Primary health care midwives’ perceptions on the use of telemedicine during the COVID-19 pandemic in Spain

Objective: To explore the experiences of primary healthcare (PHC) midwives with the implementation of telemedicine in pregnancy and puerperium care during the Covid-19 pandemic. Method: Exploratory qualitative study based on an inductive content analysis of 15 semi-structured


Introduction
In March 2020, the World Health Organisation (WHO) declared coronavirus disease (COVID-19) a global public health emergency.In Spain, a state of alert was decreed, strict lockdown was enforced, and non-essential activities were suspended. 1During the first wave of the pandemic, measures were implemented with regard to pregnancy and the postpartum period such as redistributing staff functions, transforming maternity units into COVID-19 units, excluding partners during delivery, separating mother and baby in the immediate postnatal period, placing restrictions on breastfeeding, cancelling visits, reducing access to prenatal care, shortening postpartum stays, and barring accompanying persons. 2 ---4 The aim of telemedicine is to provide clinical support using information and communication technology (ICT) to improve health outcomes, and is a changing practice dependent on technological advances, needs, and health contexts. 5It was widely used in primary health care (PHC) for preparation for delivery, early antenatal interviews, pregnancy follow-up visits, and postnatal visits, and followup. 6,7As a consequence, routine pregnancy checks were reduced, which may have influenced the number of caesarean sections and instrumental deliveries, 3,8 as well as attendance at hospital antenatal care, postnatal clinics, and infant immunisation, 4 and home visits increased to avoid travel to health centres. 9nternational studies conclude that implementing telemedicine made it possible to continue providing healthcare during this period, saving time for patients in travelling and waiting in consultation rooms, providing greater time flexibility, and greater coverage in both urban and rural areas. 10---13Even so, drawbacks to implementing telemedicine in the future need to be examined, such as concerns about incomplete assessment and physical examination, more barriers to a relationship of trust with healthcare staff, and a deepening of inequalities resulting from limited access to technological devices and connectivity. 12,13n the Spanish context, the experiences and attitudes of midwives in the care during pregnancy and childbirth of women infected by COVID-19 have been explored 14 ; the perceptions of midwives who were on the front line of care, both in PHC and in specialised care, during the first months of the pandemic 15 ; the role of nurses and midwives in implementing video-consultation, 16 and evaluating the effects of other measures implemented in some hospitals, such as early discharge and home visits for postpartum follow-up from the perspective of midwifery residents. 9,17However, what using telemedicine as a unique care tool for the care of pregnant and postpartum women by PHC midwives has entailed has not been specifically addressed.
The aim of this study was to explore the experiences of PHC midwives in implementing telemedicine in pregnancy and postpartum care during the pandemic.

Study design
Qualitative phenomenological study conducted in four Spanish autonomous communities (AC) between July 2021 and February 2022.This theoretical-methodological perspective was used because it is a strategy that enables us to focus on experiences and interpretations of social phenomena based on people's experiences. 18

Population
Purposive sampling from which 15 midwives were recruited (13 women, 2 men) who worked in pregnancy and postpartum care in PHC during the COVID-19 pandemic with a minimum of two years of professional experience in Catalonia, Madrid, Canary Islands, and Castilla y León.The selection was made through contact with key informants in the Health Services, previously identified by one of the researchers.Afterwards, the midwives interviewed facilitated contact with other participants, and thus snowball sampling was also conducted.

Data collection
Semi-structured interviews using an interview script designed by the investigators, based on the objectives of the study and the literature review (Table 1).One interview per participant was conducted by video call (between 30 and 60 min), which was recorded and transcribed after the informed consent form was signed.

Data analysis
The transcripts were analysed following inductive content analysis. 19First, two of the investigators read through the interviews to get an overview of the information collected.They then identified units of meaning which were labelled with emerging codes.Thus, code clusters were formed according to their similarities.After reviewing the code groups and the textual quotations from the interviews, categories and subcategories emerged inductively and were organised into themes.ATLAS.ti9.3.1 software was used to support the management and coding of the information.

