Midwives’ experiences using personal protective equipment during COVID-19: a scoping review

Healthcare facilities depend on standard and transmission-based precautions to prevent and reduce the spread of infectious organisms, in order to protect patients and healthcare workers (Siegel et al, 2007). Especially in extreme infectious situations, certain protective measures need to be in place to limit the possibility of cross infection from both identified and unknown sources. As a result, standard precautions have been implemented on a regular basis with all patients who present in a healthcare environment, to reduce the risk of infection (World Health Organization (WHO), 1998; Centers for Disease Control and Prevention (CDC), 2007). Implementation of standard precautions includes the usage of personal protective equipment and were characteristically outlined in hospital guidelines and policies, such as by the CDC (2007) and WHO (2016).

The WHO declared COVID-19 a global pandemic in March 2020 (Arden and Chilcot, 2020). As a result of the rapid and unexpected spread of COVID-19, and in response to national and international recommendations, certain restrictions were implemented and imposed. These restrictions shaped the delivery of healthcare services around the world. In Ireland, the Health Service Executive enforced mandatory directives in all healthcare facilities, some of which included wearing personal protective equipment, social distancing and visiting restrictions. These measures were updated and communicated regularly by the Irish government following the Irish Chief Medical Officer’s and the National Public Health Emergency Team recommendations.

Personal protective equipment involves the use of gloves, aprons/gowns, masks and eye protection, and should be used when there is a potential risk of bodily fluids while providing care to a patient. These issues include transmission of communicable diseases such as hepatitis B virus, human immunodeficiency virus and hepatitis C virus. Personal protective equipment should be worn following a risk assessment (Deepthi et al, 2020) and should not be seen as a substitute for effective hand hygiene (WHO, 2009).

The COVID-19 pandemic caused difficulties for the healthcare system and its staff. In maternity services, healthcare providers were challenged by attempting to ensure the needs and safety of pregnant women, newborns and their families were met while being mindful of their own personal safety (Pollock et al, 2020). Issues in the provision of appropriate personal protective equipment to frontline healthcare workers proved to be a significant drawback to the delivery of efficient care (WHO, 2020a). The necessity for personal protective equipment has put unprecedented strain on global supply chains and in March 2020, the WHO (2020b) requested that global manufacturing of personal protective equipment be increased by 40%. This rise in manufacturing subsequently raised concerns in relation to inadequate provision of personal protective equipment and its effect on the safety of frontline healthcare workers. Longer working hours, the danger of exposure, concerns about infecting family and the inadequate distribution of personal protective equipment made healthcare workers particularly vulnerable (Lai et al, 2020; Pfefferbaum and North, 2020).

Healthcare workers reported a sense of danger and uncertainty, a negative emotional impact, a lack of support from employers and increased anxiety (Chen et al, 2020; Xiang et al, 2020). This occurred along with widespread reports that healthcare workers around the globe had to provide care with inappropriate personal protective equipment (Garber et al, 2020; Ranney et al, 2020). Midwifery is a unique area of care because although COVID-19 is not a direct treatable condition, it can still pose severe danger to pregnant women, newborns and staff.

There is little evidence on midwives’ experiences with the use of personal protective equipment during the pandemic, and a need for more research to explore midwives’ experiences in this area has been identified (Bradfield et al, 2022). This scoping review aimed to explore these experiences.

Methods

A scoping review method was used to review the literature. This method is recommended when the topic has not yet been broadly reviewed or is of a complex nature (Mays et al, 2001). The methodological approach of this study followed Arksey and O’Malley (2005) with advancements/updates by Levac et al (2010) and Bradbury-Jones et al (2021). These updates advise combining a broad review question with a clearly expressed scope of inquiry that defines the concept, population and outcomes to focus the scoping review and each stage of the review process. A scoping review allows the literature to be processed in a comprehensive and systematic manner. The Arksey and O’Malley (2005) approach consists of a five-step process:

• Identify the research question
• Identify relevant studies
• Study choice
• Plot the data
• Arrange, summarise and communicate the outcomes.

