‘Going the extra mile’: Midwives’ advocacy for woman-centred care during childbirth amid the COVID-19 pandemic: a qualitative study

‘Going the extra mile’: Midwives’ advocacy for woman-centred care during childbirth amid the COVID-19 pandemic: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ‘Going the extra mile’: Midwives’ advocacy for woman-centred care during childbirth amid the COVID-19 pandemic: a qualitative study Mario Martín Labrador, Vinita Mahtani Chugani, Felipe Santiago Fernández Méndez, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7406845/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background : The COVID-19 pandemic posed unprecedented challenges to maternity care, disrupting practices that promote respectful and woman-centred care during childbirth. Midwives play a critical role in fostering humanised care; however, restrictive policies and rapidly changing protocols during the pandemic constrained their ability to uphold these values. Although previous research has explored midwives’ experiences during the pandemic, their role in navigating the ethical dilemmas that emerged remains underexamined. This study aimed to explore the experiences and perceptions of midwives who cared for women diagnosed with COVID-19 during childbirth. Methods : A qualitative study with an ethnographic approach was conducted in two Spanish tertiary hospitals. Data were collected through two focus groups with fourteen labour ward midwives who provided care between March 2020 and May 2021. Inductive thematic analysis guided data interpretation. Results: Two themes emerged from the data analysis. The first, ‘systemic barriers to woman-centred care’, highlights the structural and organisational barriers that limited midwives’ ability to provide woman-centred care, such as hierarchical tensions, the silencing of the midwifery voice, and the loss of previously achieved gains in the humanisation of childbirth. The second, ‘upholding humanised care amid ethical dilemmas’, reflects both their commitment to defending more humanised care and the ethical dilemmas they faced when prioritising compassionate care over strict adherence to protocols. Conclusions: Midwives faced structural barriers and ethical dilemmas that limited their ability to provide woman-centred care during the COVID-19 pandemic. Despite these challenges, they continued to advocate for women’s wellbeing in line with the principles of their International Code of Ethics, striving to provide humane and respectful care while safeguarding the rights of women and their families. Women-Centred Care Midwifery COVID-19 Pandemic Ethical Dilemmas Qualitative Research. Introduction Emerging and re-emerging diseases represent one of the major public health challenges worldwide. Infections caused by various pathogens, such as influenza, SARS-CoV, MERS-CoV, Ebola virus or Zika pose a significant problem for all healthcare systems [ 1 ]. The COVID-19 pandemic has undoubtedly become one of the greatest challenges in the 21st century, affecting all areas of people’s lives and placing enormous strain on healthcare systems globally. On 31 December 2019, the World Health Organization (WHO) was alerted to a series of patients with pneumonia of unknown origin in Wuhan, Hubei province, China [ 2 ]. The virus responsible for this new disease was quickly isolated from infected patients and sequenced [ 3 ]. The International Committee on Taxonomy of Viruses (ICTV) subsequently named it Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [ 4 ]. However, it was not until 11 February 2020 that the WHO established COVID-19 as the official name for the disease caused by SARS-CoV-2 [ 5 ]. On 14 March 2020, the Spanish Government declared a state of emergency due to the COVID-19 pandemic, and the following day, imposed a nationwide lockdown. This state of emergency remained in effect until 21 June of the same year, marking the end of the first pandemic wave [ 6 – 8 ]. From the confirmation of the first case in Spain, detected on the island of La Gomera (Canary Islands) on 31 January 2020 [ 9 ], until the time of writing this article, a total of 13,980,340 cases and 121,852 deaths have been recorded at the national level [ 10 ]. Regionally, according to the Centre for the Coordination of Health Alerts and Emergencies [ 11 ], the Canary Islands reported 474,780 confirmed cases and 2,344 deaths associated with the disease as of 30 June 2023. The virus responsible for COVID-19 is highly contagious and spreads rapidly. Although it has been observed that 80% of pregnant women experience the illness in a mild or asymptomatic form [ 12 ], they are at greater risk of developing severe COVID-19 compared to non-pregnant women [ 13 ]. Despite measures adopted in Spain to curb the spread of COVID-19, such as suspending non-essential surgeries and cancelling non-urgent outpatient appointments, childbirth continued to require care in a health system overwhelmed by COVID-19 cases. As a result, maternity wards had to adapt to simultaneously care for women with a confirmed diagnosis of COVID-19 and those not affected by the virus [ 14 ]. Among the frontline healthcare professionals, midwives played a crucial role, as women continued to become pregnant and give birth, and both they and their families continued to require support and care [ 15 ]. Midwifery care is associated with improved quality of care and reduced maternal and neonatal mortality [ 16 ]. Moreover, midwives play a vital role in ensuring that women’s needs are met and that care is individualised and woman-centred [ 17 ]. The WHO stressed that even in the context of a pandemic, skin-to-skin contact, delayed cord clamping, breastfeeding, the right to be accompanied during childbirth, and avoiding mother-newborn separation should be guaranteed. Furthermore, the available evidence supports that both induction of labour and caesarean section should only be performed when medically indicated, and that a COVID-19 infection alone does not justify performing a caesarean section [ 18 , 19 ]. Pregnant and postpartum women with suspected or confirmed COVID-19 should have access to respectful, woman-centred care (WCC) [ 19 ]. However, despite recommendations urging the provision of evidence-based, respectful care during the pandemic, numerous violations of the right to woman-centred maternity care were observed in early 2020. Members of the Global Council on Respectful Maternity Care, a network made up of over 150 organisations and 350 members from 45 countries, reported practices such as mandatory separation of mother and newborn, restrictions on breastfeeding, prohibition of companionship during labour, and an increase in caesareans, instrumental births, and inductions without medical indication [ 20 ]. These situations were also denounced by international organisations and professional associations, such as the International Confederation of Midwives (ICM), which warned of the implementation of inappropriate protocols not based on up-to-date scientific evidence, resulting in harmful practices for women, their newborns, and midwives themselves [ 21 – 24 ]. Midwives are the most suitable professionals to inform and advise governments on the effective organisation of maternity services, as well as to identify and advocate for the needs of the women and newborns they care for [ 21 , 23 ]. However, the survey conducted by Hartz et al. [ 21 ] identified a lack of midwifery representation in the development of strategic government policies related to responses to emerging epidemic threats in maternity care. Five years after the onset of the pandemic, qualitative research in this area has seen notable growth. Despite the existence of studies exploring midwives’ experiences during the COVID-19 pandemic [ 14 , 25 – 28 ], including the works of González-Timoneda et al. [ 25 ] and Küçüktürkmen et al. [ 28 ] that delve into midwives’ experiences caring for women with a COVID-19 diagnosis during childbirth, there remains a marked lack of research specifically addressing the role of midwives in facing the ethical dilemmas that arose during this period. In this context, it is essential to understand how midwives dealt with these moral conflicts between providing humanised care and complying with infection control measures, as well as the strategies they employed to protect and defend women’s rights during childbirth. Methods Aim The aim of this study was to explore, in depth, the experiences and perceptions of midwives who cared for women with a diagnosis of COVID-19 during childbirth, in the two university hospitals of Tenerife, with a particular focus on their role as advocates for WCC, in a context of high institutional pressure during the first year of the pandemic. Study design and setting The qualitative analysis presented here is part of a broader study framed within a doctoral thesis project. This aims to explore the experiences of women diagnosed with COVID-19 during childbirth in Tenerife, as well as their chosen companions, and the experiences of healthcare professionals (midwives, obstetricians, and healthcare assistants) who cared for these women. This article focuses specifically on the focus groups conducted with midwives. A qualitative study with an ethnographic approach was conducted [ 29 ]. This approach is suitable for exploring shared beliefs, values, and meanings, as well as the everyday practices of midwives within their working culture. This methodology allows for an in-depth understanding of the experiences and actions of a social group within its natural context and from its own perspective [ 30 ], facilitating a deeper insight into how midwives experienced their professional roles during the first year of the pandemic. This study was conducted in the two tertiary-level public university hospitals on the island of Tenerife: Complejo Hospitalario Universitario de Canarias (CHUC) and Hospital Universitario Nuestra Señora de Candelaria (HUNSC). In 2021, the populations assigned to these hospitals were approximately 387,103 and 515,693 inhabitants respectively. In 2020, CHUC recorded 2,003 births and 1,935 in 2021, while HUNSC reported 2,498 births in 2020 and 2,332 in 2021 [ 31 , 32 ]. Ethics This study received ethical approval from the Ethics Committee for Medicinal Research of the Complejo Hospitalario Universitario de Canarias (Province of Santa Cruz de Tenerife), under reference CHUC_2022_69, on 16 June 2022, after confirming the protocol’s suitability to the study objectives. All participants signed informed consent forms prior to the interviews. They were informed that participation was entirely voluntary and that they could withdraw at any time without consequence. Confidentiality and anonymity in data handling were guaranteed. Participants and recruitment A total of fourteen midwives from both hospitals were included. Inclusion criteria were: having worked in the labour ward at any point between the declaration of the state of emergency, on 14 March 2020, and the date on which pregnant women were included in the COVID-19 vaccination strategy in Spain, on 11 May 2021 [ 33 ]; having provided care to women diagnosed with COVID-19 during childbirth; and having agreed to participate in the study. To obtain as much information as possible, all midwives who worked in the labour wards during the first year of the pandemic were invited to participate. An informational poster was designed to invite participation in the study. It included a QR code linking to a document with details about the project and the research team’s contact information. The poster was placed in both labour wards with prior authorisation from hospital management. Data collection Midwives interested in participating contacted the research team, who then reached out to those who met the inclusion criteria to coordinate the focus group sessions based on availability. After obtaining oral consent to participate in the study, data collection took place between February and July 2023. Narratives were gathered through in-person semi-structured interviews, as physical distancing restrictions associated with the pandemic had been lifted by the time of data collection. Two focus groups were conducted: one with eight midwives from CHUC and another with six midwives from HUNSC, totalling fourteen participants. The research team developed an interview guide with the opening question: ‘Could you tell me about your experience caring for women diagnosed with COVID-19 during their stay in the labour ward?’ . This guide was reviewed by several team members to ensure content validity and methodological rigour. To encourage an atmosphere conducive to open and honest sharing, the CHUC focus group was moderated by the second author, as the lead researcher was part of the CHUC midwifery team. The lead researcher moderated the focus group at HUNSC. Two observers attended each session, taking note of non-verbal expressions, gestures, and group dynamics to complement the verbal data. Data analysis The analysis began simultaneously with data collection. Transkriptor software [ 34 ] was used to generate an initial automatic transcription of the focus groups. These transcripts were then manually reviewed by the lead researcher. The qualitative analysis followed an inductive approach, combining two complementary methodological strategies. First, the six steps of thematic analysis proposed by Braun and Clarke [ 35 ] were followed: (1) familiarising yourself with your data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. Secondly, the OSOP (‘One Sheet of Paper’) method developed by DIPEx International [ 36 ] was applied. This involves individual coding, followed by team triangulation, clustering of codes into thematic areas, and the creation of thematic summaries for each topic discussed. Using these methodological strategies, the lead researcher conducted a detailed, manual line-by-line analysis of the transcripts. As the analysis progressed, the coding framework was gradually adapted to incorporate emerging codes. Findings were discussed with the research team until consensus was reached on the final thematic structure. ATLAS.Ti software was used to support the analysis of transcribed texts [ 37 ]. In line with Lincoln and Guba’s model of trustworthiness [ 38 ] to ensure research rigour, several strategies were incorporated to meet the criteria of credibility, transferability, dependability, and confirmability of the findings. To enhance analytical robustness and support a broader and more robust interpretation of the data, investigator triangulation was carried out. Given the inherently subjective nature of qualitative research, a reflexive approach was maintained through a systematic annotation process (audit trail), which documented the analytical process and the research team’s reflections in detail. This process ensured transparency in decision-making and reinforced the robustness of the analysis, contributing to the study’s methodological rigour. The findings are presented in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines to ensure the transparency and rigour of the study [ 39 ]. Results The participants’ ages (N = 14) ranged from 29 to 59 years, with a mean age of 40.6 years. All participants were of Spanish nationality. Out of the total number of participants, one identified as a man (n = 1, 7.1%) with the rest identifying as women (n = 13, 92.9%). The mean length of work experience in the labour ward was 12.8 years, with a minimum of 3 years and a maximum of 31 years. The remaining sociodemographic characteristics of the participants are presented in Table 1 . Table 1 Sociodemographic characteristics of participants. Participants Hospital Age Gender Nationality Work experience in labour ward (years) COVID-19 infection (Mar 2020 - Apr 2021) Sick leave due to COVID-19 M1 CHUC 42 Woman Spanish 19 years Once Once M2 CHUC 29 Man Spanish 4 years Once Once M3 CHUC 38 Woman Spanish 12 years Once None M4 CHUC 51 Woman Spanish 13 years Once None M5 CHUC 29 Woman Spanish 3 years None None M6 CHUC 47 Woman Spanish 22 years None None M7 CHUC 35 Woman Spanish 8 years None None M8 CHUC 29 Woman Spanish 4 years None None M9 HUNSC 51 Woman Spanish 18 years None None M10 HUNSC 59 Woman Spanish 31 years Once None M11 HUNSC 32 Woman Spanish 5 years None None M12 HUNSC 39 Woman Spanish 12 years Twice None M13 HUNSC 31 Woman Spanish 6 years None None M14 HUNSC 56 Woman Spanish 23 years Unknown None CHUC: University Hospital of the Canary Islands; HUNSC: University Hospital Nuestra Señora de Candelaria; M: Midwife. Two main themes emerged from the data analysis: ‘systemic barriers to WCC’ and ‘upholding humanised care amid ethical dilemmas’. Several subthemes were identified within these overarching themes (see Table 2 ). The following section outlines the results, supported by the most illustrative quotations. Each quotation is presented with the corresponding participant identifier (M1–M14). Table 2 Identified themes and subthemes. Themes Subthemes Systemic barriers to WCC Conflicting and restrictive guidelines Hierarchical tensions, paternalism, and the silencing of midwifery voices Loss of achieved gains in maternity care Upholding Humanised Care Amid Ethical Dilemmas Going the extra mile to defend women's rights Prioritising compassionate care over adhering to evolving guidelines Systemic barriers to WCC Three subthemes emerged within this theme: ‘conflicting and restrictive guidelines’, ‘hierarchical tensions, paternalism, and the silencing of midwifery voices’, and ‘loss of achieved gains in maternity care’. Conflicting and restrictive guidelines During the first year of the pandemic, the protocols for caring for women diagnosed with COVID-19 during childbirth were perceived by midwives as excessively restrictive and contradictory to the recommendations of scientific organisations. This situation led them to act in ways that conflicted with practices they had previously committed to upholding. “It was horrible to feel that anguish, thinking you were going to start doing things you had promised never to do in your practice.” – M1 “And we would say, but come on, if the scientific societies […] have said this doesn’t need to be done that way. But it was like this thing of saying, we need to cover ourselves to an extreme degree just in case, and the ‘just in case’ […] justified absolutely everything.” – M6 “We had learned that women had a voice and a say in their care and their health, and it was all wiped out in a moment, in the name of some theoretical safety that wasn’t actually evidence-based.” – M1 “We couldn’t believe we had to actually violate these women and do things that, in the name of safety, everyone thought were just fine. At no point was the woman’s perspective considered, nor the baby’s, nor the partner’s… and forget about the companion altogether.” – M1 Some midwives expressed distress over protocols that disrupted the early mother-baby bond, particularly those that prevented immediate skin-to-skin contact. The initial separation between mother and newborn undermined bonding and delayed the initiation of breastfeeding. “I remember once getting scolded because the baby couldn’t be on the mother’s bed, and she didn’t want to be separated from her baby, so I got told off because the baby couldn’t be transported outside the cot, it had to be transferred like radioactive material. ‘No, no, the baby must go in the cot’, isolated there, and the mother with her mask and a sheet up to here.” – M5 “The baby was admitted for the PCRs, and she stayed downstairs to express colostrum.” – M1 In cases where newborns remained with their mothers, physical barriers were imposed to prevent infection, despite their questionable effectiveness. “Skin-to-skin contact wasn’t really skin-to-skin, it was skin-to-sheet, because you had to put a sheet over her and then place the baby on top.” – M5 “We didn’t do it at first (referring to skin-to-skin contact); the skin-to-skin was done with a plastic sheet in between, I mean, just imagine…” – M14 Others found it particularly incoherent that some newborns stayed with their mothers in the labour ward, only to be transferred to the neonatal unit for polymerase chain reaction (PCR) testing hours later, questioning the logic of such measures. “Mother and baby had been together in the labour ward, just minutes!, and suddenly the baby was placed in an incubator […] And then they were going to be together again, and you just think… the incoherence.” – M6 Mandatory mask use was a common practice in both hospitals during mother-baby interactions following birth, reflecting broader infection control measures that, according to some midwives, often stigmatised newborns of COVID-positive mothers. “With the mask so she wouldn’t breathe on the baby and all that stuff. Yes, yes, always the mask. Always.” – M14 “The baby was radioactive, really, stigmatised, untouchable, it couldn’t be held, it was just seen as incredibly dangerous.” – M6 Even colostrum was treated with suspicion, prompting midwives to disinfect the syringes and bags containing it to ensure its administration. The protocol for expressing breast milk in these cases was perceived as disproportionate and lacking in logic. “The protocol for milk expression, it was like if you expressed colostrum it was radioactive, COVID-positive colostrum looked like it was going to explode while you were taking it to the neonatal ICU.” – M4. “You disinfected it, then put it in one bag, then another bag, and then you touched it with gloves, then removed your second glove…” – M6. “It was like a headache.” – M4 Hierarchical tensions, paternalism, and the silencing of midwifery voices With regard to childbirth care during the COVID-19 pandemic, many of the midwives interviewed perceived paternalistic discourses and attitudes that reflected the imposition of decisions without considering women’s opinions or those of the professionals directly involved in their care. According to their accounts, their voices were ignored on several occasions. This approach, in addition to introducing a discourse of fear to ensure compliance with measures, resulted in restrictive actions that limited women’s ability to decide about their own birth process. “I remember being extremely angry because they made it very clear that we had no say regarding the care of the pregnant women […]. We were told that we had to comply with what the neonatologists and obstetricians said. Just like that, straight from our supervisors.” – M1 “There was an extremely strong fear-based discourse, eh! The message women received was one of fear, that ‘this was extremely dangerous’.” – M6 “Women were told: ‘we’re doing this for your own good and your baby’s, for your good and your baby’s’.” – M6 “There were separations, and there was pressure, and there was even emotional blackmail towards the women.” – M1 Childbirth care regressed towards a more hierarchical and authoritarian model, reminiscent of earlier times. Many of the midwives interviewed described how hierarchy and paternalism were strongly imposed, limiting their autonomy in decision-making and undermining their experience and clinical judgement. “That anguish, that helplessness, that frustration, and that unease about the world, about the mothers, about the babies, and that rage towards authority. That authority and hierarchy that imposed senseless things on us and never listened to us. That really was a constant. We were never heard in any way […] It was an extremely rigid top-down structure.” – M6 “A system was put in place that, for me, felt like a return to the authoritarianism and hierarchy of the past.” – M1 Frustration was a constant feeling, as their professional input regarding women’s care was often disregarded. They felt compelled to follow orders rather than exercise their expertise, unable to implement practices they considered essential for women’s wellbeing. “At that time, just daring to question what was written was inadmissible.” – M1 “If you dared to raise something like, ‘Hey, really, is it necessary to do this like that? Just so you know, there’s this…’, it would cause a scene, and on top of that, the reaction was super aggressive, like, ‘What are you thinking?’, […] stop bothering us with silly things.” – M6 “With everything that’s going on, how dare you raise such nonsense?, and you think ‘do they really consider all of this nonsense?’ […] I remember it as a time of internal torture.” – M6 At the onset of the pandemic, professionals across all disciplines showed reluctance to enter the birthing rooms of women diagnosed with COVID-19, largely due to fears of contagion and the potential risk to their own families. This reluctance often led to situations such as the one recalled by a midwife, in which an anaesthetist avoided administering an epidural to a labouring woman with COVID-19 by making excuses, a situation that triggered intense feelings of frustration and helplessness. As midwives were the only ones who could not avoid going in, the distribution of work became unequal. “This woman was in pain and wanted an epidural. Anaesthesia put up a lot of obstacles. […] They asked me to get a new coagulation test because since COVID could affect clotting values, they wouldn’t give her an epidural without today’s test […] It was her second birth, I had already confirmed she was in active labour, and I begged them to prioritise the blood test because otherwise, she wouldn’t be able to have the epidural she wanted. The test results came back, anaesthesia was informed, and they still kept stalling. My impression is they didn’t want to go in. […] The frustration you felt as a professional, not even being able to step out because the woman needed you […] In the end, she gave birth without the epidural.” – M8 “The burden fell on the midwife, because she was the one who absolutely had to go in (referring to going inside the labour room). So, we were the ones inside, and the healthcare assistant…well, if you went in, because you were there, you’d just have to do everything. The obstetrician was the same, right? They wouldn’t go in, and neither would the paediatrician. Everything ended up falling on us.” – M4 Loss of achieved gains in maternity care Childbirth care underwent a significant shift, marked by clear dehumanisation of both clinical procedures and the treatment of women. Many of the gains achieved in humanised maternity care were dismantled with the implementation of new protocols, where infection prevention measures overshadowed evidence-based practices. For midwives, trying to preserve these gains was particularly challenging. “And it was also as if suddenly we were in a state of war. So in a state of war, forget about all the nonsense! It’s like, don’t come talking to me about breastfeeding, breastfeeding is the last of the last among all the humanisation things; companionship, avoiding separation… all of that was suddenly pushed not to the background, but to the umpteenth background, because we’re at war…” – M6 “A series of things were being done that we all knew went against the normal nature of childbirth.” – M14 “We had gained, over so many