Sample:
Ninety-five women expressed an interest in participation, of whom 83 were eligible and 31 were selectively sampled (aiming for demographic diversity) and interviewed between 24 April–4 May 2020. Participant characteristics are presented in Table 3, which includes information on parity collected within interviews. Of the 31 women in the sample, 20 were primiparous; the age range was 24–48 years (mean 33), at the time of interview parity ranged from 10–39 weeks (mean 24). Every IMD level (1–10) was represented and the ethnicity of our sample was: 24 White British, 1 White European, 2 Asian, 1 Black, 3 mixed. Two had medical/nursing training.
Table 3
Participant characteristics
Consent ID | IMD (from home post-code) | Gestation at time of interview* (weeks) | Current age* (years) | Ethnicity | Do you have children already?** |
01 | 9 | 25–27 | 30–34 | White | No |
03 | 3 | 16–18 | 35–39 | White | No |
05 | 1 | 28–31 | 30–34 | Black | No |
06 | 10 | 32–35 | 30–34 | White | No |
09 | 7 | 10–12 | 35–39 | White | Yes |
11 | 5 | 22–24 | 25–30 | White | No |
13 | 6 | 28–31 | 30–34 | White | No |
14 | 1 | 28–31 | 20–24 | White | No |
17 | 2 | 36+ | 25–29 | White | No |
18 | 8 | 36+ | 35–39 | White | Yes |
19 | 4 | 19–21 | 25–32 | White | No |
20 | 7 | 16–18 | 30–34 | Asian | No |
21 | 5 | 36+ | 30–34 | White | No |
24 | 4 | 32–35 | 35–39 | White | Yes |
25 | 2 | 22–24 | 30–34 | White | Yes |
31 | 4 | 28–31 | 40+ | White | Yes |
32 | 5 | 13–15 | 35–39 | White | Yes |
37 | 3 | 19–21 | 25–33 | White | No |
39 | 7 | 10–12 | 35–39 | Mixed | Yes |
40 | 9 | 10–12 | 20–24 | White | No |
41 | 4 | 32–35 | 25–34 | White | No |
45 | 2 | 14–20 | 30–34 | White | Yes |
46 | 5 | 28–31 | 30–34 | White | No |
53 | 2 | 19–21 | 40+ | White | Yes |
54 | 4 | 32–35 | 30–34 | White | No |
60 | 7 | 16–18 | 25–31 | White | No |
62 | 6 | 10–12 | 35–39 | White | No |
79 | 2 | 32–35 | 40+ | Mixed | Yes |
82 | 2 | 22–24 | 30–34 | White | Yes |
83 | 7 | 14–20 | 35–39 | Mixed | No |
85 | 1 | 22–24 | 30–34 | Asian | No |
* Participant data presented as a range to preserve anonymity |
**information collected during interview. All other demographic information in this table was collected within the expression of interest form to inform sample selection. |
The rapid analysis and team discussions during data collection indicated that reasonable data saturation for the COM-B framework themes was reached in our sample, as well as for the main additional themes, indicating that our sample was adequate and further recruitment was unnecessary.
Phase 1: Qualitative interviews: COM-B analysis and main themes
An overview of the main themes identified are presented in Table 4. For the full analysis table with supporting quotations, see Additional file 3.
Table 4
Overview of thematic analysis according to the COM-B model
COM-B category | Themes identified |
BEHAVIOUR |
Social distancing (in accordance with guidelines) | Adhering |
More extreme |
Slight deviations |
CAPABLITY – The individual’s physical and psychological capability to engage in the behaviour(s) |
Psychological capability (understanding/ mental processes) | Knowledge and understanding of guidance around social distancing behaviours |
Confidence in ability to enact social distancing behaviours |
Physical capability | Physical capability had little impact on social distancing behaviour |
OPPORTUNITY – Environmental factors influencing the behaviour(s) |
Social opportunity | Social norms to comply with social distancing |
Household composition impacts on ability to enact social distancing |
Social distancing compromised by strangers in public spaces |
Physical opportunity | Impacts of home environment and resources |
Work environment/ ability to work from home |
Shopping for essentials including preparation for the baby |
Healthcare appointments |
MOTIVATION – Individual internal factors that direct the behaviour(s) |
Reflexive motivation | Motivated to adhere to social distancing guidelines |
Establishment of routines to enable social distancing |
Intentions to continue to adhere to guidelines |
Risks and balance of risks to determine behaviour |
Automatic motivation | Emotional drivers of social distancing |
Automatic behaviours |
Beyond COM-B: cross-cutting themes |
Isolation, mental health, and loss of maternity care | Isolation and mental health impacts |
Loss of maternity care – communication issues |
Loss of maternity care |
Behaviour
Women reported that they were adhering to the social distancing guidance to the best of their abilities, describing staying home as much as possible, limiting shopping trips, not allowing others in the house, going outside no more than once per day and staying at least two metres away from others when out. Many were taking extra precautions such as limiting their healthcare appointments and engaging in other behaviours that did not relate to social distancing but that aimed to reduce risk of exposure to Covid 19. These included washing and quarantining shopping, quarantining post or asking partners to do this before items came into the house. Six women in our sample were shielding (not leaving the house at all): one due to extra health issues that increased her risk from Covid-19 (though she had not received a letter from her GP to facilitate her ‘extremely clinically vulnerable’ status); one to protect a member of her household who was in the ‘extremely clinically vulnerable’ category due to health issues; three others were shielding believing this was the requirement when pregnant. Women reported few instances of breaching the social distancing rules, and breaches were minimal and carefully considered, for example one woman drove a short distance to take exercise safely, one reported her parents and her households went into isolation for safety prior to moving in together for support.
