Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic

Abstract Background Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID19 pandemic, as defined by WHO Standards, are lacking. Methods Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures. Results 21,027 mothers were included in the analysis. Among those who experienced labour (N = 18,063), 41.8% (26.1%- 63.5%) experienced difficulties in accessing antenatal care, 62% (12.6%-99.0%) were not allowed a companion of choice, 31.1% (16.5%-56.9%) received inadequate breastfeeding support, 34.4% (5.2%-64.8%) reported that health workers were not always using protective personal equipment, and 31.8% (17.8%-53.1%) rated the health workers’ number as “insufficient”. Episiotomy was performed in 20.1% (6.1%-66.0%) of spontaneous vaginal births and fundal pressure applied in 41.2% (11.5% -100%) of instrumental vaginal births. In addition, 23.9% women felt they were not treated with dignity (12.8%-59.8%), 12.5% (7.0%-23.4%) suffered abuse, and 2.4% (0.1%-26.2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N = 2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significantly lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes. Conclusions Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed. Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

From 2020 the COVID-19 pandemic has deeply affected maternal and neonatal care. The implementation of governmental policy responses to limit the spread of the disease and the development of new hospital protocols have forced healthcare workers and women alike to adapt. The perception of the quality of hospital care by both groups has been at the core of the IMAgiNE EURO project, led by the WHO Collaborating Center for Maternal and Child Health (Trieste, IT). With a network of 18 countries and more than 40 institutions, this collaborative project has gathered so far data from more than 50 000 births and 5000 health workers, through two validated online surveys. It allows monitoring the quality of maternal and newborn care in four domains: the three domains of the WHO Standards for improving quality of maternal and newborn care in health facilities (namely provision of care, experience of care, and availability of human and essential physical resources) and the additional domain of key organisational changes related to the COVID-19 pandemic. Following multi-country analyses, and analyses at the regional and national level, the project findings show major gaps in the perceived quality of maternal and neonatal care in hospitals during the pandemic, as well as large variations in practices across different countries of the WHO European Region. In this workshop, Dr. Emanuelle Valente (WHO Collaborating Center for Maternal and Child Health, Trieste, IT) first introduces the methodological development of the project and the two validated data collection instruments. Dr. Marzia Lazzerini (WHO Collaborating Center for Maternal and Child Health, Trieste, IT) then presents the main results of the women's questionnaire for all countries. The focus will be on the Quality of Maternal and Newborn Care Index (QMNC Index) and how the different countries perform with regard to the four above-mentioned dimensions. Then, we carry on with two presentations focusing on specific topics relevant to maternity and newborn care. Dr. Ilana Chertock (College of Health Sciences and Professions, Ohio University, Athens, Ohio, USA) and Dr. Rada Artzi-Medvedik (Ben-Gurion University, Beersheva, Israel) will present findings on the factors influencing exclusive breastfeeding in healthcare facilities during the pandemic. Dr. Céline Miani (Institute of Public Health, Bielefeld University, Bielefeld, Germany) will discuss the topic of medicalisation, looking at the potential associations between individual and country-level factors and medicalisation of birth. We will conclude the workshop with a panel discussion on the implications of our research for policies and practice, and examples of the first steps already taken to bridge the gap between monitoring and implementation.

Key messages:
This workshop will present two new, validated tools to monitor the quality of maternal and newborn care in WHO European Region, from the perspective of the women and of the healthcare providers. It will also provide an overview of key findings so far, highlighting inequalities and gaps in the quality of maternal and neonatal care at hospital level in the WHO European Region. spontaneous vaginal births and fundal pressure applied in 41.2% (11.5% -100%) of instrumental vaginal births. In addition, 23.9% women felt they were not treated with dignity (12.8%-59.8%), 12.5% (7.0%-23.4%) suffered abuse, and 2.4% (0.1%-26.2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N = 2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significantly lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes.

Conclusions:
Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed. Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

Background:
Maternal experience of labour and delivery is multidimensional and is influenced by a variety of factors. Aim: to report maternal childbirth experience as described by the women themselves during the COVID-19 pandemic in Sweden using a WHO Standards-based tool adapted for an online survey (Quality of maternal and newborn care-QMNC). Methods: Women 18 years of age who gave birth from March 1, 2020 to June 30, 2021 were asked to give voluntary consent to participate in an online survey. The survey included 40 questions on four key domains: provision of care, experience of care, availability of human and physical resources and organisational changes due to COVID-19. Results: 5003 women were included in the analysis. Among those who underwent labour (n = 4528), 46.7% perceived a reduction in QMNC due to the COVID-19 pandemic, 50.7% were not allowed a companion of choice, 62.5% reported that health workers were not always using protective personal equipment and 36.5% rated the number of health workers as ''insufficient''. Fundal pressure was applied in 22.2% of instrumental vaginal births and 36.8% received inadequate breastfeeding support. In addition, 18.4% of women did not feel treated with dignity and 6.9% reported some form of abuse. In general, findings were significantly worse among women who did not undergo labour (n = 475).

Conclusions:
Swedish mothers' satisfaction of care provided during childbirth was strongly influenced by many variables. Actions to promote high-quality, evidence-based, patient-centered respectful care for all mothers and newborns are urgently needed.

Introduction:
According to the World Health Organization, the medicalisation of birth tends ''to undermine the woman's own capability to give birth and negatively impacts her childbirth experience''. The COVID-19 pandemic has disrupted maternity care, with potential increase in the medicalisation of birth and in occurrences of disrespectful maternity care. We aim to investigate potential associations between individual and country-level factors and medicalisation of birth in 15 European countries during the COVID-19 pandemic.

Methods:
We collected data through an online, anonymous survey for women who gave birth in 2020-2021. We ran multivariable, multi-level logistic regression models estimating associations between indicators of medicalisation (caesarean section (CS), instrumental vaginal birth (IVB), episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country-level. Results: Among 27173 women, 24.4% had a CS, and 8.8% an IVB. Among women with IVB, 41.9% reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalisation. For example, women who reported having CS, IVB and episiotomy reported not feeling treated with dignity more frequently than women who didn't have those interventions (respectively: OR: 1.37; OR: 1.61; OR: 1.51; all: p < 0.001). Country-level variables contributed to explaining some of the variance between countries.

Conclusions:
We recommend a greater emphasis in health policies on the promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor the medicalisation of reproductive care.