Generation COVID: pregnancy, birth and postnatal life in the pandemic

What was it like to be pregnant, to give birth and to look after a baby in the middle of a pandemic? For this Insights article, photographer and researcher of visual cultures James Clifford Kent teamed up with developmental psychologist Sarah Lloyd-Fox to write about what they learned from the people they met while conducting their research projects. James begins the story with a very personal take on the issue.

The pandemic made bringing a baby into the world an even bigger challenge for all new and expectant parents. As a photographer and researcher of visual cultures, I realised this would also be a unique opportunity to capture how COVID restrictions and unprecedented lockdowns impacted this life changing experience for me and my partner.

I began photographing our journey shortly after we got a positive pregnancy test in November 2019. The plan was to document Charley’s pregnancy, but the project quickly grew as I explored the effect of COVID-19 on our experience.

Yet it could have been so different. We had planned to have a homebirth because of COVID restrictions on birth partners. But Charley ended up being induced at the hospital and was left to labour alone through the night on the antenatal ward. Our homebirth midwife and I got there just in time to see my baby daughter being born. Charley received support on the phone from her doula (a person who supports a mother through labour and birth) and used the birthing techniques she had learned in online tutorials during her pregnancy. She said:

I felt confused and distressed throughout my labour and counted down the minutes until I would see James and my midwife again. I knew as soon as I saw them that everything would be OK and I would finally receive the support I so desperately needed.

Moments after our baby was born, the midwife asked me to push the emergency alarm button. A siren sounded immediately and seconds later hospital staff filled the room. Charley was rushed to theatre after experiencing a major obstetric haemorrhage and suddenly we were separated. Fortunately, she had expressed plenty of colostrum (the first form of breastmilk) and I was able to feed our new baby girl using a syringe.

This time in the recovery area is a blur. I received updates from midwives and surgeons dashing to and from theatre as other partners were being reunited with women and their babies. One midwife recognised me behind my mask and reassured me as I cared for our daughter.

Immediately after the birth I took a photograph of Charley with our newborn baby and our midwife. It was later shared widely on Instagram and I began to receive hundreds of messages from other people who wanted to tell their own stories about what it was like having a baby under pandemic restrictions. One woman, Stacey (35, London) told me it felt like she had “given birth to a secret baby, behind closed doors”.

And so the Pregnant in a Pandemic project was born: to give a voice to people like Stacey. A visual record of what new and expectant parents living in London were going through and the impact COVID-19 has had on their experiences. They have shared portraits and testimonies about love, loss and survival in the face of adversity, as well as personal experiences of key developmental and family milestones.

While James was beginning to document the lives of families through photography, Sarah and her team were conducting surveys and gathering data.

As a mother, and a developmental psychologist, the beginning of the pandemic also triggered in me a cascade of concerns. For many, the birth of a baby is the beginning of a web of positive relationships and connections that reach far beyond those within one household. But as the pandemic enclosed us in a new socially restricted world, I wanted to find out what unanticipated worries were being experienced by those going through pregnancies, birth and early parenthood.

And what of the baby? When their entire world became just their household, did this provide opportunity for closer relationships and improved early development, or were there also risks inherent in this changed landscape?

Our research group at the University of Cambridge and Cambridge University Hospitals set up the COVID in the Context of Pregnancy, Infancy and Parenting (CoCoPIP) online study to further understand and support families. Over 2,500 expectant and new parents have participated so far. Many of their stories bear striking parallels with the experiences of the families who reached out to James.

Our work has aligned through our common desire to provide a platform for “generation COVID” families. Here are just some of those voices.

Bisma – ‘a 1% chance of survival’

Bisma and Azlan – London, 2021. James Clifford Kent

Bisma is 34. Her waters broke prematurely at 22 weeks on the day the World Health Organization declared the COVID-19 outbreak a global pandemic. No one else could be with her at the hospital, and having already experienced loss in previous pregnancies, decisions about how to manage this pregnancy were left to her alone.

