Implications for the future of Obstetrics and Gynaecology following the COVID‐19 pandemic: a commentary

Abstract

In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. At the time of writing, more than 261 184 cases of COVID-19 have been confirmed in the UK resulting in over 36 914 directly attributable deaths.1 The National Health Service (NHS) has been confronted with the unprecedented task of dealing with the enormity of the resultant morbidity and mortality. In addition, the workforce has been depleted as a direct consequence of the disease, in most cases temporarily but in some tragic cases permanently. A lack of appreciation of the range of symptoms associated with COVID-19, as well as the prevalence of asymptomatic carriers of the virus, contributed to hospitals becoming ‘hotspots’ for infection. In order to reduce potential exposure and infection amongst healthcare professionals and patients, a widespread restructuring of services and clinical practice was rapidly undertaken. In the field of obstetrics and gynaecology (O&G), professional bodies implemented a multitude of reactive strategies as emergency measures in response to COVID-19, as summarised in Table S1. Despite being prompted by unprecedented adversity, many of the changes in process, clinical management and innovations introduced in response to COVID-19 may have a long-lasting impact, which could result in the adoption of a more streamlined approach to healthcare. It is essential that we examine whether reverting back to the way healthcare was delivered prior to the pandemic is desirable. From an academic perspective, clinical researchers have seen an accelerated institutional and ethics approval process for COVID-19-related research, with approvals being granted within 2 weeks. Clinicians have been empowered to make rapid changes in how they deliver care; for example, the swift adoption of novel technology, with telephone triage, virtual consultations, online meetings and home monitoring being implemented widely. Moreover, at a time when the NHS is underfunded and waiting times continue to rise, many of these changes may offer cost-effective benefits and reduce waiting times.2 Additionally, it is inevitable that public perception and societal values will have changed as a consequence of the pandemic. The aim of this manuscript is to discuss the impact of COVID-19 on practice within the field of O&G and how it may subsequently help shape the future of the speciality. The primary objective of restructuring healthcare services was to reduce the risk of viral transmission without jeopardising standards of healthcare. The Royal College of Obstetricians and Gynaecologists (RCOG) recommended that women should be managed by remote communication for outpatient antenatal and gynaecology clinics where possible.3 Telemedicine encompasses methods such as web-based programmes, video teleconferences and telephone consultations. In such cases, it is essential to determine which cases are suitable, with consideration of the limitations of not being able to examine or undertake investigations immediately. Although it may be appropriate for routine gynaecology outpatient clinics, there may be apprehension regarding implementation for rapid access clinic (RAC) appointments, due to potential delay in diagnosis or management of cancer. However, we have observed the efficient implementation of virtual consultations within our own department during the pandemic, particularly when informing patients of their investigation results and discussing further management following initial RAC attendance. In particular, the communication skills required to break bad news do not appear to be jeopardised, with previous data suggesting video consultations offer a greater sense of privacy, in the comfort of the patient's own home environment.4 Positive patient experiences have also been demonstrated in other emotive areas of gynaecology, such as termination of pregnancy, where telemedicine has provided quicker assessments and offered a more patient-centred approach with greater accessibility to treatment options and avoidance of travel time.5 In the context of postoperative follow up, informal feedback from patients in our unit is consistent with findings from a study following the implementation of peri-operative internet-based patient care pathways, which suggested that in addition to being cost-effective, patients report an improvement in quality of life, less pain and reduced recovery times.6 The implementation of telemedicine within obstetrics may provoke apprehension regarding aspects of care that traditionally require in-person monitoring, such as during antenatal care, where regular blood pressure monitoring and fetal assessment is required. However, the potential of telemedicine is enhanced by the proven efficacy of home blood pressure monitors7 and development of wearable fetal electrocardiography sensors.8 This may make it realistic and achievable in well selected cases. The development of pregnancy-related mobile applications, or ‘apps’, subject to appropriate regulation, also enables the opportunity for greater patient involvement. This has been identified to provide a greater sense of autonomy, while enhancing patient care.7 Moreover, the replacement of traditional