Provision of obstetrics and gynaecology services during the COVID‐19 pandemic: a survey of junior doctors in the UK National Health Service

Objective The coronavirus disease 2019 (COVID‐19) pandemic is disrupting health services worldwide. We aimed to evaluate the provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID‐19 pandemic. Design Interview‐based national survey. Setting Women's healthcare units in the National Health Service. Population Junior doctors in obstetrics and gynaecology. Methods Participants were interviewed by members of the UK Audit and Research in Obstetrics and Gynaecology trainees' collaborative between 28 March and 7 April 2020. We used a quantitative analysis for closed‐ended questions and a thematic framework analysis for open comments. Results We received responses from 148/155 units (95%), most of the participants were in years 3–7 of training (121/148, 82%). Most completed specific training drills for managing obstetric and gynaecological emergencies in women with COVID‐19 (89/148, 60.1%) and two‐person donning and doffing of Personal Protective Equipment (PPE) (96/148, 64.9%). The majority of surveyed units implemented COVID‐19‐specific protocols (130/148, 87.8%), offered adequate PPE (135/148, 91.2%) and operated dedicated COVID‐19 emergency theatres (105/148, 70.8%). Most units reduced face‐to‐face antenatal clinics (117/148, 79.1%) and suspended elective gynaecology services (131/148, 88.5%). The 2‐week referral pathway for oncological gynaecology was not affected in half of the units (76/148, 51.4%), but half reported a planned reduction in oncology surgery (82/148, 55.4%). Conclusion The provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID‐19 pandemic seems to be in line with current guidelines, but strategic planning is needed to restore routine gynaecology services and ensure safe access to maternity care in the long term. Tweetable abstract Provision of obstetrics and gynaecology services during the acute phase of COVID‐19 is in line with current guidelines, strategic planning is needed to restore routine services and ensure safe access to care in the long term.


Introduction
In less than 4 months, the emerging coronavirus disease 2019 (COVID-19) pandemic has sent shock waves through the global health system, significantly disrupting care provision with high levels of morbidity and mortality worldwide. 1 With more than three million cases and 200 000 deaths reported globally, 2 many countries have implemented strict social distancing rules with full or partial lockdown. To meet the unprecedented demand for acute and intensive healthcare services, a rapid response is urgently needed to efficiently relocate resources, revise acute-care pathways and maintain the safety and wellbeing of healthcare professionals. 3 In times of crisis, much morbidity arises from poor access to health services and depletion of valuable resources. [4][5][6] This is especially relevant to women's health where access to acute care is in continual demand. 7 Recently, both the Ebola virus (2014/15) 8 and the 'swine flu' influenza A virus (2009) 9 epidemics had direct and indirect adverse effects on the wellbeing of women, leading to a significant increase in stillbirths and maternal mortality in affected communities. [10][11][12][13] Dealing with COVID-19 is particularly challenging because of its asymptomatic presentation and the high risk of transmission to healthcare professionals. 14 The worldwide shortage of personal protective equipment (PPE) has been a particular worry to healthcare professionals caring for affected patients at great personal risk. 13 Poor logistical planning and the lack of rapid testing at the point of care have been a major worry for healthcare professionals in the UK National Health Service (NHS) facing this pandemic. 15 Efficient assessment and feedback are key to refining the planned responses facing this pandemic and ensuring the safety of both the patients and their caring professionals. We aimed to provide a snapshot assessment of current service provision in obstetrics and gynaecology in the NHS by surveying junior doctors in all women's healthcare units in the UK.

Design
We conducted an interview-based survey with junior doctors in obstetrics and gynaecology across all training units in the NHS. Participants were contacted via the UK trainees' collaborative for Audit and Research in Obstetrics and Gynaecology (UK ARCOG) network 16 between 28 March and 7 April 2020. There was no funding for the study.
The interviews included a mixture of closed-and openended questions to capture current practice and the adoption of guidance from the World Health Organization and Royal College of Obstetricians and Gynaecologists on the safe management of women with COVID-19. [17][18][19] The survey aimed to cover four main domains: availability of PPE, training specific to COVID-19, changes in maternity care services and changes in gynaecology services (see Supplementary material, Appendix S1). We aimed to evaluate the participants' levels of anxiety and perception of confidence using simple Likert scales anchored between 1 (severe anxiety or no confidence) and 9 (no anxiety and very confident). We piloted the questions among members of the UK ARCOG core committee to ensure their face validity.

