Select details of the socio-demographics of the eight women who had postpartum experiences during the early months of COVID-19 are provided in Table 1. All eight participants were married, spoke Arabic as their preferred language, and originated from Syria. Women had between two and eight children and most arrived in Nova Scotia in 2016. All women arrived through the government-assisted resettlement program.
Three main themes emerged from the data: the impacts of COVID-19 on postnatal healthcare; loss of informal support; and grief and anxiety caused by the COVID environment.
Impacts of COVID-19 on Postnatal Healthcare
Participants conveyed that COVID-19 changed their access to and use of postnatal healthcare services. Limitations on in-hospital support people, childcare restrictions, changes to services delivery, and a move towards virtual care created challenges and opportunities for women’s postnatal care.
Isolated Birthing Experiences
Many participants who delivered during the pandemic discussed the impacts that hospital restrictions and larger public health measures had on their birthing experiences. A culmination of factors, including limited access to childcare, restrictions on support people, and the unavailability of doulas, meant that many women laboured and delivered alone, or with fewer supports than they would have liked.
With the temporary closures of public schools, and daycare centres, families had limited options for childcare for their additional children. Participants also did not have extended family (e.g., mothers) in Canada and many women did not feel comfortable asking friends to watch their children, given their friends’ own responsibilities and the risk of spreading the virus. Several women in this study gave birth during the COVID-19 months with no support people, as their husbands took care of their children while they were in the hospital. Participant 1 described her experience: “No one could accompany me to the hospital because of COVID. I was alone. My husband drove me to the hospital, but I was all by myself during delivery. My husband helped me carry my things with me to the hospital, but other than that I was all by myself.” Other participants who delivered without support people had similar feelings, describing their births during COVID as “hard,” “scary,” and “lonely.”
Other women who wished for their friends to accompany them to the hospital discussed having to choose between their partners and friends, as only one support person was allowed to accompany women. Participant 7 said, “My friend was with me. My husband stayed with the kids at home, and he couldn’t even come because during COVID only one person was allowed to accompany the woman who gives birth. He used to bring us food, give them to my friend outside the hospital, but he never entered.” Visitation after birth was also limited, which was difficult for several participants who had hoped they could see their families or friends after delivery. Participant 3 described how emotionally challenging and isolating it was to not have her partner visit after her birth: “The hospital rules are strict during COVID. Visits are forbidden, friends can’t come, and they could not be there to help me. My husband was allowed to visit me twice a day in the hospital. I stayed for two days. I felt really lonely, it was a hard experience.” Participant 1 also mentioned how difficult it was to be separated from her other children while recovering after birth, stating, “I didn’t see my children for two days, I wanted them to come to the hospital so I could see them, but it wasn’t possible because of COVID. My little baby girl was crying all the time without me… I just wanted to be discharged from the hospital and go home to them” (Participant 1).
In addition to the restrictions on support people, several women who delivered during the first wave were unable to access doula services, as doulas were temporarily suspended with the rise in COVID-19 cases. Doulas were frequently used by Syrian newcomer women prior to the pandemic, and as Participant 7 said, “before COVID, many Syrian women were offered doulas by [immigrant support group], but I was not offered one. Because of COVID they stopped this service.” Not having access to doula support services left women isolated and exhausted without their assistance. Even after doula services resumed, they were not classified as healthcare staff, and had to accompany women as one of their designated support people, limiting the additional family members or friends who could be with participants while they delivered.
Changes to Interpretation Service Provision
All participants spoke Arabic as their preferred language and were often dependent on interpretation services to effectively communicate with healthcare providers. Due to public health and hospital policies at the time of COVID-19, most participants reported that use of in-person interpretation services were largely restricted. Postnatal appointments that would have typically been translated by in-person interpreters were moved to telephone interpretation. Telephone interpretation was preferred over no translation at all, but it was often slow. Participant 7 said, “Before COVID I had an in-person interpreter. But during COVID, it was hard. The interpretation over the phone was not efficient.” Several women had to wait for telephone interpreters to become available, with one participant waiting six hours in the emergency department for interpretation services to be provided, delaying her access to urgent care. Most participants outlined their preference for in-person interpretation and described how important it can be for interpreters to read women’s body language and facial expressions. As stated by Participant 3, “The in-person interpreter feels and understands what I am going through just by seeing me. The phone interpreter on the other hand can’t see me and is waiting for me to talk in order to interpret.” This participant conveyed the added comfort of having a person be present with her and the ease that brings to the appointment.
