“Winter is coming . . . ”
The Rotunda hospital's director of midwifery and nursing, Fiona Hanrahan, evokes a Game of Thrones mantra to convey the sense of foreboding as the flu season in tandem with Covid-19 approaches.
It’s the fear of the unknown, she says. Just at it was when coronavirus arrived. But then, as evidence emerged from other countries that pregnant women didn’t seem to be particularly adversely affected by Covid-19, maternity hospitals were reassured that while they needed to maintain effective infection controls, they should not see too many very sick women.
“Whereas we know with flu that when [pregnant] women get flu, they can get very sick very quickly,” says Hanrahan. “Then you don’t know what Covid and flu will do together as nobody has seen Covid and flu together yet – and that is a big worry for us – that is the scary part.”
Does she think the worst may be yet to come?
“Yes – but having said that the experience in Australia with flu hasn’t been what it normally is.”
She is taking comfort from that, although she also comments that it is a different climate there.
Hanrahan is hopeful that with social distancing, hand hygiene and mask-wearing, “we shouldn’t see massive flu, and flu is not as contagious as Covid, but for a pregnant woman getting flu it is actually scarier than getting Covid”.
Pregnant women are at greater risk of becoming severely ill from flu because their immune system is weaker and their heart and lung function is affected by pregnancy. Getting flu in pregnancy may also lead to premature birth, lower birth weight and even stillbirth.
For pregnant women with a pre-existing health condition such as a heart problem or renal disease, “the double bubble of getting Covid and flu would be desperate”, says Hanrahan. That is the primary worry in the Rotunda for the high-risk, inner-city population it serves.
At least there is a robust defence against one of those respiratory diseases, and she urges all pregnant women to make sure to get the flu vaccine as soon as it’s available, no matter what stage of pregnancy they are at.
She also recommends that they be particularly vigilant in observing social distancing, hand hygiene and mask-wearing to keep themselves safe over the winter.
The flu vaccine is always recommended to pregnant women who are included in the “at-risk” category, to whom it is offered free of charge. But the usual uptake among pregnant women is thought to be only around 30-40 per cent, “but nobody really knows because nobody gathers the stats”, says Hanrahan.
Normally the Rotunda doesn’t provide the flu vaccine to patients, but this year it is looking at the possibility of making it available at ante-natal visits.
“The evidence tells us that if we can not only advise but also offer and provide a vaccine women are more likely to take it.”
It would also then be on their records there, and it would be comforting to the hospital, she explains, to know their patients are vaccinated. They also hope staff uptake for this vaccine will exceed the normal level of about 80 per cent.
While the maternity hospitals’ fear is flu, for the children’s hospitals it is whooping cough. The Rotunda is being asked by nearby colleagues in CHI@Temple Street to encourage women to get the Tdap vaccine, which protects against pertussis, aka whooping cough.
Pregnancy weakens a woman’s immunity to whooping cough, and this top-up vaccine helps to protect the newborn before childhood immunisations are administered at two, four and six months.
On the other side of the city, the Coombe Women and Infants University Hospital has recruited a team of “peer vaccinators” among consultants, other doctors, nurses and midwives to facilitate a speedy and widespread uptake among staff as soon as the flu vaccine becomes available.
Once vaccinated the health professionals will be “protecting their families and the patients under their care”, says the hospital master, Prof Michael O’Connell, in a written response to queries from The Irish Times.
He also stresses that the flu vaccine is always recommended to pregnant women but particularly this season. As the majority of pregnant women split their ante-natal care between a GP practice and a maternity hospital, this vaccine can be delivered by the GP/nurse at one of the shared care appointments or a local pharmacist, he suggests.
O’Connell believes it is too early to say if the worst is yet to come for the maternity services but he wants to reassure patients that the Coombe is prepared and that women “will continue to experience the excellent care we provide, no matter what the circumstances”.
