Introduction
Coronavirus disease 2019 (COVID-19) is an acute respiratory infection which was first reported in the Wuhan area of Hubei Province, China in late December 2019 and which quickly spread throughout the world. The International Committee on Taxonomy of Viruses officially named this coronavirus “Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2)”. The World Health Organization (WHO) confirmed the disease caused by SARSCov-2 is Corona Virus Disease-19 (COVID-19) [1]. In early March 2020, World Health Organization declared COVID-19 a pandemic. This was due to the increasingly widespread development of COVID-19 cases around the world [2].
According to the update on the global situation of COVID-19 around February 2021, there were 108,153,741 confirmed cases with as many as 2,381,295 deaths [3]. According to the World Health Organization regional data, America ranks first in confirmed cases of COVID-19 with as many as 48,137,377 cases [3]. Meanwhile, of the data for the South East Asia region, in first place is India with 10,904,940 total cumulative cases and in second place is Indonesia with as many as 1,210,703 cases [3]. The COVID-19 situation in Indonesia as of February 14, 2021, comprises 1,217,468 confirmed COVID-19 cases, 1,025,273 recovered cases, 33,183 deaths and 159,012 active cases [4]. Papua Province data in early April 2021 showed 19,692 positive cases, 10,431 recovered cases, and 203 deaths [5]. In Jayapura in early April 2021, there were 8,905, registered positive cases, 8,276 recovered cases and 153 deaths [5]. Data from Marthen Indey Hospital in the beginning of May 2021 showed 598 positive cases, and 35 deaths [6].
One of the vulnerable groups affected by the COVID-19 pandemic is pregnant women. Pregnant women are a group that is prone to health problems, especially infectious diseases, due to physiological changes during pregnancy, such as a decrease in the volume of functional residues, an increase in the diaphragm, and changes in immune cells causing increased susceptibility to viral infections [7].
There is uncertainty regarding the potential for vertical or perinatal transmission of SARS-CoV-2 from infected pregnant women to their infants [8]. Several reports found that the result of Rapid Test - Polymerase Chain Reaction (RT-PCR) on amniotic fluid, cord blood, and the smear from the throat of infants from six COVID-19 positive mothers born by cesarean section, all declared negative [9,10].
Special attention is needed in caring for infants whose mothers are positive for COVID so that the infants are not infected at birth from their mothers. Nevertheless, for new mothers who are positive for COVID-19, whenever possible, it is advisable to plan joint management of the mother with her baby, to promote the onset of breastfeeding, while assessing on a case-by-case basis if the drugs given to the infected mother can be dangerous to the baby [11]. However, if there is uncertainty, the baby's care is carried out in a separate room from the mother with the aim of reducing contact and preventing the transmission of COVID-19 from mother to baby.
During the pandemic, the perinatology section in Marthen Indey Hospital has three rooms on of which is devoted to infants born to mothers suspected of COVID-19 and mothers who are confirmed positive for COVID-19. Arrangements are made where the baby will be placed in the room until the results of the PCR swab examination on the baby test negative; then the baby will be transferred to the usual treatment room.
The number of infants born to mothers who were confirmed positive for COVID-19 from May to December 2020 amounted to 16 infants [12]. One of the efforts to prevent the transmission of COVID-19 from mothers to their infants is by giving adequate parental education about safe infection control practices, such as use of surgical masks at al. times and frequent hand hygiene [13]. Nurses are expected to be able to properly educate the baby's mother about the COVID-19 health protocol
Nurses are health professionals have the authority to carry out nursing care and are expected to have the ability to perform actions that are intellectual, interpersonal, moral, and responsible [14]. Nurses, as one of the components of Human Resources (HR) in the hospital health care system, are the spearhead, directly in charge of the front line that deals with most patients. The medical personnel dealing with COVID-19 patients, with all the obstacles, have many experiences as they provide services to patients with the objective of complete recovery and return to their families to live life as usual.
According to several nurses at the Marthen Indey Hospital, treating COVID-19 patients requires extra energy and concentration. Situmorang's research (2021) [15] found that the burden experienced by nurses during the COVID-19 pandemic is very heavy psychologically and physically, because, in addition to the fear of being infected, they also have a substantially increased workload compared to before the pandemic period.
