Background
The SARS-CoV-2 and related disease (COVID-19) is a rapidly evolving pandemic, which, along with its associated prevention and control measures, have globally led to adverse effects on maternal and newborn healthcare use, provision and quality [
1,
2]. During the pandemic, the adverse effects of COVID-19 were not limited directly to maternal and newborn morbidity, mortality, or respiratory complications resulting from infection with the SARS-CoV-2 virus, but also encompass indirect effects [
3‐
5]. For example, fear of infection while using health facilities, transportation bans and lockdowns prevented pregnant women from traveling to healthcare facilities to give birth, and were unable to seeking essential healthcare services, such as antenatal and postnatal care [
6,
7]. From the healthcare provision perspective, disruptions of health service availability were document, including the closure of outpatient clinics because the services were not deemed to be essential, the closure of labor wards because of staff shortage as a result of infection or because of the reallocation of maternity staff to provide COVID-19 care [
6,
7]. These factors collectively had negative consequences on the wellbeing of pregnant women and their babies and their ability to seek essential services during the pandemic [
6,
7].
Health systems globally have faced a rapid increase in health care demand due to the COVID-19 pandemic. When health systems are overwhelmed, mortality from infections and vaccine-preventable conditions increases [
8]. Public confidence in the ability of the health system to meet basic needs in health facilities is essential and enables continuity of public adherence to seeking emergency obstetric care and neonatal intensive care [
9,
10]. The success of the response to COVID-19 on limiting the disruption in maternal and newborn care services differed substantially across countries [
11]. In addition, the impact of COVID-19 on the availability and quality of maternal and newborn health services depends on the scale of the epidemic (number of reported cases and deaths) in a given area, as well as the preparedness of the health system (organization, availability of skilled health personnel, sufficiency of personal protective equipment [PPE]).
Tertiary referral hospitals for maternal and newborn care play a crucial role in health systems as they provide care to some of the most complicated obstetric and neonatal cases, including by receiving referrals [
6,
12‐
14]. Due to the high volume of patients they serve, the role they play in a health system and their capacity of expert staff, these hospitals seemed to be the first to develop protocols, train staff, encounter cases of COVID-19 among pregnant women, and trial processes on how to provide good quality maternal and neonatology care during the pandemic [
12,
14‐
16].
Guinea is a country that carries a high burden of maternal mortality, with a ratio estimated at 553 deaths per 100,000 livebirths in 2020, and neonatal mortality at 31 per 1000 livebirths [
17]. The progression of COVID-19 in Guinea has been characterized by a gradual increase in cases between March and December 2020, with a total of 14,840 confirmed cases including 54 deaths during this period [
18‐
20]. However, among the decisions made and the strategies implemented during the response to the COVID-19 pandemic, some important aspects were not considered. These include healthcare providers’ needs to timely access to accurate information, and involving healthcare providers in decision making and management of a health crisis of this scale [
21,
22]. Study in Brazil showed that infection with COVID-19 during pregnancy increases the risk of mortality [
23]. However, such data does not exist from Guinea. A quantitative study conducted in three hospitals in Guinea looking at aggregate routine data showed an increasing trend in maternal and neonatal deaths during the COVID-19 pandemic [
24]. These shortfalls occurred despite the country’s previous experience with the Ebola Virus Disease (EVD) epidemic, which presented learning opportunities to overcome difficulties related to affected countries’, including Guinea’s, preparedness and response to epidemics [
18,
25].
This study was part of a multicenter mixed-methods research project conducted in four sub-Saharan African countries: Guinea, Uganda, Tanzania and Nigeria [
26]. The multicenter study aimed to understand the perceptions, views, and experiences of healthcare providers in providing care to women and newborns in large referral hospitals during the first year of the COVID-19 pandemic. The objective of this paper was to explore healthcare providers’ perceptions and experiences of the response to the COVID-19 pandemic in three referral maternal and neonatal hospitals in Guinea.
Methods
Study design and duration
We conducted a longitudinal qualitative study between June 1 to December 31, 2020. The prospective nature of the study consisted of interviewing several respondents in each included hospital repeatedly over four rounds of data collection conducted three to 4 weeks apart.
Study setting
This study was conducted in three referral hospitals: two maternity wards (Hôpital National Ignace Deen (HNID) in Conakry and Hôpital Régional de Mamou (HRM) in Mamou) and the neonatology ward of the Institut National de Nutrition et de Santé de l’Enfant (INSE) in Conakry. The HNID maternity ward, located on the Kaloum peninsula in Conakry, is among the apex referral services in the country’s health system pyramid, with about 6000 births per year. The maternity ward of the HRM, located 275 km northeast of Conakry, is at the top of the health pyramid in the Mamou region, with an average of 3600 births per year. INSE is located in Kaloum, Conakry within the Donka National Hospital compound and is the sole intensive neonatal care referral ward in the country, with an average of 2100 neonatal admissions per year [
20]. At the time of this study, the Donka National Hospital maternity ward was closed for renovation, meaning that all neonatal admissions at INSE were referrals from other facilities or self-referrals.
