Maternity in times of the Covid-19 pandemic: what mothers admitted in a reference hospital have to tell us

The Covid-19 pandemic has affected all aspects of our lives. Women in the perinatal period have unique needs, demanding health and safety guidelines regarding the risks associated to social isolation. The objective was to know the women’s experience during pregnancy or puerperium in the pandemic while being cared at a hospital. Qualitative study referenced on concepts of integrality of care and daily life. Eighteen pregnant and postpartum participated. Three themes emerged: Repercussions on pregnancy and puerperium, repercussions on practical life, and coping strategies created by women. The reports reveal different repercussions of the pandemic in the lives of women and their families, also the strategies and precautions used to mitigate its adverse effects. We suggest directing preventive measures and public health policies to prioritize pregnant and postpartum women, recognizing and embracing subjective issues involved at this moment in women’s lives


Background
SARS-CoV-2 infections have spread worldwide, with a rapid increase in cases and deaths, becoming a pandemic 1 .It is a disease with respiratory manifestations, a clinical situation that varies from asymptomatic infections to severe cases, and may progress to death.About 80% of people recover without hospital treatment, but in severe cases it can affect other organs besides the respiratory system 2,3 .
The people at highest risk are the elderly and those with comorbidities, such as high blood pressure, heart and lung problems, diabetes, or cancer, including pregnant women and women who have recently given birth 4,5 .Protective measures, such as hand hygiene, covering the mouth when coughing or sneezing, wearing a mask, keeping physical distance, knowing the symptoms of Covid-19, monitoring, and especially vaccination, have been disseminated 5,6 .Despite this, Brazil faces challenges in complying with the guidelines and in the effectiveness of the surveillance of the rules and regulations for the control and fight against the pandemic 7 .
Covid-19 affected people's lives with changes in family routines, the closing of schools, and more time spent together between parents and children 8 .Social distancing measures, although necessary, may impose risks to women's physical and psychological integrity, with an overload of domestic work and care activities for family members, including the less visible mental burden of emotional labor related to providing for the family's needs.This unequal distribution on women 9 can affect their health and life satisfaction 10 .Motherhood brings about changes, creating occupational needs, not only related to caring for children, but also influenced by social expectations and responsibilities assigned to mothers 11 .
During the pandemic, women during pregnancy, childbirth, and the puerperium have unique needs that require health and safety guidelines regarding the risks of infection and the implications of physical distance for them, their child or children, and their family.Women are a vulnerable group at risk of psychological distress exacerbated by deprivation of social support, a high-risk external environment, lack of comprehensive information about isolation and safety during pregnancy, and increased risk of infection with Covid-19 at health care facilities and restrictions during delivery 12 .
This overall context of insecurity experienced, concomitant with the recognition of the difficulties and duties involved in the act of giving birth, becomes more impacting when faced with the transformations of pregnancy, permeated by doubts, fears, and emotional instability in relation to the exercise of motherhood [13][14][15] .The uncertainties associated with infection, which justified the inclusion of pregnant and postpartum women in risk groups 16 , contributed to increase stress and insecurity about the babies' health.Studies to know the maternal emotional aspects and the repercussions of the separation between the baby and the mother diagnosed with Covid-19 have been recommended 8 .
The impacts of the pandemic are still undetermined, with psychosocial consequences possibly greater than are being perceived 17 .Analysis of previous epidemics/pandemics 18 suggests that families, especially mothers, may be at greater risk for depressive and anxiety symptoms in this context.Furthermore, the changes in family life can have a profound effect on child rearing, relationships, marital life, the relationship with the elderly, and the maternal-fetal bond 8 , deserving special attention 18 .
Concerns and stress caused by various factors and life events during pregnancy, such as the Covid-19 pandemic, can affect women's well-being and negatively impact the health of mothers and children 19,20 .Studies regarding stress and anxiety in pregnant and postpartum women during the pandemic show that women with a history of mental health treatment, those in the first trimester of pregnancy, and those who are single or in an informal relationship tend to have high levels of psychological distress and anxiety [21][22][23] , which may be exacerbated by the absence of a partner during and after childbirth 24 .
Listening to women in order to reveal their perceptions about how the pandemic affected their lives, what changes were necessary in the perinatal period and in baby care [25][26][27][28][29] , as well as identifying their attitudes and practices to prevent infection, can contribute to improve healthcare.Mothers and babies cared for by the Brazilian National Health System (SUS) became more vulnerable during pregnancy and in the first days after birth, because the access to specialized health services, in the context of the pandemic, was compromised due to the need to reorganize the flow and the creation of specific sectors to meet the demand of Covid-19 30 .
It is noteworthy that organizations have invested in providing open access resources with guidelines to support families 31 .
Considering that understanding the mothers' perspective can contribute to provide information and adjust the care to meet the women's needs, the objective of the study was to know the experience of women regarding pregnancy or the puerperium in the context of the pandemic by Covid-19.