Participant 3 described how crucial it was for her to have in-person interpretation, particularly during COVID-19, as her husband and friend were unable to be with her during her cesarian section. Not only did this interpreter ensure that the participant was able to communicate with her healthcare team, but she also acted in lieu of the participant’s support people, providing comfort and support: “When I entered the surgical room I cried. I was so lonely. I was scared. I needed someone to be with me to ease my stress. So, the interpreter, who I thank from the bottom of my heart, told me not to worry and told me that she will be there for me” (Participant 3). This participant conveyed the added benefits of in-person interpretation, which go beyond reading body language, to providing emotional support. Other participants even discussed their interpreters acting as advocates for patient safety.
Several participants indicated that they were not given any interpretation at all and were forced to navigate healthcare interactions in English during COVID-19: “Sometimes they explained things to me by using signs and I understand a little English but it’s hard to understand medical terms and they didn’t use an interpreter for this” (Participant 6). This participant felt particularly frustrated by this experience and did not feel like she fully understood the health information shared by her care providers. Moreover, information shared online about changing public health restrictions and hospital-based restrictions was predominantly provided in English. This language barrier made it difficult for women to keep up with the constantly evolving guidelines and restrictions related to COVID − 19and their understanding of access to postnatal care.
Transition to Virtual Care
The transition to telehealth and virtual care had both positive and negative implications for participants. Primary care services and in-home postnatal supports, such as those provided by doulas and public health nurses, were offered virtually. Telehealth appointments did pose some challenges for interpretation. Women described how complicated it was to connect with their primary care providers, and interpreters, over the phone. Appointments were carried out through back-and-forth telephone calls with a translator, who would relay information to the physician and then separately call back the participant: “I ask the interpreter and she speaks to the doctor and then they get back to me with the answers. It is complicated, but what could we do?” (Participant 4). Some participants felt a sense of hopelessness around this form of interpretation, feeling as though they had no alternative ways to communicate with providers. Though it was inconvenient for them, they felt it was the only option considering the restrictions caused by the pandemic.
Participants indicated that in-home services provided by doulas and public health nurses during the postnatal period were cancelled in the first wave. While public health nurses continued to follow-up with women virtually, the hands-on care they had provided pre-COVID-19 was not available. Primary healthcare services also transitioned to be mostly virtual during the first wave of COVID-19, impacting women’s ability to access long-acting contraceptives after birth. Women were only able to access condoms or oral contraceptives through virtual care appointments. Participant 4 described her experience: “I asked the doctor for an IUD insertion. I was prepared for its insertion, but it didn’t happen. Because of COVID, everything was delayed, and until now I haven’t gotten it.” Though this woman was able to access alternative contraceptive options in the interim, she was particularly interested in long-acting contraceptive options, for their preferable side-effect profile (over hormonal contraceptives) and heightened effectiveness.
Though virtual care did create challenges for some women, it was actually preferred by others. Telehealth appointments alleviated the need for some women to find childcare and transportation to attend in-person appointments. Participant 1 described her preference for virtual care: “I found the services I got when I delivered during COVID much better than those with my first-born baby here. I liked the services while delivering and the period after. They kept calling me, checking on me and asking how I was doing.” Similarly, participant seven said telephone appointments were “much easier” than in-person visits.
Loss of Informal Support
Stay-at-home orders, isolation requirements, and limitations on in-person gathering limited women’s access to informal support people after birth. This was compounded by the temporary closure of schools and daycare facilities, leaving women to care for their children and newborn without external support people, causing exhaustion, fatigue, and isolation.
Missing Support People
Gathering limits and physical distancing requirements additionally meant that women had few sources of in-person, informal support during their postpartum period. Several participants described the ways in which their neighbours and friends had supported them through previous, non-COVID births in Canada by providing meals, cleaning, offering emotional support and advice, and caring for their other children. These supports were no longer available to women during the first wave of the pandemic because of restrictions concerning household visitation. As all participants had already been separated from their extended family before COVID-19, as a result of forced migration and resettlement, their sense of loss was compounded by also not being able to see local friends after birth, who had become a kind of chosen family. Participant 7 described how difficult it was to be separated from her family and local friends, comparing her emotions to the experience of drowning: “It was really hard during COVID. In Syria I had my family… but to give birth here with no one with me?! It was really hard. I needed someone with me, my neighbours, my friends… I felt like I was drowning.” Several other participants had limited social connections even before COVID-19. For these women, nothing had changed between prior births in Canada and their birth during COVID-19, and as one participant explained, “Things haven’t changed because even before COVID I didn’t have any friends here” (Participant 6). These women were already extremely isolated and lonely, having been separated from their family in the Middle East, and having limited or no support people in Canada. Their pre-COVID postpartum experiences were no different than the isolating periods women endured during the pandemic lockdowns.
