COVID-Related Visitor Restrictions and Childbirth Experiences in One U.S. Hospital

Introduction

Childbirth can be a physically and mentally stressful process. Support from friends, family, clinical staff, and birth companions is considered essential for a positive birth experience.¹ Labor support has demonstrated psychological benefits. Social support during labor and birth can be as important as support after birth to prevent postpartum depression.² Support during labor has also been linked to higher rates of spontaneous vaginal birth, reduced epidural use, and shorter time in labor.³ While the importance of support persons during labor and birth is clear, the characteristics and ideal number of support persons is widely debated.

The COVID-19 pandemic resulted in wide-ranging public health restrictions that forced hospitals and providers in the United States (US) to limit the number of support persons allowed during intrapartum hospital stays. Visitor policies varied by place and setting, and a common model was to limit visitation to one person.⁴ Pandemic restrictions provided an unprecedented opportunity to explore the effect of decreasing the number of support people during pregnancy, labor, and birth. Eliminating the presence of partners, spouses, friends, or family as support persons can exacerbate women’s emotional hardship, their physical needs during and after birth, and the complexities surrounding the medical decision-making process.⁵ Support persons can serve as advocates who provide protection from health care professionals exhibiting discriminatory behavior.^4,6,7 Reducing or eliminating support people removes a potential advocate for birthing persons; for communities that experience racial bias or language barriers, this threatens to worsen existing disparities and inequities in maternity care.⁸

The role that health professionals play in labor support appeared to shift during the pandemic; for example, the United Nations reported that midwives felt a stronger obligation to offer emotional support for pregnant women.⁹ In contrast, many registered nurses (RN) in the US believed that pandemic restrictions interfered with their ability to provide labor support.^10,11 Support systems play an important role in labor and birth, but it is unclear whether providers alone can fulfill the complex individual needs of patients. Researchers examined the perceptions of healthcare providers on COVID-19 visitor restrictions, and few were in favor of excluding all support people.^6,10

The aim of our study was to explore the childbirth experiences of birthing persons during COVID-19 visitor restrictions. While there is a growing body of literature on the effects of pandemic visitor restrictions on birth experiences, many researchers utilize a remote survey approach with static questionnaires.^6,12,13 The semi-structured interviews we used are more illustrative of participant perspectives as they experienced visitor restrictions. Therefore, our findings will contribute to the literature with first-hand accounts.

Methods

Design

We took a phenomenological approach using one-on-one interviews to explore real-time lived experiences with visitor restrictions.¹⁴ Our design, grounded in Husserl’s descriptive phenomenological method, provided us with the ability to explore birthing persons’ experiences with unprecedented visitor restrictions as they were experiencing them.¹⁵ Data analysis was guided by Northall and colleagues’ method tailored from Colaizzi’s phenomenological approach and the principal investigator (PI) oversaw and recorded the application of all steps in the analysis.^16–18 We reported methods using a 32-item checklist (Supplement One) according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ).¹⁹ We referenced the work of LaDonna et al. (2021) to guide our reporting of findings.²⁰ This study was approved by the Medstar Health Research Institute and the Georgetown University Institutional Review Board Institutional Review Board.

Setting

We purposively sampled birthing persons after they gave birth at a large urban level IV birthing hospital located in the Mideastern US at which 3,617 births occurred in 2019. Before COVID-19 visitor restrictions, persons in labor were permitted up to six support people older than the age of 13 during labor and birth. Siblings of the expected newborn were permitted on the unit during visiting hours regardless of age. In the postpartum unit, unlimited visitors older than the age of 13 and siblings of the newborn of all ages were permitted during visiting hours; one support person older than the age of 13 could stay overnight. COVID-19 restrictions that permitted only one support person for the duration of the stay were put in place on March 12, 2020. This designated support person could not be switched out or leave and come back.

