Precarity and preparedness during the SARS‐CoV‐2 pandemic: A qualitative service evaluation of maternity healthcare professionals

Abstract Introduction The SARS‐CoV‐2 pandemic has devastated populations, posing unprecedented challenges for healthcare services, staff and service‐users. In the UK, rapid reconfiguration of maternity healthcare service provision changed the landscape of antenatal, intrapartum and postnatal care. This study aimed to explore the experiences of maternity services staff who provided maternity care during the SARS‐CoV‐2 pandemic to inform future improvements in care. Material and methods A qualitative interview service evaluation was undertaken at a single maternity service in an NHS Trust, South London. Respondents (n = 29) were recruited using a critical case purposeful sample of maternity services staff. Interviews were conducted using video‐conferencing software, and were transcribed and analyzed using Grounded Theory Analysis appropriate for cross‐disciplinary health research. The focus of analysis was on staff experiences of delivering maternity services and care during the SARS‐CoV‐2 pandemic. Results A theory of “Precarity and Preparedness” was developed, comprising three main emergent themes: “Endemic precarity: A health system under pressure”; “A top‐down approach to managing the health system shock”; and “From un(der)‐prepared to future flourishing”. Conclusions Maternity services in the UK were under significant strain and were inherently precarious. This was exacerbated by the SARS‐CoV‐2 pandemic, which saw further disruption to service provision, fragmentation of care and pre‐existing staff shortages. Positive changes are required to improve staff retention and team cohesion, and ensure patient‐centered care remains at the heart of maternity care.


| INTRODUC TI ON
The pandemic caused by the novel coronavirus, SARS-CoV-2 (COVID- 19), has been the first such an outbreak in a generation. The pandemic has devastated populations, and posed unprecedented challenges for healthcare services, staff and service-users. In UK maternity services, rapid implementation of virtual care delivery (i.e. telehealth via video-call or telephone), reduced face-to-face care, and limited birthplace options transformed the landscape of antenatal, intrapartum and postnatal care. 1,2 The rapid onset of the COVID-19 pandemic caught healthcare systems around the world by surprise, leaving them uncertain about how they should, could, or would prepare for the challenges ahead. [3][4][5] These included an unexpected surge in COVID-19-related hospital admissions 4 and significant reductions in staff availability. 6 Maternity services globally reported screening and containment of COVID-19 in their workforce, 7,8 while facing high levels of staff burnout and negative mental health outcomes. [9][10][11][12] Staff shortages were caused by a myriad of SARS-CoV-2-related reasons. Some staff "shielded" due to their own vulnerability to infection or that of household members 13 while others self-isolated following SARS-CoV-2 infection or that of close contacts. 14 Some staff became more seriously ill, with particularly high numbers of minority ethnic healthcare professional (HCP) staff ultimately dying. 11,15,16 In response, retired HCPs were encouraged to return to practice and part of the existing workforce was redeployed to frontline care of infected patients, 17,18 including re-deployment of clinically trained non-clinical staff (from managerial or research positions) to clinical roles, community-based staff to hospital roles; and some maternity care staff to frontline clinical roles in emergency departments or COVID-19 wards. 8,[19][20][21] The result was inordinate strain upon healthcare systems, further fragmenting care. 22 Whilst the concepts of burnout, understaffing and services running over capacity are not new to maternity services, 23-28 the circumstances of the pandemic exacerbated service-level deficits. This study explored the system-level response of reconfigured primary and referral maternity services in a large South London Trust providing care during the initial stages of the SARS-CoV-2 pandemic, with the aim of learning for future service delivery improvements. recovery. We received feedback on recruitment, study design and interpretation on findings from both lay and expert stakeholders, including members of the public, those with lived experience, health and social care professionals, researchers, and policy makers.

| Design
Qualitative semi-structured interviews were used to explore the experiences of service reconfiguration of HCPs at GSTT. Using a post-positivist research paradigm, we adopted a critical realist ontology (enabling empathic understanding) and an objectivist epistemological stance (positioning interviewers and analysts as objective outsiders). This theoretical perspective was engaged in order to be faithful to our Grounded Theory methodology requirements and to our understanding that knowledge creation (i.e. interview narratives) can itself be falsified accounts of events but at the same time the "truths" or "lived realities" of a person; and it is the acquisition of knowledge-even false knowledge-which can bring us closer to understanding the true reality of a phenomenon. Respondents consented to interviews based on their understanding that their identity would not be disclosed to the Trust, and de-identified data being published and shared with the Trust.

