Perspective of women health care workers of a medical institute on care of their under-five child during COVID-19 pandemic

INTRODUCTION

The higher burden of the COVID pandemic in India put stress on the frontline healthcare workers as they had to work for longer hours, manage and safeguard themselves, manage drugs, workforce allocation, disrupted sleep patterns, and work-life balance.¹ Though in general, both male and female healthcare workers are involved in the fight against COVID, a study conducted among healthcare professionals (HCP) from India during this challenging period showed that women HCPs have two times higher odds of developing stress and depression that would require treatment.² With a broad age group of women healthcare professionals, the physician-mothers or healthcare-mothers with younger children were at more stress.³ Though several studies have also been conducted to understand the coping strategies of women HCPs parenting minor children in other parts of the world, there is a lacuna to understand their coping strategies in India who undertook COVID duties.^4-7

The first five years of a child are crucial in an Indian scenario, HCPs mothers having kids of such age are at higher stress than other women with grown kids.^8-10,3 Among these women, there is a higher fear of infecting their children, though little is known to understand the effect of this pandemic among the under-five age groups.^11,12 In addition, this age group of children is also a great sensitive observer to the stress that their parents, family, and community undergoes.¹² Therefore, considering the stress on the HCPs, and the higher risk of stress and depression among female HCPs compared to males, and additional higher stress on mother-HCPs parenting minor children, this study was undertaken.^1-3 The objective of this study was to understand how mother-HCPs of under-five children who had COVID duties at a tertiary care teaching hospital coped and what kind of coping strategies they used to lower their stress and managed to give their service to humankind at this very challenging hour.

METHODS

Research paradigm

A phenomenological approach was adopted in this study as it aims to understand a living experience toward a phenomenon. We adopted the Heideggerian hermeneutic phenomenology in this study with interpretivist paradigm. It is also mainly that the philosophical stance of the researcher aligns with Heidegger that the time and context shaped the understanding of the being, 'Being-in-the-world'.^13,14

Study setting

This study was done in a teaching hospitals located in the southern region of India and is a referral hospital for the surrounding districts and States. At this center, 104,034 individuals were tested for COVID-19, and 9,051 were admitted for COVID-19 care as of 31^st December 2020.

Sampling strategy and study participants

With the intended aim from the viewpoint of 'Being-in-the-world' as per Heidegger (14), this study employed purposive sampling to define the sample and snowball sampling to recruit the participants who satisfied the inclusion criteria. Women healthcare workers having child/children under the age of five, who worked in COVID duties. Individuals who had speech or hearing impairment were excluded.

Data collection

In a pandemic situation, to reduce unwanted exposure to the researcher and the participant, the interviews were undertaken via telephonic calls. The interview guide was developed considering Nurturing Care Framework (reference) and the transactional theory of stress and coping by Lazarus and Folkman.¹⁵ The interview guide was reviewed by experts from community medicine and neonatology who worked in the cultural setting for at least 10 years.

The principal investigator carried out all the interviews. Phone calls were made to explain the purpose of the study, after which they were given a couple of days to make their decision. Consent was obtained verbally. The interview duration varied between 25 minutes and 80 minutes, and they were all interviewed in English.

The interview began in alignment with Van Manen (2017) on the need to ask - what the experience was like, to seek an insightful narrative and understanding of the phenomenon experienced by the participants.¹⁶ Especially how the experience was in working at COVID ward and also managing their child/children. Later, questions like how they could maintain the work-life balance and their coping efforts were asked. Appropriate probes were also used to further the interview into more details.

Data analysis

According to Braun and Clarke (2006), inductive thematic analysis and theoretical thematic analysis are two approaches in the thematic analysis (17). This study employed a mixture of both. Thus, on one side, while the themes were actively generated by the researcher, on the other side, the over-arching themes were adapted from Nurturing care framework and from Lazarus and Folkman's coping approach. The codes and themes were finalized based on consensus with other co-investigators.

The Institute Ethics Committee approved this study. Participants were anonymized during transcription to ensure confidentiality.

RESULTS

The analysis revealed two overarching themes namely challenges related to components of nurturing care and those related to enabling environment for nurturing care.

Overarching theme 1: Components of nurturing care

Maintaining good health

Women faced challenges in accessing treatment, preventive and promotive services. With respect to treatment services women highlighted the challenges with tele-medicine services especially for skin conditions. "We used to send pictures of the skin problem to the doctor and have video calls, but the quality wasn't great. Diagnosis and treatment of skin issues like fungal rashes or eczema were challenging without direct examination under sunlight or natural light. We had to send pictures repeatedly," explained a resident doctor. Families feared contracting COVID-19 in hospital and closure of some health facility made access to preventive services challenging. A mother commented "I'm scared to get him vaccinated in JIPMER because of the crowd ... so I did not go to JIPMER."

*Paramedical cadre includes emergency medical technician, laboratory technician, physician assistant, dialysis technician and ophthalmic technician

Providing adequate nutrition

The challenges were related to breastfeeding and eating practices.

