A call for zero separation – restrictive policies and their impact on neonatal care in light of COVID-19
More than one year into the pandemic and we are well aware that COVID-19 is affecting neonatal care. In many places, possibly in more ways than we initially appreciated. Recent scientific research has revealed that neonatal care in low- and middle-income countries has been affected to an extent that threatens the implementation of life-saving interventions.1 Reasons for this development are certainly plentiful, including the concerns of medical staff and parents about contracting the coronavirus – a worry that in many places had been accelerated by the immense pressure put on the health system.Sarah Fuegenschuh
Head of Communications
Head of Scientific Affairs – Maternal and Newborn Health
European Foundation for the Care of Newborn Infants
Initial restrictions in neonatal care were noticeable early on, with neonatal intensive care units (NICUs) regulating, restricting, or even completely ceasing access for parents in many places. As the pandemic progressed, it was increasingly observed that resources (such as medical staff and equipment) were being withdrawn from neonatal units and reallocated for COVID-19 patients.2 Most would understand the cuts in staff and equipment as necessary emergency measures, nevertheless, these were severe cuts in care. What was not so clear, was the decision to no longer allow parents contact with their newborn infants or to not allow skin-to-skin contact and kangaroo mother care due to fear of infection. These are very serious measures too and some would argue, equivalent to withdrawing life-saving resources.
The benefits of skin-to-skin contact for sick and small newborn infants, such as improved weight gain, better neurological outcomes and higher breastfeeding rates for mothers, have long been scientifically recognised and are undisputed. Nevertheless, in early 2020 numerous NICUs world wide closed their doors to parents. Not long after, the Global Alliance for Newborn Care (GLANCE), a worldwide initiative, founded and coordinated by the European Foundation for the Care of Newborn Infants (EFCNI), was contacted by parent organisations all over the world asking for both help and thorough information. The fear that the implemented contact restrictions would cause long-term damage to infants’ health caused great and justified concern. In addition, there was also a big fear that right of access to one’s own child in the NICU, which had been hard-won in some countries and regions, could be permanently lost.
This is why the global campaign, ‘Zero Separation. Together for Better Care. Keep Preterm and Sick Babies Close to their Parents’, was launched under the umbrella of GLANCE (FIGURE 1).
FIGURE 1 The Zero Separation campaign launched by GLANCE, the global initiative of EFCNI.
The campaign’s goal is to raise awareness for the importance of keeping parents and their babies close and the benefits of zero separation in the NICU. Silke Mader, Chairwoman of EFCNI and founder of GLANCE, explains: “Since the global spread of the coronavirus, and the introduction of measures against the spread of COVID-19, we saw many parents struggling with very restricted or even prohibited access to NICUs due to the pandemic. They reached out to us, not only asking for help in this emotionally draining situation but also requesting information, wondering if it was really necessary to keep parents apart from their newborns.”
In order to find solid answers to these urgent questions, the foundation contacted its worldwide network of experts in antenatal and neonatal care and professional healthcare societies. “It goes without saying that health and safety is the top priority for everyone involved, the patients and the medical staff. This is why the campaign emphasises that the best outcomes for sick and preterm babies can only be achieved if parents, nurses and doctors are working together,” stresses Silke.
In exchange with international healthcare professionals and after consulting recommendations by the World Health Organization (WHO), it became clear that the separation of parents and infants was not evidence-based. In fact, WHO continuously states that ‘mother and infant should be enabled to remain together while rooming-in throughout the day and night and practice skin-to-skin contact, including kangaroo mother care, especially immediately after birth and during establishment of breastfeeding, whether they or their infants have suspected or confirmed COVID-19 virus infection.’3 Moreover, recent research conducted by a global collaboration of WHO and the London School of Hygiene and Tropical Medicine, that undertook analyses of 127 countries has highlighted that kangaroo mother care significantly reduces the mortality rate of low birthweight babies, whereas a COVID-19 infection does not significantly increase the mortality rate among newborns.1 Hence, the health risks of separation policies far exceed the risks of COVID-19 in infants regarding their survival and health.
