Zero separation: infant and family-centred developmental care in times of COVID-19

Ever since its initiation by the European Foundation
for the Care of Newborn Infants (EFCNI) more than
10 years ago, World Prematurity Day on November 17
has become a global movement to raise awareness for
preterm birth and its consequences. More than one in
ten babies are born preterm every year, and numbers
are still increasing worldwide. The immediate and long-
term health effects are severe; preterm birth is one of
the leading causes of neonatal death.1,2
World Prematurity Day 2021 highlights the specific
challenges that babies born too soon and their families
have been facing during the still ongoing COVID-19
pandemic. For almost 2 years now, societies and health
systems worldwide have been disrupted. Although the
focus has rightly been on managing the COVID-19 crisis
and its fallout, pandemic-related restrictions have also
affected quality of care, including the application of an
evidence-based infant and family-centred developmental
care approach. 3,4 Implemented restrictions have put
additional pressure on the already vulnerable group of
newborn babies and their families, with the full effect
of the long-term consequences yet to be seen.
In contrast to international agreements, such as the
2030 Development Agenda5 or the UN Convention on the
Rights of the Child,6 which underline the right to health
and the right of children to be close to their parents,
separation policies have been implemented in many
neonatal intensive care units (NICUs) across countries.
Although infection control measures were necessary to
manage the emergency situation, the pace and blanket
coverage of these measures applied also to parents of
vulnerable infants, with immediate implications for child
growth and development, and for the family as a whole.4,7,8
When the pandemic hit, we grew increasingly con -
cerned about the impact on the provision of care to
preterm babies, and sick and low birthweight infants
in NICUs. Parents having inadequate access to their child
had been voiced as a concern by several of the parent
organisations in our network. Under the umbrella of the
Global Alliance of Newborn Care (GLANCE), coordinated
by EFCNI, we formed an international and interdisciplinary
expert group, the EFCNI COVID-19 Zero Separation
Collaborative Group (appendix), to conduct a global
online survey of parents’ experiences with regard to the
disruptions on different elements of infant and family-
centred developmental care. Parents of newborn babies
receiving special or intensive care shared their experiences
regarding topics of prenatal care, parental access, infant
nutrition and breastfeeding, health communication,
and mental health. Overall, we collected responses from
more than 2100 participants in 56 countries. 4,9 The
results of the survey are alarming and have confirmed
anecdotal evidence shared by many parents in the EFCNI
and GLANCE network. More than 40% of all respondents
were not allowed to be accompanied by a support person
during prenatal appointments, and more than half even
reported that they were not permitted to have a support
person present during birth, leaving them without
any emotional, informational, and practical support.
Furthermore, presence with the newborn baby and skin-
to-skin care were heavily restricted in the respective
NICUs. One (21%) in five participants responded that
Published Online
November 16, 2021
https://doi.org/10.1016/
S2352-4642(21)00340-0
For more on World Prematurity
Day see https://www.efcni.org/
activities/campaigns/wpd/
See Online for appendix
staticnak1983/iStock
1,23,4564,7,84,9
Comment8 www.thelancet.com/child-adolescent Vol 6 January 2022
there was no parental access to the hospitalised newborn
baby. The differential treatment experienced by mothers
and their partners was astonishing—almost three quarters
of the participants indicated that the mother was allowed
to be present with the newborn baby in the NICU, but
only slightly more than half answered that the father
or partner was allowed access. Breastfeeding support
was mostly maintained according to the responses to
our survey, but less than one in five respondents still
answered that they were not encouraged to breastfeed.