years, […] so much ground for the benefit of mothers, the mother–baby dyad, and the family, and suddenly, it all fell apart.” – M14 “We’re mentally exhausted from having to fight so much, from defending things that had already been achieved and were lost.” – M7 Several midwives also shared how certain practices negatively affected birth companions, who at times were treated in an undignified manner and denied basic needs. “My impression from all these years is that many fundamental human rights were lost, I mean, not just the woman being alone, the companion would go hours without eating, peeing in a bottle, I mean, basic needs were lost.” – M3 Nevertheless, one midwife described the sense of gratification shared by many colleagues when institutional changes were eventually achieved through letters and public advocacy efforts in defence of women’s rights. “There was also a sense of satisfaction, of empowerment, seeing that in the end, the things that worked were letters from the Midwives’ Federation, through the association, through the media, well, those things worked and changes happened. And we liked that.” – M12 Upholding humanised care amid ethical dilemmas Two subthemes emerged within this theme: ‘going the extra mile to defend women’s rights’ and ‘prioritising compassionate care over adhering to evolving guidelines’. Going the extra mile to defend women’s rights The efforts to ‘go the extra mile’ in providing care during childbirth amidst the pandemic reflect midwives’ deep commitment to safeguarding the wellbeing of women and their companions. One midwife described this approach as intrinsic to their professional identity. “I went with the anaesthetist, we did a bit of a sneaky one there, to get a blood sample from the father, which I took from him in his own car (laughs), just outside the car park. It was a blood test, in the car, to check if he also tested negative (referring to the PCR) so he could be with the baby.” – M4 Midwives at one of the hospitals implemented a range of strategies to support women amid prevailing limitations and restrictions. Among many other initiatives, they set up a dedicated phone line to provide direct communication, respond to questions, and offer support during a time of uncertainty. “Do you remember we also set up a phone line? We tried to create a direct communication channel to resolve doubts.” – M6 “Many women had doubts, the usual ‘I don’t know if I should go to the hospital’, they had that number to contact us and say, look, this is happening, what should I do?” – M3 Additionally, several midwives from the same hospital created, on a voluntary and altruistic basis, a virtual nationwide support group focused on breastfeeding and the postnatal period. They described this initiative as an enriching experience that allowed them to support women using technology. Technology became a fundamental tool for exploring new ways of delivering care. “Together with (midwife’s name), and two other colleagues, we set up a virtual postnatal support group, a breastfeeding support group, where we connected once a week with people from all over, people joined from all over Spain. That’s definitely something I take with me.” – M6 “It was a balm, I think it was a balm, wasn’t it?” – M1 “Yes, I take that with me. It was beautiful, beautiful.” – M6 “For me too. (Midwife’s name) used to call me: ‘we have to do something! we have to do something!’.” – M4 They also developed a protocol for colostrum expression for newborns of mothers with COVID-19, as they were routinely admitted to the neonatal unit after birth, preventing immediate initiation of breastfeeding. “We made a protocol for expression because… well, they couldn’t (referring to initiating immediate breastfeeding), the baby was admitted for PCRs and she stayed downstairs to express colostrum.” – M4 In the absence of clear evidence, midwives devised additional clinical measures, such as washing the breasts of these women to facilitate skin-to-skin contact and allow for delayed cord clamping. “Do you remember when we came up with the idea to allow skin-to-skin contact if we washed the breast? Do you remember? We washed the woman’s breast beforehand, even just with soap, before birth, so delayed cord clamping could happen.” – M4 Prioritising compassionate care over adhering to evolving guidelines Professional commitment was evident in multiple ways. Some midwives chose to lower their masks so that women could see their faces, aiming to convey warmth and reassurance. In certain situations, they allowed women to remove their masks during the pushing stage, demonstrating empathy and assuming personal risks by prioritising physical presence and human connection. “When introducing myself, I’d lower my mask and say, ‘look, I’m so-and-so, I’m your midwife, just so you can see my face’, and then I’d put it back on. At least that, let her see your face, a smile, something.” – M6 “I couldn’t remove physical contact from the equation in my work […] I can’t do my job from one corner and have the woman in another corner, I thought, ‘that’s just not possible’, so I kind of accepted it, I said, I can’t, I just can’t do it any other way.” – M6 “I protected myself and said, ‘let the woman push however she needs to…’ Wearing that thing is unbearable […] That’s unbearable, so asking a woman to push, to take a breath and push while wearing a mask […] She took it off, of course… […] It’s impossible, it really is.” – M14 However, at times, fear of infection created ethical dilemmas that affected how care was delivered. “And every time you had to go into a labour room, you had to put on so much PPE, it would take at least 10 or 15 minutes to get dressed and undressed. And that made you want to go in as little as possible. That’s really how it felt.” – M8 “A woman with COVID would arrive, we’d put her in a delivery room, and it was like, who’s going in? […] I remember we even did a draw to decide…” – M5 The right of women to be accompanied during childbirth was also actively defended by the midwives. In some cases, companionship was allowed discreetly, in contravention of established protocols. “But come on, how is that woman supposed to be alone? She has the right to be accompanied […] She has the right to be accompanied!” – M5 “There was a time when only one companion was allowed, and she would say, ‘please, my mum is here too’. And it was like telling the healthcare assistant: ‘look, let her mum in for a moment, but don’t tell anyone’ (whispering).” – M7 “Yes, yes, everything in secret.” – M4 This commitment to WCC was equally evident in obstetric emergencies involving women with COVID-19, where midwives prioritised women’s wellbeing over the risk of infection. The urgency to provide immediate care sometimes led them to use personal protective equipment (PPE) improperly. “I didn’t have time to put the PPE on properly, I just put it on however I could, and at that moment, COVID was no longer the focus.” – M3 “But that was beautiful too, because no one even thought about not caring for her.” – M1 “Of course, it was beautiful, yes.” – M3 “In that moment, everyone was focused on what needed to be done.” – M1 “We all went in (referring to entering the labour room), even though no one wanted to at first, in that moment, we all went in because it was an emergency, and that was beautiful.” – M3 Discussion The findings of this qualitative study provide new insights into the experiences of midwives who provided care to women diagnosed with COVID-19 during childbirth in the first year of the pandemic in Tenerife. Participants’ experiences were organised into two main themes. The first, ‘systemic barriers to WCC’, highlights the structural and organisational difficulties that limited midwives’ ability to deliver WCC, such as hierarchical tensions, the silencing of midwifery voices, and the loss of previously achieved gains in the humanisation of childbirth. The second, ‘upholding humanised care amid ethical dilemmas’, illustrates both the active commitment of midwives to humanised care and the ethical dilemmas they faced when prioritising compassionate care over strict adherence to protocols. Many of the protocols implemented during the pandemic lacked reliable, up-to-date scientific evidence and were detrimental to women and their newborns [ 24 ]. Measures such as banning birth companions, separating mothers from their newborns after birth, restricting immediate skin-to-skin contact, prohibiting breastfeeding, or imposing unnecessary medical interventions constituted clear violations of the rights of both women and their babies, and therefore, a marked dehumanisation of childbirth care during the COVID-19 pandemic globally [ 21 ]. In other studies, midwives reported several of these practices in the care of women with COVID-19, expressing emotional suffering due to the dehumanisation experienced in labour wards, as well as frustration and anxiety about the potential impact of these measures on the quality of care [ 25 , 27 ]. Midwives also warned of the rapid loss of many gains related to women’s rights and voiced concerns about the potential institutionalisation of some of the practices introduced during this period [ 25 , 27 ]. These experiences are echoed in our study, in which frustration was a recurring theme among midwives, not only because they were unable to implement practices they considered essential for women’s wellbeing, but also because they felt that numerous advances in rights and quality of care, achieved after years of effort, were being rapidly undone during the pandemic. Previous research highlights how rushed decision-making during health crises can lead to the erosion of progress made in WCC and even disrupt previously evidence-based practices [ 40 ]. The pandemic exacerbated structural gaps and exposed pre-existing inequalities, revealing both the lack of recognition for midwives and a striking absence of their representation in the bodies responsible for developing protocols and policies in response to emerging epidemic threats [ 21 , 26 ]. Previous experiences, such as the Ebola crisis in Sierra Leone, demonstrated how midwives’ voices were silenced in decision-making processes, forcing them to fight for professional recognition in the face of directions from individuals without obstetric training [ 41 ]. The midwives in our study described similar experiences. To understand the significance of these findings, it is essential to consider the professional values and historical achievements based on person-centred care [ 42 ] and adherence to a Code of Ethics [ 43 ], which promote individualised, dignified care and place the family at the centre of maternity care. The experiences of the midwives in this study reflect the challenges they faced in upholding these ethical principles that define their profession. The inherent ethical commitment in midwifery places midwives in complex dilemmas when trying to balance person-centred care and professional ethics with the uncertainty surrounding a new and unknown virus. Previous studies conducted during similar health crises, such as the Ebola outbreak, as well as during the COVID-19 pandemic, reveal similar dilemmas experienced by midwives in different care settings. In Sierra Leone, some midwives took personal risks, considering physical contact indispensable to their care, which in some cases led to professional sanctions. In their efforts to improve care for these women, they resorted to creativity to find alternative care strategies [ 41 ]. Such efforts to ‘go the extra mile’ are mirrored in the professional commitment of many of the midwives in our study, who implemented various strategies to support women. In the context of COVID-19, other studies also report similar dilemmas. The inability to comfort women through physical contact hindered the creation of meaningful connections, leading some midwives to prioritise women’s emotional wellbeing over their own safety, believing it impossible to maintain physical distance during labour [ 26 ]. Additionally, behaviours that might have been deemed unethical in other contexts were described as understandable and justifiable given the extraordinary circumstances [ 14 ]. These findings are fundamental not only to understand the ethical dilemmas faced by the midwives in our study, torn between providing WCC or strictly adhering to evolving guidelines, but also to make visible the advocacy role that many of them assumed. Several studies have highlighted the critical role of midwives as advocates for safe, respectful, and compassionate care, especially during health crises, where control strategies implemented by health systems may infringe on the rights of the most vulnerable women [ 41 , 44 ]. This advocacy role was clearly reflected in the practices and attitudes of the midwives in both university hospitals in Tenerife. Implications for the future Given their key role in defending WCC, midwives should receive the necessary institutional support to ensure their active participation in planning strategies for epidemic preparedness and response. This is essential to protect the health and rights of women and their families at a global level. As professionals specialised in maternity care, midwives are best qualified to advise governments on the optimal organisation of maternity services [ 21 , 23 , 26 , 43 ]. Strengths and limitations The findings presented offer novel evidence regarding the ethical dilemmas experienced by midwives when providing care to women diagnosed with COVID-19 during childbirth in the first year of the pandemic. This