The COVID-19 pandemic has led to a transformation of healthcare management within the hospital setting worldwide. In Italy, although all ‘non-urgent’ medical care and interventions were immediately postponed from the end of February 2020, in order to free up space and personnel to care for the heavy influx of sick patients in ICUs, pregnant women were among the few groups who were nevertheless expected to continue engaging with available medical services, carry on with their antenatal care routine, and give birth in wholly reconfigured clinical landscapes.
The tendency to medicalize pregnant women is a trend which southern European nations share with the USA, and Italy is no exception. With 98.8% of births occurring in hospitals and midwifery much diminished, Italy has among the highest cesarean section rates in Europe (35.4 % on a national average and over 40.2 % in Southern regions). The high rates of medicalization also emerge from other interventions on the women’s body, such as pharmacological induction of labor (22.3% of births per year) and episiotomy (34.7% of births per year). Unlike the USA, Italy has a publicly funded national healthcare system that ensures universal access to maternity care; however, its medical infrastructure reflects regional inequalities between affluent and well-equipped northern and central regions, such as Piedmont or Tuscany, and underfunded and vulnerable southern regions like Calabria or Sicily.
From mid-March 2020, we carried out remote interviews with working and middle-class women and their relatives about the experience of pregnancy and birth in the shadow of COVID-19 across Italy. As the SARS-CoV-2 virus spread, the epidemic’s immediate effects on maternity care included the suspension of home visits, gradually cutting off preventative medicine and interpersonal sociability from pre- and postnatal care, and the shunting of women to larger hospitals where they faced a higher risk of infection and were left to give birth on their own, without kin or community support. Consequently, pregnant women experienced isolation in multiple social and material ways, from confinement at home to how they received care.
‘There [should be] this relationship with the belly… I’m in the fifth month of pregnancy, and this relationship is missing somehow, there is this absence of the gaze of others that makes your pregnancy a social reality. Other people help you understand this process which is unfolding.’ (Anna,[1] Sicily)
The majority of women we interviewed were white Italians. Many had a nagging feeling that space and time had started to operate differently, closing in on their everyday lives, limiting not only their physical movements through space but also their lived reality and sense of becoming. Some participants described this feeling as if confinement had forced them back several generations, back to a time when Mediterranean women’s daily lives were restricted to the home. This was expressed critically by Anna, a woman from southern Sicily who had made it a matter of personal emancipation to ‘be the one who breaks all the stereotypes’ by juggling work, activism and social life, including during pregnancy. All of the women we spoke with stressed how they had been living in almost complete self-isolation at home, never leaving the house except for medical check-ups, which they now had to attend alone.
‘I never go out, except for my medical appointments, and I don’t see anyone, and then of course, wash my hands like a thousand times when I get home, I take my clothes off and put them straight to wash…I haven’t seen a human being in the past 20 days, except for yesterday at the hospital.’ (Sara, Piemont)
‘I am nervous about going to the hospital for my next check-up; bear in mind that I haven’t left the house in almost a month, confined on my veranda, so it will be my first venture outside…last time I was out was before the emergency, and here in Sicily no one was going around wearing masks, there wasn’t this atmosphere of emergency.’ (Alice, Sicily)
Some couples chose to live segregated lives if they were not both working from home. The fear of contagion led, in these cases, to a transformation of physical intimacy in all its aspects, such as meals, use of the bathroom, and sleeping, leading to a stringent self-isolation of pregnant women both within and beyond the domestic space. The few outings now permitted principally involved traveling to the hospital for medical checks. There, our participants emphasized the strangeness of new forms of social interactions in medical spaces, such as those divided between ‘COVID’ and ‘Non-COVID’ wards, where all staff wore ‘space-suits,’ no-one including the patients in the waiting room spoke to one another, and the fear of contagion was omnipresent.
‘Certainly, the confidence I had in hospitals has changed. Before the epidemic arrived, I had no doubts about hospital safety, but now, every time I see a doctor for medical check-ups, I am scared of getting sick.’ (Beatrice, Veneto)
Although the women we spoke with underlined that they no longer thought of maternity wards as safe places to give birth, in both northern and southern Italy, they generally ruled out the option of homebirth, especially for first pregnancies. One of our interviewees, Beatrice, noted the paradoxical pressure felt by expecting mothers to face the risk of contracting COVID-19 in hospitals.
The women we spoke to were anxious about birth. They feared being forced to undergo unwanted interventions to speed up labor (above all, cesarean section surgery); they wondered how they would manage to breathe with a mask on; and they were terrified of being separated from their babies in case of suspected infection. All of them had heard stories of infected mothers separated from their newborns and denied the opportunity to breastfeed, despite clear WHO guidelines stating that separation is unnecessary. Marzia, from Sicily, described the doctor-patient interaction as now ‘less caring’, which compounded her worries: ‘Every time I meet a doctor, I have to wear a mask and plastic gloves…everything is more sterile, and the human dimension is lacking’.
Several women addressed the divergence between their expectations of childbirth and its ultimate, probable reality: ‘Childbirth happens a few times in life, honestly, I did not expect this to happen only with doctors, without partners and with no emotional support’ (Costanza, Lombardy). Uncertainty about the possibility of their mothers or partners being present during labor and delivery was an additional source of anxiety. Most women sought to quell their fears by not thinking about and preparing for birth, physically and materially. A few women in northern Italy, like Costanza, decided to transfer their obstetric care to smaller, midwife-led clinics, which did not have ‘COVID wards’ and the higher risk of infected personnel working there, but this option was unavailable to women living in southern Italy.
Self-confinement, lockdowns and the suspension of physician house calls left women primarily responsible for their prenatal and post-partum care, including the decision to self-medicate or move to bottle-feeding due to breastfeeding difficulties and absent lactation support. Alessia, from Umbria, still felt isolated and inadequately cared for after the birth of her first baby a few weeks ago, despite her extensive use of online services. This was even though she regularly met family members and friends through videocalls, had attended childbirth training classes via smartphone applications, shared blood test results with midwives, and received breastfeeding supervision by telephone.
These realities underline women’s need for a sense of community and reveal the new centrality of telemedicine in obstetric care, while also exposing the latter’s limits. For non-Italians living far away from their families (such as women from Canada and Romania in our sample), many expressed experiencing an even greater sense of solitude, as the national lockdown in March 2020 coincided with the closure of international borders. Additionally, their limited knowledge of the Italian healthcare system and the obstacles they encountered while trying to participate in online networks of mothers led many to be poorly prepared to meet their health needs. Depending on the degree of women’s access to technologies, legal and economic status, migration status, and language skills, their ability to access care and escape isolation are thus unequally and unevenly available, increasing existing inequities at the expense of women’s wellbeing.
Vanessa Grotti is Associate Professor of Anthropology at the University of Bologna and Part-time Professor at the European University Institute, where she leads an ERC-funded project on migration and maternity care, EU Border Care. She has published on kinship, gender and the body, medicine and colonialism, migration and borderlands, and death and memorialisation. Over the past 15 years, she has worked in Lowland South America, Burkina Faso and the Mediterranean.
Chiara Quagliariello is Postdoctoral Research Fellow at the European University Institute where she works for EU Border Care project. She has a long experience in field research in Italy, France and Senegal. Her research interests include medical anthropology, with a particular attention to childbirth models, sexual and reproductive health; social and health inequalities; gender, class and ethnicity; sub-Saharan African women’s migrations.
[1] All names used in this article are pseudonyms.