID-19 misinformation, with most medical/midwifery respondents recognizing the Internet/social media groups as the leading source of COVID-19 misinformation. COVID-19 myths were noted to cause increased patient fear and anxiety, requiring additional time and resources for medical providers to refute patient misinformation.

Table 4 Major theme: COVID-19 vaccine discourse
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Theme 4. Virtual pregnancy care

COVID-19 reduced in-person appointment visits, transitioning perinatal care to virtual care. Three subthemes emerged: disadvantages and benefits of virtual pregnancy care, and adaption of standard patient care practices (Table 5). The subtheme disadvantages of virtual pregnancy care includes the challenges of provider-patient interactions surrounding pregnancy and COVID-19. Providers described their experiences feeling disconnected from patients and perceptions that information was being missed due to lack of in-person care. Benefits of virtual pregnancy care described ease of access for some populations and greater efficiency for routine appointments. Adaptation of standard care practices referred to patient care transitions to virtual formats for communication, information sharing, patient tools and consultations.

Table 5 Major theme: virtual pregnancy care
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Discussion

We report here the first published account of the professional and personal impacts of the COVID-19 pandemic on a key informant sample of Ontario healthcare workers and providers, specifically in the context of perinatal care delivery. Our respondents shared their pandemic experiences of evolving hospital policies, emerging and often contradictory science, rapid transitions to virtual care, and increased patient anxiety. Perinatal providers recognized that virtual modes of perinatal care both limited the quality of patient-provider interactions, but also contributed significant efficiencies and benefits, similar to a survey of Western Canadian healthcare providers, which included family physicians and midwives [21]. Perinatal care is essential care, and as such typically exempted healthcare providers and most staff from redeployment to intensive care units during the pandemic [22]. Perinatal care is ideally collaborative, woman-centered care with a foundation of shared decision-making [6, 9]; essential principles challenged by healthcare system adaptations to COVID-19 [22].

Provider workplace stress, institutional adaptations

Ontario perinatal healthcare professionals and support workers in our sample, like many of their counterparts in other countries [23, 24], experienced workplace-related stress and frustration due to the pandemic. Although increased anxiety and depression were experienced by some New York City perinatal healthcare providers [25], and were reported in a scoping review of studies describing providers’ experiences from multiple countries [26], our respondents conveyed primarily workplace-related stress and concerns about personal infection risk. Workload burden and frustration with the inconsistencies of hospital policies and public health recommendations in the early days of the pandemic contributed to the challenges faced by this cohort of Ontario perinatal providers and support workers – even for those working outside of hospital settings. Implementation of almost universal healthcare policies to limit spread of SARS-CoV-2 such as reductions in prenatal visits, transitions to virtual care, and PPE/barriers to minimize physical interactions between patients and providers [11, 26,27,28] did not take into consideration the individualized needs of prospective parents seeking pregnancy care [22]. Hospital-based respondents – Ob/Gyn, nurses and to some extent, midwives – seemed resigned to the increased workload, recognizing the necessity of infection control protocols as measures to keep both staff and patients safe. Hospital and public health policies, including cancelled/reduced in-person prenatal appointments, virtual care, and infection control measures, were perceived by some respondents as reducing their capacity to establish connections with their patients beyond their essential clinical roles. It seems evident that pandemic safety measures were barriers to a woman-centered care approach [7,8,9,10], such that pregnant patient choice, continuity of care and control were at times sacrificed to comply with hospital and healthcare system policies. Clinical management of COVID-19-infected pregnant patients was not specifically identified as a greater stress for our respondents, in contrast to obstetricians from New York City [25] and the UK [29] who recognized rapidly changing quarantine and PPE policies as factors in their stress and uncertainty when caring for COVID-19-infected patients.

Although providers from multiple countries reported reduced capacity to deliver adequate perinatal care, in part due to limited training, resources and fear of infection [23, 24, 26, 30], this was not described by our participants. In Ontario, hospital infection control policies including PPE, transitions to virtual care, and the restriction of support companion(s) were implemented in early spring 2020 [22], with no apparent increase in adverse outcomes such as preterm birth and stillbirth [31]. Study participants generally did not report concerns about the quality of clinical care provided, however they did acknowledge heightened patient anxiety and distress due to virtual care appointments and policies related to limitations on support companion(s)/visitors – policies which directly contravened the principles of woman-centered care [7,8,9,10]. Our sample of perinatal support workers and midwives in particular, were deeply empathetic about their patients’ distress, discussed below, due in part to the restrictive healthcare policies. Further, interviewed doulas described feelings of disappointment about missing their patients’ deliveries, with midwives articulating a sense of loss at their inability to meet patients’ family members, including children they had once delivered. Clear clinical guidelines, updated training protocols, and transparent communication strategies, which include procedures to report concerns, are recommended as strategies to support the adaptation of perinatal care to rapidly changes in healthcare emergencies, including future pandemics [22, 32]. Two of our respondents were pregnant themselves during the pandemic, and although they did not elaborate significantly on their own pregnancies, their experiences are reflective of the substantial occupational risks faced by healthcare providers, as previously reported [33, 34]. Lessons from previous public health emergencies and disaster preparedness policies can be adapted to perinatal care [35,36,37], but must incorporate the principles of woman-centered care to ensure women’s autonomy and agency are preserved even during disasters.