Sampling and recruitment
Participants (i.e. healthcare providers) were purposively recruited to capture diversity of professional cadres (medical doctor, nurse, midwife), seniority levels (professor/head of ward, junior providers, interns) and genders, to capture a range of perspectives and experiences, allowing for maximum variation in the information collected, and until information saturation was achieved [
27]. Saturation was defined to be reached after the lack of generation of new information in the interviews, among different types of respondents and different rounds, and considering the stabilization of the COVID-19 situation in the country. We conducted IDIs in the three study sites with two types of respondents: first, regular respondents i.e. managers and directors of the wards and their assistants, as well as the supervisors of healthcare service activities in the two maternity wards and INSE, who were interviewed regularly during each of the four rounds; second, with irregular respondents who included healthcare providers, namely medical specialists and trainees, midwives and state registered nurses and who were interviewed only once during the study.
Data collection
A total of n = 46 in-depth interviews were conducted during the study period. Four rounds of interviews (around 12 IDIs planned per round over the three study sites) were conducted over 6 months namely June, July, August–September, and November–December 2020. We developed and used an interview guide with 18 main questions, to capture changes and adaptions to healthcare facility infrastructure, hygiene, care provision, data capture and community care-seeking behaviors in light of the COVID-19 pandemic. We also explored respondents’ personal experiences with stress and access to personal protective equipment. The interview guide was adapted to each facility context, respondent, and round of data collection. The interviews were conducted by an experienced qualitative researcher (ND) in French and audio-recorded. The necessary infection prevention and control measures were respected to protect the respondents and researchers from risk of infection transmission. In HRM, the first seven interviews were carried-out in person and the rest on the phone.
Data analysis
The audio-recordings were transcribed into French. From these, some quotes were translated into English, while pseudo-anonymizing. Qualitative data analysis was performed by developing an initial coding scheme, guided by the study objectives, after carefully reading and re-reading the transcripts. The coding tree was developed based on the main multi-country study, with specificities elaborated in relation to concepts specific to Guinea (e.g. links to Ebola outbreak). The coding tree included four mother-codes: changes resulting from COVID-19, adapting to changes, provider behavior towards patients, and management of COVID-19 cases. Coding was done by ND with N-Vivo v12. We then used an inductive approach of content analysis by identifying new themes in the data. An iterative process was used involving researchers and social scientists from different backgrounds (ND, BSC, AS, TD) to enhance the validity of the findings. The data were summarized by theme and sub-theme per study site and chronologically by data collection rounds, presented in a table, and narratively summarized.
Discussion
This study provides useful information on the adaptive response of maternal and newborn referral services during the COVID-19 pandemic in Guinea. Thus, many strategies were explored in the three wards, that including adapting and reorganizing in care provision, interactions (between providers and/or between providers and patients) and difficulties encountered. It describes also healthcare providers’ perceptions (quality of care provided, fear etc.…) and their experiences in the response to infectious diseases (e.g., EVD). This reporting followed how these evolved over the time (first year of COVID-19 pandemic), context (Conakry and Mamou) and specificity of each of these large referral hospitals during COVID-19 pandemic.
Among the strategies implemented, respondents identified the reduction of health care staff as one of the most effective strategies for reducing the risk of COVID-19 spread through referral hospitals. This reduction consisted of keeping only tenured providers (removing interns and volunteers) on the wards and was in line with physical distancing efforts. A global survey conducted by Semaan et al. and a rapid review of evidence from past epidemics carried-out by Desborough et al. [
1,
28] had similar findings. Despite the advantages of this strategy in preventing the disease spread and maintaining care quality improvement using only more experienced providers, it is known to be a source of mental and psychological discomfort for the retained healthcare providers (due to work overload) and for those on standby (due to their difficulties in dealing with daily life, particularly in such a pandemic context) [
29,
30]. In addition, the number of patient companions was also limited (one companion per newborn and up to two per woman) and visits were prohibited during the hospital stay. This decision was made in relation to healthcare providers’ experiences in the fight against previous infectious disease outbreaks such as the EVD. Although this decision sometimes created tension between providers and users, it was beneficial not only to reduce the risk of virus spread between providers and users, but also to facilitate the daily work of regular providers. Then, some activities, such as daily staff meetings (initially used as a means of communication) and which required the gathering of more than five providers, were suspended in these hospitals. Thus, to address the lack of communication within the teams, the use of platforms such as WhatsApp or Zoom were introduced as new means of communication. This adaptation has been useful for sharing information on ward functioning and on COVID-19 pandemic evolution (especially in the hospitals and wards). The continuity of this practice will depend on its understanding and acceptance by other professional categories (midwives and nurses). Another issue is that it could mean to additional costs for providers which were not covered by the facility [
31].