She was told that she could give birth within 48 hours to a baby that had just a 1% chance of survival. Azlan was born at 32 weeks and is now a healthy one-year-old. Bisma said:

I was assigned a bereavement midwife at 22 weeks and my husband was not allowed to stay with me. I spent three days on my own in a bereavement labour room. I could still feel the baby kicking and my faith was strong. I refused to take the tablet to induce labour and I carried my baby for another ten weeks. Azlan was in NICU [Neonatal Intensive Care Unit] for seven weeks while I made lifelong friends – they held my hand, wiped away my tears and gave me hope.“

Bisma’s sense of isolation aligns strongly with findings from the first 500 pregnant women in the CoCoPIP study. During 2020, a common theme was the way in which the changes to healthcare provision increased parents’ anxiety levels and feelings of not being supported.

Repeatedly, women commented on the acute anxiety from having to attend antenatal appointments alone or by phone or video call, and the chronic anxiety associated with the uncertainty of whether they would have to give birth in the hospital without family or friends present. Antenatal and maternity services for expectant parents have been consistently reported as being disproportionately affected by social distancing requirements put in place worldwide (Human Rights in Childbirth, 2020).

For example, there was a four-fold increase in stillbirths observed in a sample of 1,681 births in London between February and June 2020. This was attributed to a lack of preventative antenatal care.

Izzy – the miscarriage taboo

Izzy – London, 2021. James Clifford Kent

Izzy (31, London) is a school teacher. She was pregnant three times during the pandemic and is expecting her first child this summer. She told us:

I’ve always been familiar with pregnancy and baby loss, as my earliest memory is the stillbirth of my sister. Despite this, I could never have imagined getting pregnant three times in 2020 and losing two of them during a pandemic. I found out my first baby had died during a scan. I was all alone as my husband wasn’t allowed in the hospital and there was no mental or physical follow up. Not knowing why was the hardest thing.

Izzy talked about how miscarriage remains a taboo subject. Most people either didn’t want to talk to her about it or just didn’t know how. She found herself withdrawing from groups but she had to carry on working. She did plenty of research before seeing her GP and he agreed to prescribe progesterone – a hormone that helps maintain pregnancy – despite stating that she had "only” suffered two miscarriages. Now in the third trimester (as of July 2021), she is so grateful that she didn’t take no for an answer. She added:

I take each day as it comes, holding onto hope that I am just a few months away from holding my healthy baby in my arms.

Izzy’s comments illustrate how pandemic-related social restrictions have not only generated new sources of anxiety but also magnified existing challenges in society. Her description of miscarriage, loss and the taboo of grief will resonate.

Lots of people will be familiar with this story. Many of us will have female friends and family who have had a miscarriage or have struggled to get pregnant. Yet miscarriage and neonatal death remains a subject shrouded in silence. Inadequate care and support persists across both high and low income countries, even the language used around miscarriage and stillbirth can be traumatic (an “incompetent cervix”, for example). The stigma, fatalism and inequalities surrounding stillbirths and miscarriages should be a priority for action.

Nicole – bereavement

Nicole – London, 2021. James Clifford Kent

Nicole (38, London) miscarried as the second wave of the pandemic hit. With her family all living outside the UK, she felt isolated from the people who loved her and ignored by the system designed to support her.

I went in for an emergency ultrasound. My partner paced the parking lot while I sat in the waiting room bleeding through my tracksuit bottoms. There was one other woman there. We looked at each other, two metres apart, faces obscured by masks but eyes rimmed with tears. Between us passed a silent acknowledgement that we were two women experiencing the same trauma.

The midwife who had seen me once before was there for the emergency shift. Her daughter and I share the same first name, so she remembered me. She told me there was no heartbeat. She asked me if I had questions. I had no way of forming words. Without my partner there, I had no earth beneath my feet.

I could tell she wanted to comfort me but couldn’t risk too much contact, as she wasn’t wearing full PPE. Plus, she didn’t have any time, she had to move on – presumably to the other woman in the waiting room.

Nicole and Izzy’s experiences of healthcare echo the voices of many parents in both our studies. Overwhelmingly, women have felt inadequately supported with responses largely negative or neutral in tone and only around 20% containing positive comments.

While lack of sympathy from health workers was highlighted often by our parents, many – like Nicole – sympathised with the healthcare staff and contextualised this lack of sympathy as being a consequence of COVID-related restrictions. One parent from the CoCoPIP study, upon hearing she would have to give birth alone, took strength from her midwife’s sympathy. She said:

This was a shock to me and I had a very emotional response. She was also upset by this. I appreciated that this was out of her control and that there was nothing she could do, I just really appreciated her empathetic response, I felt less alone in that moment.