It is without doubt that hospital staff are reaching their limits in many places and the wellbeing and safety of patients and staff must always come first. Yet, the long-term impact of this separation policy on the newborn infant’s health outcomes can be tremendous. What the Zero Separation campaign therefore aims for is an approach that encourages infant and family-centred developmental care when and wherever possible, even in times of a pandemic.
In six different focus topics, the campaign addresses the direct and indirect effects of separation policies. These include: the impact on breastfeeding and providing human milk; lung diseases (eg respiratory syncytial virus), and the long-term effects on former preterm infants. The lifelong mental health consequences for the parents and their child are addressed as well as the consequences of separation policies on discharge management and follow-up appointments. The role of fathers and family members is another cornerstone of the campaign, as fathers in particular had either no access to their infant in many hospitals or their presence was limited to only a few days or hours per week.
To inform about the short- and long-term consequences of parent and child separation, the campaign sheds light on the parents’ view by sharing experience reports from parents and other relatives. Furthermore, it has been following the recommendations of the WHO in regards to the provision of newborn and maternal care in times of COVID-19. From its very beginnings, a significant number of international healthcare professionals and medical societies have been supporting the campaign and providing knowledge and scientific data underlining the positive effect on long-term health outcomes of zero separation in NICUs. As of today, more than 130 parent and patient organisations, global non-profit organisations and healthcare societies support and endorse the campaign. Now, medical experts are also sharing insights from their daily work and giving advice on how contact between parents and their newborn infants can be safely ensured in times of COVID-19.
FAQs for parents and parent representatives
In order to address the many unanswered questions regarding SARS-CoV-2 and newborn and maternal health, EFCNI has also developed a comprehensive frequently asked questions (FAQ) section in close collaboration with international experts. This FAQ is divided into different topics such as COVID-19 and pregnancy, childbirth, breastfeeding, the NICU and the period of discharge and follow-up. The FAQ is updated as soon as current information in any of these topic areas changes, or if new questions arise, eg regarding vaccinations,
The COVID-19 survey
To get detailed insight into how the COVID-19 pandemic is challenging neonatal care, we asked recent parents of preterm, sick, and low birthweight infants around the globe to share their experiences regarding care provision in the previous year. Our study, which was translated into 23 languages and covers more than 50 countries worldwide, is currently being analysed. We already see from the preliminary findings that several cornerstones of infant and family-centred developmental care have been severely affected. Our initial findings confirm that COVID-19 related measures had alarming implications on the presence of parents with their newborns treated in NICUs. In many cases, parents were not allowed at all; in most cases only with severe restrictions (eg just one parent and/or only a few minutes per day). The findings will be presented in full later in 2021 and will give important messages for policy makers and hospital administrators in how to apply family-centred care approaches in times of crisis.
The future of family-centred care – a call for zero separation
The pandemic has shown that even accepted concepts and well-established practices in neonatal care can be replaced quickly if deemed necessary or more practical. With the withdrawal of 24/7 access to the NICU or the ban of skin-to-skin care and kangaroo mother care in many hospitals (FIGURE 2), we have seen cuts in care that have imminent effects on hospitalised infants and their families. Intended to manage the number of people in the unit to ensure safety for staff and/or patients, research has shown that the long-term damage of separation policies outweighs the risks of a COVID-19 infection.
FIGURE 2 Skin-to-skin contact has positive consequences for the health and development of the vulnerable infant and for the family as a whole. ©Nascer Prematuro.
Infant and family-centred developmental care, however, is one important pillar of a holistic, long-term positive treatment approach that benefits the health outcome of hospitalised infants, the mental wellbeing of the parents and ultimately also the healthcare system and staff. It is therefore hoped that the knowledge gained during the pandemic will lead to infant and family-centred developmental care being re-installed where it was discontinued, promoted where it was questioned and protected where it was banned.
For more information on ‘Zero Separation. Together for Better Care’ visit: www.glance-network.org/covid-19/campaign
For more information on EFCNI visit: www.efcni.org