Ethical aspects
This work was approved by the Ethics Committee of the Hospital Universitario Arnau de Vilanova en Lleida in 2021 (CEIC-2460).To maintain the confidentiality of the data, participants' data were replaced by a randomly assigned number.All data in the textual quotations that could make the participants identifiable were eliminated.Testimonies were identified by the letter E for ¨entrevista (interview)änd a number.

Reflexivity
The authors have extensive experience in qualitative health and clinical nursing research.There was no prior relationship between them and the participants.A reflexive process was used in the design, data collection, data analysis, and drafting of the manuscript.For example, by collecting field notes during and after the interviews and discussing the results with the rest of the team.

Results
The characteristics of the participants are shown in Table 2.
We organised the results into five categories, the first two of which are divided into six sub-categories.Representative testimonies can be found in Tables 3 ---6 .

Changes in the modality of care in pregnancy and puerperium (Table 3) Prioritisation of pregnant women
In response to the health crisis of the first wave, all face-toface visits were cancelled to avoid the risk of contagion as much as possible.Subsequently, and in accordance with protocols, an order of prioritisation was established for the care of women, giving special emphasis to pregnant women, and leaving aside other practices such as screening, for example.

Unprotected postpartum and increased home visits
Postpartum visits were switched to telephone or video-call visits during the first wave of the pandemic.In pregnancy, visits were maintained for longer periods of time on a non-face-to-face basis, except for specific cases requiring immediate attention.The midwives agreed that women's health in the postpartum period was unprotected for this reason.

The decline of parental education groups
The midwives explained that the groups were cancelled once the pandemic was declared.While in some Spanish regions they were not restarted until late in the pandemic, in others they were implemented virtually, which was one of the most long-lasting changes.The midwives stated that they perceived that women were resistant to this change from groups to a virtual modality because they did not trust and did not know how to use the platforms.
Implementing telemedicine was a challenge for the midwives, as they had received no training to adapt to this new modality.The main changes made were a reduction in delivery of content and information, and support with visual and auditory stimuli in the presentations.The main limitation identified with the change of modality in the parental education groups was that support networks with other mothers, which had constituted one of their major benefits, were impeded.Interaction was not the same through online contact, despite the efforts of the midwives.
According to the testimonies both attendance and participation in these groups was clearly affected by the change of modality.Some midwives explained this as resulting from the loss of group facilitation activities combined with the women's mistrust, which led to a loss of interest in these activities.However, the midwives agreed that it made it easier for parents to participate because they were able to better coordinate attendance with work schedules and/or look at the content at a later time.
This, according to the midwives, had to do not only with compatibility of schedules but also with the convenience of not having to face a group of women, in many cases alone.Virtuality allowed them to participate with less pressure and more ease, without feeling like ¨weirdos¨o or standing out too much.These were all the first measures to be restricted'' (E15) ''They were suspended at first, they were suspended for two weeks, which was when the state of emergency was declared and then they continued to be cancelled.They were resumed online when we're already talking about June/July.The mothers were left without this maternal education for many months'' (E13) Mistrusting the new care format ''It was as if they didn't believe that this format was going to offer them anything, but as the pandemic continued, it became more and more a part of our daily lives and it was becoming clear that this was not going to be over in two days, and therefore there was much less resistance to the online groups.Because

Implementation of telemedicine in a changing scenario (Table 4)
The positive side of telemedicine and its contribution during the pandemic According to the midwives, the implementation of telemedicine made it possible to maintain care for women, which would otherwise have been cancelled due to the restrictive measures during the pandemic.The main advantages reported were saving time for telephone consultations, which allowed time to be spent on visits that required it, and greater accessibility to migrant and rural populations and to those for whom being face-to-face impeded visiting the health centre.The use of new technologies allowed greater accessibility, dissemination, and reach of information, encouraging the involvement of other family members.

The negative side of telemedicine
The loss of closeness to women and warmth in health care was one of the main difficulties reported by the midwives.They felt that valuable information was lost in the assessment of the women, mainly because of the role played by paraverbal language and the bond of trust with the women.Also, access to technological devices or stable internet connection was identified as a limitation for the women.This digital divide also extended to the midwives, as the lack of technological resources in health centres delayed implementing virtual visits to train midwives in the use of these new technological tools.This meant they had to teach themselves how to use them, especially those who were not digital natives.