Participants

From March to May 2021, we recruited patients from a postpartum unit who met inclusion criteria for participation: 18 years of age or older, birth at 37 weeks gestation or greater, at least one birth experience in the US prior to the COVID-19 pandemic, and able to speak English or Spanish. We excluded persons who experienced a fetal demise with their current pregnancy. Nurses identified eligible persons during their postpartum stay. The research team then explained the study in detail before performing a final screening for inclusion/exclusion criteria. We obtained written informed consent before all interviews and scheduled in-depth interviews at the convenience of participants before hospital discharge. Research team members, who identified as women (PS, RMB) and had experience and training in conducting qualitative interviews, interviewed participants in postpartum hospital rooms.^21,22 Prior to scheduling participant interviews, research team members met to discuss their thoughts on our study aim, allowing awareness of our own critical stance prior to data gathering.^17–19 The PI reviewed all recordings and post-interview memos after each recruitment day. Interviews took an average of 36 minutes¹⁴, after which we compensated participants with a $15 Amazon gift card. We continued recruitment until data sufficiency was achieved²⁰ as guided by the concept of information power:^14,23 our study aim was narrow; we used purposive sampling to include participants with experiences specific to our study aim; our dialogues were focused and driven by participants’ experiences; our ongoing review of post-interview memos allowed us to reflect on interview dynamics and an iterative analysis strategy determined when no additional patterns arose from the data.

Procedure

We developed a semi-structured interview guide informed by the literature and the PI’s expertise in qualitative research and maternal health nursing (Table 1). The guide included open-ended questions followed by probes we generated from current and prior interviews to elicit more detailed perspectives. This approach to data collection helped our researchers manage the process of questioning by permitting us some structure in our interview process and supporting methodological consistency and trustworthiness.^21,24 We asked participants to self-identify their race and ethnicity, age, highest level of formal education, marital status, number of total births, and type of health insurance if any. We did not ask participants to self-identify their gender or sex; we acknowledge the existence of various gender identities and recognize that people who experience birth may not experience gender along the binary. We pilot-tested the guide with one English-speaking and one Spanish-speaking participant to assess interview dynamics and optimize the study protocol. We did not include this data in the final sample.

Table 1.

Summation of Semi-Structured Interviews Surrounding Participant Birth Experiences.

Domains	Main Questions	Probes
Previous Birth Experience(s)	Tell me about your previous birth experience(s) prior to COVID-19.	Labor and birth expectations versus reality Vaginal versus cesarean birth experience Experiences with pain Overall feelings during inpatient stay
	Tell us about the support people who were present during this/these previous birth(s)?	Experience with support people present How did support people affect the birthing experience Ways support people offered support
	Tell me about having support people present during your previous birthing experience(s).	Vitality of having a support person be present during birth Is more than one support person more or less beneficial on the birthing experience
Current Birth Experience(s)	Share your thoughts about having a birth during a global pandemic.	Level of comfort comfortableness and safety during this pregnancy
	Tell me about the support people present during this birth.	How many people were present during this birthing experience and in what ways did they offer support?
	Tell me about any complications experienced during this birth.	Decision-making when complications arose Decision-making process during labor Thoughts on if differences in support that could have prevented complications from occurring
	Tell me about the staff present during your birth.	Feelings during birthing experience Who stood out to you during this labor experience and why Support from medical staff
	Tell me about your opinion on having support people present during your birthing experience.	Tell me about how your opinion has changed since your experience with pregnancy during a pandemic. Pregnancy planning during a pandemic
Perspectives on how hospitals reacted to the pandemic	Share your thoughts on decisions the hospital made in restricting the number of support people present during birth.	What would you do the same or differently?

We audio-recorded all interviews to free the interviewer from note-taking and build rapport between interviewer and participant. We completed post-interview memos after each interview to maintain reflexivity, reflect on interview dynamics, and record any inconsistencies or breaks in the protocol.²⁵ This gave researchers context when reading through interviews and allowed researchers to examine data for emerging patterns to explore in later interviews. Finally, we used memos to determine information power iteratively. We determined information power when no additional patterns arose from the data.²³ A professional transcription company transcribed the recorded interviews verbatim.

Data Analysis

Five team members independently read participants’ transcripts to gain familiarity with the interviews. Statements related to our aim were extracted from each transcript and patterns noted across participants were extracted as potential themes. We then formulated meanings based on the statements we extracted. Emerging themes and response patterns were discussed at weekly meetings and synthesized into an initial codebook. Discrepancies were discussed through open discussion to arrive at a consensus, a method that allowed the research team to focus on the lived experiences shared by the participants in our study rather than on the generated codebook.²⁶ We then uploaded all transcriptions to a qualitative software program, Dedoose, where team members (IS, KR, RMB) independently applied and validated the generated descriptive codes.^24,27 Multiple researchers independently analyzed data, allowing for improved confirmability and credibility of findings.²⁵ We compared this codebook to the initial codebook and reconciled discrepancies prior to finalizing study themes. Team members extracted and verified illustrative quotes for each theme,¹⁴ as well as assigned fictional names (Table 2) to participants for reporting of quotes. The PI thoroughly documented and audited methods throughout data collection and analysis, enhancing the dependability, confirmability, and credibility of findings.^17,25

Table 2.