Methodology
This is a qualitative study conducted in a maternity hospital specialized in care for women and children, located in Belo Horizonte/MG.It is a model maternity hospital, which serves exclusively through the SUS, with a predominance of a low-income population.Women assisted in different programs of the hospital were recruited: pregnant women in hospital follow-up, mothers of newborns admitted to the Neonatal Intensive Care Unit (NICU) and mothers of newborns assisted in the Outpatient Clinic for the Newborn at Risk.Data were collected from August to October 2020, using a demographic questionnaire, answered by consulting the woman's or the newborn's medical records, and a semi-structured interview containing guiding questions 30 , presented in Frame 1.The identification of the participants was done through the daily census of the units, in the case of hospitalized women, and the outpatient appointment schedule, for those at home.The interviews were conducted by researchers inserted in the study setting, who had previous contact with the mothers, reducing the risk of embarrassment and facilitating the interviews, that were conducted at times that did not interfere with the baby's routines and care.In the outpatient clinic, the mothers were interviewed after the baby's appointment.
Theoretical saturation was considered for the interruption of data collection, when new elements to support the intended theorization were no longer encountered, and the researchers identified that the data collected allowed answering the objective in a deep and comprehensive way and empirical saturation, when the interaction between the research field and the researcher no longer provided elements to deepen the theorization through the information provided by the participants 32,33 .
The interviews were recorded, transcribed in full, and submitted to content analysis 34 .Two researchers (AL and CM) did the in-depth reading, independently, identifying the central themes, grouped by similarity, forming thematic categories.Each category was conceptualized, and a new meeting was held with the participation of two other researchers (RHVTJ and ESD), aiming for consensus.
After categorizing the themes, the data produced were related to the object of study and discussed based on the literature 34 .As for the methodological rigor, credibility was sought through the interviews being conducted by five researchers (AL, CM, LA, PRC, and ESD) who worked at the site of the study.Confirmability was achieved by describing the methodological route, to allow other researchers to reproduce it 35 .

Results
Eighteen women participated, ten primiparous and eight multiparous, with ages ranging from 19 to 42 years and mean education of 11.4(±1.7)years.Among the pregnant women, the degree of gestation ranged from 26 weeks and 4 days to 35 weeks and 3 days.Among the postpartum mothers, newborns had gestational ages ranging from 26 weeks to 39 weeks and 3 days, with a mean birth weight of 1,487(±693.25)grams.The family structure was mostly composed of the husband/partner and the support network included the mother, partner, and family members (Table 1).Caption: P (Participant): G1 to 6 (pregnant woman), P1 to 6 (puerperal woman in rooming-in), P7 to 12 (mothers of newborns in outpatient follow-up for weight gain), Parity: G (gestation) P (delivery) A (abortion), GA: Gestational Age, BW: Birth Weight N/A: not applicable In the analysis of the interviews, three thematic categories were identified (Frame 2).
Frame 2. Thematic categories that emerged from the analysis of the interviews and their description Category Description

Repercussions on pregnancy and puerperium
Refers to the experience of pregnancy during the pandemic, the feelings of pregnant and postpartum women, the condition of having a baby hospitalized in a NICU and the experience after hospital discharge.It includes changes of plans as a result of the pandemic, birth planning and pregnancy celebrations, as well as the interruption of planned activities.

Repercussions on practical life
These are the precautionary measures identified by the mothers as necessary to avoid contamination by the virus.
It includes occupations and changes in routine.

