Intended for healthcare professionals

Rapid Response:

Re: Care during covid-19 must be humane and person centred - Partner attendance at maternity services

Dear Editor,

We read this editorial with interest. Coulter and Richards rightly highlight the concern held by many, that restrictions on hospital visitors have been applied in a blanket fashion which ignores the important role played by some visitors [1]. They cite several examples, including “barred fathers from labour wards”. The most obvious concern is that partners will miss the birth of their children, or at least be asked to leave shortly afterwards. But beyond this, there are the possibilities that women will receive devastating news at antenatal scans; have to make extremely difficult decisions without the support of their partners, at a highly vulnerable time; reduce patient choice; and that safeguarding concerns may be missed.

Beyond the moral imperative, there is a wealth of evidence demonstrating the importance of partner attendance in maternity care, not just during birth, but more generally across maternity services. The World Health Organisation recommends the involvement of a companion during pregnancy, birth and the postpartum period as an effective intervention to improve both maternal and newborn health outcomes, and to promote gender equality [2] – a recommendation that they have re-iterated during the COVID-19 pandemic [3]. Studies investigating the effect of interventions to engage partners in the antenatal care pathway have reported improvements in antenatal care attendance, couple communication and shared decision making [4]. Cochrane reviews have reported that partner support during the intrapartum period is associated with improved short-term (e.g. shorter labours, decreased operative or instrumental births, reduced pain, and improved five‐minute Apgar scores) and longer-term outcomes (reduced negative feelings about childbirth experiences) [5,6]. Finally, involvement of partners has been reported as a key component to successful interventions to prevent postnatal depression [7].

We sent a freedom of information request, on the 24th of August 2020, to every maternity service in England. We asked for details of restrictions on partner attendance at each stage of the maternity pathway, from antenatal scans through to postnatal care in the community, during the first peak of COVID-19 in England. We received responses from 81 of the 127 trusts (64%). Every trust reported implementing some degree of restriction on partner attendance during the COVID-19 pandemic, however, the extent of these restrictions varied significantly. Taking each part of the maternity pathway in turn:
• Antenatal Care: The vast majority of trusts prohibited partners attending the 12 week (73/81 trusts, 90%) and 20 week (71/81, 88%) routine antenatal scans during the first peak. Even more trusts (77/81, 95%) restricted attendance at non-routine services, which include assessment for reduced foetal movements. As restrictions have been slowly eased, the postcode lottery faced by partners has worsened, with 20 (25%) and 31(38%) trusts lifting restrictions for 12- and 20-week scans respectively.
• Intrapartum Care: All trusts allowed partners to attend services for the birth, however, 70 trusts (86%) applied some level of restriction e.g. prohibiting attendance during induction of, or the latent phase of labour; or reduction in the number of hours they could be present for after birth - in the most severe case this was reduced to less than one hour. Regarding homebirths, 16 trusts (20%) stopped offering women the choice of a homebirth during the first peak, and 39 trusts (48%) restricted partner attendance at the homebirth.
• Postnatal Care: 80/81 trusts (99%) restricted partner attendance in some way at postnatal services, with 40/81 (49%) barring partners from attending altogether.

Coulter and Richards also highlighted the plight of vulnerable patients, including those who may have mental health problems or disabilities, being denied the support they need. Specific to maternity services, patients may also experience acute challenges related to previous sexual abuse. Encouragingly, all trusts reported that their partner restriction policy included provision for making exceptions where appropriate, however only 27 trusts (33%) actually had a formal process agreed for this. The remaining reported reviewing on a case-by-case basis, which in practice is likely to have resulted in high levels of subjectivity in the application.

Additionally, the authors lament the “failure to include lay people in decisions about reconfiguration of services”. We found that 26 trusts (32%) had neglected to work with patients or patients groups on the design and implementation of local policies to restrict partner attendance.

These results demonstrate significant inconsistencies between trusts, leading to a postcode lottery for new parents around the country. It is therefore perhaps unsurprising that different trusts reported having used a range of organisational guidance to develop their restrictive policies including: the Royal College of Obstetricians and Gynaecologists (n=53), the Royal College of Midwives (n=39), Public Health England (n=18), NHS England (n=12), the Society of Radiographers (n=6), the Nursing and Midwifery Council (n=2), and the Royal College of Radiologists (n=2); many of whom adopted subtly different stances regarding partner and visitor attendance at maternity or healthcare services in general. Two thirds of trusts reported using more than one external source of guidance. Broadly, all of the national guidance and local policies were intended to reduce footfall in healthcare settings in order to promote social distancing, whilst continuing to provide services. Clearly this makes sense as an overarching aim, appropriate in most areas of healthcare. But nuance is required for maternity services, where visitor restrictions do not just result in minor inconvenience, but cause an increased risk of negative outcomes, significant distress, an erosion of shared decision making, a reduction in patient choice, and deprive partners of being fully present during the process of birth of their own children.

Encouragingly, several of the aforementioned national bodies have come together with NHS England to issue new joint guidance, urging trusts to rescind these blanket restrictive policies for maternity services [8]. However, 35 trusts (43%) indicated that they had not yet started action to reverse their restrictive policies on partner attendance, and 17 trusts (24%) explicitly stated an intention to reinstate restriction in their original form in the event of local lockdowns, or a significant second national spike in COVID-19. “Care during COVID-19 must be humane and person centred”, write Coulter and Richards. We wholeheartedly agree, and concerted efforts are required to make this a reality for maternity services.

Dr Sebastian Walsh
Academic Public Health Specialty Registrar, University of Cambridge
Corresponding Author:

Fiona Simmons-Jones
Public Health Specialty Registrar, East of England

Rebecca Best*
Public Health Specialty Registrar, East of England
*Worked as a Ward Manager of an English Maternity Unit during the first wave of the COVID-19 pandemic

1. Coulter A, Richards T. Care during covid-19 must be humane and person centred. BMJ 2020; 370.
2. Organization WH. WHO recommendations on health promotion interventions for maternal and newborn health 2015. World Health Organization, 2015.
3. Organization WH. Companion of choice during labour and childbirth for improved quality of care: evidence-to-action brief, 2020. World Health Organization, 2020.
4. Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: a systematic review of the effectiveness of interventions. PLoS One 2018; 13: e0191620.
5. Bohren MA HGJSCFRK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017;
6. Bohren MA BBOMH, Tunçalp Ö. Perceptions and experiences of labour companionship: a qualitative evidence synthesis. Cochrane Database Syst Rev 2019;
7. Morrell CJ, Sutcliffe P, Booth A et al. A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technol Assess (Rockv) 2016; 20.
8. NHS England and NHS Improvement. Framework to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services. 2020.

Competing interests: No competing interests

25 September 2020
Sebastian J Walsh
Academic Public Health Registrar
Fiona Simons-Jones, Rebecca Best
University of Cambridge
Cambridge Public Health, University of Cambridge