Psychological Capability
Women reported making efforts to access “credible” and “reputable” sources for information. These included: government advice, BBC (British Broadcasting Corporation) news, Royal College of Obstetricians and Gynaecologists (RCOG)/ midwives, NHS, pregnancy apps/emails (e.g. Bounty), Tommy’s (online), some social media groups, select social contacts, scientific sources, and newspapers.
While the women in our sample mainly reported feeling able and confident that they could adhere to the guidelines and showed good understanding about what was expected of them, women reported a lack of clarity about what it meant to be in an “at risk” category, or why pregnant women were placed in it. Some women felt it was a precaution and many wanted more information about the rationale and what it meant. Uncertainty around the risk category was evident in women’s different interpretations of what was expected of them: some interpreted it as requiring them to shield due to the ‘at risk’ status of being pregnant, while others stated that the guidance was no different for pregnant women from the rest of the population. Many women felt the advice was confusing at first, though seemed clearer by the time of interview. Some details of the behavioural recommendations remained unclear, such as how to handle shared parenting between households, how to stay safe at work for those not working from home/ furloughed and whether to attend healthcare appointments for minor issues.
One aspect of psychological capability was the emotional ability to adhere to social distancing. While some women reported positive experiences about lockdown (e.g. enjoying extra time at home with their family), many reported feeling isolated, low, and suffering loss of joy, which impacted on their perceived ability to sustain the behaviour. This was particularly acute when living alone and fully shielding.
Physical Capability
Personal physical abilities had little relevance to adhering to social distancing recommendations. Interviews revealed only one example (a woman reported that due to being pregnant she struggled to lift her toddler to stop the child running close to others when outside).
Social Opportunity
Women in our sample reported strong support from their immediate social circle to adhere to the social distancing guidelines, citing examples of friends, family and partners being strict about keeping them safe, particularly because of being pregnant. Women also described general social norms with ‘everyone’ adhering to the social distancing guidelines, or people generally expecting them to stay away (e.g. from work) due to being pregnant, with several reporting gaining priority in their organisation’s home working or furlough schemes. By contrast some women reported a minority of friends or family who did not adhere to the rules, though this did not seem to influence their own social distancing behaviours. Women chose to reaffirm and explain the rules or keep a distance, with one participant reporting losing friends over this.
The household composition had a significant impact on women’s ability to maintain social distance. Many reported having supportive partners who were taking care of practical tasks to keep them safe, or other family members in the house who upheld social distancing practices. Others’ household composition brought added risks or challenges, such as co-parenting teenagers across two households, having to take small children to nursery, coping with the risks of other household members going out to work, or living alone, which made social distancing challenging both emotionally and practically.
While women reported being mindful of staying at least two metres away from others when out of the house, many commented on not being able to control other people when outside, giving examples of people coming too close, with some women wishing for a visible sign that they were ‘at risk’ to warn people to stay away.
Physical Opportunity
There were multiple physical opportunity determinants of social distancing behaviour reported in our sample. Home environment and access to resources had a key impact on women’s ability to maintain social distancing. Participants recognised how lucky they were for the resources they had, for example access to a garden or local green space, exercise equipment at home, a car to avoid public transport, or for digital technology to enable them to stay in contact with people. Those in small flats or without gardens commented on how challenging it was to maintain social distancing and these women were hugely limiting their lives to adhere to the guidance and suffering negative mental health effects.