Nurses are required to have knowledge and approaches in carrying out every action of care and handling of newborns in accordance with standard operating procedures that refer to the COVID-19 management protocol in neonates that has been set by the Indonesian Pediatric Association [16]. The knowledge of nurses about handling newborns of mothers suspected of COVID-19 and mothers who are confirmed positive for COVID-19 needs to be enhanced. This is to ensure quality nursing services for mothers and infants, especially during the pandemic by paying attention to protocols to prevent the transmission of COVID-19 in the work environment. However, it is reported that infants born from mothers with positive SARS-CoV-2 infection rarely acquire the disease [17].
Given that nurses are with patients for 24 hours, it is important to explore their experiences while working on newborns of COVID-19 positive mothers. Knowing more about the experience of these nurses will reveal the challenges and obstacles they face and could contribute appropriate measures for the improvement of their knowledge and skills.
Method
Data Collection
This research used descriptive qualitative research methods. The participants of this study were 6 nurses who work in the Perinatology Room Marthen Indey Hospital, had met the inclusion and exclusion criteria, and were determined based on purposive sampling. Data were collected using telephone and video call interviews to explore nurses’ experiences in caring for infants of mothers with COVID-19. Data were analyzed using Creswell’s six-step qualitative data analysis method.
Participants’ Profiles
Participants in this study were six nurses who work in the Perinatology Room Marthen Indey Hospital and had met the inclusion and exclusion criteria. The participants’ profiles are presented in Table 1 below.
Results
Data obtained provided insight into the nurses’ experiences in caring for infants of mothers with COVID-19. The data analysis revealed four themes: “management of care of infants of COVID-19 positive mothers”, “internal and external factors’’, “support for nurses”, “nurses' expectations”. Seven sub-themes emerged. Table 2 shows the themes and the sub-themes of the study.
Theme 1: Management of care of infants of COVID-19 positive mothers
The theme, the management of the care of infants of COVID-19 positive mothers, consists of two sub-themes, namely self-protection and standard operating procedures for caring for infants of COVID-19 positive mothers. Almost all participants explained that, in caring for infants of COVID-19 positive mothers, they protected themselves by using PPE, as expressed by participants 1, 3 and 6:
Services are not as usual, especially in the use of PPE, which is usually level 1. Now it must be level 2 and even level 3. (P1)
When caring for infants we have to really take care of ourselves by using personal protective equipment (PPE).
(P3) When caring for infants whose mothers have a positive swab, we use PPE level 2. (P6)
Regarding standard operating procedures for the care of infants of COVID-19 positive mothers, participants stated that infants must be separated from the mother, early breastfeeding must not be initiated, and infants must be bathed and be given formula milk. This is expressed by 3 participants below:
Infants whose mothers are positive for COVID-19 are immediately kept away from their mothers and 10 minutes later are bathed and are placed in the incubator. (P2)
Infants born to COVID-19 positive mothers should not be initiated to early breastfeeding and are bathed and given formula milk. (P3)
Infants born to mothers with COVID-19 must be bathed immediately so that they are not infected with the virus from their mothers. (P5)
Theme 2 Internal and external factors
This theme describes the internal and external factors that affect the care of infants of COVID-19 positive mothers, namely the availability of facilities and infrastructure. Participants stated that the internal factors include medical equipment and rooms. They reported on the availability of facilities and infrastructure, as stated by participants 2,4 and 5 below:
The space for infants born to COVID-19 positive mothers is so limited that we feel overwhelmed with the very few cribs for infants. (P2)
The problem is that the medical equipment is still lacking. (P4)
Inefficient places and rooms that are not up to standard. (P5)
Participants in this study also talked about the external factors that affect the care of infants of mothers who are positive for COVID-19, namely psychological factors experienced by the family. These psychological factors were that families did not believe in COVID-19 and refused to allow the baby to be isolated. This was revealed by participants 1, 4 and 5:
Sometimes it is difficult for families to accept that if the mother is positive, the baby must be isolated and have to undergo PCR as well, and the family refuses. So we have difficulty and sometimes the family does not accept [our advice]and asks to bring the baby home without PCR. (P1)
Families always say that babies don’t have COVID19, it can't be COVID and why does the baby have to be isolated and not join the other infants. (P4) Families don't accept infants being isolated in COVID-19 locations and think because the baby has just been born it is unlikely to be exposed to COVID-19. (P5)
Theme 3: Support for nurses
This theme describes the support system for nurses caring for infants of COVID-19 positive mothers. In the sub-theme, participants said that a support system was needed for nurses caring for infants of COVID-19 positive mothers. This support system must be in the form of continually encouraging enthusiasm and motivation, as expressed by participants 2, 4 and 6:
Don't be discouraged in caring for the baby and really pay attention to the baby's health. (P2)
We are always given motivation and encourage each other with our colleagues. (P4)
Our work is always treated with enthusiasm. (P6)
Theme 4: Nurses' expectations
Theme four describes the expectations of nurses in caring for infants of mothers who are positive for COVID-19. There are two sub-themes, namely healthy, free from COVID-19 mothers and healthy infants. Participants explain their hope that mothers who give birth are always healthy and free from COVID-19, as expressed by three participants below:
Patients with COVID-19 positive mothers are reduced. (P1)
Hopefully during this pandemic there will be fewer
COVID-19 positive pregnant women. (P2) Mothers during pregnancy must take care of themselves and stay healthy so they are not infected with COVID-19. (P5)
Almost all participants in this study expressed the same hope for infants to be born healthy and free from COVID-19, as expressed by participants 1, 3, 4 and 6:
I want infants born to mothers who are positive for COVID-19 to be negative their condition remains good. (P1)
I want infants to stay awake and healthy, so they don't get infected with COVID-19. (P3) Hopefully the baby stays healthy and fine, and mothers can recover soon so the baby can have breast feeding as soon as possible. (P4)
I wish all infants are healthy and free from COVID-19. (P6)
Discussion 1. Management of the care of infants of COVID-19 positive mothers
The results of this study found that the management of care of infants of COVID-19 positive mothers is very important, comprising selfprotection and working based on standard operating procedures of care. Personal protection in the form of using Personal Protective Equipment (PPE) while handling infants of mothers who are positive for COVID-19 is vital. Participants said that the service given during the pandemic was not as usual. “When caring for a baby whose mother had a positive COVID-19 test, we must really take care of ourselves by using PPE level 2 and even level 3”. It is recommended that medical staff must use Personal Protective Equipment (PPE) during neonatal resuscitation including gowns, gloves, N 95 respiratory masks, and eye protection goggles or air filter breathing apparatus [18]. In accordance with the practical protocol issued by the task force for the acceleration of handling COVID-19 (2020), in complications and emergencies, attention must be paid to the procedures and flow of maternal and infant health services in the COVID-19 pandemic situation. These procedures include the use, removal and disposal of Personal Protective Equipment (PPE). Personal Protective Equipment (PPE) is a tool for the protection of a person whose function is to isolate part or all of the body from potential hazards in the workplace [19].
Personal Protective Equipment (PPE) is one of the COVID-19 protocols that nurses must use in treating patients during the COVID-19 pandemic. The correct use of Personal Protective Equipment (PPE) can protect and prevent the occurrence of COVID-19 infection. Rizqullah (2021) [20], revealed that Personal Protective Equipment (PPE) is a set of safety equipment to protect all or part of the body from occupational diseases. Therefore, the use of personal protective equipment can be said to be a tool to prevent the transmission of infection.
In caring for infants, especially infants of positive COVID-19 mothers, nurses must really pay attention to the use of personal protective equipment in carrying out every nursing action so that they can protect themselves from the transmission of COVID-19 infection. Nurse compliance in implementing safe behavior while working by using personal protective equipment is one of the main components of vigilance in carrying out nursing actions, especially in patients with COVID-19.