antenatal, labour or breastfeeding classes with virtual multidisciplinary classes may enhance accessibility and allow greater consistency in teaching methods.9 However, despite the undoubted potential of telemedicine in O&G, many healthcare professionals remain sceptical, due to fear of late presentation of emergencies, lack of personalised care and concern regarding the replacement of the human workforce by machines.10 Telemedicine can also facilitate training and education, and contribute towards continued professional development. For example, remote feedback from experienced surgeons during real-time surgery has been shown to provide a cost-effective method of learning with a similar efficacy and safety profile as in-person mentoring.11 It also facilitates multi-site learning, which allows greater consistency in teaching and training methods.9 Telemedicine can also facilitate multidisciplinary meetings between health professionals. For example, 81% of 667 participants involved in an online gynaecology oncology teleconference, felt that the experience enhanced educational training between colleagues, and offered a time-saving opportunity to access to a wide range of expert specialists.12 Despite evidence that restructuring services can have multiple advantages, this may adversely impact health outcomes among vulnerable groups such as low-income populations and ethnic minorities.13 In the context of telemedicine, communication inequality inhibits certain individuals from seeking access to healthcare, such as immigrant or refugee populations, those low literacy levels or without access to internet/technology. It is imperative, therefore, when considering the transition from temporary implementation of service provision to long-term application, that such limitations are addressed to ensure healthcare is not compromised among vulnerable groups. Owing to demographic changes, such as an increasingly ageing population and evolution in societal expectations, there has been a rise in the number of new referrals to secondary care over the last two decades, at significant expense to NHS resources.14 In order to reduce demand and clinically prioritise, extensive triaging strategies have been implemented to ensure the appropriateness of referrals to secondary care. For example, the utilisation of telemedicine between O&G specialists and general practitioners (GP) prior to the pandemic resulted in a third of referrals being de-escalated back for management in primary care.15 This suggests a significant proportion of referrals could be managed by the GP providing they have access to specialist input. Moreover, in the context of RAC, data from a single centre identified half of referrals were inappropriate when compared with protocol-driven referral criteria.16 By continuing to implement measures to reduce the number of unnecessary referrals, an anticipated reduction in demand should shorten waiting times and enable more timely diagnosis and management. To maintain the quality of care provided to women, restructuring of services was implemented, primarily to increase utilisation of outpatient management. The introduction of ‘one-stop’ clinics in both obstetrics and gynaecology reduces the number of appointments required. This is associated with a reduction in time from referral to investigation, improves service efficiency and is highly acceptable to patients.17, 18 In gynaecology, updated recommendations further emphasised a preference for expectant or medical management of miscarriage and ectopic pregnancies over surgical management (Table S1). Not only is expectant management more cost-effective,19 but 84% of women would opt for it in the future after using it previously, suggesting it is well accepted by patients.20 During the government-imposed ‘lockdown’, risking exposure by leaving home to collect contraception may impact compliance. Irrespective of the pandemic, one in five pregnancies are unplanned,21 and postnatal women who are breastfeeding are thought to be at particularly high-risk for unintended pregnancy.22 Current guidance suggests all women should be informed during pregnancy of the superior effectiveness of long-acting reversible contraception (LARC), particularly as it is more efficacious, cost-effective and can be used immediately postnatally.23 A number of units have taken this opportunity to escalate postnatal contraceptive services to help prevent unintended pregnancy by offering it prior to discharge. The progesterone-only pill or progesterone-only implant can be offered, and those who undergo elective caesarean section have the additional option of an intrauterine system (IUS) or intrauterine device (IUD). Given the ongoing trend of unplanned pregnancies, proactive contraceptive counselling during pregnancy and enhanced accessibility should continue after the pandemic. This may facilitate the achievement of women's reproductive aspirations and concomitantly reduce NHS workload and the associated economic burden. Following the first week of the government-imposed ‘lockdown’, there was a 25% reduction in the number of accident and emergency (A&E) attendances, despite the provision that leaving home for medical treatment was allowed.24 It is therefore likely that the perception of what was previously deemed