In particular, communication between health-care pro -
fessionals and parents, health information, and mental
health support were largely inadequate during the first
year of the pandemic. One third of respondents were
lacking information on how to protect themselves and
their child from COVID-19 transmission during the
hospital stay and at discharge, and a large majority (75%)
were worried because of the COVID-19 situation during
pregnancy and after birth, adding additional stress in
an already challenging situation. Overall, the results
show country-specific differences, which also depend
on the extent of COVID-19 related restrictions (eg, social
distancing and lockdown).4,9
In view of the concerning nature of this feedback,
we call for policy-makers, public health experts and
health-care professionals to take immediate action to
achieve zero separation and infant and family-centred
developmental care.9 Although an increasing number
of neonatal units worldwide already adopt this care
approach, policies need to be developed to ensure
such care is maintained in emergency situations. A safe
environment and respectful and supportive care during
pregnancy, labour, and birth should be guaranteed,
and support people should be allowed during prenatal
appointments and birth. Every baby born too soon, too
small, or too sick should receive high-quality care in all
settings for the best start in life. Health providers should
value, include, and empower parents as key caregivers of
their newborns at all times. Hospitals should establish
zero separation and family-inclusive policies, and ensure
parental presence to enable immediate skin-to-skin
and Kangaroo Mother Care, and family–infant bonding.
Health providers should also prioritise breast milk and
encourage breastfeeding when possible, emphasising
the benefits of adequate infant nutrition for all newborn
babies. There should also be adequate provision of
health information and continuous and respectful
communication between health-care professionals and
parents. Parents and families in need should be offered
access to and receive mental health support.
Worldwide, a holistic approach to infant and family-
centred developmental care needs to be strengthened
urgently. This is even more important in times of crisis,
in which restrictions are quickly implemented. The
reports from our networks strengthen our position as
we continue to advocate for a zero-separation policy
of infants from their parents and caregivers. Infant and
family-centred developmental care must be reinstalled
where it was discontinued, it must be promoted where
it was questioned, and it must be protected where it was
restricted. Zero separation must be realised to give all
newborn babies the best possible start in life.
SM is the co-founder and chairwoman of the European Foundation for the Care
of Newborn Infants (EFCNI). The survey has been independently conducted by
the members of the EFCNI COVID-19 Zero Separation Collaborative Group,
in cooperation with representatives of national parent organisations and the
professional healthcare societies: Council of International Neonatal Nurses,
European Society for Paediatric Research, Newborn Individualized
Developmental Care and Assessment Program, and Union of European Neonatal
& Perinatal Societies. EFCNI has received an earmarked donation by Novartis
Pharma AG in support of this project. A full list of the EFCNI COVID-19 Zero
Separation Collaborative Group members is in the appendix.
Johanna Kostenzer, Luc J I Zimmermann, *Silke Mader,
on behalf of the EFCNI COVID-19 Zero Separation
Collaborative Group
[email protected]
European Foundation for the Care of Newborn Infants, 81379 Munich, Germany
(JK, LJIZ, SM)
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action report on preterm birth. 2012. www.who.int/pmnch/media/
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2 WHO. Preterm birth. 2018. www.who.int/news-room/fact-sheets/detail/
preterm-birth (accessed Oct 29, 2021).
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2021; 6: e004347.
4 Kostenzer J, Hoffmann J, von Rosenstiel-Pulver C, et al. Neonatal care
during the COVID-19 pandemic – a global survey of parents’ experiences
regarding infant and family-centred developmental care. EClinicalMedicine
2021; 39: 101056.
5 UN General Assembly. Transforming our world: the 2030 agenda for
sustainable development. 2015. https://sdgs.un.org/2030agenda
(accessed Oct 29, 2021).
6 UN Commission on Human Rights. Convention on the Rights of the Child.
1990. https://www.ohchr.org/Documents/ProfessionalInterest/crc.pdf
(accessed Oct 29, 2021).
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8 van Veenendaal NR, Deierl A, Bacchini F, O’Brien K, Franck LS,
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9 EFCNI, Kostenzer J, von Rosenstiel-Pulver C, et al. Zero separation. Together
for better care! Infant and family-centred developmental care in times of
COVID-19—A global survey of parents’ experiences project report. 2021.
https://www.glance-network.org/covid-19/survey (accessed Nov 11, 2021)