Standard operating procedures of the care of infants of COVID-19 positive mothers, such as not initiating early breastfeeding, separating infants immediately from mothers and giving formula or breast milk expressed by the participants, are parts of the management of care. The care of infants of COVID-19 positive mothers is different from infants born to COVID-19 negative mothers. The aim is to reduce the risk of transmitting COVID-19 from mother to baby. Newborns born to COVID19 positive mothers with symptoms or without symptoms are categorized as suspect of COVID-19. For this reason, the care of the infant will be carried out in an isolation room and separated from the mother. Neonates are included in the criteria for high-risk close contact, so they are not hospitalized, but are treated separately from the mother in the COVID-19 isolation room [21]. This is supported by Sighaldeh and Kalan (2022) [22], who recommend that it is important to separate infants from mothers with confirmed or suspected COVID-19 infection for at least 2 weeks.
After the baby is separated from the mother, the way of providing nutrition for the baby can be by giving expressed breast milk or formula milk. As Cheema et al. (2020) [23], said, temporary separation from mothers and expressed breast milk rather than direct breastfeeding can reduce the risk of postnatal infection of the baby from the mother's respiratory secretions. This is in line with Bakhtiar (2020) [24], who said that infants of mothers with COVID-19 should receive treatment in terms of care and nutrition, including consideration of breastfeeding or formula milk. This is done with various considerations, one of which is the condition of the mother with a positive confirmed case of COVID-19 with or without symptoms.
Nurses who work in a perinatology room must first know whether the case of the mother who is about to give birth is confirmed positive for COVID-19 or not, so that the care that will be given to the newborn can be carried out in accordance with the standard operating procedures that have been set. Standard Operating Procedures (SOPs) are very important and really help nurses to achieve quality nursing care, enabling nurses to think systematically about all aspects of nursing care in health services [25]. Nurses in carrying out every nursing action must always refer to Standard Operating Procedures (SOPs) so that they can achieve quality nursing care.
Internal and external factors
Internal factors that affect the care of infants of COVID-19 positive mothers are the availability of facilities and infrastructure. The availability of facilities and infrastructure such as baby beds and medical equipment in the Marthen Indey Hospital is still limited, and the room is not up to standard, as expressed by the participants. Lewis et al., (2020) [26], found that health service facilities and infrastructure supported by good service quality will undoubtedly realize service satisfaction. Patterson et al., (2017) [27], also stated that appropriate facilities and infrastructure in hospitals positively affect service satisfaction, and the more comprehensive and useful the facilities and infrastructure are, the better service satisfaction will be.
Effective and efficient usage of health service facilities and infrastructure can be identified as a collaborative process in the provision of services in a professional manner [28]. In the current era of the COVID-19 pandemic, hospitals are still trying to provide support facilities and infrastructure in nursing services, especially for infants born to COVID-19 positive mothers, such as the provision of isolation rooms for these infants. All of this is done in order to minimize the transmission of COVID-19 from mother to baby and minimize contact with other infants born to COVID-19 negative mothers. The availability of health facilities and infrastructure has a positive effect on service quality. Service quality is an important factor in increasing service satisfaction, and to achieve that, comprehensive facilities and infrastructure are needed.
External factors comprise the psychological factors experienced by the family. Specifically, as reported by the participants, these factors include families’ understanding about caring for newborns, their fears and concerns about their infants, their difficulty in accepting that infants must be isolated and their belief that infants cannot have COVID-19. Family fears greatly affect the care of infants, hampering the services provided to infants of mothers who are positive for COVID-19. Paju and Dwiantoro (2018) [29], stated that nurses need patterns, strategies and effective communication skills that will have an influence on patient and family satisfaction.
Nurses are also educators, conveying information and education related to COVID-19 disease, infant care and treatment and hospital policies during the COVID-19 pandemic. Nurses should educate families so that they understand all treatments and care given to their infants, which would build trusting relationships with patients and families.