Emily – NHS midwife

Emily and Cleo – London, 2021. James Clifford Kent

Emily (34, London) described the way her personal experience of having a baby during the pandemic was an opportunity to learn, grow and educate herself as a midwife.

Like millions of other women, she attended scans and appointments alone, waited anxiously for news and results by herself, watched her partner leave the hospital just hours after the baby’s birth and cared for her newborn baby in complete isolation.

My experience of becoming a new parent during the pandemic has inspired me to educate myself and further develop my practice. Returning to the frontline from maternity leave, I want to be ready to meet the new challenges that COVID-19 has brought about with an understanding of what people have been through.

One such lifeline that has continued to support women throughout the pandemic is described by Alanya and is open to those suffering severe or acute mental health issues.

Alanya – finding a community

Alanya and Casper – London, 2021. James Clifford Kent

Alanya (24, London) lost her partner suddenly just before her 20-week scan and gave birth at the beginning of the first lockdown. She said:

Just after I gave birth the nurses told me that the country had gone into lockdown. I was alone on the ward with the baby and I was terrified. It was a massive relief to return home with him but that first lockdown was really hard. It was just the two of us. I wasn’t getting any sleep and it became unbearable.

My mental health quickly deteriorated and we ended up spending three months in a mother and baby unit. It was a fairly positive experience. We were surrounded by staff, new mums and their babies from all walks of life. Now I’m living in a new place and I’ve returned to my old job. My baby Casper will go to the nursery down the road and I’m surrounded by friends. The last 12 months have been really tough but I can feel the sun beginning to shine again.

While the world was rocked, traumatised and turned upside down, Alanya was already going through her own personal trauma during pregnancy. Her partner had taken his own life, leaving Alanya and her unborn baby in an extremely vulnerable position while she dealt with her grief and emotional wellbeing.

Grief in pregnancy may also lead to physical changes such as an increase in stress hormones, sleep issues, physical discomfort for the mother, which in turn have been linked to small negative effects on birth (lower birth weight and increased probability of a caesarian section). Some researchers have linked grief in pregnancy to impacts on the child’s later mental health, while others have found no impact on later life in adulthood. The long term impact for the child is a complex story.

As well as access to additional mental health support, Alanya’s time at a mother and baby unit gave her and her growing baby a near unique experience in the UK during the first lockdown. She lived, for a time, in a communal family of healthcare support staff and mothers and babies – who were therefore able to support, learn from, and socialise with each other at a time when others were isolated and often alone.

The importance of babies having positive bonding, stronger attachments and more positive social interactions with their caregivers for their survival and healthy development cannot be under-emphasised. Alanya added:

People tend to see, hear, about what we’ve been through and panic. There have been challenging times but we are doing well – Casper is happy and overachieving developmentally. We’ve been well supported but other people aren’t as lucky.

Sarah – mental health

COVID-19 maternity restrictions have made it especially challenging for new and expectant parents looking to safeguard their mental health.

Sarah and Bee – London, 2021. James Clifford Kent

Sarah (34, London) said she would never forget the bewildered look on her partner’s face as she was briskly wheeled away holding their daughter, shortly after a long and traumatic labour and birth. It encapsulated her experience of the pandemic.

She felt lost, alone and without the support she needed due to COVID maternity restrictions and an overstretched healthcare system. She said:

I experienced a short episode of depression when I first moved to London at 24 years old and was terrified of feeling like that again with a new baby. I did everything I could to protect my mental health and to give us the best possible start as a new family. Despite my best efforts, I could never have predicted the pandemic. I attended midwife appointments and scans alone, spent nights with the baby in the hospital without my partner and had no health visitor checking up on us.

Sarah was very conscious of the need to support her own mental health during her pregnancy so that she had a positive experience when her baby arrived. Her intuitive stance to protect her family was an important step. Parental anxiety, depression and stress during pregnancy and the postnatal period have been shown to have far reaching impact.

Mental health issues can trigger both physiological (stress hormones) and social (interactions between parent and baby) changes in both the parent and foetus, baby or child. The prenatal environment of babies of mothers with anxiety or depression has been shown to impact on early brain development.

Studies have shown that babies of depressed mothers may have lower rates of interactive behaviour, poorer concentration and increased negative responses with strangers. When older, children of post-natally depressed mothers are also more likely to experience depression or lower academic performance by the age of 16.