Identifying the research question

The purpose of this review was to explore midwives’ experiences using personal protective equipment during the COVID-19 pandemic. The design aims to discover, understand and portray these experiences while remaining close to the participant’s descriptions (Neergaard et al, 2009; Sandelowski, 2010; Kim et al, 2017).

Identifying relevant studies

The review search was performed in December 2021 and updated on 28 November 2022, using seven databases: Scopus, Academic Search Complete, CINAHL, Embase, Medline, MIDIRS and Web of Science. Searches were performed on the title or abstract in each of the databases using key words with Boolean and truncation methods. The search method (Table 1) and criteria (Table 2) were agreed by all authors and no judgement or conclusion was made on quality of the literature obtained, as the aim of this review was to identify and map the evidence retrieved.

Study selection

All articles retrieved from each database search (n=275) were exported to Endnote and screened, with 111 duplicates being removed, leaving 162 for screening. Two reviewers (AO’F, OD) then independently reviewed the titles and abstracts against the inclusion criteria (Table 2), with a further 132 papers being removed. The remaining papers (n=32) were retrieved for full text review by the two reviewers, who worked independently to decide which papers met the criteria. Grey literature (World Health Organization, Trip medical database, OPENGREY, GreyNet International) were also screened in an attempt to maximise the review; however, of the six articles retrieved, none were deemed suitable as they did not meet the criteria. The review process is outlined in a PRISMA flow diagram (Figure 1) (Page et al, 2020).

Plotting the data

The systematic search and application of inclusion and exclusion criteria resulted in 16 studies being reviewed. These studies included were analysed using Braun and Clark’s (2021) thematic analysis framework of familiarisation, coding, generating themes, then reviewing, defining and naming these themes.

Collating, summarising and reporting the results

Data extraction was completed, summarising the author, year, title and location of study, aim of the study, methods and methodology used, summary of the findings, key messages from the study and limitations, if any.

Results

Study characteristics

Of the reviewed papers (n=16), seven were quantitative studies (Issadeen et al, 2020; Kotowska and Gawlik, 2020; Del Piccolo et al, 2021; Homer et al, 2021; Izhar et al, 2021; Munn et al, 2021; Haegdorens et al, 2022) and nine were qualitative (González-Timoneda et al, 2021; Gutschow and Davis-Floyd, 2021; Hantoushzadeh et al, 2021; Hazfiarini et al, 2022; Hearn et al, 2022; Hijdra et al, 2022; Jacobsen et al, 2022; Küçüktürkmen et al, 2022; Fumagalli et al, 2023). Sample sizes ranged from 8 (Hearn et al, 2022) to 452 (Izhar et al, 2021) participants and settings included community-based to hospital-based maternity units across 10 countries. Three studies were from the USA, two were from Australia, two from Italy and one each from Pakistan, Poland, Turkey, Spain, Belgium, Iran, Indonesia, the Netherlands and Sri Lanka.

Themes

Four themes were established from the literature review: fear and anxiety, personal protective equipment/resources, education and training needs and communication.

Fear and anxiety

Midwives experienced fears in their role, such as fear while caring for pregnant mothers (Hantoushzadeh et al, 2021; Homer et al, 2021; Hazfiarini et al, 2022), of contracting COVID-19 (Hantoushzadeh et al, 2021; Homer et al, 2021; Hazfiarini et al, 2022) or of inadequate personal protective equipment (Hazfiarini et al, 2022). Some feared infecting others (Hantoushzadeh et al, 2021; Hazfiarini et al, 2022) or an increased workload (Hazfiarini et al, 2022), while others experienced fear of the unknown (Hantoushzadeh et al, 2021), fear for the wellbeing of family members (Hantoushzadeh et al, 2021; Hazfiarini et al, 2022) and fear for mothers (Fumagalli et al, 2023).