contribution is particularly valuable for future researchers, as it offers insight into the challenges faced by certain healthcare professionals in crisis contexts, where they must navigate between the implementation of strict infection control measures and the ethical duty to uphold humane and compassionate care in accordance with their professional code, despite the uncertainty and challenges of the context. As qualitative researchers and healthcare professionals, we are aware of the methodological and ethical challenges that this dual identity may entail. While sharing a professional background with participants facilitated recruitment and helped build trust, it may also have led to shared knowledge and experiences going unchallenged, as well as a tendency for both interviewer and participants to avoid sensitive topics in order to protect professional image. To mitigate these risks, investigator triangulation was applied during data analysis, and the lead researcher refrained from interviewing his own colleagues. Conclusion Despite the restrictions imposed by institutional protocols and public health guidelines, the actions of midwives were grounded in the principles set out in the International Code of Ethics for Midwives. From this ethical foundation, they sought to ensure humane and respectful care, safeguarding the rights of women and their families, even in a context marked by uncertainty, clinical pressure, and hierarchical imposition. It is important to recognise that analysing the actions taken during a time of crisis such as the COVID-19 pandemic provides a clearer perspective and understanding of the situation. This work does not aim to judge those decisions, but rather, from a constructive standpoint, to emphasise the value and importance that must be given to family-centred care in the planning of future responses to public health emergencies. Abbreviations CHUC Complejo Hospitalario Universitario de Canarias HUNSC Hospital Universitario Nuestra Señora de Candelaria PCR Polymerase chain reaction PPE Personal protective equipment WCC Women-centred care. Declarations Ethics approval and consent to participate This study received ethical approval from the Ethics Committee for Medicinal Research of the Complejo Hospitalario Universitario de Canarias (Province of Santa Cruz de Tenerife), under reference CHUC_2022_69, on 16 June 2022, after confirming the protocol’s suitability to the study objectives. All participants signed informed consent forms prior to the interviews. They were informed that participation was entirely voluntary and that they could withdraw at any time without consequence. Confidentiality and anonymity in data handling were guaranteed. Consent for publication Not applicable. Funding This study was supported by the Canary Islands Health Research Institute Foundation (FIISC), through grant number ENF22/03. The grant was held by the institution, and expenses were reimbursed upon submission of itemised invoices and proof of payment. No equipment or drugs were provided in support of the research. Author Contribution MML and VMC conceived and designed the study, collected and curated the data, conducted the analysis, and contributed to the methodology, project administration, resources, and funding acquisition. MML prepared the visual materials and drafted the original manuscript. VMC and EJSA provided supervision. VMC, FSFM and EJSA contributed to funding acquisition, resources, and reviewing and editing. All authors read and approved the final manuscript. Acknowledgement The authors would like to thank all the midwives who chose to participate in this study and share their experiences with the research team. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. References Gao GF. From AIV to ZIKV: Attacks from Emerging and Re-emerging Pathogens. Cell. Cell Press; 2018. pp. 1157–1159. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506. Wu F, Zhao S, Yu B, et al. A new coronavirus associated with human respiratory disease in China. Nature. 2020;579(7798):265–9. Gorbalenya AE, Baker SC, Baric RS et al. Severe acute respiratory syndrome-related coronavirus: The species and its viruses – a statement of the Coronavirus Study Group [Internet]. bioRxiv; 2020. 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The State of the World’s Midwifery. 2021: Building a health workforce to meet the needs of women, newborns and adolescents everywhere [Internet]. New York; 2021 [cited 2025 Apr 3]. Available from: https://www.unfpa.org/sowmy ICM UNFPA. Protecting midwives to sustain care for women, newborns and their families in the COVID-19 pandemic: A global call to action [Internet]. The Hague; 2020 [cited 2025 Apr 3]. Available from: https://internationalmidwives.org/wp-content/uploads/1call-to-action.pdf ICM. Women’s Rights in Childbirth Must be Upheld During the Coronavirus Pandemic [Internet]. 2020 [cited 2025 Apr 2]. Available from: https://internationalmidwives.org/womens-rights-in-childbirth-must-be-upheld-during-the-coronavirus-pandemic/ González-Timoneda A, Hernández Hernández V, Pardo Moya S, et al. Experiences and attitudes of midwives during the birth of a pregnant woman with COVID-19 infection: A qualitative study. Women Birth. 2021;34(5):465–72. Memmott C, Smith J, Korzuchowski A, et al. Forgotten as first line providers: The experiences of midwives during the COVID-19 pandemic in British Columbia, Canada. Midwifery. 2022;113:103437. Bradfield Z, Hauck Y, Homer CSE, et al. Midwives’ experiences of providing maternity care during the COVID-19 pandemic in Australia. Women Birth. 2022;35(3):262–71. Küçüktürkmen B, Baskaya Y, Özdemir K. A qualitative study of Turkish midwives’ experience of providing care to pregnant women infected with COVID-19. Midwifery. 2022;105. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 2nd ed. Thousand Oaks, CA: Sage; 2007. Hammersley M, Atkinson P, Ethnography. Principles in Practice. 4th ed. London: Routledge; 2019. Hospital Universitario Nuestra Señora de Candelaria. Memoria anual de actividad 2021 [Internet]. 2021 [cited 2025 Apr 23]. Available from: https://www3.gobiernodecanarias.org/sanidad/scs/scs/as/tfe/27/Memorias/2021/indei.html Complejo Hospitalario Universitario de Canarias. Memoria 2021 [Internet]. 2021 [cited 2025 Apr 23]. Available from: https://www3.gobiernodecanarias.org/sanidad/scs/scs/as/tfe/28/memorias/2021/indei.html Ministerio de Sanidad. Actualización 7. Estrategia de vacunación frente a COVID-19 en España [Internet]. 2021 [cited 2025 May 4]. Available from: https://www.sanidad.gob.es/areas/promocionPrevencion/vacunaciones/covid19/ActuActualizaci_Estrategia_Vacunacion/docs/COVID-19_Actualizacion7_EstrategiaVacunacion.pdf Transkriptor, Transkriptor. AI-powered transcription software [Internet]. 2024 [cited 2025 May 22]. Available from: https://www.transkriptor.com Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Ziebland S, McPherson A. Making sense of qualitative data analysis: An introduction with illustrations from DIPEx (personal experiences of health and illness). Med Educ. 2006;40(5):405–14. ATLAS.ti Scientific Software Development GmbH. ATLAS.ti Mac (Version 25) [Internet]. ATLAS.ti Scientific Software Development GmbH; [cited 2023 Jul 27]. Available from: https://atlasti.com Lincoln YS, Guba EG. Naturalistic Inquiry. Naturalistic Inquiry. Beverly Hills, CA: Sage Publications, Inc.; 1985. pp. 289–331. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Renfrew MJ, Cheyne H, Craig J, et al. Sustaining quality midwifery care in a pandemic and beyond. Midwifery. Churchill Livingstone; 2020. Erland E, Dahl B. Midwives’ experiences of caring for pregnant women admitted to Ebola centres in Sierra Leone. Midwifery. 2017;55:23–8. Stewart M, Brown JB, Weston WW, et al. Patient-Centered Medicine: Transforming the Clinical Method. 2nd ed. Oxford: Radcliffe Medical; 2003. ICM. International Code of Ethics for Midwives [Internet]. The Hague, The Netherlands. 2014 [cited 2025 Jun 1]. Available from: https://internationalmidwives.org/resources/international-code-of-ethics-for-midwives/ Davis-Floyd R, Gutschow K, Editorial. The Global Impacts of COVID-19 on Maternity Care Practices and Childbearing Experiences. Front Sociol. 2021;6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7406845","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516740309,"identity":"482d0a32-f9de-4716-bd41-5e1f40486c42","order_by":0,"name":"Mario Martín Labrador","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIie3PsUrEMBzH8X8JpAg5uwYq7SskFg6loq+SUtBNOFwyiPYo9BkqHD6Dk3NLoC5RV+EGc7vDTYeb9qpOGjk3h3zHwIf/LwAu13/MB2gEo5cxPC7MUsLOdv9IfyUIPGPknuBTjXitgeANCOJGSwFK43Cr2oAEJRnTrKKnXnXfhd616glq5wQOjmyEqg9y5pOHPJ3crgnOUwLHWWEzn8Sb1g2fXw2EjEMCSthE/EWKZ8PC0WxNglVP3qzDmCIJE5pmRaN3w1ExXME9aTzbMK7wxAhJE150Oa+7E4IRTvZnLLf+Jborb9pXdhHFoFqzPE+jwC8XTy/y0Drsh9Aw+A/A5XK5XN96B/c+Un3A2tiUAAAAAElFTkSuQmCC","orcid":"","institution":"University of La Laguna, Santa Cruz de Tenerife","correspondingAuthor":true,"prefix":"","firstName":"Mario","middleName":"Martín","lastName":"Labrador","suffix":""},{"id":516740310,"identity":"2ee9af67-55f8-4bba-a8ef-09a81755c164","order_by":1,"name":"Vinita Mahtani Chugani","email":"","orcid":"","institution":"Santa Cruz de Tenerife","correspondingAuthor":false,"prefix":"","firstName":"Vinita","middleName":"Mahtani","lastName":"Chugani","suffix":""},{"id":516740311,"identity":"752d6038-83ab-4fde-875e-f6a6b0371503","order_by":2,"name":"Felipe Santiago Fernández Méndez","email":"","orcid":"","institution":"University Hospital of the Canary Islands (CHUC), Santa Cruz de Tenerife","correspondingAuthor":false,"prefix":"","firstName":"Felipe","middleName":"Santiago Fernández","lastName":"Méndez","suffix":""},{"id":516740312,"identity":"bd1ece12-3658-44b3-95ab-bb59db6d1629","order_by":3,"name":"Emilio J. Sanz Álvarez","email":"","orcid":"","institution":"University Hospital of the Canary Islands (CHUC), Santa Cruz de Tenerife","correspondingAuthor":false,"prefix":"","firstName":"Emilio","middleName":"J. Sanz","lastName":"Álvarez","suffix":""}],"badges":[],"createdAt":"2025-08-19 09:23:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7406845/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7406845/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91714978,"identity":"340a401e-bdad-4cf0-8002-b8de8b383853","added_by":"auto","created_at":"2025-09-19 13:09:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":881789,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7406845/v1/cf678192-bc18-4362-bfd1-264fd142f6bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"‘Going the extra mile’: Midwives’ advocacy for woman-centred care during childbirth amid the COVID-19 pandemic: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEmerging and re-emerging diseases represent one of the major public health challenges worldwide. Infections caused by various pathogens, such as influenza, SARS-CoV, MERS-CoV, Ebola virus or Zika pose a significant problem for all healthcare systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The COVID-19 pandemic has undoubtedly become one of the greatest challenges in the 21st century, affecting all areas of people\u0026rsquo;s lives and placing enormous strain on healthcare systems globally.\u003c/p\u003e\u003cp\u003eOn 31 December 2019, the World Health Organization (WHO) was alerted to a series of patients with pneumonia of unknown origin in Wuhan, Hubei province, China [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The virus responsible for this new disease was quickly isolated from infected patients and sequenced [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The International Committee on Taxonomy of Viruses (ICTV) subsequently named it Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, it was not until 11 February 2020 that the WHO established COVID-19 as the official name for the disease caused by SARS-CoV-2 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOn 14 March 2020, the Spanish Government declared a state of emergency due to the COVID-19 pandemic, and the following day, imposed a nationwide lockdown. This state of emergency remained in effect until 21 June of the same year, marking the end of the first pandemic wave [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. From the confirmation of the first case in Spain, detected on the island of La Gomera (Canary Islands) on 31 January 2020 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], until the time of writing this article, a total of 13,980,340 cases and 121,852 deaths have been recorded at the national level [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Regionally, according to the Centre for the Coordination of Health Alerts and Emergencies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the Canary Islands reported 474,780 confirmed cases and 2,344 deaths associated with the disease as of 30 June 2023.