Healthcare restrictions to support companion(s)

Experiences of perinatal providers [23, 24, 26,27,28,29] and patients [16, 17, 38, 39] from multiple countries suggest that institutional healthcare policies for infection control impaired the quality of woman-centered, perinatal care – a perception echoed by perinatal support workers in our sample. Doulas particularly reported the loss of professional control, as they were often restricted from birth attendance under hospital support companion(s)/visitor limitations. Perinatal support workers also articulated concerns that hospital vaccination policies would further restrict support companion(s) from attending births. For patients, such hospital support companion(s) restrictions were identified globally as major COVID-19 perinatal stressors, with most global healthcare settings banning partners from prenatal appointments and limiting birth attendants to the period of active labor and immediately postpartum [30, 38, 39]. Support companions, recognized as essential components of woman-centered care [9, 10], improve pregnancy outcomes, facilitate rapport with healthcare providers and can enhance agency during reproductive decision-making [40, 41]. Support companions may be partners or perinatal support workers, such as the doulas interviewed in our study. Although traditionally described as labor or birth companions [40, 41], we recognize the contributions of support companion(s) throughout the perinatal period, including during prenatal appointments. Our perinatal health professionals described their patients scrambling to include partners on the phone or video-appointments, consistent with experiences from the UK [42, 43] and Australia [44], demonstrating respondents' perceived impacts to patients’ reproductive decision-making and support. Restrictive support companion(s) hospital policies were perceived by perinatal support workers in our study as distressing to their patients, who increasingly sought reassurance and support from their providers. Although perinatal healthcare providers commonly serve as educators and medical system guides in addition to their clinical roles [18], some of our respondents felt an increased psychological burden as they served as emotional surrogates in the absence of partners. Certainly it is now evident that hospital policies restricting support companion(s) during both prenatal care and L&D exacerbated patients’ experiences of isolation and loneliness, and contributed to adverse perinatal mental health [16, 30, 38].

Virtual patient care- benefits, disadvantages and adaptations

For decades, virtual healthcare or telehealth has complimented in-person care and has gained acceptance as a strategy to improve healthcare access for remote and rural patients due to the geographic realities in Canada [21, 45, 46]. Unlike most Canadians, Indigenous women in remote regions of Canada must often travel great distances to receive perinatal care as their communities lack hospitals, obstetricians, or other perinatal care providers; factors contributing to poor perinatal health outcomes [47]. Our sample of Ontario perinatal health professionals acknowledged that the abrupt transition to widespread virtual perinatal care modalities required adaptations to new technologies, and adjustments to novel patient interactions. In general, respondents acknowledged many benefits associated with virtual care, including reduced COVID-19 exposure, improved accessibility for some patient populations, and improvements to their own workflow, consistent with rural Western Canadian healthcare providers [21] and a global survey of perinatal providers [48]. Similarly, scoping and systematic reviews [26, 27, 49] report that providers perceive virtual care as a generally acceptable form of delivering perinatal services with the capacity to improve access to care. Respondents appreciated virtual care’s reduction of transportation, childcare and time constraint barriers to perinatal care access, particular for their rural and remote patients. They also recognized that some patients would face challenges to virtual care due to limited high speed Internet access and low digital literacy, consistent with previous studies [21, 48]. Participants were concerned that COVID-19 further exacerbated already limited postnatal services in rural and remote communities.

Despite the efficiencies and healthcare access improvements for some patients, ultimately our participants asserted that virtual care is not a substitute for in-person care. Respondents agreed that virtual care reduced their perceptions of personal connection and relationship-building opportunities with their patients. The relationship between perinatal care providers and their patients is an essential aspect of woman-centered care, with the establishment of trust-based relationships identified as a key factor in patient satisfaction and their likelihood to seek future perinatal care [6, 9, 10, 18, 50]. These findings suggest that our sample of Ontario perinatal care providers sometimes struggled to develop this relationship through virtual care, highlighting the importance of ensuring patient-provider rapport even through pandemic-induced healthcare system changes. Further, participants discussed the importance of being able to see their patients during virtual consultations and were concerned about missed cues from body language, not being able to physically examine patients or provide hands-on emotional support, which they described as a standard part of their clinical care. Our findings are consistent with the global experiences of perinatal health professionals, who framed the use of patient masking, physical distancing, and virtual patient care as impersonal and dehumanizing, associating these practices with reduced relationship building capacity [23, 24, 26, 30, 48]. Canadian perinatal mental health providers recognized the transition to virtual care as worsening patients’ isolation, anxiety and created privacy concerns for virtual consultations [51]. Integration of virtual visits within perinatal care models will undoubtedly remain a regular feature of healthcare for many settings given the high level of provider satisfaction ratings across studies [48, 49]. Optimization of virtual perinatal care must address inequities related to diminished accessibility for individuals with disabilities, socioeconomic or technical Internet service challenges [45, 48], and ensure that virtual care complements but does not replace in-person clinical care.