NHS doctor Larisa Corda described to us how, during the pandemic, “women have had to make decisions faced with fatigue, exhaustion, rage, despair and a level of anxiety we have never seen before. It’s led to many feeling scared for themselves and their babies, fearful of going into hospital and traumatised by the sense of isolation”.

Claire – high-risk pregnancy

Claire and Marnie – London, 2021. James Clifford Kent

Being pregnant, diabetic and mixed race meant that the pandemic was a scary time for Claire (36, London) and her partner Phil. Being diabetic meant fortnightly – sometimes weekly – clinic appointments with close monitoring. She constantly tried to avoid getting her hopes up in case they lost the baby.

“By the time we got to the 12-week scan we were in lockdown and I suddenly found myself alone at a scan with my partner waiting anxiously outside the hospital,” she said. The increased risk to her pregnancy was really hard for her partner who had PTSD from being on the Aldgate train in the 7/7 London bombings.

I spent a total of two weeks alone at the hospital, from the moment my waters broke to being discharged after the birth. Phil was only allowed to join me during the C-section. During that time, doctors told me that damage to my kidney function meant I might not be able to carry another baby in the future. I was on my own and in a lot of pain but just had to get on with everything. That’s all you can do. I had a little cry and got on with being a mum.

While there have been positive changes in paternal parental culture, fathers continue to feel undervalued and unsupported during pregnancy and their child’s early life. During the pandemic, these feelings may have been amplified given that fathers have been excluded from the majority of pregnancy appointments and some from the birth of their own child.

Sally – catching COVID

At Christmas in 2020, Sally (38, London) – who was then 20 weeks pregnant – contracted COVID-19 along with the rest of her family, including her mother and 18-month-old son.

Sally – London, 2021. James Clifford Kent

I was taken aback, since I didn’t have a high temperature or a cough … I felt numb with fear of the unknown and the harm the virus could cause the baby. There were no answers … Like dominoes, everyone in my household went down with COVID.

Sally said she was afraid to take pain relief in case it would affect her unborn child. For the next three weeks her entire body was overtaken by surges of excruciating pain, but caring for her toddler was the hardest part. She added:

He would scream for hours, sleeping only when he was propped up on my already protruding tummy. When he stopped eating and then drinking altogether all the GP could advise was to “try harder” – presumably to keep us out of an already overwhelmed NHS hospital … We just had to wait it out.

While for many of us the year represents a series of tumultuous restrictions on our lives, Sally’s story highlights the additional strain (both physical and mental) that the pandemic has brought into some households whether due to themselves or their wider family contracting the virus.

Nichelle – frontline NHS worker

Nichelle gave birth to her daughter Alaiyah just before the first UK lockdown in March 2020. After returning to work as an NHS midwife, she began to write notes about her experience of the pandemic and its effect on NHS staff.

Nichelle and Alaiyah – London, 2021. James Clifford Kent

Towards the end of my pregnancy, I was working as a midwife providing support and reassurance to women as the situation worsened. Then suddenly I was in their position, with difficulties accessing maternity services as I prepared to have my baby.

The postnatal experience was difficult. I received excellent support but it was never in person. Friends, family and colleagues stayed away – terrified of passing on the virus. I was thankful for having all this uninterrupted time with my girls but felt so alienated and craved proper human interaction as I witnessed remotely how the pandemic was affecting my peers and colleagues and felt helpless.

Learning from the pandemic

Birth could be thought of as the most dramatic change in environment that a baby undergoes in its lifetime. A pivotal moment on a journey begun months before, where myriad experiences have already affected a baby’s growth and development during pregnancy.

These cascading events are punctuated by birth itself, before a whole new host of experiences and factors continue to shape a baby’s early behaviour. And in the wake of each new life come ripples of changes to the lives of the family that supports them.

Many of the difficulties faced by expectant families having a baby during the pandemic have accentuated existing inequalities in antenatal and postnatal experiences across the UK.

And the UK government’s own report concerning NHS and social care staff burnout has highlighted that staff shortages have been exacerbated by the pandemic.

Our projects are documenting the real life consequences that stem from these issues, as well as the hardship, courage and resilience that families are showing in the face of adversity. We intend to give “generation COVID” families a voice for months and years to come and we hope these stories, and the research data generated by them, will be a force for change in these most vital areas.