Data collection
Data were collected by a nominated UK ARCOG representative at each Local Educational Training Board (LETB) using a standardised electronic data collection tool. Data were harmonised and merged centrally by the same moderator (MPR) and quality checked for any entry errors.

Statistical analysis
We reported data using natural frequencies and percentages. Where relevant, we used Kruskal-Wallis test to compare medians of non-parametric data with significance at P < 0.05.
We analysed open comments thematically using a framework analysis to understand the participants' experiences and perspectives. 20 This was done in two steps, first we reviewed open comments and developed a list of emerging topics and salient themes. Afterwards, we coded all the submitted comments into the final framework. We reported on prominent themes arising from the framework narratively. All statistical analyses were performed using SPSS (version 22, SPSS Inc., Chicago, IL, USA) and Microsoft EXCEL (version 16, Redmond, WA, USA).

Core outcome sets and patient involvement
No core outcome sets exist for this area of research. We did not seek input from patients when developing this tool as it sought to seek responses from healthcare staff only.

COVID-19 response
A majority of junior doctors reported having undergone specific training drills for dealing with obstetric and gynaecological emergencies in women with COVID-19 (89/148, 60.1%) and two-person donning and doffing of PPE (96/ 148, 64.9%), though only 80% had a face-mask (FFP3 or equivalent) fit tested (119/148, 80.4%) ( Table 1). Most participants expressed the need for more frequent training sessions on COVID-19-specific emergency drills and clearer elearning resources for specific skills such as two-person  Table S1). Most participants felt confident about their unit's ability to deal with COVID-19 appropriately (median 6, range 1-9), which was not different across the included LETBS (P = 0.15) ( Table 1). General anxiety was on the higher side among participants (median 6, range 1-9), largely due to uncertainty about the future of the health service and the ability of the NHS to cope; this also was not different across the included LETBS (P = 0.08). In total, 62.8% of junior doctors felt that they were adequately supported by senior staff when dealing with this health crisis (Table 1). This was exemplified by increased presence of consultants on labour wards and regular communication from clinical managers (see Supplementary material, Table S1).

Changes to obstetrics and gynaecology services
Most included units had developed departmental protocols on the management of pregnant women with suspected or confirmed COVID-19 on the labour ward (130/148, 87.8%), though some participants reported that these protocols were changing rapidly, leading to confusion and Median score Range of scores How do you rate your confidence in how your unit is managing this pandemic on a scale from 1 to 9? 1 being no confidence and 9 being very confident 6 1 -9 How do you rate your anxiety at present on a scale from 1 to 9? 1 being severe anxiety and 9 being no anxiety   Table S1).
At the time of this survey, the majority of units had suspended their elective gynaecology services including fertility and urogynaecology (131/148, 88.5%) with some units operating virtual clinics (see Supplementary material, Table S1). About two-thirds of surveyed units started offering medical management as the first line of treatment for miscarriage (87/ 148, 58.8%) and ectopic pregnancies (42/148, 28.4%) to reduce inpatient stays in acute gynaecology wards. Many participants expressed concerns for the lack of clarity on using laparoscopy in COVID-19 patients with only two-thirds of units adopting laparotomy as first-line surgical approach in such women (65/148, 44%).
Around half of the surveyed units did not change the timelines of the gynaecology oncology 2-week referral pathway (76/148, 51.4%), but half reported a planned reduction in oncology operating lists (82/148, 55.4%). Only a minority moved oncology surgery to a COVID-19-free site such as the premises of non-NHS private hospitals (37/148, 25%) as well as postoperative wards (39/148, 26.4%).