Participant Pseudonyms (N = 22).

Participant	Age, years	Births	Non-medical Support During Current Birth
Amani	21–30	3 or more	Father of newborn
Annette	21–30	2	Father of newborn
Betha	31–40	2	Father of newborn
Carolea	31–40	3 or more	Father of newborn
Chandraa	31–40	2	Father of newborn
Deba	31–40	3 or more	Father of newborn
Denise	31–40	2	Father of newborn
Estera	31–40	3 or more	Father of newborn
Fara	31–40	3 or more	None
Ginaa	31–40	2	Father of newborn
Jada	31–4	3 or more	None
Kiara	31–40	2	Father of newborn
Ladonna	31–40	3 or more	None
Lee	31–40	3 or more	Father of newborn and family member
Marion	21–30	3 or more	Family member
Mica	31–40	2	Father of newborn
Nevaa	31–40	2	Father of newborn
Patricia	21–30	3 or more	Father of newborn
Rachelle	21–30	2	Father of newborn
Sadie	31–40	2	Father of newborn
Tonya	21–30	3 or more	Father of newborn
Yvonne	21–30	2	Father of newborn

^aFather of newborn present during participant interview.

Results

Participant Characteristics

We screened forty-nine patients from the postpartum unit. Of those screened, we did not interview 25: 10 did not meet inclusion criteria, eight declined for no reason, six had no time for an interview or were discharged early, and one partner declined on the patient’s behalf. Of 24 participants who provided interviews, we excluded two from the final analysis because, during their interviews, they reported that they did not experience a prior birth in the US. Therefore, our final sample consisted of 22 participants who were 24 to 41 years old (Table 3). More than half of our participants identified their race as non-Hispanic Black (n = 14). Most participants reported being married or living with their partners (n = 19). All participants had health insurance, with a majority (n = 14) reporting public insurance. The fathers were present for seven of the interviews.

Table 3.

Participant Characteristics (N = 22).

Variables	Value, n (%)
Age, years
20–30	7 (31.8)
31 and above	15 (68.2)
Marital Status
Single	3 (13.6)
Living with Partner/Married	19 (86.4)
Health Insurance
Public	14 (63.6)
Private	8 (36.4)
Self-Identified Race/Ethnicity
Non-Hispanic Black	14 (63.6)
Hispanic, all races	3 (13.6)
Non-Hispanic White	3 (13.6)
Non-Hispanic Asian	2 (9.1)
Parity
2 births	11 (50.0)
3 births	7 (31.8)
4+ births	4 (18.2)

We organized participant perspectives into six themes after iterative analysis: A Shared Personal Connection is a Valued Trait, A Female Support Person is Important, Nurses Went the Extra Mile, Support People Help with Decision-Making, Two is an Ideal Number of Support People, and Increased Psychological Burden.

A Shared Personal Connection is a Valued Trait

In the first theme, A Shared Personal Connection is a Valued Trait, participants shared traits they valued in a support person. The most salient was a shared personal connection between the participant and their support person (n = 14). A personal connection came down to the ability of the support person to understand, without being explicitly told, the needs of the participant. Marion explained how her husband recognized her contractions based on her facial expressions. His knowledge of her nonverbal cues enabled him to be an effective advocate. At one point she insisted, “I’m fine.” To which he replied, “No you’re not, you’re in pain!” This ability to identify the severity of someone’s pain based on facial expressions and other nonmedical cues was attributed to having an extensive personal connection with the participant. Like Marion, Ester valued her support person’s advocacy. She explained: “He’ll ask questions like if I’m in pain. He’ll ask questions to healthcare providers, and he’ll be kind of like an advocate.” Many participants felt comforted by support people who assured them that everything would be alright, making this one of the most frequently identified forms of helpful support (n = 17). Though physical touch, including hand holding, was also mentioned. Fara noted, “I could be independent and do it myself, but it’s also really nice to have someone just there with you holding your hand, letting you know that everything’s going to be okay.” Such personalized support was something many participants felt only a family member or friend could offer. Chandra explained that while hospital staff are professionals with the potential to support and help, “it’s just another day at the office” and not “a special experience for them.”