Breastfeeding

Workplace especially COVID-19 wards were unconducive for expressing breast milk due to time constraints and lack of privacy. Donning and doffing process left them with insufficient time. "I don't get time to express my breast milk at the workplace as it takes at least 30 to 40 minutes. We don't have a separate room, and people come knocking on the door" - commented a doctor with a seven-month-old child. Women also avoided physical contact with the child during their COVID duty which led to early discontinuation of breastfeeding: "We have a total of seven days of COVID duty. For the first three days, I didn’t go near her, and then on the fourth day, when I was about to breastfeed her, she refused.” (commented a doctor). Some lactating mothers experienced reduced breast milk secretion and they attributed it to psychological stress and inadequate fluid intake due to prolonged use of personal protective equipment (PPE) at duty. Less time was available for childcare because of the time-consuming hygiene protocols they followed on returning from duty. Emergency calls from hospital also interrupted breastfeeding: “Every time when I come home, I have to take bath and wash the clothes which takes up most of the time and if I get a call in between while feeding, that there is an emergency caesarean-section, I have to stop the feeding in the middle.” commented a doctor from obstetrics department.

Eating behavior

Many parents offer junk food to manage children's behavioral issues. A paramedical healthcare worker with a four-year-old shared, "Since we can't take our child outside, he becomes distressed and starts screaming. My husband used to give him junk food to stop the screaming." Children were consuming more snacks per day during the COVID-19 pandemic. Staying at home led for extended durations without engagement led to increased consumption of snacks such as French fries, cutlets, cakes, and chocolates. Mothers struggled to maintain good eating habits without the structure of school or daycare. Whereas, in school or daycare, children learn from their peers. Mothers commented that it was difficult to make children eat without using mobile devices for distraction. A paramedical staff member, "My child didn’t eat properly at home... Kids learn eating habits at school... if any child is eating, he will also eat by watching them."

Providing opportunities for early learning

Early childhood development impact during lockdown

School closures impacted cognitive and socio-emotional development. A mother noted that children learn new words and conversational rules by observing others' behavior and facial expressions, which were limited during lockdowns. "My child is constantly fighting with others. If he had been in school with other children, he would have learned some manners and had a respectful fear of teachers," said a paramedical healthcare worker with a 2½ year old. They also did not get used to routines. During the lockdown, children had limited exposure to the outside world, affecting their sensory stimulation and development as they missed interactions with animals, birds, and plants. "When I finally took my child outside, he saw even a cow as a stranger, and it took a long time for him to understand animals like dogs and cows," said a nursing officer with an 11-month-old child. Children’s physical activity decreased as they were not attending school, playgrounds, or parks.

Challenges of online learning during the pandemic

Healthcare professionals struggled to be involved in their children's online classes, adversely affecting their learning. "Since online classes are new for children under five, I had to spend a lot of time on them, sitting with my child; otherwise, he wouldn't pay attention to what's happening on the laptop," said a doctor, mother of a four-year-old. "I don't have time to monitor her online learning because classes are during the day. As a mother, I've never been able to help her with online classes.” said a doctor with a three-and-a-half-year-old child. The reliance on online classes led to increased screen time and concerns on internet security. "Children are learning everything except what they're supposed to from the mobile. We were hiding everything from them, and now they've seen everything without our knowledge," said a nurse with two children under five. Also increased recreational screen time negatively affected their child's behavior. "My child started hitting us because he's watching fighting cartoons all day. If he had gone to school, he would have learned some rhymes and studied a bit, which would have been a better distraction," said a mother of a three-year-old.

Responsive caregiving

Fear of COVID-19 transmission led to reduced physical contact such as kissing and hugging and quality playtime with children. "After returning from night duty, I need time to finish household chores, take a bath, and settle down. So, when my child wants to play with me, I'm too tired to join in," shared by a nurse with a 1½ years old child.

Providing safety and security

Ensuring children followed COVID-19 preventive measures were challenging. "When my child goes out, he forgets his mask, and when we return, he immediately wants to climb on us… It takes at least three or four of us to get him to wash his hands," said a nurse with a 2 ½ year-old child.

Overarching theme 2: Enabling environment for nurturing care

Caregiver capabilities

Increased workplace stress spilled over to home life, affecting how mothers handled their children’s behavior. "Before COVID, I would handle my kids' mistakes calmly. But during the pandemic, I can't control my anger and have been hitting them due to increased work stress," said a nurse with two children. Children also echoed the stress of parents causing behavioral issues among children. "My child became more stubborn and started throwing tantrums loudly, needing attention… When a colleague tested positive, I had to isolate myself at home. During that time, it was challenging for my mother to care for him as he became quite rude," said a paramedical staff with a three-year-old child. Self-quarantining to prevent transmission caused emotional trauma for both mother and child. "After operating on patients with unknown or positive COVID status, I would come home and isolate myself in a room for days, avoiding contact with my child. We would lock the door and turn off the lights so she wouldn't know I was home. She (child) would lie outside the door, peeping through the gap and crying for hours. I would place a doormat under the door to make her think no one was inside (tear filled eyes)." told a doctor with a three-year-old child.