Midwives also experienced anxiety around spreading the disease to colleagues and of taking it home to families and loved ones (Hazfiarini et al, 2022). This fear was greater at the start of the pandemic (Hantoushzadeh et al, 2021; Hazfiarini et al, 2022) when midwives had to care for women suspected of having COVID-19 or when there was a lack of knowledge of and misinformation surrounding the COVID-19 virus (Issadeen et al, 2020; Homer et al, 2021; Haegdorens et al, 2022).

In the initial stages of the pandemic, information was seen as lacking, everchanging or overloaded (Hijdra et al, 2022; Fumagalli et al, 2023); however, as midwives had time to come to grips with the information, they adapted (Jacobsen et al, 2022; Küçüktürkmen et al, 2022; Fumagalli et al, 2023) and this assisted in alleviating some fear and anxiety. Nonetheless the initial stages created fear that resulted in trauma, leaving midwives feeling scared and shocked as they lost colleagues (Hazfiarini et al, 2022). This also affected wellbeing, as there was a feeling that organisations lacked understanding of emotional support needs, and that the workload had increased with inadequate staffing to safely care for patients, resulting in a lower degree of psychological safety (Munn et al, 2021).

Moving deeper into the pandemic, midwives’ continual anxiety and fear for the safety of their own families, especially their children, was observed (Hazfiarini et al, 2022). The global intensity and demand for midwifery roles placed an additional stressor on midwives while working (Del Piccolo et al, 2021).

Personal protective equipment/resources

Midwives were among the healthcare professionals negatively impacted by access to or lack of appropriate personal protective equipment and relevant COVID-19 resources (Kotowska and Gawlik, 2020; Gutschow and Davis-Floyd, 2021; Haegdorens et al, 2022; Hearn et al, 2022; Hijdra et al, 2022; Jacobsen et al, 2022; Fumagalli et al, 2023). Personal safety was a leading motivator, and the use of personal protective equipment was a priority for all frontline staff (Hazfiarini et al, 2022). However, the lack of availability and associated resources impacted the provision of care to pregnant mothers (Kotowska and Gawlik, 2020; Homer et al, 2021; Haegdorens et al, 2022) with some midwives avoiding professional duties (Kotowska and Gawlik, 2020), lacking the ability to provide a full spectrum of services (Homer et al, 2021; Jacobsen et al, 2022) or the available time to engage (Haegdorens et al, 2022).

The issues with personal protective equipment and relevant resources posed drawbacks in maternity care, as women could not be screened for COVID-19 before coming into contact with staff. Screening was not possible, as women did not always communicate with a maternity service prior to visits or abide by restrictions and social distancing advice, such as staying out of public areas, wearing masks and adhering to hand washing advice (Kotowska and Gawlik, 2020; Homer et al, 2021).

Education and training needs

In principle, midwives appeared to have adequate understanding and knowledge of using personal protective equipment (González-Timoneda et al, 2021; Haegdorens et al, 2022; Hazfiarini et al, 2022). Haegdorens et al (2022) highlighted the proper role of personal protective equipment education and training was vital in reducing COVID-19 infection risk among midwives. Two quantitative studies (Issadeen et al, 2020; Homer et al, 2021) reported that while general knowledge and perception of personal protective equipment was good, there were gaps; only 36% of their participants recognised the specific indication for using personal protective equipment.

A need for further education and training in the use of personal protective equipment was identified (Kotowska and Gawlik, 2020; Izhar et al, 2021; Haegdorens et al, 2022; Hazfiarini et al, 2022). Implementation differences were noted by midwives as guidelines changed quickly (Hijdra et al, 2022; Jacobsen et al, 2022), but learning occurred as they had to develop their skills (Fumagalli et al, 2023), and interpret and apply them to practice (Hijdra et al, 2022). However, education, training or preparation could not offset the fact that midwives were wearing personal protective equipment for such a long time each day (Küçüktürkmen et al, 2022; Fumagalli et al, 2023). Wearing personal protective equipment for a prolonged period of time made the situation more strenuous and created a feeling of oxygen deprivation (Fumagalli et al, 2023).