A Female Support Person is Important

The second theme, A Female Support Person is Important, revealed a common struggle among participants when asked to choose only one person to support their birth experience. Many participants (n = 14) were conflicted about choosing between the female support they wanted and the perceived obligation to have the male father of the newborn present at the birth. As Carole shared, it was “obvious” she would have to choose the newborn’s father because of “the relationship.” Participants also shared that mothers, grandmothers, aunts, and other female family members are better at providing support: “[I] would love to have my younger sister here because I’m really close to my younger sister. He’s a man, he wouldn’t understand… I just want my sister to do it for me” (Beth). Other participants noted that fathers of the newborn themselves would have to be calmed down and reassured. Deb explained that to be a support person, you “have to put yourself in that person’s shoes regardless on the situation. And you have to be very understanding and just be calm… for a male, it’ll be different because they don’t understand what we’re going through.” Marion added, “With his father just being there, he was just like there. It wasn’t like any real help…. So, I just kind of felt like I was alone in the delivery room.”

Some participants did not align with this theme and specifically wanted their male partners present during labor (n = 3). Neva described her husband’s support as crucial, explaining “He’s the person I trust the most of anyone in my life.” She went on to say “Well, I love my mom. She’s the only other person I would ever invite in, but we do not [get] along so I would rather have my best friend there than my mom.”

Nurses Went the Extra Mile

The third theme, Nurses Went the Extra Mile, revealed that participants were satisfied with the support they received from nursing staff during the visitor restrictions. Nurses were viewed as supportive figures. Participants noted that visitor restrictions provided an opportunity for nursing staff to serve a more focal role as support persons, a phenomenon identified by Fara as giving “110%”: “All the nurses in labor and delivery upstairs, shout out to them…. It’s like they went the extra, I guess because you can’t really have people --- so they went the extra mile.” When asked to elaborate on the support she experienced from nurses during the current birth experience as compared with her previous one, Fara noted, “…they [nurses] really do care. I would say it’s always been good, but it was a little better. It was 110% this time around.” Some participants, however, did not sense a difference in care or support in births that occurred prior to and those that occurred during COVID-19 restrictions. Nurses were frequently (n = 15) described as supportive for births before and during COVID-19 visitor restrictions. Lee described her experience of the nursing staff as having the “same decency, same courtesy, and same level of professionalism and respect” before and during visitor restrictions.

Fara attributed to the nursing staff several characteristics identified in our analysis as important for support — physical touch and reassurance: “They held my hand. They just kept reassuring me that everything would be fine and that I was doing a good job.” Attentiveness was another quality mentioned. Lee described how the diligent care of the staff inspired her to return to the current hospital for care: “Yeah, they were very helpful, very hands-on, making sure my pain was okay, I wasn’t feeling anything, checking if I needed anything… so yeah, they were wonderful. That’s probably the reason why I came back.” Midwives were also specifically highlighted by participants (n = 3). Amani shared her thoughts on the midwives: “they’re very friendly and playful like they always make you feel like you guys are friends.”

Support People Help with Decision-Making

Theme four, Support People Help with Decision-Making, illustrates that while participants felt empowered to make their own decisions, they found input from support people valuable to the decision-making process. Decision-making processes surrounding cesarean births, epidurals, and health concerns were altered by the presence or absence of support people. Ester detailed how her support people helped with her decision-making process when staff asked her about an epidural:

I turned to him [husband] and asked him, what do you think about that kind of thing. So, I use him to help with the decision-making. Someone who can help me think through decisions we have to make. And then once that decision is made that person is supporting it like what can I do to make the decision smoother or how can I support you in this way?

A shared personal connection played a role in decision-making for some participants. Gina and her partner “talked beforehand about kind of queuing each other.” She acknowledged that although she was in charge of the decisions, it was helpful to have her partner there. Deb noted that it provided her with an opportunity to include the father of the newborn more deliberately:

…we came to an agreement with each other cause I understand how I felt but at the end of the day, it wasn’t just about me. So, I guess cause I’m older now and I care about his feelings, so I just asked him, and as long as we both was on the same page, that’s really all that mattered to me.

