The COVID-19 pandemic brought to light several questions about how to develop and operationalize an effective method to identify patients with a novel virus and its impact on pregnant patients. This included how to anticipate and address obstacles to COVID testing, as issues of trust and transparency with healthcare and public health systems rapidly emerged with the onset of the pandemic, particularly among underserved and minority populations [25]. Many concerns centered on the interplay between public health ethics and medical ethics, when the need to address infection control at a population level departed from what many patients were accustomed to considering when encountering the medical system before that time [26].
While questions of individual choice and autonomy were paramount for all patients and communities during the pandemic, they were particularly salient for pregnant patients. This special population could not defer healthcare during the pandemic, requiring consideration for infection control for patients and healthcare providers when presenting for in-person outpatient and inpatient medical services. It was also a population for whom mandatory COVID testing was enacted at several healthcare centers, something not robustly applied in the non-gravid population. At the same time, pregnant patients were subject to delays in evidence-based infection prevention and management strategies because of initial exclusions of pregnant persons from studies during the early stages of the pandemic [2]. Despite these unique aspects, there was little data to understand how trust and transparency issues would manifest in this population and the impact of those factors on pregnant patients’ ability and willingness to undergo COVID testing. Such data are essential to implementing and maintaining infection control strategies during the different waves of the COVID-19 pandemic and planning for future public health emergencies.
Our findings demonstrated that pregnant patients in our study shared many of the same concerns as non-gravid patients and communities. Reasons cited included: doubts about test reliability, the implications of a positive result, and the ability to make voluntary decisions about accepting or declining testing [13]. However, repercussions and stressors associated with those concerns were nuanced for pregnant individuals. For instance, the risk of SARS-CoV-2 exposure when presenting to a testing center was a reason observed for non-gravid individuals who refused testing. This concern was also reported among the pregnant participants in this study. They discussed this concern in the context of policies enacted about COVID testing specific to pregnant persons. These policies recommended universal testing for pregnant patients, including asymptomatic patients, before admission for delivery [17, 27]. In addition, many healthcare systems enacted a policy of treating pregnant patients who declined testing as COVID positive to prevent viral spread among healthcare staff. The fear of being exposed in the testing process and spreading the virus among their family (including children and elderly adult relatives) compared with the fear of being treated as if COVID positive while, in fact, COVID negative, presented a decisional dilemma for participants and raised important questions for them about the integrity of their autonomy during pregnancy.
In addition, pregnant patients in this study reported similar concerns as non-gravid individuals about test accuracy, the ramifications of a positive result, or the chance that the result may be a false positive. One of the primary concerns about a positive result was the implications of isolation from others to prevent infection spread. Fears of isolation and quarantine were documented across populations during the pandemic [28–30]. Yet, there was scant data on what isolation and separation meant for pregnant patients admitted as inpatients. Our study demonstrates that the idea and practice of social isolation had specific significance and implications for pregnant patients, particularly when COVID testing was performed in preparation for admission to the hospital for delivery. For this population, isolation meant potential separation from family or other support persons during labor (e.g., doula). It also meant separation from the infant after birth, affecting the ability to see and hold the baby, skin-on-skin contact, breastfeeding, and bonding. While many healthcare systems did not have policies (or modified their policies) regarding obstetric patient isolation over the pandemic, stories of the experiences of other pregnant patients gained through personal experience or social media. Stories of those who had to labor without family present and who could not hold their newborn reverberated among the group. Studies demonstrate the needs of different type of support obstetric patients may when admitted for inpatient management. This includes patients who desire a support person during routine labor and delivery and those who experience an obstetric emergency that requires immediate intervention [31, 32]. These concerns must also be extended to patients who may experience preterm labor of a pre-viable newborn or undergoing induction of labor for a fetal loss. Data emerging from perinatal care during the pandemic support these concerns, particularly the impact of separation from family, support persons, and infants during the pandemic [33–36]. Our study findings highlight the priority to obtain data about the needs and concerns of pregnant patients who tested positive for COVID-19.
A second important factor contributing to testing hesitancy pertained to the ramifications of a positive test result on healthcare delivery, particularly during inpatient admissions for delivery. Study participants expressed several concerns about diminished quality of care and patient experience during the birthing process. Specifically, there was the issue of whether and to what extent healthcare providers would be delayed in preparing to provide routine or emergent care, given the amount of PPE needed and their familiarity with the donning process. They were also concerned about the chance of stigmatization by healthcare providers if they were positive, and this led to questions about the decisions and actions the pregnant individual had taken during pregnancy. Indeed, studies have demonstrated how the pandemic impacted the quality of maternal healthcare, including inpatient services [35, 36]. Studies also document the type and amount of stigmatization experienced by pregnant persons who tested positive for COVID [37–39]. This is concerning, given the degree to which the behaviors and choices of pregnant persons have been scrutinized before the pandemic [40]. Finally, it is important to highlight that there was uncertainty and trepidation about the available evidence to guide obstetric management if a patient were COVID-positive, particularly as there were delays with emerging data about how to prevent and manage SARS-CoV-2 in this medically complex population.
While there was significant pressure to implement testing during the pandemic in a time-sensitive fashion, these findings highlight the need for strategies that address the needs of different patient populations, particularly given the support for a universal testing approach for this population [41, 42]. For instance, participants recommended the establishment of separate testing facilities to test pregnant patients, enabling them to comply with testing recommendations from their healthcare provider with reduced concerns about viral exposure in the process and the myriad of concerns that come with a COVID positive result. Additionally, participants called for clear communication and transparency about hospital policies regarding the management of patients who are COVID-positive or decline testing. Our study findings also call for the need to include pregnant patients as key stakeholders in developing guidance about developing and implementing strategies for this unique patient population. Their voice, with respect to experiences during this pandemic and concerns for future pandemic management, has a vital role in the successful implementation of public health strategies. It is also essential to develop strategies that are cautious when data do not yet exist about the public health threat on pregnant patients without restricting the choices they can make because of a delay in the inclusion of pregnant persons in clinical studies. As stakeholders, pregnant patients can speak to how to find this balance while also attending to the priority of controlling an infectious threat throughout the population.
While our study provides insights into COVID test utilization and decline among pregnant patients, the findings should be contextualized with the limitations of this study. The study was based on patients from two healthcare systems in Ohio that adopted telehealth protocols similarly during the pandemic. Nonetheless, it is possible that there were subtle differences in the ways in which participants learned about and accessed COVID testing in addition to the clinical ramifications of the choice to accept or decline testing. In addition, participants, most of whom accepted COVID testing, self-selected for study participation. While these participants could speak to reasons why pregnant patients may decline testing, the perspectives of those individuals were not broadly represented in this population. Although we sought a broad demographic representation in our recruitment efforts, most participants were < 35 years of age, self-described race as White, and had at least one prior pregnancy. Different patient characteristics, including experience with the healthcare systems before, during, and after pregnancy, may also affect perspectives. We acknowledge that other healthcare systems and geographic areas of the U.S. may have had other experiences or practices with respect to COVID-19 testing education, delivery, and management. While our sample represented patients of different reproductive histories, our sample was limited in racial and ethnic representation. Despite these limitations, the study brings to light important findings for which further research is needed to elucidate pregnant patients' access and use of COVID testing among larger and more diverse patient populations and at different stages of the pandemic.