\u003c/p\u003e\u003cp\u003eThe virus responsible for COVID-19 is highly contagious and spreads rapidly. Although it has been observed that 80% of pregnant women experience the illness in a mild or asymptomatic form [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], they are at greater risk of developing severe COVID-19 compared to non-pregnant women [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite measures adopted in Spain to curb the spread of COVID-19, such as suspending non-essential surgeries and cancelling non-urgent outpatient appointments, childbirth continued to require care in a health system overwhelmed by COVID-19 cases. As a result, maternity wards had to adapt to simultaneously care for women with a confirmed diagnosis of COVID-19 and those not affected by the virus [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Among the frontline healthcare professionals, midwives played a crucial role, as women continued to become pregnant and give birth, and both they and their families continued to require support and care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Midwifery care is associated with improved quality of care and reduced maternal and neonatal mortality [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Moreover, midwives play a vital role in ensuring that women\u0026rsquo;s needs are met and that care is individualised and woman-centred [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe WHO stressed that even in the context of a pandemic, skin-to-skin contact, delayed cord clamping, breastfeeding, the right to be accompanied during childbirth, and avoiding mother-newborn separation should be guaranteed. Furthermore, the available evidence supports that both induction of labour and caesarean section should only be performed when medically indicated, and that a COVID-19 infection alone does not justify performing a caesarean section [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Pregnant and postpartum women with suspected or confirmed COVID-19 should have access to respectful, woman-centred care (WCC) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, despite recommendations urging the provision of evidence-based, respectful care during the pandemic, numerous violations of the right to woman-centred maternity care were observed in early 2020. Members of the Global Council on Respectful Maternity Care, a network made up of over 150 organisations and 350 members from 45 countries, reported practices such as mandatory separation of mother and newborn, restrictions on breastfeeding, prohibition of companionship during labour, and an increase in caesareans, instrumental births, and inductions without medical indication [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These situations were also denounced by international organisations and professional associations, such as the International Confederation of Midwives (ICM), which warned of the implementation of inappropriate protocols not based on up-to-date scientific evidence, resulting in harmful practices for women, their newborns, and midwives themselves [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMidwives are the most suitable professionals to inform and advise governments on the effective organisation of maternity services, as well as to identify and advocate for the needs of the women and newborns they care for [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, the survey conducted by Hartz et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] identified a lack of midwifery representation in the development of strategic government policies related to responses to emerging epidemic threats in maternity care.\u003c/p\u003e\u003cp\u003eFive years after the onset of the pandemic, qualitative research in this area has seen notable growth. Despite the existence of studies exploring midwives\u0026rsquo; experiences during the COVID-19 pandemic [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], including the works of Gonz\u0026aacute;lez-Timoneda et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and K\u0026uuml;\u0026ccedil;\u0026uuml;kt\u0026uuml;rkmen et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] that delve into midwives\u0026rsquo; experiences caring for women with a COVID-19 diagnosis during childbirth, there remains a marked lack of research specifically addressing the role of midwives in facing the ethical dilemmas that arose during this period. In this context, it is essential to understand how midwives dealt with these moral conflicts between providing humanised care and complying with infection control measures, as well as the strategies they employed to protect and defend women\u0026rsquo;s rights during childbirth.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eThe aim of this study was to explore, in depth, the experiences and perceptions of midwives who cared for women with a diagnosis of COVID-19 during childbirth, in the two university hospitals of Tenerife, with a particular focus on their role as advocates for WCC, in a context of high institutional pressure during the first year of the pandemic.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy design and setting\u003c/h3\u003e\n\u003cp\u003eThe qualitative analysis presented here is part of a broader study framed within a doctoral thesis project. This aims to explore the experiences of women diagnosed with COVID-19 during childbirth in Tenerife, as well as their chosen companions, and the experiences of healthcare professionals (midwives, obstetricians, and healthcare assistants) who cared for these women. This article focuses specifically on the focus groups conducted with midwives.\u003c/p\u003e\u003cp\u003eA qualitative study with an ethnographic approach was conducted [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This approach is suitable for exploring shared beliefs, values, and meanings, as well as the everyday practices of midwives within their working culture. This methodology allows for an in-depth understanding of the experiences and actions of a social group within its natural context and from its own perspective [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], facilitating a deeper insight into how midwives experienced their professional roles during the first year of the pandemic.\u003c/p\u003e\u003cp\u003eThis study was conducted in the two tertiary-level public university hospitals on the island of Tenerife: Complejo Hospitalario Universitario de Canarias (CHUC) and Hospital Universitario Nuestra Se\u0026ntilde;ora de Candelaria (HUNSC). In 2021, the populations assigned to these hospitals were approximately 387,103 and 515,693 inhabitants respectively. In 2020, CHUC recorded 2,003 births and 1,935 in 2021, while HUNSC reported 2,498 births in 2020 and 2,332 in 2021 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThis study received ethical approval from the Ethics Committee for Medicinal Research of the Complejo Hospitalario Universitario de Canarias (Province of Santa Cruz de Tenerife), under reference CHUC_2022_69, on 16 June 2022, after confirming the protocol\u0026rsquo;s suitability to the study objectives. All participants signed informed consent forms prior to the interviews. They were informed that participation was entirely voluntary and that they could withdraw at any time without consequence. Confidentiality and anonymity in data handling were guaranteed.\u003c/p\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eA total of fourteen midwives from both hospitals were included. Inclusion criteria were: having worked in the labour ward at any point between the declaration of the state of emergency, on 14 March 2020, and the date on which pregnant women were included in the COVID-19 vaccination strategy in Spain, on 11 May 2021 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]; having provided care to women diagnosed with COVID-19 during childbirth; and having agreed to participate in the study.\u003c/p\u003e\u003cp\u003eTo obtain as much information as possible, all midwives who worked in the labour wards during the first year of the pandemic were invited to participate. An informational poster was designed to invite participation in the study. It included a QR code linking to a document with details about the project and the research team\u0026rsquo;s contact information. The poster was placed in both labour wards with prior authorisation from hospital management.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eMidwives interested in participating contacted the research team, who then reached out to those who met the inclusion criteria to coordinate the focus group sessions based on availability. After obtaining oral consent to participate in the study, data collection took place between February and July 2023. Narratives were gathered through in-person semi-structured interviews, as physical distancing restrictions associated with the pandemic had been lifted by the time of data collection. Two focus groups were conducted: one with eight midwives from CHUC and another with six midwives from HUNSC, totalling fourteen participants.\u003c/p\u003e\u003cp\u003eThe research team developed an interview guide with the opening question: \u003cem\u003e\u0026lsquo;Could you tell me about your experience caring for women diagnosed with COVID-19 during their stay in the labour ward?\u0026rsquo;\u003c/em\u003e. This guide was reviewed by several team members to ensure content validity and methodological rigour.\u003c/p\u003e\u003cp\u003eTo encourage an atmosphere conducive to open and honest sharing, the CHUC focus group was moderated by the second author, as the lead researcher was part of the CHUC midwifery team. The lead researcher moderated the focus group at HUNSC. Two observers attended each session, taking note of non-verbal expressions, gestures, and group dynamics to complement the verbal data.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe analysis began simultaneously with data collection. Transkriptor software [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] was used to generate an initial automatic transcription of the focus groups. These transcripts were then manually reviewed by the lead researcher. The qualitative analysis followed an inductive approach, combining two complementary methodological strategies. First, the six steps of thematic analysis proposed by Braun and Clarke [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] were followed: (1) familiarising yourself with your data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. Secondly, the OSOP (\u0026lsquo;One Sheet of Paper\u0026rsquo;) method developed by DIPEx International [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] was applied. This involves individual coding, followed by team triangulation, clustering of codes into thematic areas, and the creation of thematic summaries for each topic discussed. Using these methodological strategies, the lead researcher conducted a detailed, manual line-by-line analysis of the transcripts. As the analysis progressed, the coding framework was gradually adapted to incorporate emerging codes. Findings were discussed with the research team until consensus was reached on the final thematic structure. ATLAS.Ti software was used to support the analysis of transcribed texts [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn line with Lincoln and Guba\u0026rsquo;s model of trustworthiness [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] to ensure research rigour, several strategies were incorporated to meet the criteria of credibility, transferability, dependability, and confirmability of the findings. To enhance analytical robustness and support a broader and more robust interpretation of the data, investigator triangulation was carried out. Given the inherently subjective nature of qualitative research, a reflexive approach was maintained through a systematic annotation process (audit trail), which documented the analytical process and the research team\u0026rsquo;s reflections in detail. This process ensured transparency in decision-making and reinforced the robustness of the analysis, contributing to the study\u0026rsquo;s methodological rigour.\u003c/p\u003e\u003cp\u003eThe findings are presented in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines to ensure the transparency and rigour of the study [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe participants\u0026rsquo; ages (N\u0026thinsp;=\u0026thinsp;14) ranged from 29 to 59 years, with a mean age of 40.6 years. All participants were of Spanish nationality. Out of the total number of participants, one identified as a man (n\u0026thinsp;=\u0026thinsp;1, 7.1%) with the rest identifying as women (n\u0026thinsp;=\u0026thinsp;13, 92.9%). The mean length of work experience in the labour ward was 12.8 years, with a minimum of 3 years and a maximum of 31 years. The remaining sociodemographic characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eSociodemographic characteristics of participants.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eHospital\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eWork experience in labour ward (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eCOVID-19 infection\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e(Mar 2020 - Apr 2021)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003eSick leave due to COVID-19\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCHUC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHUNSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHUNSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHUNSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHUNSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTwice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHUNSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHUNSC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSpanish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eCHUC: University Hospital of the Canary Islands; HUNSC: University Hospital Nuestra Se\u0026ntilde;ora de Candelaria; M: Midwife.