Design

Qualitative focus group discussions (FGDs) were conducted online, with clinically active midwives, nurses in midwifery care, and midwifery educators in four mixed groups. Qualitative thematic analysis inspired by Braun and Clarke¹⁸ was used to analyze the data. Ethical permission was provided by the Directorate General of Nursing and Midwifery in Bangladesh (2017).

Recruitment and participants

To achieve a variety of perspectives, a purposive sampling method was applied. A total of 23 participants, comprising clinically active midwives, nurses in midwifery care, and midwifery educators were approached and asked to participate in the study. They were all undertaking a Master’s degree program in sexual and reproductive health and rights (SRHR) in Bangladesh, offered as a top-up education for midwives, nurse-midwives and midwifery educators by Dalarna University, Sweden, supported by UNFPA. The participants worked in different parts of the country, and in various types of healthcare facilities. They were all female and aged 39–47 years. Initially, the participants were contacted by email, to explain the objective of the research. The course supervisor then informed all the students in the program about the study, both orally during class and in writing through an online learning platform. Information given included an outline of the study and the voluntary nature of participation. Students were then contacted by phone (by NIP), had the study objectives explained to them, and were asked if they were interested in participating. All participants provided informed consent both over the phone and at the beginning of the recorded FGDs.

Data collection

Data were collected through four internet-based FGDs¹⁹ with mixed participants of all three professional groups, in a virtual setting in Bangladesh. The criteria for selection were that all participants should be clinically active midwives, nurses active in midwifery care, or midwifery educators. All other healthcare professionals were excluded from the study. With a focus on the possibility of midwives being able to provide quality care in Bangladesh during the COVID-19 pandemic, an interview guide was developed to capture perceptions at individual, family, community, and societal levels²⁰. The interview guide was created and pilot tested in an initial FGD. Only minor adjustments were needed, so it was deemed that these data could be included in the analysis. During the first part of each FGD, participants were asked to discuss threats and possibilities during the COVID-19 pandemic from the perspective of women’s lives and health in Bangladesh at individual, family, and community levels. The second part of the FGDs included questions addressing threats and possibilities for respectful care during labor and birth at the time of the COVID-19 pandemic on institutional and political levels. All FGDs were audio recorded. Each group met once, and the discussions were between 61 and 103 minutes in length. The FGDs were conducted by an anthropologist who was bilingual and an interpreter, and were held in English and Bangla, which was inspired by Chen and Boore²¹. Data were transcribed verbatim by the data collector (NIP) who translated all the parts spoken in Bangla into English during the process of transcription.

Data analysis

Reflexive thematic analysis inspired by Braun and Clarke¹⁸ was used to analyze the collected data¹⁸. Phase one, ‘familiarizing yourself with the data’, started with two authors (JH, SG) reading the data individually several times to get a holistic understanding of the material. As the material was read, notes were made and ideas for coding were written in the margins. In phase two, ‘generating initial codes’, basic features of interest were identified and transformed into codes. The material and codes were placed in an excel document which became a basis for phase three, ‘searching for themes’. The excel document was used to organize codes, provide an overview, and create mind-maps with potential themes. During phase four, ‘reviewing themes’, codes, and data extracts were then reread, reanalyzed, and reorganized several times until patterns were established to form a clear and important context. During this process, similarities were noted with the domains of the analytical framework ‘What prevents quality midwifery care’ by Filby et al.²², a framework that has previously been used to explore quality midwifery care in Bangladesh^8,9 , which led the initial inductive approach in a more deductive direction with the above framework applied as an analytical lens. The already created sub-themes with underlying codes and text extracts were reflected against the domains of the framework which thereafter in phase five, ‘defining and naming themes’, could guide the forming of main themes. Finally, appropriate names for the sub-themes were created. Citations from the data are used to illustrate results.