Childcare Burden
COVID-19 restrictions also resulted in the closure of schools and daycares between the months of March and June, 2020.33 As a result, all participants indicated that they had between one and seven additional children at home, fulltime after delivery. Participants discussed the stress and exhaustion experienced while juggling homeschooling or childcare for their additional children in addition to caring for their new baby. One participant stated, “There is a lot of stress. My son doesn’t go to daycare because of COVID, so both my sons are home all the time… It was very stressful at home, especially when I felt depressed, and the kids were there all the time… This was the hardest part” (Participant 6). Women discussed how tiring it was to have a newborn, let alone care for one in a context with limited support, and while caring for their additional children. Another participant described the social withdrawal that she felt while postpartum during COVID-19 as a result of the physical exhaustion she was feeling, “I was so tired and fatigued that I didn’t talk to anyone. I didn’t have the energy for anything” (Participant 7).
Anxiety and Grief Caused by COVID-19
COVID-19 had significant impacts on women’s mental health. The COVID environment overshadowed the joyous moments of childbirth, with women enduring heightened levels of anxiety triggered by a fear of the virus. Participants further reported feelings of sadness and disappointment as their expectations around their birth and postnatal period were disrupted by COVID-19.
Fear of COVID-19
A significant source of anxiety for many participants was the risk of themselves or their family being exposed to COVID-19. Women were particularly concerned for their infant’s health, feeling as though they were particularly vulnerable to the virus: “I was scared of COVID. I was scared over my children’s health and because I had recently delivered, I was afraid of my last baby’s health” (Participant 1). Several participants’ husbands were working in essential services (e.g., food delivery, construction) and continued to work during the first wave. This caused concern, for their husband’s health and that the husband may carry the virus into their home: “I was really scared. Because he was the only one who went outdoors and was exposed to people so I was afraid that he might get infected with the virus and carry it home” (Participant 6). Women were particularly hesitant to visit the hospital, or other healthcare clinics, fearing that it was a hotspot for the virus, “It was hard because I didn’t know how the situation was in the hospital, I was scared that the hospital might be an epicenter of the pandemic. I was scared that the virus spreads easily in the hospital” (Participant 6). Fear of COVID was a severe enough that one participant skipped certain postnatal appointments at the hospital. Others described the sadness that it caused them to have to leave their partners and infants at home and visit the hospital alone:
“I had to take all the precautions measurements and put on a mask and gloves. It was really hard. To go to the hospital a few days after birth, all by myself and to leave my baby at home because nobody is allowed to be with me was really very hard. I was thinking that even if I die, I will die alone. It saddened me” (Participant 7).
Several women also spoke of the concerns and anxieties they had for family members living in other countries (e.g., the United Kingdom, Lebanon, Syria), where there were high rates of COVID-19. “In Syria, where my husband’s family is, the situation is very hard, so many COVID cases” (Participant 5). Women also spoke of the fear their older children had around the virus. Participant 8 said that her children were “terrified of COVID.” Not only did they have to manage their own anxieties around their virus, but their children’s as well, to ensure their mental health was supported through the pandemic.
Broken Expectations
Several women described the hopes and anticipations that they had about their postnatal experiences, prior to the onset of the pandemic. Many participants were eagerly anticipating their “Canadian baby” and were looking forward to sharing this event with their new, local social network of neighbours and friends. Yet physical distancing and gathering limits meant that there were few opportunities for friends to meet and socialize in person with mothers and their new babies. Participants described feeling saddened that this significant life event could not be celebrated in person: “We really wanted to have a new baby here and were excited... I had been dreaming of having a big party after my birth here, to invite my friends but suddenly COVID happened, and I had no one to support me” (Participant 7). Other participants were looking forward to enjoying more intimate moments with their husbands and children, such as having their children visit in the hospital, which was not possible because of COVID-19, leaving women and their families disappointed, “My kids at home were so upset that they couldn’t visit me at the hospital and see the baby. They had been so excited during my pregnancy saying that they are waiting to visit me in the hospital after I give birth and to hold the baby, they wanted to bring me flowers but of course because of COVID none of that happened” (Participant 6). Most participants felt a sense of loss or grief, as they were not able to share in person the joys of having a new baby with their friends and community members—a key moment of the postpartum experience.