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTwo main themes emerged from the data analysis: \u0026lsquo;systemic barriers to WCC\u0026rsquo; and \u0026lsquo;upholding humanised care amid ethical dilemmas\u0026rsquo;. Several subthemes were identified within these overarching themes (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The following section outlines the results, supported by the most illustrative quotations. Each quotation is presented with the corresponding participant identifier (M1\u0026ndash;M14).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eIdentified themes and subthemes.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThemes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSubthemes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystemic barriers to WCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConflicting and restrictive guidelines\u003c/p\u003e\u003cp\u003eHierarchical tensions, paternalism, and the silencing of midwifery voices\u003c/p\u003e\u003cp\u003eLoss of achieved gains in maternity care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpholding Humanised Care Amid Ethical Dilemmas\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGoing the extra mile to defend women's rights\u003c/p\u003e\u003cp\u003ePrioritising compassionate care over adhering to evolving guidelines\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eSystemic barriers to WCC\u003c/h3\u003e\n\u003cp\u003eThree subthemes emerged within this theme: \u0026lsquo;conflicting and restrictive guidelines\u0026rsquo;, \u0026lsquo;hierarchical tensions, paternalism, and the silencing of midwifery voices\u0026rsquo;, and \u0026lsquo;loss of achieved gains in maternity care\u0026rsquo;.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eConflicting and restrictive guidelines\u003c/h2\u003e\u003cp\u003eDuring the first year of the pandemic, the protocols for caring for women diagnosed with COVID-19 during childbirth were perceived by midwives as excessively restrictive and contradictory to the recommendations of scientific organisations. This situation led them to act in ways that conflicted with practices they had previously committed to upholding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It was horrible to feel that anguish, thinking you were going to start doing things you had promised never to do in your practice.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And we would say, but come on, if the scientific societies [\u0026hellip;] have said this doesn\u0026rsquo;t need to be done that way. But it was like this thing of saying, we need to cover ourselves to an extreme degree just in case, and the \u0026lsquo;just in case\u0026rsquo; [\u0026hellip;] justified absolutely everything.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We had learned that women had a voice and a say in their care and their health, and it was all wiped out in a moment, in the name of some theoretical safety that wasn\u0026rsquo;t actually evidence-based.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We couldn\u0026rsquo;t believe we had to actually violate these women and do things that, in the name of safety, everyone thought were just fine. At no point was the woman\u0026rsquo;s perspective considered, nor the baby\u0026rsquo;s, nor the partner\u0026rsquo;s\u0026hellip; and forget about the companion altogether.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome midwives expressed distress over protocols that disrupted the early mother-baby bond, particularly those that prevented immediate skin-to-skin contact. The initial separation between mother and newborn undermined bonding and delayed the initiation of breastfeeding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I remember once getting scolded because the baby couldn\u0026rsquo;t be on the mother\u0026rsquo;s bed, and she didn\u0026rsquo;t want to be separated from her baby, so I got told off because the baby couldn\u0026rsquo;t be transported outside the cot, it had to be transferred like radioactive material. \u0026lsquo;No, no, the baby must go in the cot\u0026rsquo;, isolated there, and the mother with her mask and a sheet up to here.\u0026rdquo; \u0026ndash; M5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The baby was admitted for the PCRs, and she stayed downstairs to express colostrum.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn cases where newborns remained with their mothers, physical barriers were imposed to prevent infection, despite their questionable effectiveness.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Skin-to-skin contact wasn\u0026rsquo;t really skin-to-skin, it was skin-to-sheet, because you had to put a sheet over her and then place the baby on top.\u0026rdquo; \u0026ndash; M5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We didn\u0026rsquo;t do it at first (referring to skin-to-skin contact); the skin-to-skin was done with a plastic sheet in between, I mean, just imagine\u0026hellip;\u0026rdquo; \u0026ndash; M14\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOthers found it particularly incoherent that some newborns stayed with their mothers in the labour ward, only to be transferred to the neonatal unit for polymerase chain reaction (PCR) testing hours later, questioning the logic of such measures.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Mother and baby had been together in the labour ward, just minutes!, and suddenly the baby was placed in an incubator [\u0026hellip;] And then they were going to be together again, and you just think\u0026hellip; the incoherence.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMandatory mask use was a common practice in both hospitals during mother-baby interactions following birth, reflecting broader infection control measures that, according to some midwives, often stigmatised newborns of COVID-positive mothers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;With the mask so she wouldn\u0026rsquo;t breathe on the baby and all that stuff. Yes, yes, always the mask. Always.\u0026rdquo; \u0026ndash; M14\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The baby was radioactive, really, stigmatised, untouchable, it couldn\u0026rsquo;t be held, it was just seen as incredibly dangerous.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEven colostrum was treated with suspicion, prompting midwives to disinfect the syringes and bags containing it to ensure its administration. The protocol for expressing breast milk in these cases was perceived as disproportionate and lacking in logic.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The protocol for milk expression, it was like if you expressed colostrum it was radioactive, COVID-positive colostrum looked like it was going to explode while you were taking it to the neonatal ICU.\u0026rdquo; \u0026ndash; M4.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You disinfected it, then put it in one bag, then another bag, and then you touched it with gloves, then removed your second glove\u0026hellip;\u0026rdquo; \u0026ndash; M6.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It was like a headache.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eHierarchical tensions, paternalism, and the silencing of midwifery voices\u003c/h2\u003e\u003cp\u003eWith regard to childbirth care during the COVID-19 pandemic, many of the midwives interviewed perceived paternalistic discourses and attitudes that reflected the imposition of decisions without considering women\u0026rsquo;s opinions or those of the professionals directly involved in their care. According to their accounts, their voices were ignored on several occasions. This approach, in addition to introducing a discourse of fear to ensure compliance with measures, resulted in restrictive actions that limited women\u0026rsquo;s ability to decide about their own birth process.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I remember being extremely angry because they made it very clear that we had no say regarding the care of the pregnant women [\u0026hellip;]. We were told that we had to comply with what the neonatologists and obstetricians said. Just like that, straight from our supervisors.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There was an extremely strong fear-based discourse, eh! The message women received was one of fear, that \u0026lsquo;this was extremely dangerous\u0026rsquo;.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Women were told: \u0026lsquo;we\u0026rsquo;re doing this for your own good and your baby\u0026rsquo;s, for your good and your baby\u0026rsquo;s\u0026rsquo;.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There were separations, and there was pressure, and there was even emotional blackmail towards the women.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eChildbirth care regressed towards a more hierarchical and authoritarian model, reminiscent of earlier times. Many of the midwives interviewed described how hierarchy and paternalism were strongly imposed, limiting their autonomy in decision-making and undermining their experience and clinical judgement.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;That anguish, that helplessness, that frustration, and that unease about the world, about the mothers, about the babies, and that rage towards authority. That authority and hierarchy that imposed senseless things on us and never listened to us. That really was a constant. We were never heard in any way [\u0026hellip;] It was an extremely rigid top-down structure.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A system was put in place that, for me, felt like a return to the authoritarianism and hierarchy of the past.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFrustration was a constant feeling, as their professional input regarding women\u0026rsquo;s care was often disregarded. They felt compelled to follow orders rather than exercise their expertise, unable to implement practices they considered essential for women\u0026rsquo;s wellbeing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At that time, just daring to question what was written was inadmissible.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If you dared to raise something like, \u0026lsquo;Hey, really, is it necessary to do this like that? Just so you know, there\u0026rsquo;s this\u0026hellip;\u0026rsquo;, it would cause a scene, and on top of that, the reaction was super aggressive, like, \u0026lsquo;What are you thinking?\u0026rsquo;, [\u0026hellip;] stop bothering us with silly things.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;With everything that\u0026rsquo;s going on, how dare you raise such nonsense?, and you think \u0026lsquo;do they really consider all of this nonsense?\u0026rsquo; [\u0026hellip;] I remember it as a time of internal torture.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAt the onset of the pandemic, professionals across all disciplines showed reluctance to enter the birthing rooms of women diagnosed with COVID-19, largely due to fears of contagion and the potential risk to their own families. This reluctance often led to situations such as the one recalled by a midwife, in which an anaesthetist avoided administering an epidural to a labouring woman with COVID-19 by making excuses, a situation that triggered intense feelings of frustration and helplessness. As midwives were the only ones who could not avoid going in, the distribution of work became unequal.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;This woman was in pain and wanted an epidural. Anaesthesia put up a lot of obstacles. [\u0026hellip;] They asked me to get a new coagulation test because since COVID could affect clotting values, they wouldn\u0026rsquo;t give her an epidural without today\u0026rsquo;s test [\u0026hellip;] It was her second birth, I had already confirmed she was in active labour, and I begged them to prioritise the blood test because otherwise, she wouldn\u0026rsquo;t be able to have the epidural she wanted. The test results came back, anaesthesia was informed, and they still kept stalling. My impression is they didn\u0026rsquo;t want to go in. [\u0026hellip;] The frustration you felt as a professional, not even being able to step out because the woman needed you [\u0026hellip;] In the end, she gave birth without the epidural.\u0026rdquo; \u0026ndash; M8\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The burden fell on the midwife, because she was the one who absolutely had to go in (referring to going inside the labour room). So, we were the ones inside, and the healthcare assistant\u0026hellip;well, if you went in, because you were there, you\u0026rsquo;d just have to do everything. The obstetrician was the same, right? They wouldn\u0026rsquo;t go in, and neither would the paediatrician. Everything ended up falling on us.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLoss of achieved gains in maternity care\u003c/h2\u003e\u003cp\u003eChildbirth care underwent a significant shift, marked by clear dehumanisation of both clinical procedures and the treatment of women. Many of the gains achieved in humanised maternity care were dismantled with the implementation of new protocols, where infection prevention measures overshadowed evidence-based practices. For midwives, trying to preserve these gains was particularly challenging.