Two is an Ideal Number of Support People

Theme five, Two is an Ideal Number of Support People, illustrates perspectives on the ideal number of support people during labor. All participants agreed that at minimum one person was necessary. Ladonna shared her unique experience of having experienced three births without a personal support person and three births with support:

Let me say, mentally it’s a lot better. Knowing you have somebody that’s going to support you during the birth, it was a lot of help I’m going to say mentally, emotionally, physically versus me giving birth by myself. I have to do it all alone, it’s very stressful. I would recommend that if someone wants to give birth, to have [a] support system.

While some participants noted that the number of people is not as important as long as the people present are supportive (n=4), there was a general consensus that two support people is the optimal number (n = 14). Some support was essential, but excessive crowding was often counterproductive to the birthing experience. Some participants felt “overwhelmed” by the amount of people in the room during prior births and noted that the COVID-19 visitor restrictions gave them space and peace. Ester shared that visitor restrictions helped limit the number of people in the room and provided space “to breathe and sit and whatever. If you add family and friends on top of the medical professionals that have to be in the room. Then it’s like almost no time to yourself.” Tonya shared that she too thought more than one support person was preferable, but noted that because only her partner was allowed to be present, he took more of an intentional role during the current birth experience:

He was more there… he tried to help better with the pain management… So, he kind of had to step up more. Even afterwards -- how people can’t come here -- usually people can come and see the baby and all that. So, it’s just been me and him.

Several participants who spoke favorably of their partners as support people also discussed similarly positive partner experiences for births prior to visitor restrictions. Increased partner involvement appeared to be intrinsic qualities of the partner rather than of visitor restrictions.

Sometimes the number of support people preferred by participants was driven by family dynamics. Rachelle noted that her mother was present at her first birth because it was important that her mother feel included and not “left out.” However, for the current birth, only one visitor was permitted so Rachelle felt obligated to choose her partner: “For this one, she wants to be here, but you’re only allowed one visitor, and the father of the baby has to be here.” Rachelle was not the only participant to express a desire to have additional visitors to support family dynamics rather than because of the support person’s qualities or personal experience with birth.

Increased Psychological Burden

In the last domain, Increased Psychological Burden, participants shared increased hardships during birth due to visitor restrictions. Many participants described visitor restrictions as an unfortunate, yet necessary, decision, and overwhelmingly agreed that visitor restrictions were warranted given the circumstances of the COVID-19 pandemic: “I understand why they did. It’s a tough place. You have very vulnerable people coming” (Kiara). However, because COVID-19 restrictions did not allow the support person to leave and return, many participants found it challenging to care for other children during their birth experience. Amani explained that her partner “didn’t want to leave me, but my son, he’s about to turn one. He [son] started having separation anxiety because of COVID.” Efforts to have her son stay with her parents and relieve her partner were to no avail, and she eventually told her partner to “Go home, get the kids, and be there with them and I’ll be fine.”

Participants’ shared perspectives revealed that visitor restrictions exacerbated existing stresses and contributed to feelings of loneliness. Jada noted missing culturally significant food and support from family and friends. Denise wished more of her family members could have been involved in her birthing and postpartum experience: “I would have loved for my mom to be there or his mom to be here or even for my kids to experience at least one birth of one of their siblings.” Participants reported feelings of loneliness despite understanding the rationale behind the restrictions. Jada shares: “My kid’s father dropped me outside and came here, and now I’m lonely. Nobody’s coming. I’m still waiting. It’s a little stressful…. I’m not feeling comfortable.” Lee agreed with the restrictions, but acknowledged the diversity of patient needs for support during labor:

I think that it always should be a choice because some people need more than others but at the same token when it comes to pandemic I feel like only if they’re vaccinated because you have to understand it’s still not just your health, you’re putting in danger.

Poor communication of restrictions was also identified; by several accounts, restrictions were not communicated in a clear, consistent, and timely manner. Carole points out, “... that they [the hospital] should communicate a little better, because even in the welcoming package, it still has hours of operations for visitors. Even the welcoming packages don’t have the updated COVID restrictions.” Others noted they were not aware of details such as the number of support people permitted during birth and the fact that visitors could not come and go until the day of their birth and that hospital communication was generally poor (n = 9). Participants reported receiving conflicting information: “Some people were like, ‘He can’t go in there,’ and then some doctor’s like, ‘He can go in there.’ So last time I was down there, he came in. I was confused y’all got me going in circles,” (Patricia). When comparing the current birth experience versus a previous one thirteen years ago, Denise felt there were many differences:

Even like the ice chips. They wouldn’t give me anything this time…. All of that was due to the pandemic. They said because it causes contamination. They didn’t want to bring cups in the room. They don’t want to have to take cups out and keep replenishing. So, they just said just wait until after your birth.