Main findings
Our findings offer a rapid comprehensive overview of the provision of obstetrics and gynaecology services in the NHS in response to the COVID-19 pandemic.
Overall, the majority of units seem to be following national guidance during the acute phase of the crisis but variation in practice and misinterpretation of guidance were expressed by our participants, especially where limited evidence is available to inform practice such as the emergency gynaecology care. 17,21 Most surveyed units were offering adequate PPE and revising care pathways to safely manage women with COVID-19 with an apparent reliance on e-learning to promote training and education on the safe use of PPE. 13,22 We acknowledge that little time has elapsed to allow adequate synthesis and implementation of evidence-based guidelines, but measures to protect healthcare workers are crucial to sustain the workforce, respond to the rising demand for acute care and avoid the collapse of the healthcare system. 23,24 Although there was an overall sense of anxiety among junior doctors, the majority felt well supported by senior colleagues when caring for women with COVID-19. Many trainees expressed the need for more practical training and the desire to be more involved in the planning of future service provision.

Strengths and limitations of findings
Our findings are limited by the scope of the interview questions and the limited representation of each unit (one participant per unit). A detailed analysis is likely to yield more information on the current practice and to identify areas for improvements in women's healthcare provision. This is especially relevant for topics such as the availability of PPE, which could change daily across the surveyed units. Still, our findings are comprehensive and contemporary to evaluate the COVID-19 response across all women's healthcare units.

Interpretation and implications for practice
The COVID-19 crisis is likely to have both short-term and long-term impacts on women's healthcare services worldwide. Our findings suggest an overall good initial response in the NHS during the acute phase of this pandemic in line with current evidence-based health policies and clinical guidelines. Still, some alarming features emerged, such as the suspension of elective gynaecology, the deferring of antenatal screening tests and the reduction of oncology operating capacity. Prolonged suspension of these essential services is likely to increase morbidity in the long term.
Strategic planning is, therefore, required to mitigate the risk of the adverse outcomes to women's health seen during similar crises. 4,7 As we flatten the infection curve awaiting an effective vaccine, regular evaluation of care provision is essential to optimise our response and ensure women can safely access the care they need. 25 This is especially relevant to essential, though non-acute, services such as contraception, termination of pregnancy and cancer treatment. Rapid testing and triaging systems for COVID-19 patients are urgently needed, especially beyond the acute phase, to minimise the risk of exposure of unaffected women and their healthcare professionals. This is likely to become a daily practice as we transform to the 'new normal' over the next 18 months until reliable treatments and vaccines are developed.
Using innovative interventions to reduce inpatient stay in hospital has been pivotal in managing this crisis powered by the rapid uptake of telemedicine technology. 26 Such interventions are likely to gain momentum worldwide giving rise to a new healthcare system where women can undergo diagnostic testing and be followed up by their caring clinicians at distance. 26,27 It is important, however, to rationalise their use because not all aspects of antenatal and postnatal care can be delivered using telemedicine. Reducing face-to-face antenatal appointments could increase pregnancy complications in high-risk groups such as victims of domestic violence, deprived populations with limited access to advanced technology and those with mental health issues. 28,29 As with every new endeavour, efficient data collection and analysis are essential elements to advise our response to this global pandemic. Our findings shed some light on the impact of COVID-19 on obstetrics and gynaecology healthcare services in the UK, but more stringent long-term data collection and sharing are needed to fully evaluate the impact of this pandemic on women's health outcomes and to coordinate a global response to eliminate it.

Conclusion
The provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID-19 pandemic seems to be in line with current guidelines, but strategic planning is needed to restore routine gynaecology services and ensure safe access to maternity care in the long term.

Disclosure of interests
None declared. Completed disclosure of interests forms are available to view online as supporting information.

Contribution to authorship
BHAW and MPR conceived the idea, wrote the protocol, analysed data and wrote the final manuscript. All other coauthors actively helped in data collection and drafting of the final manuscript.

Details of ethics approval
Not required.

Funding
None.

Supporting Information
Additional supporting information may be found online in the Supporting Information section at the end of the article. Table S1. Thematic analysis of participants' open comments on the provision of obstetrics and gynaecology care in the NHS during the acute phase of the COVID-19 pandemic.
Appendix S1. Questionnaire on the provision of obstetrics and gynaecology services in the NHS response during the acute phase of the COVID-19 pandemic.