Sociocultural perspectives

Social views of COVID-19 jeopardize the security and health of midwives

Beliefs in the community that midwives and other healthcare professionals carry the virus from hospitals to communities resulted in midwives developing ambivalent feelings towards their work. Being excluded and isolated from their families influenced the possibility of midwives being able to provide quality midwifery care at their workplace during the COVID-19 pandemic. Most of the interviewees received some degree of support from their own families, although some were not welcome to return home after work due to their family’s fear of COVID-19:

‘Our relatives and neighbors treated us badly and saw what we were doing as a great sin when we helped COVID-19 patients in the hospital. They tortured us mentally and were aggressive. The pandemic era has left a scar on our minds and souls, it has also left us asking many questions, such as, to whom do we give care? Who are these people and why are they so aggressive towards us?’ (FGD4, P2)

Lockdown reinforces gender inequalities and affects women’s health

The possibility of midwives being able to provide quality midwifery care in Bangladesh during the pandemic was affected by women’s restricted movements during lockdown periods. Many women did not visit antenatal clinics for antenatal care or clinics for delivery care, which resulted in an increase of home deliveries. In addition, women did not visit clinics for family planning purposes resulting in an increase of unwanted pregnancies. Women were hence able to access midwifery care only in limited ways:

‘Women who were pregnant were the worst affected because due to the pandemic they stopped visiting healthcare facilities for antenatal checkups. During lockdown periods women were not allowed to leave their homes and they didn't even visit the delivery centers to deliver their babies. This has been the major healthcare barrier.’ (FGD4, P3)

During the pandemic midwives also witnessed how frustration among men in society was often taken out on women. Women were victimized by their husbands and more women sought healthcare because of violence and rape:

Since July (2020) the [monthly] number has increased ... All these are either gender-based violence or rape cases.’ (FGD4, P3)

Economic perspectives

Poverty in society aggravates midwifery practice

Participants described a picture of increased poverty as a consequence of the pandemic as many people lost their jobs during lockdown periods. It was sometimes expected that the patients themselves should bury protection equipment. Thus, they continued to explain how unreasonable it was to expect patients to buy protective equipment such as masks to wear at the facilities, when they were already struggling to feed themselves and their families. This situation led to increased risk for midwives since they faced potential COVID-19 carriers who were presenting without PPE. This created high levels of stress among the midwives striving to provide quality care during the pandemic:

‘We are caring for mothers who are part of outreach programs living in villages where they don't have access to healthcare and when they come to us they don't even have sandals/shoes to wear. How can we neglect them and how can we ask them to purchase safety equipment?’ (FGD1, P2)

Professional perspectives

Low professional status places midwives in challenging situations

The possibility of midwives being able to provide quality midwifery care in Bangladesh during the pandemic was affected by their lack of influence. Participants expressed concerns regarding their low status and lack of influence as healthcare professionals. This was made visible in more explicit ways during the pandemic when their need for close communication with higher authorities and functioning structures was even more urgent. They felt that they were not listened to:

‘Our voices are not reaching a higher level where things are being planned. No one is coming to listen to us. We are facing a huge barrier to communicate with higher authorities.’ (FGD2, P6)

The nurses, midwives, and midwifery educators were appointed to care for patients with symptoms of COVID-19 without adequate equipment, endangering themselves and the health of their patients, families, and communities. Women they were caring for, who were presenting with symptoms of COVID-19, were not always tested, and healthcare providers who were tested would stay at work until the test results came back, and sometimes they came back positive which spread the virus at the workplace:

‘We are facing enormous difficulties in providing care to those who are not tested. We are in a dangerous position because we don't know if the patients we meet every day in the non-COVID-19 ward are infected or not. We are becoming more vulnerable and the risk of infection is high but the government is not prioritizing us at moment.’ (FDG3, P1)

Deficient implementation of policies compromise safety

Low rates of policy implementation, such as health packages and monetary help to health facilities and labor wards during the pandemic, were described. These safety measures had not reached the facilities of labor wards, which made it difficult for midwives to provide quality midwifery care without the fear of transmission of the virus and unreasonably long work shifts. The lack of access to safety measures, or ability to use them in a satisfactory way, plus long work shifts affected the possibility of midwives being able to provide quality midwifery care:

‘During our shifts at the hospital, we can't follow the safety measures according to instructions. There is a difference between practice and theory. We are given a single set of PPE for a 12-hour shift. How scientific is it to wear a single set of PPE for twelve hours? I doubt its functionality and protectiveness.’ (FGD1, P3)

The greed of companies and individuals led to them taking advantage of society’s vulnerable position in order for them to make a profit. Selling fake safety equipment, for example, meant that women did not get the safe maternity care they deserved during the pandemic:

‘There were many bad companies that started up during the emergency period, supplying low-quality or fake masks and equipment to the hospitals. Some of the employees and administrators of the health ministry were involved in these fake businesses. They made a syndicate to sell fake equipment to the hospitals and made a huge profit. These people made us suffer and put us [the health workers] in danger.’ (FGD4, P5)

Increased workload for midwives endangers quality care

The possibility of midwives being able to provide quality care was affected by an increased workload. Their field of responsibility was broadened due to the increase in severely ill patients, work outside the hospital, clinics reporting statistics regarding the pandemic to the health authorities, needing to attend home deliveries, and being available to women in the community by providing health advice over the telephone. While midwives worked in their spare time, lockdowns led to an increase in the number of women exposed to violence, unintended pregnancies, and abortions taking place in facilities:

‘Many young girls were coming for treatment for unintended pregnancies, perhaps because due to the lockdown, the village 'quack' and homemade remedies were not available.’ (FGD 2, P3)

The considerable increase in workload included longer shifts, working overtime, and having little time for rest and recovery. This led to less time for proper sleep and midwives finding it difficult to maintain focus and provide quality care. The risk of infection during the pandemic made women with pregnancy-related complications wait at home for as long as possible, causing an increased number of emergencies. Some women went to private clinics first, because they believed the risk of infection was less there. Since private clinics experienced a lack of midwifery expertise, women would then present at general hospitals in a worsened condition, which added to the workload, and to the already existing lack of privacy. This, in turn, contributed to emergencies escalating even more, due to the care seeking delays.

New possibilities for independent midwifery practice

The COVID-19 pandemic opened up possibilities for midwives to practice midwifery care independently. It was described how midwives during the pandemic regularly provided intrapartum care to women without a physician’s involvement, as physicians tended to take a step back and work more at a distance from patients during the pandemic to avoid being infected. Physicians were seldom present in the labor ward; hence, midwives were left alone to manage the care provided, informing physicians by phone when possible. In this way, they worked more independently, with increased workloads and heavier responsibilities, but also with increased self-esteem, professional skill and confidence in providing quality midwifery care as a result:

‘ ... So, this is a significant change that I pointed out – that we are providing all the services in the absence of the doctor, and we are becoming more skilled.’ (FGD1, P1)

Strengths and limitations

To minimize the risk of presenting misinterpreted results, the authors did reflect upon their experiences prior to analysis, and the primary analysis was conducted by the two authors who did not have any previous experience of the Bangladeshi context, thereby strengthening the credibility of the study³². Another factor strengthening its credibility was that the FGDs were conducted by a Bangla-speaking author, and recorded and transcribed verbatim, which reduced the risk of losing data due to misunderstandings, incomplete note taking or faulty recall³². Further, this made it possible to clarify uncertainties by replaying a sequence, if needed. This constitutes a strength in interpreting the data and presenting findings in an accurate way, thereby strengthening the dependability of the study³². The Bangla-speaking author could cross-check that the content shared in the FGDs was correct both during the interviews and in the transcripts. The FGDs comprised a mix of three cadres, based on the intention to achieve variety within the data. A side effect can, however, have been that a potential power tension between cadres may have silenced some perspectives. The online setting here may have limited the possibility to note such unspoken signals during the sessions. The qualitative design entails a limited number of participants, not allowing the findings to be generalized. The sampling method, participants, data collection, and analysis have been described in as much detail as possible to increase the transferability³².