Flu is more of a health providers' issue at the moment, suggests Krysia Lynch of the Association for Improvements in Maternity Services (AIMS) Ireland, whereas the immediate concern of many pregnant women is not only the continuing restrictions but that that the rising number of Covid-19 cases will cause maternity services to reintroduce measures that were there during the first surge.
“Women are very aware what other women went through when it did tighten up,” she says.
In at least one maternity unit back in March and April, men couldn't be with their partners even for the birth of their child. Now many new fathers outside Dublin can still only be in the hospital while their partner is in a delivery room or theatre for a Caesarean section and he won’t see their baby again until the mother is discharged.
Pregnancy and birth are always times of heightened anxiety for expectant parents, and going through it during this pandemic increases the tension. Becoming a parent “is going to be the biggest transformation in your life ever”, Lynch points out, and inconsistencies in restrictions among the 19 hospitals that provide maternity care around the country are difficult for people.
AIMS Ireland has been asking hospitals to consider evidence and research in making their decisions.
“Some of these decisions definitely had a flavour of knee-jerk reactions, and there was no evidence to substantiate them,” says Lynch. In the absence of evidence, and with different practices in different hospitals, people “feel they are losing out on something, which they probably are”.
She is also concerned the numbers of inductions and Caesarean sections are increasing. From feedback of mothers and midwives, she says it seems a lot more people were being offered inductions not for clinical reasons but more for planning for the arrival of the baby to help hospitals manage resources.
While understandable perhaps, she says, “you wouldn’t condone it because it increases the risk to mother and baby – and you are shifting possibly the requirement for resources somewhere else”.
Comparing the self-reported figures for January and June this year among a number of maternity units, certainly induction seems up in some, although this is only a snapshot in time and we will have to wait for end-of-year figures to give a fuller picture.
For example, in Wexford General Hospital the induction rate was 34.5 per cent of all mothers delivered in June compared to 29.4 per cent in January. In Letterkenny it was 31 per cent, up from 27.8 per cent in January, and in Mayo 27.4 per cent in June compared with 23.6 per cent in the first month of the year.
Yet, in the National Maternity Hospital (NMH) and Coombe the rates were very similar, at 32.6 per cent compared with 31.2 per cent and 36.1 per cent compared to 35.7 per cent respectively, while in the Midland Regional Hospital, Portlaoise, the induction rate was actually lower in June (32.5 per cent) compared with January (38.1 per cent).
Other issues being raised with the AIMS support service about current practices include:
THE IMPACT OF VISITOR RESTRICTIONS
The exclusion of partners from ante-natal and post-natal wards is one of the biggest concerns among new parents. It means women going in for inductions, for instance, must go in alone, and only when their labour has progressed can their partner or nominated support person join them.
“You see behaviour being modified because of restrictions,” says Lynch. For example, women may not go into hospital as soon as they might have before in early labour because unless they are advanced enough to go into a delivery room their partner can’t stay with them.
“For some women that might be a good thing, they are comfortable with the labour process, maybe have had another baby before. But for other people that might only serve to increase their tension and levels of stress.”
Hanrahan says she wants the Rotunda to get back to a situation where women being induced or in early labour can have their partner with them. They were looking to lift that restriction at the end of July, and then when the issues arose with Kildare, Offaly and Laois they felt they could not.
“It’s hugely important [for women] to have their partners with them, and it is very worrying for the partner to be outside the hospital not knowing what’s going on,” she says.
Ante-natal and post-natal patients in the Rotunda can now have their nominated companion in between 5pm and 7pm on weekdays and between 2pm and 7pm at the weekend.
In the Coombe since July the partner/nominated visitor has been able to visit between 2pm and 4.30pm, with facemasks supplied by the hospital for the duration of the visit.
However, outside Dublin there has been very little relaxation of visitor restrictions. HSE recommendations are cited by one hospital group for not allowing any visiting to ante-natal and post-natal inpatients.