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And it was also as if suddenly we were in a state of war. So in a state of war, forget about all the nonsense! It\u0026rsquo;s like, don\u0026rsquo;t come talking to me about breastfeeding, breastfeeding is the last of the last among all the humanisation things; companionship, avoiding separation\u0026hellip; all of that was suddenly pushed not to the background, but to the umpteenth background, because we\u0026rsquo;re at war\u0026hellip;\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A series of things were being done that we all knew went against the normal nature of childbirth.\u0026rdquo; \u0026ndash; M14\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We had gained, over so many years, [\u0026hellip;] so much ground for the benefit of mothers, the mother\u0026ndash;baby dyad, and the family, and suddenly, it all fell apart.\u0026rdquo; \u0026ndash; M14\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We\u0026rsquo;re mentally exhausted from having to fight so much, from defending things that had already been achieved and were lost.\u0026rdquo; \u0026ndash; M7\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSeveral midwives also shared how certain practices negatively affected birth companions, who at times were treated in an undignified manner and denied basic needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My impression from all these years is that many fundamental human rights were lost, I mean, not just the woman being alone, the companion would go hours without eating, peeing in a bottle, I mean, basic needs were lost.\u0026rdquo; \u0026ndash; M3\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNevertheless, one midwife described the sense of gratification shared by many colleagues when institutional changes were eventually achieved through letters and public advocacy efforts in defence of women\u0026rsquo;s rights.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There was also a sense of satisfaction, of empowerment, seeing that in the end, the things that worked were letters from the Midwives\u0026rsquo; Federation, through the association, through the media, well, those things worked and changes happened. And we liked that.\u0026rdquo; \u0026ndash; M12\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eUpholding humanised care amid ethical dilemmas\u003c/h2\u003e\u003cp\u003eTwo subthemes emerged within this theme: \u0026lsquo;going the extra mile to defend women\u0026rsquo;s rights\u0026rsquo; and \u0026lsquo;prioritising compassionate care over adhering to evolving guidelines\u0026rsquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eGoing the extra mile to defend women\u0026rsquo;s rights\u003c/h2\u003e\u003cp\u003eThe efforts to \u0026lsquo;go the extra mile\u0026rsquo; in providing care during childbirth amidst the pandemic reflect midwives\u0026rsquo; deep commitment to safeguarding the wellbeing of women and their companions. One midwife described this approach as intrinsic to their professional identity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I went with the anaesthetist, we did a bit of a sneaky one there, to get a blood sample from the father, which I took from him in his own car (laughs), just outside the car park. It was a blood test, in the car, to check if he also tested negative (referring to the PCR) so he could be with the baby.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMidwives at one of the hospitals implemented a range of strategies to support women amid prevailing limitations and restrictions. Among many other initiatives, they set up a dedicated phone line to provide direct communication, respond to questions, and offer support during a time of uncertainty.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Do you remember we also set up a phone line? We tried to create a direct communication channel to resolve doubts.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Many women had doubts, the usual \u0026lsquo;I don\u0026rsquo;t know if I should go to the hospital\u0026rsquo;, they had that number to contact us and say, look, this is happening, what should I do?\u0026rdquo; \u0026ndash; M3\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, several midwives from the same hospital created, on a voluntary and altruistic basis, a virtual nationwide support group focused on breastfeeding and the postnatal period. They described this initiative as an enriching experience that allowed them to support women using technology. Technology became a fundamental tool for exploring new ways of delivering care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Together with (midwife\u0026rsquo;s name), and two other colleagues, we set up a virtual postnatal support group, a breastfeeding support group, where we connected once a week with people from all over, people joined from all over Spain. That\u0026rsquo;s definitely something I take with me.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It was a balm, I think it was a balm, wasn\u0026rsquo;t it?\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I take that with me. It was beautiful, beautiful.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For me too. (Midwife\u0026rsquo;s name) used to call me: \u0026lsquo;we have to do something! we have to do something!\u0026rsquo;.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThey also developed a protocol for colostrum expression for newborns of mothers with COVID-19, as they were routinely admitted to the neonatal unit after birth, preventing immediate initiation of breastfeeding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We made a protocol for expression because\u0026hellip; well, they couldn\u0026rsquo;t (referring to initiating immediate breastfeeding), the baby was admitted for PCRs and she stayed downstairs to express colostrum.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn the absence of clear evidence, midwives devised additional clinical measures, such as washing the breasts of these women to facilitate skin-to-skin contact and allow for delayed cord clamping.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Do you remember when we came up with the idea to allow skin-to-skin contact if we washed the breast? Do you remember? We washed the woman\u0026rsquo;s breast beforehand, even just with soap, before birth, so delayed cord clamping could happen.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePrioritising compassionate care over adhering to evolving guidelines\u003c/h2\u003e\u003cp\u003eProfessional commitment was evident in multiple ways. Some midwives chose to lower their masks so that women could see their faces, aiming to convey warmth and reassurance. In certain situations, they allowed women to remove their masks during the pushing stage, demonstrating empathy and assuming personal risks by prioritising physical presence and human connection.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When introducing myself, I\u0026rsquo;d lower my mask and say, \u0026lsquo;look, I\u0026rsquo;m so-and-so, I\u0026rsquo;m your midwife, just so you can see my face\u0026rsquo;, and then I\u0026rsquo;d put it back on. At least that, let her see your face, a smile, something.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I couldn\u0026rsquo;t remove physical contact from the equation in my work [\u0026hellip;] I can\u0026rsquo;t do my job from one corner and have the woman in another corner, I thought, \u0026lsquo;that\u0026rsquo;s just not possible\u0026rsquo;, so I kind of accepted it, I said, I can\u0026rsquo;t, I just can\u0026rsquo;t do it any other way.\u0026rdquo; \u0026ndash; M6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I protected myself and said, \u0026lsquo;let the woman push however she needs to\u0026hellip;\u0026rsquo; Wearing that thing is unbearable [\u0026hellip;] That\u0026rsquo;s unbearable, so asking a woman to push, to take a breath and push while wearing a mask [\u0026hellip;] She took it off, of course\u0026hellip; [\u0026hellip;] It\u0026rsquo;s impossible, it really is.\u0026rdquo; \u0026ndash; M14\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHowever, at times, fear of infection created ethical dilemmas that affected how care was delivered.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And every time you had to go into a labour room, you had to put on so much PPE, it would take at least 10 or 15 minutes to get dressed and undressed. And that made you want to go in as little as possible. That\u0026rsquo;s really how it felt.\u0026rdquo; \u0026ndash; M8\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A woman with COVID would arrive, we\u0026rsquo;d put her in a delivery room, and it was like, who\u0026rsquo;s going in? [\u0026hellip;] I remember we even did a draw to decide\u0026hellip;\u0026rdquo; \u0026ndash; M5\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe right of women to be accompanied during childbirth was also actively defended by the midwives. In some cases, companionship was allowed discreetly, in contravention of established protocols.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But come on, how is that woman supposed to be alone? She has the right to be accompanied [\u0026hellip;] She has the right to be accompanied!\u0026rdquo; \u0026ndash; M5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There was a time when only one companion was allowed, and she would say, \u0026lsquo;please, my mum is here too\u0026rsquo;. And it was like telling the healthcare assistant: \u0026lsquo;look, let her mum in for a moment, but don\u0026rsquo;t tell anyone\u0026rsquo; (whispering).\u0026rdquo; \u0026ndash; M7\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, yes, everything in secret.\u0026rdquo; \u0026ndash; M4\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis commitment to WCC was equally evident in obstetric emergencies involving women with COVID-19, where midwives prioritised women\u0026rsquo;s wellbeing over the risk of infection. The urgency to provide immediate care sometimes led them to use personal protective equipment (PPE) improperly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t have time to put the PPE on properly, I just put it on however I could, and at that moment, COVID was no longer the focus.\u0026rdquo; \u0026ndash; M3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;But that was beautiful too, because no one even thought about not caring for her.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Of course, it was beautiful, yes.\u0026rdquo; \u0026ndash; M3\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In that moment, everyone was focused on what needed to be done.\u0026rdquo; \u0026ndash; M1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We all went in (referring to entering the labour room), even though no one wanted to at first, in that moment, we all went in because it was an emergency, and that was beautiful.\u0026rdquo; \u0026ndash; M3\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this qualitative study provide new insights into the experiences of midwives who provided care to women diagnosed with COVID-19 during childbirth in the first year of the pandemic in Tenerife. Participants\u0026rsquo; experiences were organised into two main themes. The first, \u0026lsquo;systemic barriers to WCC\u0026rsquo;, highlights the structural and organisational difficulties that limited midwives\u0026rsquo; ability to deliver WCC, such as hierarchical tensions, the silencing of midwifery voices, and the loss of previously achieved gains in the humanisation of childbirth. The second, \u0026lsquo;upholding humanised care amid ethical dilemmas\u0026rsquo;, illustrates both the active commitment of midwives to humanised care and the ethical dilemmas they faced when prioritising compassionate care over strict adherence to protocols.\u003c/p\u003e\u003cp\u003eMany of the protocols implemented during the pandemic lacked reliable, up-to-date scientific evidence and were detrimental to women and their newborns [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Measures such as banning birth companions, separating mothers from their newborns after birth, restricting immediate skin-to-skin contact, prohibiting breastfeeding, or imposing unnecessary medical interventions constituted clear violations of the rights of both women and their babies, and therefore, a marked dehumanisation of childbirth care during the COVID-19 pandemic globally [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In other studies, midwives reported several of these practices in the care of women with COVID-19, expressing emotional suffering due to the dehumanisation experienced in labour wards, as well as frustration and anxiety about the potential impact of these measures on the quality of care [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMidwives also warned of the rapid loss of many gains related to women\u0026rsquo;s rights and voiced concerns about the potential institutionalisation of some of the practices introduced during this period [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These experiences are echoed in our study, in which frustration was a recurring theme among midwives, not only because they were unable to implement practices they considered essential for women\u0026rsquo;s wellbeing, but also because they felt that numerous advances in rights and quality of care, achieved after years of effort, were being rapidly undone during the pandemic. Previous research highlights how rushed decision-making during health crises can lead to the erosion of progress made in WCC and even disrupt previously evidence-based practices [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe pandemic exacerbated structural gaps and exposed pre-existing inequalities, revealing both the lack of recognition for midwives and a striking absence of their representation in the bodies responsible for developing protocols and policies in response to emerging epidemic threats [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Previous experiences, such as the Ebola crisis in Sierra Leone, demonstrated how midwives\u0026rsquo; voices were silenced in decision-making processes, forcing them to fight for professional recognition in the face of directions from individuals without obstetric training [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The midwives in our study described similar experiences.