Brazilian Physicians Mental Health: A Cross-Sectional Nationwide Study exploring factors associated with prevalence of suicide planning and attempts

OBJECTIVES

To report suicide planning and attempts' in a lifetime among Brazilian physicians and to explore associated risk factors.

METHODS

A nation-wide, online survey based on the Tool for the Assessment of Suicide Risk and Satisfaction with Life Scale was conducted among Brazilian physicians (January 2018 - January 2019). Multivariate explored associations of demographics, psychological, and work-related factors on suicide planning and attempts reports.

RESULTS

Among 4,148 respondents, 1,946 (53.5%) were male, 2,527 (60.9%) were 30-60 years old, 2,675 (64.5%) had 2-4 work-contracts and 1,725 (41.6%) reported a weekly workload of 40-60 hours. Overall prevalence of suicide plans was 8.8% (n=364) and suicide attempts were reported by 3.2% (n=133) of respondents. Daily (AdjOR=7.857;95%CI 2.282-27.051, p=0.002) or weekly emotional exhaustion (AdjOR=7.953; 95%CI 2.403-26.324, p=0.001), daily frustration with work (AdjOR=3.093;95%CI 1.711-5.588, p<0.001), and being bisexual (AdjOR=5.083;95%CI 2.544-10.158, p<0.001) were significantly associated with higher odds of reports. Among extremely dissatisfied professionals 38.3% reported having made suicide planning and attempts, while among extremely satisfied only 2.8% reported it (p<0.001).

CONCLUSIONS

Brazilian physicians with a lifetime history of suicide planning and attempts presented a higher association with emotional exhaustion and frustration with work. Urgent actions are needed to promote professional protection policies and resilience.

Measuring Knowledge of Healthcare Providers on Pediatric Palliative Care with an Online Questionnaire Based on the National Core Curriculum in Italy

There is a lack of highly reliable tools evaluating healthcare professionals' competences on Pediatric Palliative Care (PPC) and Pain Therapy (PT). The aim of this study is to document the development of an online questionnaire to assess Perceived, Wished and Actual Knowledge of healthcare workers on PPC/PT. The tool was built on the basis of the Italian Society for Palliative Care PPC Core Curriculum (CC) for physicians, nurses and psychologists. Face validity, internal consistency and the underlying structure were evaluated after a field testing in a referral hospital, Friuli-Venezia Giulia, Italy. One hundred five respondents completed the questionnaire. High internal consistency for both scales of Perceived and Wished Knowledge was found (α = 0.95 and α = 0.94, respectively). Psychologists reported higher levels of self-Perceived skills on the psychosocial needs of the child and family at the end of life (p = 0.006), mourning (p = 0.003) and ethics and deontology in PT/PC (p = 0.049). Moreover, when Actual Knowledge was tested, they also provided the highest number of correct answers (p = 0.022). No differences were found by profession for Wished Knowledge. The questionnaire showed promising psychometric properties. Our findings suggest the need of continuous training in this field and identify contents to be addressed in future training programs.

Factors associated with exclusive breastfeeding in Israel during the COVID-19 pandemic: a subset of the IMAgiNE EURO cross-sectional study

BACKGROUND

Evidence has shown that restrictions during the COVID-19 pandemic have negatively affected breastfeeding support and outcomes in hospitals in many countries. The aims of the study were to describe exclusive breastfeeding rates and identify factors associated with exclusive breastfeeding at hospital discharge among women who gave birth during the COVID-19 pandemic in Israel.

METHODS

A cross-sectional online anonymous survey based on WHO standards for improving quality of maternal and newborn care in health facilities was conducted among a sample of women who gave birth to a healthy singleton infant in Israel during the pandemic (between March 2020 and April 2022). The socio-ecological approach was employed to examine intrapersonal, interpersonal, organizational, and community/society factors associated with exclusive breastfeeding at hospital discharge according to women perspectives.