“Maternity units across the South/South West Hospital Group, which includes University Hospital Kerry, Cork University Maternity Hospital, South Tipperary General Hospital and University Hospital Waterford, are following the current guidance of the National Women and Infants Health Programme on this matter,” says a spokesperson for the group in a written statement.
However, “we are also very sensitive to specific situations regarding pregnancy loss, stillbirth and unexpected complications, and have relaxed our visiting restrictions in these situations.”
Yet go on to the HSE website and you will find variations. For example, Letterkenny University Hospital revised its restrictions from August 31st to allow birth partners on the maternity ward, post-delivery between 8am and 8.30pm and a 30-minute visit the following day at an allocated time. If a mother stays in for more than 48 hours the partner is offered a two-hour visit.
It’s not just geographical variations but differences within groups of patients in the same hospital that make it difficult for new parents to understand the logic.
Lynch says the three Dublin maternity hospitals have more autonomy because they are all voluntary hospitals and are stand-alone maternity services, while most of the other maternity units are part of general hospitals owned and funded by the HSE.
“As a user there should be no distinction, and women having a baby should be able to expect the same treatment in, say, Sligo and Mullingar and Kerry, as they would in the Rotunda. But the reality of the situation is you are not possibly going to get that because you have rules in the general hospitals that apply to all patients.”
However, she points out that these visitor restrictions in general hospitals have been varied for patients identified as vulnerable, such as those with dementia, “yet a father isn’t able to visit his son or daughter”.
So in drawing up these rules, “it has been clearly decided that new mothers and their infants don’t need visitors”.
NEO-NATAL INTENSIVE CARE UNITS
Initially in the pandemic parents were kept out of the Rotunda’s NICU.
“We couldn’t risk Covid getting into the NICU because nobody knew what Covid would do to a premature baby,” says Hanrahan. But now it’s open again, from about 10am to 7pm, to both parents.
The numbers in the Coombe’s NICU are small, and “throughout the pandemic we have worked closely with parents to ensure they could see their baby”, says O’Connell. Currently, “only one parent may visit during normal, daytime visiting hours, but in certain pre-arranged situations both parents may be allowed to visit at the same time”.
The NMH has lifted visiting restrictions for its NICU, and says mothers and fathers can visit whenever they choose.
Generally women are continuing to be asked to attend ultrasound scans on their own across the maternity services. It would appear that the Rotunda is alone in permitting partners to attend a scan – the anatomy or anomaly scan at 20-22 weeks.
The NMH allows partners to accompany women to a scan “if there is a significant issue”, says a spokesman, while acknowledging that this can not always be foreseen.
“Women are telling me they have had to weather the storm of losing a baby alone – you can only imagine what that would do for your mental health,” says Emily McElarney, a volunteer with the AIMS support group.
Ciara Turbett, who lives in Co Leitrim, can empathise with women in that position because before Covid, she attended alone what she thought would be a routine scan at 10 weeks and then got bad news of a missed miscarriage unprepared and unsupported.
Now pregnant again during Covid, she could not have anybody at her 12-week scan and “I had actually bled the day before so I was really, really nervous”. For her anomaly scan at 24 weeks,partners were still not getting in.
“It’s really tough on the Dads too,” says Turbett, who has heard of other women receiving bad news alone at scans.
She wonders why “you can have 50 people at a wedding but you can’t have a partner beside you to support you through something like that?”
Currently at 30 weeks in her pregnancy, she is worrying about what might be ahead of her if the numbers of Covid-19 cases continue to go up.
“Will your partner only get in literally for the birth? It’s amazing to see it so different around the country.”
But she certainly does intend to get the flu vaccine as soon as it is available to protect herself and her baby, and has done so in previous pregnancies.
Meanwhile, Hanrahan appeals to the public at large to play their part too. “Give pregnant women that bit of extra space because they just can’t get flu and Covid this year.”