Difficulties and limitations in implementing telemedicine
The midwives were self-critical of their work and reported limitations in the care of women.For example, the prioritisation of prevention of COVID-19 infection over other needs of pregnant and postpartum women; delay in restarting face-to-face visits and parenting education groups, in many cases related to the convenience of the professionals; restriction of parents from attending extended visits, despite the importance for the wellbeing of the women and children.One of the midwives commented that the exclusion of men directly affected their involvement and bonding with their newborn infants.

Reaction of women to telemedicine (Table 5)
The midwives perceived that, although the women adapted to the care they received, and adopted compassionate attitudes towards the professionals because of the pandemic context, the lack of face-to-face care made them feel neglected.They also perceived that there was an increase in loneliness among both pregnant and postpartum women, which added to the anguish and fear brought about by the uncertainty of the pandemic.This added to the mistrust that the women felt, according to the midwives, towards the health system because of the fluctuating guidelines that were issued to the whole population.This was also experienced by the midwives, with the constant changes in protocols and differences in the application of measures in each Autonomous Community, which generated uncertainty and insecurity.

Strategies implemented by midwives for humanised care (Table 6)
The strategies used by the respondents to provide humanised care in this new context were facilitating direct contact or even their own personal telephone number in order to be more accessible to the women and provide them with peace of mind, answering queries and following up by e-mail, prioritising video-call visits over telephone visits to transmit greater closeness, and collaborating with other midwives to resolve concerns and challenges with telemedicine, by means of WhatsApp ® groups.
Strategies were deployed in an attempt to replace the cancelled parental education groups.Some of the measures included referring women to websites with reliable informa-

Limitations of the lack of non-verbal communication ''When you are facing the other person, in non-verbal communication, you get clues where you need to go. On a physical and psychological level, I think, but over the phone you lack that face-to-face connection. So, we miss things that we do need in the consultation, on an emotional level, especially for women who have had postpartum depression or who are at risk of developing it. It's difficult to talk about this issue over the phone''(E13)
Factors that influenced the midwives' and women's access to telemedicine ''My patients were not very wealthy.Many didn't have phones; the coverage was terrible.Many did not have internet.And if they had internet, they didn't have the devices to be able to access the virtual classes (. ..)So you also have to rely on not only your own resources, those that are given to you, but also on the woman's resources'' (E1) ''They hadn't provided us with an online platform to work on.So, if we made groups, it was with our Teams or Skype profiles (. ..)Age was sometimes a bit of an issue, if they weren't digital natives.It was very difficult for some people to get started in these areas without training or anything'' (E4) Difficulties and limitations in implementing telemedicine Self-criticism of the midwives regarding women's needs during the pandemic ''But it is true that perhaps we could have used telephone consultations a little less and the issue of face-to-face care, I think it could have been resumed earlier.As could accompaniment in the consultation'' (E10) ''There was a time when the restrictions reached the point that pregnant women could not be accompanied to visits.This was something that, rightly, the population let us know was not correct.And I totally share their opinion in that gestation is not a woman's process'' (E15) ''Lack of the father figure'' ''I think that they are taking away the beginnings of bonding with the child and participation. . .such as the role of the father throughout the follow-up of pregnancy.So, I would say that this is the biggest impact that the whole issue of the pandemic is having on pregnancy and the postpartum period, the lack of the father figure'' (E13) tion that they had checked, creating blogs where midwives wrote posts with information, creating profiles on social networks both as a platform for holding online parental education groups and as a means of disseminating information, taking advantage of the resources of other colleagues, and referring women to these spaces.

Learning for the future
To improve care and accessibility to health services in times of pandemic, they suggested the need for more material and human resources, such as more answering machines or staff to take all calls from users, increased time for visits, pro-