| Respondent recruitment, setting, and data collection
Respondents (n = 29) were recruited between August and November 2020 at a time when the UK had imposed restrictions to daily life (including restricted numbers to both indoor

Key message
Maternity services are precarious, with many maternity professionals feeling their services are stretched.
Retention-related incentives and balance between service efficiency and patient-centered care may help maternity staff to be better prepared for health system shocks in the future. and outdoor gatherings, and measures to reduce visitors to hospital patients to almost zero) in an attempt to reduce the spread of SARS-CoV-2. Initially, these were less stringent than the first UK lockdown (23 March-23 June 2020), but as infection cases increased again after the summer, a three-tier system of local "lockdown" (Government-mandated "stay-at-home" order) was announced in October 2020, with a second national "lockdown" coming into force in early November 2020. In parallel, maternity services continued with their restrictions which had been in force since March 2020, even during the summer of 2020, when people were encouraged to support the hospitality sector, through Government-funded schemes.
We utilized a critical case purposeful sampling technique 29 at GSTT, recruiting via directorate-wide e-mails inviting staff to take part in interviews. This enabled the Trust to act as the "critical case" and meant we attempted to achieve a maximum variation of respondents (eg professional roles) when recruiting from within the bounded setting of maternity services at one NHS Trust. To ensure anonymity from their clinical managers, interested respondents e-mailed a non-clinical member of the team (SAS), rather than a clinical colleague who circulated the recruitment e-mails.
At the start of each interview recording, all respondents were asked to confirm their willingness to participate. Semi-structured interviews 30 following a chronological order, were conducted via video-conferencing software, 31 which allowed both flexibility of inquiry around a core set of questions and the interviews to take place during government-mandated lockdowns and physical-distancing restrictions (see Appendix S1 for Interview Schedule). Interviews were conducted by one of two authors (SAS-an academic Psychologist specializing in research on women's lifecourse health, who does not work clinically; KDB-a Perinatal Mental Health Midwife who at the time was working academically and clinically, but not at GSTT), dependent on availability. Interviews lasted an average of 50 minutes (range: 28-79 minutes) and were recorded and de-identified while the audio was transcribed. Each transcript was given a unique number.

| Data analysis
This analysis was focused on the system-level response to service reconfiguration; analysis of individual-level experiences will be reported elsewhere.
Grounded Theory Analysis 32 appropriate for cross-disciplinary health research 33 was chosen and interviews were conducted until the point of theoretical saturation. 34 Grounded Theory Analysis allows researchers to generate a theory from qualitative data which is focused on a specific population, experiencing a specific phenomenon, in a specific context. This theory can then act as a working hypothesis, and can be "tested" in subsequent studies by changing the population, phenomenon, or context, to see whether the theory holds true. This was assessed by employing "constant comparison", where each transcript is coded and compared with previously analyzed transcripts and memo notes made by the researchers during the interviews and analysis, and "theoretical sampling", where particular demographics of respondents may be associated with experiences divergent from the majority. 32 By employing these established recruitment techniques, we were able to gain confidence in the selection of respondents to participate in interviews, increasing the overall trustworthiness of our data and subsequent analysis.
Data were electronically coded, first "by hand", using Microsoft Word, "line-by-line" or "open" codes (KDB) where each sentence of the data are coded with a key word from that sentence. Then data were subjected to a more nuanced, "focused" coding (SAS, KDB), which allowed open codes to be grouped more conceptually and these more conceptual codes to be applied to greater portions of the transcripts. Focused codes were analytically adapted and augmented to develop super-categories (preliminary themes made up of groups of focus codes which are aligned or related), at which point a third analyst (JMB), masked to the original coding, checked for accuracy of super-categories and reliability by re-coding ~15% of transcripts. 33 Finally, themes were developed by sorting and naming groups of supercategories (see Figure 1).
The relation between themes, which formed the basis of the grounded theory, was twice-subjected to within-team defense, to ensure that no other explanations were possible, 33

| Ethics statement
This project was approved as a service evaluation by Guy's and St Thomas' NHS Foundation Trust on July 7, 2020 (reference: 11046).