RESULTS

Among the 235 Israeli participants, 68.1% exclusively breastfed, 27.7% partially breastfed, and 4.2% did not breastfeed at discharge. Results of the adjusted logistic regression model showed that factors significantly associated with exclusive breastfeeding were the intrapersonal factor of multiparity (adjusted OR 2.09; 95% Confidence Interval 1.01,4.35) and the organizational factors of early breastfeeding in the first hour (aOR 2.17; 95% CI 1.06,4.45), and rooming-in (aOR 2.68; 95% CI 1.41,5.07).

CONCLUSIONS

Facilitating early breastfeeding initiation and supporting rooming-in are critical to promoting exclusive breastfeeding. These factors, reflecting hospital policies and practices, along with parity, are significantly associated with breastfeeding outcomes and highlight the influential role of the maternity environment during the COVID-19 pandemic. Maternity care in hospitals should follow evidence-based breastfeeding recommendations also during the pandemic, promoting early exclusive breastfeeding and rooming-in among all women, with particular attention to providing lactation support to primiparous women.

TRIAL REGISTRATION

Clinical Trials NCT04847336.

Women's suggestions on how to improve the quality of maternal and newborn care during the COVID-19 pandemic in Italy: A co-occurrence network analysis

Background

Recent evidence revealed significant gaps in the quality of maternal and newborn care in the World Health Organization (WHO) European Region (EUR) countries. Collecting and analyzing women's views on their needs and priorities is crucial for developing actions to improve the quality of maternal and newborn care. With this study from the IMAgiNE EURO Project, we aimed to add to previous quantitative studies by analysing emerging themes from women's suggestions on how to improve the quality of maternal and newborn care during facility-based birth in Italy during the COVID-19 pandemic.

Methods

We collected data from mothers giving birth during the coronavirus 2019 (COVID-19) pandemic using a validated online anonymous WHO standard-based questionnaire consisting of open-ended questions. Using a word co-occurrence network (WCON), we analysed responses in Italian from women who gave birth between March 2020 and March 2022. This approach entails a graphical representation of word pairings that frequently co-occur across sentences and compose clusters.

Results

The texts, produced by 2010 women participating in the study, consisted of 79 204 words and 3833 sentences. Eight clusters emerged with WCON, the three largest of which were related to companionship during childbirth, breastfeeding support, and physical resources. The term "swab", associated with other terms in the COVID-19 domain, had the highest degree of centrality, thus representing a core topic.

Conclusions

The key emerging themes from women's suggestions can be used to shape policies to improve the quality of care for mothers and newborns. Our WCON analysis offers a valid approach to quickly screen large textual data on quality of care, providing a first set of major themes identified by clusters. As such, it could be used to improve documentation of service users' suggestions promoting the engagement of both researchers and policymakers.

Registration

ClinicalTrials.gov: NCT04847336.

Women's experiences and views on early breastfeeding during the COVID-19 pandemic in Norway: quantitative and qualitative findings from the IMAgiNE EURO study

BACKGROUND

Little is known about women's experience of care and views on early breastfeeding during the COVID-19 pandemic in Norway.

METHODS

Women (n = 2922) who gave birth in a facility in Norway between March 2020 and June 2021 were invited to answer an online questionnaire based on World Health Organization (WHO) Standard-based quality measures, exploring their experiences of care and views on early breastfeeding during the COVID-19 pandemic. To examine associations between year of birth (2020, 2021) and early breastfeeding-related factors, we estimated odds ratios (ORs) with 95% confidence intervals (CIs) using multiple logistic regression. Qualitative data were analysed using Systematic Text Condensation.

RESULTS

Compared to the first year of the pandemic (2020), women who gave birth in 2021 reported higher odds of experiencing adequate breastfeeding support (adjOR 1.79; 95% CI 1.35, 2.38), immediate attention from healthcare providers when needed (adjOR 1.89; 95% CI 1.49, 2.39), clear communication from healthcare providers (adjOR 1.76; 95% CI 1.39, 2.22), being allowed companion of choice (adjOR 1.47; 95% CI 1.21, 1.79), adequate visiting hours for partner (adjOR 1.35; 95% CI 1.09, 1.68), adequate number of healthcare providers (adjOR 1.24; 95% CI 1.02, 1.52), and adequate professionalism of the healthcare providers (adjOR 1.65; 95% CI 1.32, 2.08). Compared to 2020, in 2021 we found no difference in skin-to-skin contact, early breastfeeding, exclusive breastfeeding at discharge, adequate number of women per room, or women's satisfaction. In their comments, women described understaffed postnatal wards, early discharge and highlighted the importance of breastfeeding support, and concerns about long-term consequences such as postpartum depression.

