The dissemination post went online at the end of the year 2020 (exact date retracted to prevent identification). At the date of data download, a week later, it had been liked 86 times, shared 48 times, and commented 213 times (direct comments to the post and replies to comments). Each comment also generated its own share of engagement or reactions in the form of “like” buttons and emojis. Many of the contributions were tags to point out the study to women who met the requirements or might be interested in participating (n = 68). Another set (n = 17) was signifying own participation (e.g. “participated!”). One comment was someone using the post as an opportunity to advertise a product. This left 127 written contributions from 69 individual contributors for the content analysis, as well as contributions from further users in the form of reactions, i.e. “likes” and emojis. The majority of comments generated 1 to 5 reactions, 5 comments more than 10 reactions, and one comment 109 reactions. The most mentioned topics and related themes created through the analysis pertain to (i) own mask-wearing, (ii) the presence or absence of a birth partner and supportive care at different stages of the birth process, and (iii) visiting rules, i.e. the (im)possibility to welcome visitors in addition to the birth partner. A fourth, less explicit theme runs through all topics and relates to the way COVID-19 measures are understood and accepted or rejected. Not all women indicated when they had given birth, but for those who did, we mention the birth month after their identifier. For a better understanding of the epidemiological context, Fig. 1 plots the study timeline against the COVID-19 incidence in Germany between March 2020 and December 2020.
Own mask-wearing as a physical and psychological threat to birth integrity
The comments on own mask-wearing during birth refer to the different phases of labour, birth, and the postpartum stay at the maternity ward. Overall, the comments indicate that mask-wearing in communal spaces (outside the patient room, e.g., corridors) and when healthcare professionals entered the patients’ room was obligatory for almost all women. One woman reported having to wear a mask “day and night”, as a healthcare professional could enter the room any time (A126, April).
Some women were not obliged to wear a mask during birth, including women with a planned caesarean section (A28, A106), and others having a vaginal birth (e.g. A120):
Fortunately, I didn’t have to wear one [mask] either. The midwife immediately said that the masks can be removed, you cannot give birth with it (A120).
Still, many comments disclose that women were requested to wear a mask during the active phase of labour and until either a healthcare professional or themselves got rid of the mask:
Mask on, even during the birth. But when it went into full labour, the thing flew through the delivery room once. Nobody said anything. (A96, September)
I always wore a mask in the room when someone came in. […] in the delivery room during CTG [Cardiotocography] and other exams [I was] always wearing a mask. During birth, when things got really serious, I was fortunately allowed to take the mask off. (A55, November)
In the beginning the mask had to be on, during birth, it didn’t matter at some point, only the midwife and the doctor had theirs on. We had to put ours back on when we went to the ward. (A84, September)
The comments demonstrate a discrepancy between the formal instruction to wear a mask and the actual, more flexible handling from the healthcare professionals when women went into full labour.
What the above quotations have already indicated (omission of the mask as a relief), is explicitly expressed in the following comments, demonstrating that mask-wearing at any time during birth (including during expulsion) was perceived as an unpleasant and stressful experience:
I also had to wear a mask. Quite horrible. (A22)
Oh, I’ll take a look at that [survey]. If it helps that women do not have to give birth with a mask, like me, it would be a success. (A111)
This last comment by A111 was met with 16 supportive reactions, primarily emojis expressing sadness and shock. It also led to a controversial discussion as one contributor claimed the salutary role of masks in protecting the healthcare professionals from infection in a rather offensive tone, e.g., claiming that women make “a huge drama out of everything and get hysterically worked up about it” (A26). Most of the subsequent commentators solidarised with the women having had negative mask-wearing experience and gave reasons against wearing a mask during active labour, e.g., according to their midwife, “oxygen supply is the most important thing”, why mask-wearing is not requested in their hospital (A23) or pointing out that the German midwifery association clearly states “no to mask-wearing” (A30). One contributor held accountable the hospital management and policy for providing midwives with “appropriate masks (FFP2) for their own protection” and:
(…) let her [the parturient] damn breathe freely. Not because otherwise, she will suffocate (…). But because she is about to give life to a little human being and breathing is essential. (A24)
For many who mentioned mask-wearing without emphasis and without diving deeper into the pros and cons of general mask-wearing, we can assume that they share a general understanding and acceptance of mask-wearing as a measure to contain the spread of SARS-COV-2. However, the discussion specifically about mask-wearing during the active phase of labour reveals that acceptance of the rules comes with limits and that women explicitly articulate the difference between what seems an acceptable public health measure and what is considered an infringement to the physiological process of birth or to their bodily integrity.
Limited presence of a companion of choice during birth and lack of supportive care: women at risk of abandon
Whether a companion of choice was allowed to accompany the women throughout labour and birth varied: while some women who had undergone a planned caesarean section had their partners with them throughout the procedure (A106, A28), one woman had to deliver without her partner:
Husband was not allowed to attend the caesarean section! (was worst part of the [experience] for me) (A79, May).