Supportive services

Closure of day care services and difficulty in hiring domestic help added to challenge of childcare, sometimes necessitating job changes. A paramedical staff member from Kerala explained, "My husband has stopped going to work because someone needs to be with our child. I can't leave my job during this critical time. This affected our family's finances,"

Enabling policies

Long working hours with extended shifts and difficulty obtaining leaves hindered childcare. "My personal life is overshadowed by my professional life; the balance is completely skewed. I'm eager to switch from 12-hour to 8-hour shifts as soon as possible," explained a senior resident in obstetric department. A nurse working in a trauma care ICU, mother to two children under five, lamented, "There have been instances where I couldn't get leave even when my child had a medical emergency. Despite his crying, I was told to report for duty. It's disheartening when I can't care for my own child but am responsible for others…".

Overarching theme 1: problem-focused coping

Mothers relied on support from family, spouse and supervisors to manage childcare. Spouse of the healthcare worker adjusted their work shifts to ensure that one parent is at home. Women appreciated supportive supervisors or in-charges who accommodated leave requests or adjusted work schedules to cope with the situation. Women adhered to preventive measures such as wearing mask and hand hygiene to protect their child/family from infection and also continued breastfeeding.

Mothers compensated for the lost school learning with educational toys/books and activities at home. A physician mother has set up a nurturing environment at home for her one-year-old with educational toys, mini laptops, library of tactile books, and interactive activities with animal sounds and visual learning. Over time women learnt to balance domestic responsibilities and childcare.

Overarching theme 2: emotion-focused coping

Mothers practiced gratitude and positive thinking to stay motivated. Women sought support from spouse, colleagues, and friends. The support and counselling from family members played a crucial role in women’s decision to continue their work shared a female doctor with a seven-month-old child.

DISCUSSION

This qualitative study showed that women healthcare professionals (HCPs) used various strategies to cope with challenges during the COVID-19 pandemic. These included seeking social support, following safety precautions, using creative early learning methods for children, spending quality time with them, practicing positive thinking, and relying on emotional support from family and colleagues.

Maintaining good health through timely preventive and curative care is essential for nurturing care. However, many women HCPs faced difficulty accessing routine health services for their children due to fear of COVID-19 infection. To manage this, they followed strict infection prevention practices. Measures such as mask use, hand hygiene, and other precautions allowed them to continue caregiving activities like breastfeeding safely, even while working in high-risk settings. These practices also helped reduce anxiety related to disease transmission.

Participants also adopted careful hygiene routines before entering their homes, such as bathing and disinfecting clothes, to protect family members. These behaviors reflected a strong sense of responsibility and high-risk awareness, similar to findings from earlier outbreaks. Such practices helped them balance their professional responsibilities with their roles as mothers.

Social support played an important role during the pandemic. HCPs depended on spouses, family members, and colleagues for help. Although joint family systems are declining in India, many participants received support from spouses and grandparents for childcare.¹⁸ This support gave them peace of mind and strengthened intergenerational relationships.¹⁹ However, those without such support, especially during lockdowns, struggled to find reliable caregivers. This highlights the need for stronger and more dependable social support systems, especially for nuclear families.

In addition to family support, HCPs also relied on colleagues and seniors to manage their fears about infecting their children.²⁰ Similar concerns were observed during previous outbreaks such as SARS in Taiwan and MERS-CoV, where workplace support was crucial.^21,22 In this study, open communication and observing colleagues successfully follow preventive practices increased confidence among participants. Since such positive behaviors are difficult to develop during crises, they should be encouraged at all times.

The challenges faced by nurses with young children, such as weak system support, fear of infection, and limited social support, were also seen in our study participants. Many women adopted positive coping strategies like gratitude and optimism, which have been shown to improve wellbeing during COVID-19.²³

Balancing a career and family life requires flexible work hours, supportive families, and clear work boundaries.²⁴ Parenting responsibilities tend to affect women more than men, and institutional support is often insufficient, particularly for resident doctors.⁶ Similarly, studies from the USA showed that 21% of healthcare workers reported childcare-related stress, with slightly higher rates among women compared to men.²⁵

Healthcare workers frequently face emergencies such as pandemics and disasters. Therefore, it is important to develop leadership skills, interpersonal abilities, and positive coping strategies so they can respond effectively. During crises, there is little time to build these skills, so they should be strengthened in advance.²⁶ This is especially important because pandemics significantly impact the mental health of healthcare workers.¹ Women HCPs also supported their children’s early learning during the pandemic by using digital tools and creating learning environments at home. This increased the quality of time spent with their children.

CONCLUSION

Including perspectives from supervisors and family members could have provided deeper insights into parenting challenges faced by healthcare workers. Overall, this study shows that women HCPs faced multiple challenges in ensuring proper child development during the pandemic. They used both problem-focused and emotion-focused coping strategies to manage stress. These findings highlight the need for supportive workplace policies, better childcare support systems, and measures to promote emotional resilience among working mothers.

Funding: This study was supported by the JIPMER Intramural Research Fund

Conflict of interest: None declared

Ethical approval: The study was approved by the Post Graduate Research Monitoring Committee (PGRMC) and Institute of Ethics Committee (IEC), JIPMER, Puducherry, India

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