an emergency has changed, with the risk associated with attending hospital outweighing the necessity for attendance.25 However, it is inevitable that patients with significant pathology, who are acutely unwell or have symptoms suggestive of cancer, who truly need A&E or urgent care, have avoided such in a bid to avoid exposure to the virus, signifying the less publicised but significant collateral damage of COVID-19.25 Becoming pregnant during the COVID-19 pandemic has been associated with greater uncertainty and anxiety, as demonstrated by a study of almost 2000 participants whereby 68% of women reported elevated pregnancy-related anxiety.26 Within our own maternity triage unit, we observed a 30% reduction in attendance, from an average number of 28 patients per day before the pandemic to 20 thereafter, with a trough being evident in association with an escalation in the number of reported COVID-19 daily deaths (Figure 1). Although it is unknown which patients did not attend, if these were women with presenting complaints such as abdominal pain, vaginal bleeding or reduced fetal movements, this may subsequently have an adverse impact upon the stillbirth rate.27 This highlights the need for appropriate education, antenatal counselling and implementation of public health strategies to ensure women continue to seek appropriate care when necessary. A further public health opportunity lies in the promotion of wellbeing and the empowerment of women to take responsibility for their own health. It has been well publicised that outcomes following COVID-19 are worse in individuals who are obese or live a sedentary lifestyle.28, 29 For most people, lifestyle changes are rarely maintained from positive intention alone. However, decisive change is often triggered by a specific event, experience or consequence, referred to as the ‘Sentinel Event Effect’.30 It is highly likely COVID-19 will promote positive lifestyle changes, particularly in light of the vulnerability many may have felt by being at increased risk as a consequence of potentially reversible lifestyle choices. By permanently adopting lifestyles including an increase in exercise and an improved diet, there are likely to be significant long-term health benefits.31 The attrition rates for trainees within O&G are among the highest of all specialities. Just over 30% leave the speciality and at least 75% give it consideration.32 Commonly reported reasons for leaving include a lack of morale, concerns relating to bullying and undermining, administrative issues related to training, and poor work-life balance or support.32 Moreover, according to a recent study, 36% of all doctors working within O&G in the UK met the criteria for burnout using a validated tool.33 When focusing on trainees alone, the level of burnout rose to 43%.33 The existential threat posed by the global pandemic, coupled with the perils associated with treating COVID-19 patients and the need to reduce personal risk of disease, seem likely to exacerbate psychological strain among doctors worldwide, further impacting on wellbeing and retention in the specialty. In a survey of Obstetric and Gynaecology junior doctors within the UK, 64.9% reported they had received adequate training on two-person donning and doffing of PPE but remained anxious regarding the safety of PPE provided.34 Such anxieties can be reduced through increased use of practical and e-learning resources for training and active involvement in the planning of service provision within departments.34 In a study of 500 healthcare professionals working during the COVID-19 pandemic in Singapore, 14.5% were identified to have anxiety, 8.9% had depression and 7.7% had levels of stress consistent with post-traumatic stress disorder (PTSD).35 A perceived lack of control over decision-making is believed to promote stress,35 which is unavoidable when treating a novel disease with no vaccine or cure. In addition, a reduction in elective services and changes in rotas may inadvertently make it impossible for individuals to meet training competencies, further increasing levels of anxiety among trainees. Conversely, having pride and seeing value in one's work has been shown to help prevent burnout.33 As such, it is possible the appreciation and gratitude demonstrated by the public throughout the crisis will enhance feelings of existence and self-worth among clinicians. None declared. Completed disclosure of interests forms are available to view online as supporting information. The purpose of this manuscript is to understand how implementation of new strategies aiming to prioritise and optimise clinical care within O&G in response to the COVID-19 pandemic may improve service provision in the future. A comprehensive literature review was performed to provide evidence for the pertinent clinical arguments discussed. LSK wrote the article. SS and TB helped write the article and reviewed the final draft. JB, JY, KJ, CS, JBN, RS and CL provided input and revised the final draft. BPJ conceived the manuscript, helped write the article and reviewed the final draft. No ethical approval was required for the purpose of this paper. No funding was required for this paper. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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