Many women shared the experience of having to manage the contractions alone and that their partner was only allowed to join when they went into active labour (A82, August; A19, September; A84, September) or, when after going into labour, a caesarean section was performed:
My husband was only there for the C-section. During labour, I was alone - and the 3 days afterwards on the ward [I was] also alone [sad emoji and crying emoji] (A76, March).
My husband was not allowed in the delivery room until it started. (…) I could only call him after the water broke. He almost missed the birth [crying emoji] (A96, September).
This woman, whose birth was induced, was alone until the onset of labour as well. Nevertheless, she felt well supported “since everyone at the hospital was really totally sweet”, and her husband was called in time to attend the birth (A124, November). Her positive perception of being well cared for seemed to balance out the absence of her partner, at least partially.
In contrast, A122 not only had to cope with labour and birth on her own but in addition was confronted by a lack of supportive care that added to her overall negative birth experience,
I gave birth (…) in April alone, without my husband. Even though it was the third child, it was just awful because the support was lacking. Also, the staff was hardly there, so I was alone in the delivery room for 11 h and had to go through labour alone. It wasn’t until the final spurt that a super lovely midwife came and supported me (…) this [experience] was awful for me, and I struggled with it for a long time (A122, April).
Another woman who also gave birth "alone" in April was similarly denied supportive care:
[I gave birth] in April, delivered alone, and no visit of my husband or child was allowed afterwards.[…] [I] was also not allowed to be present at any examination of the child. (A126)
Her comment generated 109 reactions, with many emojis manifesting the anger, shock, sadness and empathy of the other contributors. The complete isolation of the woman, including from her newborn during examinations, was upsetting to many, with the words “horrible” and “inhuman” being used to describe the situation.
The absence of a birth partner and supportive care was generally seen as detrimental to the birth experience and considered as an extreme (somewhat unjustifiable) measure that was going “too far”. The women who were allowed to be accompanied throughout their hospital stay showed gratitude and acknowledged how “lucky” they had been compared to those who were denied such support.
Limited visiting hours and restricted access: contrasting impacts on birth integrity
The comments reveal restricted partner visiting regulations for all patients, ranging from a complete ban on visitors, including partners presence during and after birth (A122), to restricted visiting hours (A19):
My husband wasn’t allowed to visit us, so he didn’t see his little nugget live until he picked us up from the hospital two days after delivery. (A122)
After the birth, there were visiting hours of 3 h for my husband. He also had to go home two hours after the birth and was allowed to come back at visiting hours… On the day of discharge, he was also not allowed to pick us up from the room, there haven’t been visiting hours… (A19, September).
Welcoming other visitors, including the newborn’s siblings, was not possible. Due to those restrictions and sometimes lack of childcare for older siblings, some partners had to refrain from visiting (A84):
My husband could have visited from 2 to 8 p.m., but he didn’t because my son was not allowed to come to the hospital. Other visitors were not allowed to come. (A84, September)
My husband was there [hospital] once for exactly one hour because he was not allowed to bring our three year old, and we had no one to watch her. I discharged myself on the 3rd day after having many discussions. (A119, June)
The clinic had already sealed itself off. Visits for an hour a day and without children. On the third day, I was discharged at my own request. (A42, March).
Those rules negatively affected many women, which sometimes led them to request a shorter length of stay and early discharge from the hospital (as seen in the two last comments above)Footnote 2. In some cases, women decided to circumvent the rules by choosing to deliver in settings that would allow them more freedom, for example, a smaller hospital with “loser rules” (A26, A28) or a home birth (A109):
We didn’t want all these rules. We gave birth at home. Midwife no mask, me none and my husband none. Visits from the first hour the way I wanted it. Thank you, COVID-19 for this indescribable and self-determined birth. (A109)
Although the limitations of partner’s visits and the ban for siblings of the newborn was for many women problematic, the limited visiting hours and low number of visitors in the hospital was the most appreciated pandemic-related measure.
Much quieter without other visitors compared to my 1st [time at the maternity ward]. (A10)
It was quiet and relaxed in the ward. Lovely. No crowds of visitors. (A96, September)
Other women shared these feelings and experiences, commenting how the maternity ward felt calm and relaxing, thanks to the absence of visitors (A58, A96).
New mothers and healthcare professionals alike saw the relative emptiness and quiet of the maternity wards as an opportunity to rest, heal and recover. It also provided a protective setting for the important developments in the postpartum phase (e.g. breastfeeding) and the nurturing of a bond between the mother and her newborn:
My husband was allowed to come daily at visiting time, but other visitors were not, which did not bother me at all. We were able to be in peace and quiet, and the staff on the ward also told us that the women recover so much faster from birth, the milk comes in more quickly (A58, October).
It was wonderfully quiet in the hospital, and we could relax without the stress of visitors, and I could recover. (A38, April)
Similar to own mask-wearing, the restrictions put on the number of visitors and visiting hours were, to some extent, understood and accepted by most women. Several contributors even identified in quieter surroundings positive aspects of the pandemic and an opportunity to revel in the postpartum period. But common to all testimonies remain the need to take into account, as much as possible, the personal circumstances, wishes, and expectations of every woman, e.g. the one with other children, the one who prefers to be discharged early, the one who needs quiet.