| RE SULTS
Respondents were multi-ethnic, primarily female and, on average, in their mid-40s. They were primarily midwifery (41%) or obstetrics staff (21%), with representation across a wide spectrum of care-providers. Almost half were frontline clinicians, with about 40% of others in senior clinical or managerial roles. The vast majority were neither clinically vulnerable themselves nor had close family or household contacts who were. Most HCPs were experienced, with an average of more than 15 years' provision of clinical care and almost 10 years at their current Trust. A distinct minority (24%) were redeployed from their normal duties, and about twothirds had no history of confirmed or suspected COVID-19 (see Table 1).
The analysis comprised three main themes: "Endemic precarity: A health system under pressure"; "A top-down approach to managing the health system shock"; and "From un(der)-prepared to future flourishing". Partial theoretical saturation was reached with 18 respondents, and full theoretical saturation achieved with 29. These themes are supported by the most illustrative quotations and a graphical representation (Figure 2), where appropriate. Additional quotations can be found in Table 2

| DISCUSS ION
Our Grounded Theory Analysis of 29 HCPs from a large South London Trust, illustrated three themes. "Endemic precarity" illustrated a maternity service under constant pressure pre-pandemic-stretched and fragile, like other services within the NHS-due to the lack of built-in "slack" to cope with additional strain. This pre-existing precarity was drastically amplified by the SARS-CoV-2 pandemic. The "health system shock" theme described experiences of HCPs delivering care and fulfilling their professional roles within maternity care during the pandemic; the health system shock was unexpected and there was no "off-the-shelf" manual for how best to cope, and having continually to adapt and reconfigure services. Our final theme, focused on "un(der)-preparedness and flourishing", demonstrating fractured and fragmented services, addressed the pervasive narratives that services (and staff) were under-prepared at best, and un-prepared at worst, to cope with the magnitude of the COVID-19

TA B L E 2 Supplementary quotations
health system shock.
Taken together-and in line with our Grounded Theory analytical approach-these themes can be interpreted as the theory: "Precarity and Preparedness" (Figure 3). In this theory, we see the specific population (maternity staff), phenomenon (delivering care during  and context (one NHS Trust in South London) struggle to prepare for and overcome the health system shock, because of the endemic precarity which already existed across and throughout the service. What we see, therefore, is a service reaction which stretches the expected in-built resilience past its point of being plastic, rendering the service fractured, fragmented, and fragile. This has been seen globally in maternity HCPs. [35][36][37] Ultimately, staff conceded that the service and they themselves were not prepared for this type of health system shock, or for the sustained level of added precarity it brought with it. The prolonged and cumulative effect of endemic precarity, and the un(der)-prepared service, and the health system shock was occasionally seen as a chance to innovate and transform, 38 albeit usually with a top-down or "command and control" style approach, which was not always appraised positively. Furthermore, innovation has often been reported as a proxy term for the reality of time being spent on paring back services and delivering only essential care causing poorer outcomes for women, their families, and their babies; 2,39-44 and demoralizing staff who did not believe they were providing the level of care they ought to and were trained to deliver.
To address both previous concerns about over-stretched maternity services, [23][24][25][26][27][28] as well as the current challenges after the Trust, and one member who was not based in London who acted as a "critical friend" for the study group.
Future research will be able to take the theory developed in this analysis, and by changing the specific population, phenomenon, or context, will be able to "test" whether the theory holds true. 33,46 Our F I G U R E 3 Representation of the Grounded Theory: Precarity and preparedness theory can also be re-tested at the same Trust in due time, to re-visit the themes emerging from this study and assess progress or positive changes made since.

| CON CLUS ION
Maternity services were under significant strain before the outbreak of the COVID-19 pandemic, leading to an inherently precarious healthcare system. This precarity was subsequently exacerbated by the health system shock, as SARS-CoV-2 caused disruption to staff availability and service delivery, with enduring consequences leading to fragmentation of care and systemic staff shortages. Positive change is required to improve staff retention and balance service efficiency while sustaining high quality, patient-centered care at the heart of the NHS.