Discussion

We sought to explore how pandemic-related hospital visitor restrictions affected birth experiences. The need for support starts from the time of conception and continues through prenatal appointments, labor and birth, and into the postpartum period. While Breman et al., (2023) focused on the importance of support during the postpartum period²⁸, our study demonstrated specifically how COVID-19 visitor restrictions hampered efforts to satisfy the multifaceted support needs of our participants during labor. Limiting companions during birth has been shown to affect birth satisfaction.¹³ Based on survey responses to the Childbirth Satisfaction Scale, investigators found that birth preferences of nearly half the women were not met due to pandemic conditions. This resulted in considerably lowered birth satisfaction.¹³ Our study elucidates the importance of non-direct or non-physical support networks such as helping care for other children, visiting after birth, and having family bring food. These measures could mitigate the emotional burden discussed in the systematic review.

When admitted to the hospital for labor, a majority of participants expressed a desire to have a female figure present -- specifically someone in their life who had experienced giving birth -- but felt obligated to have the father of the newborn present when only one support person was allowed. This is consistent with a prior study indicating that women rely upon female family and friends for emotional support and the personal experiences they offer.⁶ Our participants, however, also highlighted the idea that having only their partners present increased the partner’s involvement. This was generally received as a positive experience, as fathers could deliver nuanced personal support to their partners and have greater involvement with the child. Participants tended to view increased partner involvement as more intimate support during birth, which in some cases improved the birth process. Lalor et al. (2023) also found that during restricted visitation, women and their partners valued “the peace and time to adjust to parenthood” (p. 208).²⁹ The general consensus among our participants was that two support people had a strong reported influence on the decision-making process and support during childbirth and that more than two support people would not have been helpful. Allowing only one support person may introduce an issue of inequity, especially when that one support person is not permitted to leave and come back. For families with limited childcare options or familial support, this leaves them making difficult decisions as to who will care for their older children during labor and who can support the laboring person, if anyone. Our participants had different preferences than birthing persons in similar investigations. While our participants widely preferred two support people and definitely more than one, another study found that over 1/3 of women felt that having a companion would not help.³⁰ A separate study found that 63% of women did not desire any companionship during childbirth.³¹ Dichotomies such as these illuminate the heterogeneous nature of support person preferences.

Nursing staff were also reported to play a critical role in the birthing experience for participants. This aligns with a study by Jackson et al. (2022), which indicated that healthcare professionals displayed compassion in their attempts to respond to social disconnect stemming from COVID-19 restrictions.³² Our findings add a contrasting perspective to numerous existing studies that found that women who gave birth during the pandemic were less satisfied with quality of care and their overall birth experience, in addition to perceiving increased health care discrimination.^33,34 Conversely, in our study, many participants expressed that the nursing staff were supportive, while others expressed that at worst, they saw no difference in treatment from the staff between their pre-COVID-19 birth compared to their birth during COVID-19. Whether it was the participant’s partner, a close family member or friend, or nursing staff, the participants involved in this study expressed that they wanted a support person they had a personal connection with, someone who could read their body language, who could offer reassurance, validate and support decision-making, and act as an advocate for them. Lunda et al. (2018) found that when women met their support person for the first-time during birth, they experienced additional feelings of apprehension with the added social pressure and uncertainty.³⁵ Conversely, having a support person with a personal connection increases feelings of control over the birth process, and is perhaps why so many participants in our study valued this in their chosen individual(s).³⁵

Limitations

Several limitations existed in this study. First, participants were recruited from a single recruitment site, which may not be reflective of birth experiences elsewhere. This study did not include participants who tested positive for COVID-19 during their birthing experience, potentially missing an important perspective on birth experiences during the pandemic. We also did not collect clinical outcome data from our participants since our research question was strictly focused on capturing their perceptions of their birth experiences. Additionally, we incorporated careful documentation and auditing of all procedures and analysis, but we did not seek verification of our themes from our participants.^16,17,25 Lastly, there is the potential for recall bias when participants reflect on birth experiences prior to COVID-19.