\u003c/p\u003e\u003cp\u003eTo understand the significance of these findings, it is essential to consider the professional values and historical achievements based on person-centred care [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] and adherence to a Code of Ethics [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], which promote individualised, dignified care and place the family at the centre of maternity care. The experiences of the midwives in this study reflect the challenges they faced in upholding these ethical principles that define their profession.\u003c/p\u003e\u003cp\u003eThe inherent ethical commitment in midwifery places midwives in complex dilemmas when trying to balance person-centred care and professional ethics with the uncertainty surrounding a new and unknown virus. Previous studies conducted during similar health crises, such as the Ebola outbreak, as well as during the COVID-19 pandemic, reveal similar dilemmas experienced by midwives in different care settings. In Sierra Leone, some midwives took personal risks, considering physical contact indispensable to their care, which in some cases led to professional sanctions. In their efforts to improve care for these women, they resorted to creativity to find alternative care strategies [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Such efforts to \u0026lsquo;go the extra mile\u0026rsquo; are mirrored in the professional commitment of many of the midwives in our study, who implemented various strategies to support women. In the context of COVID-19, other studies also report similar dilemmas. The inability to comfort women through physical contact hindered the creation of meaningful connections, leading some midwives to prioritise women\u0026rsquo;s emotional wellbeing over their own safety, believing it impossible to maintain physical distance during labour [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, behaviours that might have been deemed unethical in other contexts were described as understandable and justifiable given the extraordinary circumstances [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings are fundamental not only to understand the ethical dilemmas faced by the midwives in our study, torn between providing WCC or strictly adhering to evolving guidelines, but also to make visible the advocacy role that many of them assumed. Several studies have highlighted the critical role of midwives as advocates for safe, respectful, and compassionate care, especially during health crises, where control strategies implemented by health systems may infringe on the rights of the most vulnerable women [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This advocacy role was clearly reflected in the practices and attitudes of the midwives in both university hospitals in Tenerife.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eImplications for the future\u003c/h2\u003e\u003cp\u003eGiven their key role in defending WCC, midwives should receive the necessary institutional support to ensure their active participation in planning strategies for epidemic preparedness and response. This is essential to protect the health and rights of women and their families at a global level. As professionals specialised in maternity care, midwives are best qualified to advise governments on the optimal organisation of maternity services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThe findings presented offer novel evidence regarding the ethical dilemmas experienced by midwives when providing care to women diagnosed with COVID-19 during childbirth in the first year of the pandemic. This contribution is particularly valuable for future researchers, as it offers insight into the challenges faced by certain healthcare professionals in crisis contexts, where they must navigate between the implementation of strict infection control measures and the ethical duty to uphold humane and compassionate care in accordance with their professional code, despite the uncertainty and challenges of the context.\u003c/p\u003e\u003cp\u003eAs qualitative researchers and healthcare professionals, we are aware of the methodological and ethical challenges that this dual identity may entail. While sharing a professional background with participants facilitated recruitment and helped build trust, it may also have led to shared knowledge and experiences going unchallenged, as well as a tendency for both interviewer and participants to avoid sensitive topics in order to protect professional image. To mitigate these risks, investigator triangulation was applied during data analysis, and the lead researcher refrained from interviewing his own colleagues.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite the restrictions imposed by institutional protocols and public health guidelines, the actions of midwives were grounded in the principles set out in the International Code of Ethics for Midwives. From this ethical foundation, they sought to ensure humane and respectful care, safeguarding the rights of women and their families, even in a context marked by uncertainty, clinical pressure, and hierarchical imposition.\u003c/p\u003e\u003cp\u003eIt is important to recognise that analysing the actions taken during a time of crisis such as the COVID-19 pandemic provides a clearer perspective and understanding of the situation. This work does not aim to judge those decisions, but rather, from a constructive standpoint, to emphasise the value and importance that must be given to family-centred care in the planning of future responses to public health emergencies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHUC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComplejo Hospitalario Universitario de Canarias\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHUNSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHospital Universitario Nuestra Se\u0026ntilde;ora de Candelaria\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolymerase chain reaction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePersonal protective equipment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWCC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWomen-centred care.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study received ethical approval from the Ethics Committee for Medicinal Research of the Complejo Hospitalario Universitario de Canarias (Province of Santa Cruz de Tenerife), under reference CHUC_2022_69, on 16 June 2022, after confirming the protocol\u0026rsquo;s suitability to the study objectives. All participants signed informed consent forms prior to the interviews. They were informed that participation was entirely voluntary and that they could withdraw at any time without consequence. Confidentiality and anonymity in data handling were guaranteed.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis study was supported by the Canary Islands Health Research Institute Foundation (FIISC), through grant number ENF22/03. The grant was held by the institution, and expenses were reimbursed upon submission of itemised invoices and proof of payment. No equipment or drugs were provided in support of the research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMML and VMC conceived and designed the study, collected and curated the data, conducted the analysis, and contributed to the methodology, project administration, resources, and funding acquisition. MML prepared the visual materials and drafted the original manuscript. VMC and EJSA provided supervision. VMC, FSFM and EJSA contributed to funding acquisition, resources, and reviewing and editing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank all the midwives who chose to participate in this study and share their experiences with the research team.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\u003cp\u003eCompeting interests\u003c/p\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGao GF. From AIV to ZIKV: Attacks from Emerging and Re-emerging Pathogens. Cell. Cell Press; 2018. pp. 1157\u0026ndash;1159.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuang C, Wang Y, Li X, et al. 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Midwives\u0026rsquo; experiences of caring for pregnant women admitted to Ebola centres in Sierra Leone. Midwifery. 2017;55:23\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStewart M, Brown JB, Weston WW, et al. Patient-Centered Medicine: Transforming the Clinical Method. 2nd ed. Oxford: Radcliffe Medical; 2003.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eICM. International Code of Ethics for Midwives [Internet]. The Hague, The Netherlands. 2014 [cited 2025 Jun 1]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://internationalmidwives.org/resources/international-code-of-ethics-for-midwives/\u003c/span\u003e\u003cspan address=\"https://internationalmidwives.org/resources/international-code-of-ethics-for-midwives/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis-Floyd R, Gutschow K, Editorial. The Global Impacts of COVID-19 on Maternity Care Practices and Childbearing Experiences. Front Sociol. 2021;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Women-Centred Care, Midwifery, COVID-19 Pandemic, Ethical Dilemmas, Qualitative Research.","lastPublishedDoi":"10.21203/rs.3.rs-7406845/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7406845/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The COVID-19 pandemic posed unprecedented challenges to maternity care, disrupting practices that promote respectful and woman-centred care during childbirth. Midwives play a critical role in fostering humanised care; however, restrictive policies and rapidly changing protocols during the pandemic constrained their ability to uphold these values. Although previous research has explored midwives’ experiences during the pandemic, their role in navigating the ethical dilemmas that emerged remains underexamined. This study aimed to explore the experiences and perceptions of midwives who cared for women diagnosed with COVID-19 during childbirth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A qualitative study with an ethnographic approach was conducted in two Spanish tertiary hospitals. Data were collected through two focus groups with fourteen labour ward midwives who provided care between March 2020 and May 2021. Inductive thematic analysis guided data interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Two themes emerged from the data analysis. The first, ‘systemic barriers to woman-centred care’, highlights the structural and organisational barriers that limited midwives’ ability to provide woman-centred care, such as hierarchical tensions, the silencing of the midwifery voice, and the loss of previously achieved gains in the humanisation of childbirth. The second, ‘upholding humanised care amid ethical dilemmas’, reflects both their commitment to defending more humanised care and the ethical dilemmas they faced when prioritising compassionate care over strict adherence to protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Midwives faced structural barriers and ethical dilemmas that limited their ability to provide woman-centred care during the COVID-19 pandemic. Despite these challenges, they continued to advocate for women’s wellbeing in line with the principles of their International Code of Ethics, striving to provide humane and respectful care while safeguarding the rights of women and their families.\u003c/p\u003e","manuscriptTitle":"‘Going the extra mile’: Midwives’ advocacy for woman-centred care during childbirth amid the COVID-19 pandemic: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-19 13:01:09","doi":"10.21203/rs.3.rs-7406845/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:23:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96692855443913513639692173918900433681","date":"2026-04-22T21:14:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-25T01:54:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48415056214367981587592559202965040037","date":"2026-03-15T20:49:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-12T12:05:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-21T17:59:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-21T00:26:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-21T00:26:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-08-19T09:17:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5ae14a8-50df-48a0-bcba-8286828b85fc","owner":[],"postedDate":"September 19th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:23:55+00:00","index":132,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-19T13:01:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-19 13:01:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7406845","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7406845","identity":"rs-7406845","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}