The ability to work from home enabled many women in our sample to maintain social distancing. Most felt these arrangements had been prioritised for them due to being pregnant. By contrast, one woman employed by the NHS reported having to push for changes to their work environment and responsibilities to reduce her contact with patients, and some chose to continue going to work if they could not work from home and judged the risk to be relatively low. Several women worried about future relaxing of the guidance (lockdown ending) meaning they may be expected to return to the workplace. Some women who were unable to work from home chose to leave work, taking sick leave or early maternity leave to enable them to stay at home. These women reported potentially facing financial consequences rather than put themselves at risk, though mortgage holidays, furlough schemes and workplace financial support made these decisions easier.
Shopping for essentials was an important behaviour for which it was challenging for women to adhere to social distancing behaviours. Many commented on being unable to gain online shopping slots. Many relied on their partner or family members to do regular food shopping or reported having to go themselves, which made them feel unsafe. Though one woman, who expressed less anxiety than most, reported that going out for the weekly shopping was the highlight of her week. One woman who was single and shielding reported that she was growing her own vegetables due to difficulties getting fresh food. Several women mentioned the difficulty with preparing for the coming baby – being unable to buy baby items from shops, online shops being out of stock, and having to consider how to manage handover of baby items from family members in a socially distanced way.
Healthcare appointments were also a key source of concern when it came to social distancing. Women worried about whether they would be able to maintain distance when attending clinics and some chose to limit visits. Labour itself was a source of concern in this context, with women knowing that they would be unable to maintain social distancing and worrying about it, with single women needing someone to take them to hospital. Some reported that antenatal appointments were the only times they had contact with other people and felt that their social distancing abilities were compromised by needing to attend appointments. For women with other children they had to consider how to manage childcare, with one commenting that she would ask a relative to shield for two weeks prior to her maternity appointment to facilitate childcare. Most participants acknowledged that changes to maternity care had been put in place to enable social distancing, mentioning more telephone consultations, limited face-to-face time, staff wearing personal protective equipment (e.g. masks), spacing out waiting areas or enabling women to wait in their car to be called in to their appointment. Women also reported that partners were not permitted to attend appointments as a social distancing measure and antenatal classes had been cancelled for the same reason. Some women sought alternatives online.
Reflexive Motivation
Despite some of the challenges identified above, there was strong motivation to adhere to social distancing guidelines in our sample, with women adhering closely to the behavioural restrictions and many taking extra precautions. Women cited the safety of themselves and their baby as motivating factors as well as social responsibility motives around protecting others, protecting the NHS and stopping the spread of the virus. Some women talked about having a lower immune system during pregnancy which makes them more susceptible to infections; many expressed particularly high motivation to avoid the virus near the birth. Some women mentioned their own higher risk status, such as a higher risk ethnicity or having comorbidities which made it even more important to adhere to the rules. No-one reported being motivated by the law or police sanctions. Many women talked about having consciously established routines to enable the maintenance of the new social distancing lifestyle as well as to maintain sanity during lockdown.
When asked about their intentions to continue with social distancing behaviours, most women in our sample described their plans to continue with adhering to the behavioural advice, some wanting to continue with the current stringent measures if the lockdown was to ease, especially when nearing the time of birth. The birth event itself was pivotal, with some wanting to continue to maintain social distance afterwards to protect their new-born baby, and others expressing a need to ‘break the rules’ to gain support with the new-born baby or see people, weighing up the relative risks of this decision.
Decision-making and planning around social distancing behaviours often involved weighing up relative risks. Women described difficult decisional processes such as being unsure whether it was safer to attend the midwife appointment or avoid it, or whether risks of exposure outweighed the mental and physical health effects of outdoor exercise. This was compounded by a lack of understanding around the reasons for being in the ‘at risk’ group (as described in psychological capability, above). Planning arrangements around the birth were particularly fraught in this respect as women grappled with how to plan for a parent to come and help look after their existing children when they went into labour or to support them with the new-born after the birth, or if their partner became ill.
Automatic Motivation
Fear was identified throughout interviews as a motivating factor for adhering to social distancing guidance. Fears focused on worries about catching Covid-19 near the birth date, or the partner becoming ill, as well as general risk to self and baby. Other emotional drivers of social distancing included guilt or an anticipated guilt of catching the virus due to going out, especially compounded by a sense that women felt capable of adhering to the rules. Conversely, the sadness and low mood some women experienced from their social isolation posed a challenge to adherence.