Communication

Communication was often seen as sub-optimal (Homer et al, 2021; Hearn et al, 2022). There was a lack of clear communication that resulted in adverse events (González-Timoneda et al, 2021; Hazfiarini et al, 2022). These effects were considered as related to poor communication or being unsure what the right thing to do was, especially when in opposition to one’s values, such as providing each woman and partner with the best available care (González-Timoneda et al, 2021). This lack of clear communication around being ethical in adverse situations, infection prevention and control guidelines and the enforcement of infection control procedures affected communication with women and the development of trust (González-Timoneda et al, 2021; Jacobsen et al, 2022).

There were multiple instances where uncertainty was dominant around the appropriate course of action. This uncertainty was regarding protection from the virus (Kotowska and Gawlik, 2020) because of misinformation and upper management’s lack of coordination and guidance (Izhar et al, 2021). Additionally, information was ever changing (Fumagalli et al, 2023).

Discussion

This scoping review aimed to explore midwives’ experiences of using personal protective equipment during the COVID-19 pandemic and highlights that there is little specific research into barriers and facilitators, with the 16 reviewed articles addressing general care/COVID-19 issues.

The present review found that midwives experienced fear, similar to that of other healthcare workers, who have been found to fear the risk of infection for their family or friends (Wang et al, 2020; Alnazly et al, 2021). This fear can lead to other conditions, such as excessive stress, anxiety and despair, which may have long-term psychological consequences (Lai et al, 2020; Zhu et al, 2020). There has been an increase in levels of selfreported depression, stress, fear, anxiety, uncertainty and helplessness among healthcare workers during the pandemic (Li et al, 2020). According to one study, during the pandemic, healthcare workers working in respiratory, infectious and emergency departments experienced more anxiety than those working in other hospital wards (Relias Media, 2020). In particular, insecurity and lack of knowledge often seem to be related to the fear of not having/knowing appropriate, relevant or important information and a lack of open communication across the multidisciplinary team (Sun et al, 2020).

Personal protective equipment is a key application of measures for protecting healthcare workers from contamination and preventing disease transmission to the professionals and subsequent patients (Hinton, 2020). It is thought that improving awareness through systematic and repeated training in the use of personal protective equipment is required to prevent infection (Livingston et al, 2020). Healthcare workers employed during the pandemic reported feeling safe in their work environment, having received education and training on the use of personal protective equipment. This highlights the importance of education in the positive impact of personal protective equipment for all healthcare workers (Arumugam et al, 2020; Master Brewers Association of the Americas, 2020).

Many healthcare workers reported a perceived lack of effective communication and coordination (Cheng et al, 2020) and a desire to be kept informed about management choices and participate in recovery plans (Dodds and Fakoya, 2020). Burnout among healthcare workers has been linked to perceived alienation and inadequate collaboration among management, administrative and clinical staff in studies conducted in both hospitals and primary care settings (Bauchner et al, 2020). Fear and anxiety caused by a lack of communication can escalate if there is inadequate availability of personal protective equipment (WHO, 2020a). Sufficient personal protective equipment with training and clear guidance on its use can enable healthcare workers to feel prepared and positive while providing care to their patients (Kucharski et al, 2020). Furthermore, this review identified that midwives encountered multiple logistic or administrative challenges while providing care, including inadequate supply of personal protective equipment, lack of appropriate training on its use and inconsistent guidance (González-Timoneda et al, 2021; Hazfiarini et al, 2022). In particular, midwives felt that personal protective equipment was not easily accessible (Homer et al, 2021) or implemented early enough (Gutschow and Davis-Floyd, 2021) and when implemented, conflicting information regarding its use was a major source of anxiety and fear (González-Timoneda et al, 2021; Hazfiarini et al, 2022). These issues are evident across the literature, as midwives had to abandon normal care and handle challenges and structural adjustments during COVID-19; it is important to learn from this to protect staff during future epidemics (Hanley et al, 2022;Whiteing et al, 2022).