Coping strategies
Refers to the new activities reported by pregnant and postpartum women in their daily lives.It includes the importance of the support network, defined here as the set of systems and significant people that make up the relationship links established and perceived by the individual36.

Repercussions on pregnancy and puerperium
The pandemic situation led pregnant women to experience feelings such as fear, worry, anxiety, and insecurity.These feelings are associated with the lack of knowledge about the disease, the possibility of affecting the baby, the need to change habits and behaviors, and the restrictions to social life 16 .
it is very difficult because we are very afraid of catching the disease [...] it has not been proven that it passes to the baby [...] very apprehensive" [...] everything you touch [...] you are afraid.(G6) In this way, a moment so desired and imagined by pregnant and postpartum women, important for the exchange of affection and formation of bonds through baby care, may have been harmed by the pandemic, which limited or prevented the various possibilities of sensory and interactive exchanges between mothers and their babies.
The repercussions in the lives of pregnant women can be intensified since they are a risk group for complications and death from Covid-19, demanding more rigorous and restrictive preventive measures 37 .As a consequence, there are exacerbated worries and fears, although justified, changes in social behavior, reduced family contact and support, and frustration of expectations and experiences of a unique moment in the life of the woman and her family.It may be also mentioned the reduction or cancellation of prenatal appointments and tests, which can affect the health of the mother and baby and increase the risk of pregnancy 37,38 .
Puerperal women expressed that the concern with the baby being premature was intensified during the pandemic, making evident the fear and uncertainty about the future.
we were not expecting her [daughter] now [...] it is not easy for mothers to gain premature baby in the middle of the pandemic.(P1) I became more fearful about the future [...] more fearful and cautious about everything.(P10) The birth of a baby that requires admission to the NICU is a challenging experience that generates feelings of sadness, fear, uncertainty, anxiety, and stress 39,40 .Parental stress is greater when associated with prematurity, due to the long hospitalization of the child and the increased risk of clinical complications 41 .Premature birth has repercussions on the mother and the family waiting for a baby, who did not arrive at the expected time and conditions.This, by itself, generates anxiety and fear, including about the baby's survival 42 .Prematurity during the pandemic time adds more fears, since mothers are not welcomed by family or friends due to social isolation.Being weakened, they find themselves alone and without support.
The frustration of not being able to share the pregnancy and the birth of the baby and to fulfill the rituals of the moment were expressed in the reports.Interface (Botucatu) https://doi.org/10.1590/Interface.220381[...] being so far from home and not being able to receive anyone [...] After he is born, no one can go to the hospital to see him, I always dreamed of this [...] when I get home [...] We should be very careful, I don't know if I will be able to receive everyone.(G5) Mothers who remain in the hospital with their hospitalized child are away from family life, which can contribute to a worsening in their emotional state 43 .
The repercussions of the pandemic on women's lives during pregnancy and the puerperium period are challenging, causing the reduction or suspension of baby showers, photo shoots, and participation in groups for pregnant women.The physical distancing measures influence the daily life and mothers need to adapt to this new model of behavior 38,43 .

Repercussions of Covid-19 in the practical life of pregnant women and new mothers
Disease prevention measures became part of the participants' daily lives.The birth of the baby and the need to stay in the hospital intensified the use of the mask and hand hygiene.mask, which we did not use.Wash our hands when [...] we got home [...] and alcohol gel -.... in the bag, in the car, wherever we go we have alcohol gel, we use it frequently.(P10) When responding to the demands to reduce the risk of contagion, mothers started to adopt new routines and habits, characteristic of this new daily life that causes changes in their way of life.The participants report preventive measures consistent with the preventive recommendations to contain the spread of the virus 10 .They also report restrictions of their and their family members' circulation to the home or hospital space.The daily life with new hygiene habits imposed by the pandemic changed everyone's lives, especially when a new baby arrives in the family, because there is the fear that the baby will be contaminated.The care is intensified with the use of alcohol gel in all spaces and objects and with the restriction of visits.This change has a great impact on family life and, mainly, on the mental health [44][45][46] of the mothers, since culturally it is something contrary to what is expected for the birth of a child.
Being necessary to prevent the circulation of the virus, the social distance weakens the woman's contact with her support network, especially when she needs to stay away from her husband and other children to accompany the hospitalization of the newborn 47 .When members of this network belong to the risk group for severe forms of the Covid-19, a more intense and conscious distancing on the part of the mothers is observed.
In other times we could have contact, like me here in the ICU with my son, we could receive visits.We could have face-to-face support [...] even because I have a mother who is in the risk group, I have people who are also in the risk group [...] difficult time for coexistence.(P3) In many families it is usual for grandmothers to be present at the birth and the first moments of the child's life.The pandemic prevented these exchanges, as many grandmothers are from the risk group and because protocols have been established in the ICU that do not allow visits to avoid contamination.Although justifiable, this generates impacts and insecurity for the mother who finds herself alone in an environment very different from the one she prepared to receive the baby.