Practical Implications

Nursing practice is based in holistic care that focuses on the emotional, spiritual, and mental health of patients in addition to their physical health. Understanding patient preferences for visitor support during birth may decrease demands placed on nurses to provide extensive psychological support, allowing them to focus more on other essential tasks and decreasing emotional strain. Considering the current rates of nursing burnout and turnover, which cost hospitals time, money, and resources, hospital policy makers have a duty to emphasize measures that improve the well-being of their nurses.^36,37

Nurses are recognized as important patient advocates. While safety during a pandemic necessitated stringent restrictions, perspectives gained from our research provide obstetric nurses insights that can assist them in advocating for more equitable and supportive visitor policies. First, our research revealed that limiting visitors to one support person who was unable to leave the hospital created an inequitable situation for birthing persons without a support network to provide care for other children. Early communication of visitor restrictions to prenatal care providers as a vehicle to communicate changing policies to patients would have allowed participants more time to put networks in place. Additionally, a specific visitor policy for support persons (e.g., required use of personal protective equipment; rapid COVID testing) that would allow visitors to leave and come back is necessary for birthing persons without the ability to put a support network in place, an approach supported by a systematic review conducted by Iness et al. (2022).³⁸ Our participants also highlighted how the lack of standardized communication concerning the visitor policy caused them and their families additional distress. Information provided to participants was outdated, creating unwarranted stress by forcing last minute changes to birth plans. Nurses need to be kept up to date with policy changes and advocate for the equitable upholding of hospital policy. Studies examining hospital communication during the pandemic from the perspective of nurses are necessary to determine if this was a site-specific issue or a universal point of improvement. Of note, printed materials may not offer the flexibility required for evolving situations such as a global pandemic. Communicating with pregnant persons and health providers through text messages or QR codes would allow timely and standardized communication of policy changes.^39,40

Lastly, study participants expressed a desire to have someone, in addition to the newborn’s father, who had experienced childbirth present during their birth experience. Hospital-based doula programs offer the opportunity for trained non-clinical professionals to serve as advocates who can provide comfort and help guide decision-making if complications or situations arise during childbirth that do not permit the presence of support people.^41–44 Hospital-trained doulas may also offer important assistance to the obstetric nurse if nurses play a role in the creation of such programs, allowing for more deliberate and organized support during birth. We recommend hospital-trained doulas be recruited through community-based participatory efforts so that they reflect the demographics represented among the patients the hospital serves. Our participants stressed the importance of having support people they had a personal connection with. Recruiting from the local community could facilitate this connection.

Conclusion

This study examined the impact of restricted visitation on birth experiences. Results revealed that although participants understood the need to limit visitation, support during labor and birth were extremely important, especially with assistance in medical decision-making. Participants also emphasized their appreciation for the extra support provided by medical staff during the visitor restriction period, particularly from nurses and midwives. Participants identified a shared personal connection and ability to advocate and assist in decision-making as the most important characteristics for their support person during their birth experience. This research adds to the evidence that restricted visitation strongly influences birthing experiences. Furthermore, it highlights the role nurses play in labor support and the importance of timely, standardized, and clear communication concerning restrictions.

Table 4.

Themes and Subthemes Coded from Interview Analysis.

Theme	Sub-theme
A Shared Personal Connection is a Valued Trait	Support person understands nonverbal cues to advocate for participants without being told
	Continual assurance from support person
A Female Support Person is Important	Internal conflict about having female support person versus obligation to have infant’s father present
	Women have an easier time empathizing with the birth experience
Nurses “Went the Extra Mile”	Nurses provide support and reassurance
	Nursing staff serve more focal role as support people when other companions are absent
	For some participants, nurses were equally supportive before and during the pandemic
Support People Help with Decision-Making	Input from support people is valuable to the decision-making process
	Shared personal connections with support person can facilitate confidence in decision-making
Two is an Ideal Number of Support People	At least one support person needs to be present
	Excessive crowding is counterproductive to the experience and is overwhelming
	With fewer support people present, participants enjoyed when their partner took a more intentional supportive role
Increased Psychological Burden	Visitor restrictions caused increased loneliness and stress during birth but were respected by participants due to public health necessity
	Challenge caring for other children during birth experience since restrictions didn’t allow support person to come and go
	Poor communication of restrictions