Support for nurses
Nurses really need extra support during the COVID-19 pandemic because the workload is certainly heavier than before. As Situmorang (2021) [15] found, the burden experienced by nurses during the COVID-19 pandemic was very heavy psychologically and physically, because, apart from the fear of being infected, they also had a very increased workload. The care of newborns before the COVID-19 pandemic and during the COVID-19 pandemic is very different. This is due to the necessity of minimizing the transmission of COVID-19 from mother to baby. In the care of newborns before the COVID-19 pandemic, the newborn was directly placed on the mother's chest and the baby initiated early breastfeeding. It is crucial to provide a support system for nurses caring for infants with COVID19 positive mothers, because nurses are required to provide the best and professional services, especially in the current era of the COVID19 pandemic. The support system is important in the form of motivating nurses, nurturing their enthusiasm and encouraging peer support, as expressed by the participants.
Support in the form of cultivating motivation is an important component in achieving the success of a work process, because motivation is the driving element for someone carry out their work individually or in groups [30]. Yanti, Susiladewi & Pradiksa (2020) [31], also said that the cultivation of motivation of nurses to do good work during the COVID-19 pandemic would increase the confidence of nurses in providing nursing care. Nurses are expected to increase their work motivation so that excellent service can be maintained. Motivation becomes strength or power and readiness within the individual to move towards certain goals, both consciously and unconsciously [32]. Motivation plays an important role in improving nursing care service, both from self-motivation and from the environment. Motivation is a condition that drives behavior and directs activity towards an achievement.
Nurses' expectations
Nurses' ideals in caring for infants with COVID-19 positive mothers are for mothers to be healthy and free of COVID-19 and the condition of the babies to also be fine. This would allow the mother and baby to be treated together immediately after delivery so that a close relationship can be established.
Pregnant women need good nutrition and clean and healthy lifestyles. Providing more comprehensive information for pregnant women during the COVID-19 pandemic is very important so that they can avoid COVID-19 disease. Septiyaningsih, Yunadi & Kusumawati (2021) [33], said that with education, pregnant women would understand how to prevent COVID-19 infection, would understand pregnancy check-up procedures and how to maintain their health. They would also understand the efforts made when they are sick in the pandemic era.
Hasnah et al., (2021) [34], emphasized the importance of increasing knowledge through health education, including efforts to maintain the health of pregnant women by encouraging them to commit to a healthy lifestyle, to avoid going out to the crowded places, to routinely check their condition by implementing health protocols and to maintain balanced nutrition. To date, the transmission of COVID-19 from mother to fetus is still not known for certain, but to prevent the occurrence of COVID-19 disease, the provision of health education to pregnant women is essential.
The condition of a healthy infant is the objective of nurses in caring for infants of mothers who are positive for COVID-19. This is because newborns are very susceptible to infections caused by exposure to viruses, one of which is the corona virus. Julianti, Waluyanti & Allenidekania (2021) [35], said nurses have an important role in improving the physical health of infants and meeting the complex needs of infants by providing comprehensive and complete care. Newborns need special nursing care and attention, and nurses must pay extra attention to infants born to COVID-19 positive mothers. The aspiration of nurses who care for infants of positive COVID-19 mothers is to have all mothers healthy and free of COVID-19 and have all infants born in good health so that mothers and babies could be together as soon as possible for early breast feeding, and bonding and attachment [36-40].
Conclusion
This study showed that the management of the care of infants of COVID-19 positive mothers is very important in the current era of the COVID-19 pandemic. This management includes nurses’ selfprotection during treatment and the implementation of standard operating procedures in the care of every infant of COVID-19 positive mothers in order to reduce the risk of COVID-19 transmission. Internal factors that affect the care of these infants are the availability of facilities and infrastructure in services, while external factors are psychological factors experienced by families regarding the care of these infants. The support provided to nurses in caring for infants with COVID-19 positive mothers, namely the existence of a comprehensive support system will increase the confidence of nurses so that they can provide professional services. Nurses' expectations in caring for infants with positive COVID-19 mothers is for all mothers to be healthy and free from COVID-19 at the delivery, and for all infants to be born in good health so that mothers and babies could be together as soon as possible for early breast feeding and bonding attachment.
Acknowledgement
I would like to express my gratitude to Dr. Maria Flutsch for editing my paper.