Mothers report concern in performing the precautionary measures against
Covid-19 during pregnancy and when establishing contact with the baby.
we have to do [preventive measures], even more when pregnant, right, you have to be much more careful, I was careful, I am still careful today.(G3) I started to wash my hands more, before I did not wash them frequently.The use of alcohol now is frequent.(P3) Concurring with this study 43 , mothers have stopped performing some types of care such as touching or holding the baby in their laps and have intensified the basic personal care, to avoid contagion.As mentioned, sensory experiences have decreased in this period, being restricted to basic care.This may bring future consequences for these babies, because touch is an important need in this period of development 48 .
The mothers' reports show that the care to avoid contracting Covid-19 changed their daily lives and the way they started to perform their routine activities, such as work, affective contact with people close to them, and living with others.
[...] I was very damaged in the issue of jobs, in my city there is no job, the crisis affected a lot there [...] (G2) has been more reclusive [...] The coexistence [...], sometimes you want a hug, you want to sit everyone together and discuss something [...], because of the pandemic, this isolation has to be respected.(P3) It can be noticed that there are concerns with the issue of work, which also affects caregiving, since with one more member in the family, the responsibility of maintenance is fundamental, generating more insecurity.Another point is the mother's own affective need to feel touched and welcomed, willing to exchange experiences in this unique moment: that of being a mother.
The social distancing measures to reduce the spread of the disease influenced the distance from family members and the need to stay longer at home, and some women showed fewer difficulties in adapting than others.
as I was very homely, I think that for me, it was even quiet, [...], at first.Of course, after [...], I started to feel a little bit like going out [...], I understood well what was happening and the need for social distancing.(G4) The way in which women carried out their daily activities was influenced, with alternatives being incorporated for commuting and for using services such as pharmacies and supermarkets.
Respecting this question of distance.Avoiding as much as possible, like riding the bus.Using a car, an app driver, to avoid crowds.Avoiding as much as possible to go to the supermarket, [...].When you go, try to go as fast, as objectively as possible.Whenever possible to order.Order from the pharmacy, so that we don't go there, to avoid this street contact.(P10) It can be stated that as Covid-19 spread, it made it necessary for people to adopt objective actions and changes in behavior to stay healthy and feel safer.