Providers’ perceptions of their patients

As described, Ontario perinatal care providers in our study were sensitive to the pandemic and healthcare policy-impacts on their patients’ experiences of pregnancy and delivery. Given the provincial stay-at-home orders [13] and resulting self-isolation practiced by many pregnant patients for fear of COVID-19 exposure, interactions with health professionals in our sample often served as opportunities for surrogate socialization. During these perinatal visits, providers learned of their patients’ increased stress and anxiety, complicated by their lack of social support and social isolation. Even prior to the COVID-19 pandemic, poor social support during pregnancy was an established risk for depression, anxiety, and self-harm [51, 52]. Perinatal mental health services, like most healthcare, was impacted by the pandemic [38, 51], exacerbating pregnant patients’ experiences of psychological distress and mental illness [16, 51, 53, 54]. The intersections of patient characteristics such as language barriers, recent immigration, forced relocation for perinatal services, Indigenous and racialized identities, and disability contribute to limited social support and adverse perinatal mental health [47, 51]. Systemic racism and the legacy of colonialism are established healthcare barriers in Canada [55, 56], the US [57] and many countries [23, 58, 59], which contribute to poor pregnancy outcomes despite Canada’s ‘universal’ healthcare system [60, 61]. Despite the efficiencies of virtual care, our respondents perceived that structural barriers to perinatal care access were amplified during the pandemic, consistent with previous studies [17, 30, 58, 59]. Participants acknowledged that their patients with high levels of anxiety, competing childcare demands, low socioeconomic backgrounds, immigrants, racialized or Indigenous were particularly at risk during the pandemic, reflecting exacerbation of societal and health disparities during disasters like pandemics [34].

Although pregnancy was identified as a priority condition for COVID-19 vaccination by April 2021 in Ontario, COVID-19 vaccine uptake among pregnant people was substantially lower (71.2%) than reproductively-aged women in the general Ontario population (88%) [62]. Ontario medical providers interviewed here, expressed both frustration and concern about patients’ vaccine hesitancy, believed to be fostered by social media-based misinformation. Time spent addressing patient vaccine hesitancy increased workloads and was yet another source of provider stress during the pandemic. Although participants were empathetic to the genuine concerns expressed by their patients about the potential teratogenic risks of COVID-19 vaccines and long-term health outcomes for their babies, medical perinatal providers in particular, described considerable efforts to encourage COVID-19 vaccination and combat misinformation. The launch of COVID-19 vaccines was initially heralded with hope for a speedy end to the pandemic, however this optimism quickly eroded as variants emerged, community restrictions and vaccination mandates were introduced, and public confidence began to wane [19]. Social media-fostered misinformation promulgated myths that COVID-19 vaccination caused adverse reproductive affects including infertility, miscarriage, and stillbirth, which contributed to vaccine hesitancy [63]. There is a substantial literature recognizing the pivotal role of the perinatal provider as an essential determinant of vaccine uptake (influenza, Tdap- tetanus, diphtheria, and pertussis) during pregnancy [63,64,65]. Ultimately, the quality of the provider-patient relationship in terms of respect, trust and transparency along with the provider’s willingness to continue to offer vaccines even after initial patient refusals, may mitigate vaccine hesitancy during pregnancy [63, 64]. Even post-pandemic, misinformation driven by social media will continue to challenge evidence-based perinatal practice, with suggestions that a woman-centered care approach requires development of practitioner skills in ‘infodemic management’ to address patient perinatal health misinformation successfully [66].

Limitations

The qualitative design of this study is a strength, which enabled participants to contribute their perspectives and experiences of perinatal care in Ontario. This study also provides a uniquely heterogeneous sample, such that the diversity of providers highlights the many different aspects of perinatal care that were influenced and changed by the pandemic. There were, however, some limitations to this work which should be considered. First, this qualitative study is not generalizable to the Ontario perinatal provider population and is not meant to be representative. Second, despite efforts by the research team to recruit a geographically diverse sample, most of the sample were from Eastern Ontario, such that rural and remote maternity care providers, as well additional respondents serving large, diverse urban populations, would have contributed valuable perspectives of their experiences during the pandemic. Finally, as this study is focused on provider perspectives, additional research is required to gain patient perspectives of their pregnancy care experiences.

Conclusion

Ontario perinatal care providers described workplace stress and increased workloads due to the COVID-19 pandemic, vaccine hesitancy and general misinformation. Providers perceived that their patients were distressed both by the pandemic, but also by hospital policies which limited support companion(s), in-person appointments and reduced perinatal care services. Amplification of existing social, economic, and other patient barriers to care was attributed to the pandemic by providers. Finally, although virtual care reduced capacity to provide interactive patient care, providers generally accepted the efficiencies and accessibility of virtual care as an appropriate complement to in-person perinatal care.