Unconscious processes and automatic behaviours are difficult to assess in a reflective interview, though some women reported that they were now automatically enacting social distancing and other protective behaviours (e.g. keeping away from strangers, handwashing and washing shopping).
Beyond COM-B: Isolation, mental health and loss of maternity care:
While some positive aspects of following the social distancing guidance were identified by women in our sample, such as spending more time with their immediate family or enjoying working from home, there were significant negative impacts, mainly the social isolation and negative mental health, which came out strongly across interviews. Pregnant women living alone (or only with small children) were particularly vulnerable to isolation and mental health effects. Pregnancy was seen as a time when women would normally seek out connection with others (friends, family, other pregnant women). In this context, the isolation and loss of social contact during pregnancy was experienced as an acute loss.
A major concern for most of our participants was the loss of maternity care, and while they recognised that midwives were doing their best in a very difficult situation, many had experienced not only a loss of care, but a lack of communication about the changes to their healthcare, with some reporting that midwives have been ‘hard to get hold of’. The loss was particularly acute for women in their first pregnancy, who did not know what they were missing out on.
While some women felt well supported by their midwives, many reported cancelled appointments and classes, face-to-face appointments feeling rushed and stressed and feeling unable to ask questions or share positive emotions. Telephone appointments felt less personal, more removed. Women were particularly troubled that partners were not able to come to the scan appointments, experiencing this as an acute loss, with one worrying about the impact on partner-child bonding. They also felt acutely the loss of antenatal classes – for the important information they were missing out on and the chance to meet other pregnant women. Women wanted ways of replacing these losses, with some mentioning paying for digital antenatal classes, while others simply had no access.
Many women were acutely worried about what the birth would be like, and whether their partner could be with them. These concerns about maternity care were stronger than concerns about Covid-19 itself for many of the women in our sample.
What information did women want?
While recognising that services were doing their best in a difficult time, women expressed a need for more time, support and reassurance from midwives. Women wanted to know more information about their Covid-19 related risk during pregnancy (e.g. why were they in the vulnerable category, what relative risk was associated with each trimester, what is the evidence), their personal risk factors (e.g. comorbidities, ethnicity), clarity on aspects of the guidelines and clarity on changes to their maternity care. Women wanted written information from credible sources, with clear messages presented in an accessible format. Some women reported a desire for lots of detail, while some were experiencing information overload.
Phase 2: output development
Consultation with HPIG confirmed the authors’ plans to approach midwives with initial findings to gain their input with producing resources to support pregnant women. Midwives were provided with a summary report to guide the consultation process. Midwives agreed that an infographic or brief video would be acceptable for midwives to share, though recognised that as information was changing rapidly, video or written materials could become out-of-date quickly, recommending links to up-to-date information sources. They also recommended producing printable, as well as online, resources to share with women without smartphones/internet access, or for those with limited English who could then access help to read them. The midwives agreed that a more detailed report aimed at midwives would be useful to understand the context of the materials produced.
As a result, we distilled women’s main concerns from our findings to enable us to produce materials that could be shared with pregnant women. The aim was to help answer key questions, direct women to credible, up-to-date information resources and to facilitate conversations with midwives, recognising that communication had suffered due to the pandemic impact. The government, NHS and RCOG websites (4, 13, 16) informed the content, and were included as clickable links for women to access as these were trustworthy information sources that were regularly updated as guidance evolved. We took the following main headings based on our rapid analysis and initial report as a basis for an infographic resource and added summary information for each: Why am I clinically vulnerable? What is my risk? Should I go to work? Seeing family and friends? Exercise and going shopping? Are there any antenatal classes? What about my antenatal care? What will happen at the birth?
Working iteratively with a graphic designer and consultation with two midwives and two interview participants to refine the content, design and format, we produced an online sharable PDF infographic (17) – see Fig. 1, as well as a printable leaflet and poster version and a moving Graphics Interchange Format (GIF) image of the main questions that linked to the online infographic. We also adapted our initial summary into a report for midwives (18) – see Additional file 4 – to give more context and to communicate the findings that midwives may be able to act on or help with. We circulated the infographic versions and midwife report via email to the maternity services at two local NHS trusts as well as providing printed posters for them to display. We gained feedback that these were well received and were shared across teams. We also shared the infographic with all the women who had expressed an interest in taking part (as well as those who actually took part) in our study and we shared the GIF image and link to the online infographic via social media (Twitter and Facebook) and made these available online (19).