Coping strategies created by pregnant women and new mothers due to the pandemic context by Covid-19
The pregnant and postpartum women reported coping strategies that contributed to their mental health, such as meditation and courses with themes of their interest, expanding their occupational repertoire.
[…] I started to do meditation [...] to look for ways to keep my mental sanity up to date [...] I looked for courses, right at the beginning, I started to take a Cavaquinho course, I already play the guitar.Then I took a drawing course.Then I started to take a meditation course and now I am taking it to my daily life to keep myself calm, without anxiety, I tried to do that.(G4) Another strategy was to look for activities, reading books, listening to music, watching movies and sleeping, to distract and keep themselves occupied.Corroborating the strategies used by mothers to reduce the impact of the pandemic on mental health, health authorities, researchers, and organizations related to health recommend exercises and actions that help reduce stress, such as meditation, reading, and breathing exercises, as well as the search for pleasurable activities, moments to rest and relax, and the search for trusted people to talk to, recognizing and accepting their own fears and fears [44][45][46] .
In the search for distraction, puerperal women were clear in avoiding watching television and news to avoid the increase of concern and fear.
[…] I try not to think too much so that I don't get a little crazy [...] not thinking and not watching television, because if you watch television you go crazy.(P8) The spread of myths, misinformation, and difficulty in understanding the health authorities' guidelines can cause fear, anxiety, and depression 45,[49][50][51] .
Another strategy listed to face social distancing was the use of mobile devices for phone calls.The use of technology, such as the internet and video calls, is recommended to maintain contact and bonding between patients and significant others in situations of isolation 45,51 .This strategy can be used in situations of isolation for mothers who accompany their hospitalized children, favoring the support and support of the family that is far away.
Mothers who remain in the hospital with their inpatient child during a pandemic are away from family life, which can be enhanced by the contingency plan.For Heller 52 , "there is no everyday life without imitation" (p.55).Thus, knowledge acquired based on personal experiences and examples of people we take as models, are impeded in the context of family isolation, which also reduces effective support and backing, impacts the management of expectations, plans, and dreams related to the arrival of the baby and the pregnancy itself 38,42,43,53 .
The women reported that staying in the institution with other women who were in similar conditions, allowed the construction of new friendships, configuring a new form of support and coping.Interface (Botucatu) https://doi.org/10.1590/Interface.220381 […] here inside [the hospital] is bad, because we are far from the family, but here it is nice because we make friends [...] if I had it at home I would be worse [...] here I have a lot of support.(G5) If, on the one hand, the hospital stay leads to the removal of the family and the support network, on the other, there is the possibility of socializing with other mothers who are in similar conditions, effective in a relational space that extrapolates the technical care of the hospital 54 .This environment and this opportunity to socialize favor the reduction of anxiety, worry, and fear levels, since they allow the exchange of experiences and information, providing a momentary distancing from stressful situations 38,43 , as observed in this study.These exchanges should be considered as a powerful "health care device" to be encouraged by professionals and service managers.

Practical recommendations and limitations of the study
The reports of pregnant and postpartum women and mothers reveal different repercussions of the pandemic in the lives of women and their families.The adjustments in expectations regarding pregnancy and childbirth, the changes in daily routines and the distance from the support network, as well as the frustration and fear of the unknown were evident.On the other hand, the reports reveal strategies and care used to mitigate the adverse effects of the restrictions imposed by the pandemic.
Combining this information, and based, as Kalichman and Ayres 54 state, on overcoming the limits set by the traditional clinic for a health work that recognizes the subjects and their needs, values their knowledge, and takes co-responsibility for their therapeutic projects 54 , it is possible to derive some suggestions for structuring good practices in health services in the investigated context, based on meanings assumed by comprehensive care 54 .It is suggested to ensure the integrality of the care through the intersectoral articulation of the health and social services; implement guidelines on health and safety as to the risks of physical distance for women, children, and families, considering the needs of affective contact in the family context; offer informative material about Covid-19 with detailed and updated guidelines, in language accessible to the women; maintain the social support network by encouraging the use of technological tools: telephone, cell phone, internet, to maintain access of the pregnant and puerperal women to the necessary support; support the reorganization of daily routines, with inclusion of strategies for stress reduction and identification of pleasurable activities, for maintenance of physical and emotional health.
One of the limitations of this study is the socioeconomic and cultural homogeneity of the participants, since the access to the women was given by their link to a health service that covers a peripheral and metropolitan region of a state capital.The small number of participants and the variability of gestational age and birth weight of the baby restrict generalizations, but reflect the population assisted in a hospital that provides exclusive care to the SUS in Brazil.Another limitation is the cross-sectional aspect of the data collection, which occurred during a phase of the pandemic.However, the goal was to give voice to women in situations of social vulnerability, who receive limited support from health services.

Frame1.
Guiding questions for the interview a) How have your days been at this time of the pandemic?b) What has changed in your plans related to pregnancy and the arrival of your baby (For pregnant women and mothers of newborns) c) What changes have you identified in your daily life?d) What have you done to mitigate the consequences of the pandemic and the need for isolation?

[
…] the use of telephone.That's what has helped me a lot [...] I talk a lot with my relatives [...], through the apps.(P3)

Table 1 .
Characteristics of the study participants