In the three referral hospitals, the nature and frequency of information received by healthcare providers led them to adapt accordingly. When providers were given frequent updating information, they maintained a rigorous IPC measures application as they were aware that complying with IPC measures was their main weapon against the pandemic. In contrast, when the frequency of updates decreased, providers inferred that the infection risk was decreasing or even that the pandemic was over. The lifting or loosening of certain restrictive measures (travel bans or gatherings) strengthened this perception, which favored new infected cases among healthcare providers and users, thus increasing the level of stress and distrust between the two groups. These findings highlight the need for actionable recommendations to be shared together with information about an epidemic trajectory. In addition, there is a need for staff training or capacity building as a stronger information path in function of each health crisis given the specificities of infectious disease epidemics. Ensuring the appropriate information flow, followed by actionable recommendations within an epidemic context enables for coping with uncertainties, fear, questions raising, unnecessary stress and stimulating motivations among healthcare providers [
32].
The main benefit of the IPC measures put in place during the COVID-19 response was the safe environment they provided for providers to continue to offer essential care to patients. Despite this enabling environment reinforced by ward reorganization strategies, there was a decrease in the utilization of care services. In our context, this could be explained by the negative perception that users of public health services have due to their negative experience with the advent of the EVD epidemic that the country experienced in 2014–2016 [
33]. The proximity of the CTPE has helped to maintain also this negative perception.
Although the solution was self-evident, telephone calls were used (via users) as a way to facilitate continuity of care. For providers, it was seen as an opportunity to limit contact, reduce the risk of virus transmission, and ensure timeliness in the healthcare delivery. However, there are many challenges associated with the use of this technology for access to healthcare, especially in health crises period such as COVID-19, as the implications of this technology are not always understood in our context. These implications can range from the stability of these networks, to the ability to pay for the prerequisites for its use (by users) on the one hand, or its standardization and understanding (by providers) to provide quality health care on the other. Galle et al. [
34] also note that the use of this technology could be inequitable in many ways, excluding the most vulnerable/poor women.
The Lack of PPE was one of the difficulties encountered by healthcare providers in the response to the COVID-19 pandemic in the three hospitals. This situation was reported throughout the study period and contributed to the decreased motivation of many of them because they felt they were not adequately equipped to deal with a health crisis of this magnitude. Given the risk of exposure of this group especially in the response to infectious diseases, this availability is all the more important because it indirectly influences the quality of care (maintaining their level of motivation), it provides a safe working environment (reducing stress levels), and does not affect their economy (they will not have to pay out of pocket for resupply) [
35].
Lessons learned
The findings of this study point out several lessons that could guide the healthcare provision during the COVID-19 pandemic or any other similar health crisis. First, it could be helpful to use mobile applications (WhatsApp, Zoom, etc.) in referral facilities to support and improve communication among healthcare providers (especially nurses and midwives) by addressing potential communication gaps/delays in health emergencies and beyond while considering the financial implications for providers. However, we acknowledge that using such tools includes potential security risks and privacy concerns, especially if sensitive patient information is being discussed. Second, despite their experience with epidemics (e.g. EVD), which is relatively limited for most healthcare providers, they should have training/capacity-building courses on infection management, prevention, and control, tailored to each health emergency when it occurs. Third, there is a need to concretely employ the knowledge produced from responding to previous infectious disease outbreaks and health system shocks to elaborate comprehensive emergency preparedness and response strategies, and the health facility, district, regional and national levels. Fourth, health authorities should ensure that sufficient quantities of PPE (preventive stocks) are available in referral public facilities to maintain the level of motivation and these implications, also reduce the level of stress (avoid possibility of possible infection risk) of healthcare providers and thus avoid the resulting mistrust. Fifth, strategies to strengthen public confidence in the public health system and to control practices in private facilities should be implemented. Finally, the provision of quality healthcare services and continuity for pregnant women and their newborns should be prioritized in the response to future health crisis.
Strengths and limitations
Despite these limitations related to the approach used (qualitative), our study allowed us to explore changes in-depth while its prospective nature was useful to observe and document changes over time. Also, the mix of perceptions of different categories of healthcare providers and the context of the study sites (two regions with these different realities) provided a wealth of data used to generate relevant evidence. However, we acknowledge that our study bears limitations including the fact that the qualitative nature of our study cannot allow the results to be generalized. Thus, the different coping strategies and reorganization of services, the effects of these changes on healthcare providers and the delivery of maternal and newborn care services identified in this study are specific to the study contexts. Future studies, particularly ethnographic studies, are needed to deepen our findings and include other regions of the country. Additionally, we did not collect information about respondent’s age, years of experience or other characteristics which could be relevant to the interpretation of the results. However, we collected and mention information on respondents’ cadres and seniority levels, which could be a proxy of age and years of experience, and were taken into consideration during the design and analysis.
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