Discussion
This study shows that midwives identified positive and negative aspects of the implementation of telemedicine, and had to deploy strategies to promote humanised care and to supplement face-to-face parental education.
Telemedicine in PHC during the COVID-19 pandemic was implemented in both European and Latin American countries, 20,21 although it was not always successful.As evidenced by the results of this study, it was implemented as the epidemiological situation fluctuated, which affected decision-making on the part of professionals as to which protocol to follow at any given time. 11,20Internationally 22---24 it has also been highlighted that this type of practice led to great heterogeneity in the health response.According to other studies, 25,26 in some cases it was even incompatible with good practice.Health professionals expressed concern about the long-term effects of these measures. 11For example, with regard to the consequences of fathers being limited in their assuming parental responsibility. 27ike the professionals in this study, the lack of a close relationship with the women was identified as one of the main disadvantages of telemedicine. 12,23Other studies also conclude that telemedicine affects the bond of trust with the midwife through less connection, misinterpreting information provided, and less mutual understanding. 10,11A factor detrimental to the formation of this bond was the lack of non-verbal communication.Non-verbal communication fosters trust in the relationship with midwives and assessment of the women's needs. 22he lack of training in telemedicine for midwives and the digital divide, more pronounced in older midwives, were other limitations reported in this study.A recent study also relates the level of digital competence to age. 28s in this study, midwives had to teach themselves how to provide telematic care. 21In some contexts, they used social networks for health education. 23In this regard, it is important to bear in mind that social networking groups moderated and supervised by midwives enhance health education. 29,30ccess to technological devices and stable connection networks, lack of digital literacy, and language barriers were limitations for women in telemedicine, according to the midwives interviewed in our study.These issues are often exacerbated in rural or low-income settings. 10,24owever, a reported concern was the lack of privacy resulting from telemedicine consultations, especially for sensitive topics, which is confirmed by a UK study, where women reported feeling self-conscious about discussing sensitive topics such as mental health 31 or gender-based violence. 10,32everal studies 24,32 agree on the advantages of telemedicine reported in this study, such as savings in and optimisation of consultation time, greater accessibility, and improvements in the dissemination and scope of information.These advantages open up the possibility of using telemedicine beyond the pandemic according to the midwives in this study, enabling a flexible format of care between face-to-face and virtual.However, technological access would need to be guaranteed for this, and professionals and service users would need to feel confident in the use of these tools. 11,24he present study has limitations and strengths.The fieldwork was conducted after the first wave of the pandemic in Spain, and therefore the midwives' perceptions are retrospective in aspects related to the lockdown.There were also variations in the incidence of the COVID-19 pandemic and the guidelines between the different ACs, and therefore it should be borne in mind that the sample of this study is limited to midwives from four Spanish ACs.The criteria proposed by Lincoln and Guba 33 were followed to ensure the validity and quality of this qualitative research, based on credibility, transferability, dependability, and confirmability.
As future lines of research, we suggest evaluating the effectiveness and quality of protocolised interventions of hybrid care during pregnancy and puerperium in order to identify which are the most effective for future implementation.We also suggest that the experiences of pregnant and postpartum women receiving this hybrid care be studied in greater depth.
We can conclude that the use of telemedicine has facilitated the care of women during pregnancy and puerperium, and that there are various clear advantages that deserve consideration in moving towards a hybrid format of PHC.This opens up the possibility of new forms of healthcare and follow-up that may be suitable for populations with special needs.In this sense, it is essential that midwives are considered in the formulation of strategies for the use of telemedicine in a hybrid format and training needs.We suggest that training programmes in digital competencies be implemented for professionals as well as the general population.

Table 1
Interview script.

Table 2
Profile of the participants (n = 15).

Table 3
Subcategories, codes, and testimonies for category 1 Changes in the modality of pregnancy and postpartum care .

Table 3 (
Continued) A great handicap for men is their working hours, which mean they can't leave work to attend the group.But this way, with the direct groups, because I leave them posted [on social networks] for the whole time that the group is active, they can attend as many times as they want over the two months (. ..)They don't feel like weirdos either.Because to come alone, you'd have to be very confident to come to a group with eight or ten women as a man on your own''

Table 4
Subcategory, codes, and testimonies for category 2 ''Implementation of telemedicine in a changing scenario''.

Table 5
Codes and testimonies for category 3 ''Reaction of women to telemedicine''.Well, I think that the pandemic has affected women psychologically because it has been a mixture for them.Between fear, uncertainty, and loneliness.Of all those who were first-time mothers, and not for lack of family, that's what it was for me, I would point that out because it was notable on a psychological level''

Table 6
Codes and testimonies for category 4 ''Strategies implemented by midwives for humanised care''.