Upper management’s lack of efficient coordination had a significant impact for midwives, especially at the beginning of the pandemic. The CDC (2007) and WHO (2016) recommended implementation of a process in the prevention of pathogenic germs, which was designed around two core actions: correct use of personal protective equipment and hand hygiene. The literature indicates that these core actions were not always implemented in practice during the pandemic and that such inconsistences in management of the action plan had a substantial impact on midwives’ attitude while using personal protective equipment (Schmitt et al, 2021; Stulz et al, 2022).

Midwives would greatly benefit from a more structured approach to providing care during a pandemic (Cheng et al, 2020; Kucharski et al, 2020). It is also recognised in the wider literature that the shortage of personal protective equipment in healthcare was offset by public businesses supporting health services (Bavel et al, 2020). For example, in certain cases, masks were donated by nail salons (Bradfield et al, 2022) and hand sanitiser was produced at local distilleries (Pezaro et al, 2016). COVID-19 testing was the last protective barrier against the virus for healthcare practitioners and patients alike. However, there was a period of uncertainty that placed a demand on resources (Okediran et al, 2020), as testing was difficult to access (Matsuishi et al, 2012) and results were not always seen as reliable (Reddy et al, 2019). This situation often resulted in the assumption that testing subjects was a positive action to mitigate the risk of exposure and offset the risk of non-trustworthy/negative results (Yang, 2012).

Apart from access and reliability issues, COVID-19 testing was conditional for maternity service users. Many women experienced bureaucratic (such as healthcare insurance issues) or other difficulties while accessing testing (Coughlan et al, 2020). There was a lack of clear communication, affecting interaction with women because of uncertainty around how to act (Marks et al, 2020).

Limitations and implications for practice

While this scoping review used the Arksey and O’Malley (2005) framework, its limitations are acknowledged. As the focus of a scoping review is on identifying, mapping and charting, critical appraisal and risk of bias assessments were not completed. However, it is acknowledged that these are not a requirement for scoping reviews (Pollock et al, 2021). Furthermore, only English language papers were reviewed.

Despite these limitations, this is the first scoping review based on a comprehensive literature search to identify midwives’ experiences of using personal protective equipment during the COVID-19 pandemic, providing an overview of the available evidence. Moving forward, lessons must be learnt from COVID-19, with the provision of an appropriate level of national personal protective equipment, followed with a clear procurement plan, together with early intervention and clear communication on its use. A combination of these efforts may appear effective for patients and midwives alike in the event of another pandemic.

Conclusions

This review aimed to identify midwives’ experiences of using personal protective equipment during the COVID-19 pandemic. The results indicated that negative feedback from midwives centred around education and training, logistics and communication on the use of personal protective equipment. The review identified a gap in healthcare organisations’ support to staff and that support should include dealing with fears and anxieties about contracting the virus, covering relevant training and educational needs, while maintaining a clear and open channel of communication.

Personal protective equipment education should be mandatory and included in all course curricula. To reduce confusion, healthcare organisations should have a clear plan of action in place for immediate implementation in future healthcare crises. The health risks of exposure to COVID-19 and procedures were identified in the case that pregnant women contracted the virus. Staff shortages and increased workload during the pandemic were issues, along with the fear/anxiety experienced by midwives and the impact on communication.

This review highlights the benefit of appropriate education/training and effective communication for healthcare workers. The provision of appropriate personal protective equipment for frontline healthcare workers must be a priority, and there is a need for international co-operation and partnership to form an equitable, and sustainable global supply of personal protective equipment.

Key points

• Midwives’ experiences of using personal protective equipment during COVID-19 highlights fear, anxiety and resource issues, with a need for education, training and communication.
• Healthcare organisations need to address support for staff and have open channels of communication.
• Based on the COVID-19 pandemic, it is important that healthcare organisations have a clear plan of action in place for any future crises.