CONCLUSIONS

In the second year of the pandemic, WHO Standard-based quality measures related to breastfeeding improved for women giving birth in Norway compared to the first year of the pandemic. Women's general satisfaction with care during COVID-19 did however not improve significantly from 2020 to 2021. Compared to pre-pandemic data, our findings suggest an initial decrease in exclusive breastfeeding at discharge during the COVID-19 pandemic in Norway with little difference comparing 2020 versus 2021. Our findings should alert researchers, policy makers and clinicians in postnatal care services to improve future practices.

[Violated birth integrity during the COVID-19 pandemic in Germany: experiences of women with maternity care]

INTRODUCTION

The COVID-19 pandemic may increase women's vulnerability through violations of their integrity during birth. In a cross-sectional study (March 2020 to March 2022), we investigated how women giving birth experienced maternity care during the pandemic in Germany and which factors were associated with their birth integrity.

METHODS

In a survey (validated questionnaire and two open-ended questions), women ≥ 18 years described their experiences of maternity care. We conducted quantitative analyses using descriptive statistics and logistic regressions to investigate factors associated with dignified care and emotional support, which are understood as proxies of birth integrity. We analysed the open-ended questions through inductive content analysis.

RESULTS

We included data from 1271 participants and 214 comments. The majority of respondents felt emotionally supported (71%) and treated with dignity (76%). One third reported not always being involved in decision-making, while 14% felt they were subjected to physical, verbal or emotional abuse. For 57% of women, their companion of choice was absent or their presence limited. Those factors were all associated with the chances of feeling treated with dignity and emotionally supported. The qualitative comments provided an insight into what specifically women perceive as violating their integrity.

DISCUSSION

During the COVID-19 pandemic, the vulnerability of parturients lies in the violation of their birth integrity. Measures to promote respectful maternity care of women who give birth include comprehensive structural and political solutions as well as further research on the determinants of birth integrity.

Factors associated with exclusive breastfeeding at discharge during the COVID-19 pandemic in 17 WHO European Region countries

BACKGROUND

Exclusive breastfeeding is the optimal infant nutrition, providing infants immunoprotection against many diseases including SARS-CoV-2 infection. Restrictions during the COVID-19 pandemic may have negatively affected breastfeeding practices in maternity care facilities. The aims of the study were to examine exclusive breastfeeding rates at discharge over time and to identify factors associated with exclusive breastfeeding during the pandemic.

METHODS

A cross-sectional survey was conducted among mothers who gave birth in a maternity care facility in the World Health Organization (WHO) European Region countries during the COVID-19 pandemic. The socio-ecological model was employed to examine intrapersonal, interpersonal, organizational, and community/society factors associated with maternal report of exclusive breastfeeding at the time of discharge.

RESULTS

There were 26,709 participating mothers from 17 European Region countries who were included in the analysis. Among the mothers, 72.4% (n = 19,350) exclusively breastfed and 27.6% (n = 7,359) did not exclusively breastfeed at discharge. There was an overall decline in exclusive breastfeeding rates over time (p = 0.015) with a significantly lower rate following the publication of the WHO breastfeeding guidelines on 23 June 2020 (AOR 0.88; 95% CI 0.82, 0.94). Factors significantly associated with exclusive breastfeeding outcomes in the logistic regression analysis included maternal age, parity, education, health insurance, mode of birth, inadequate breastfeeding support, lack of early breastfeeding initiation, lack of full rooming-in, birth attendant, perceived healthcare professionalism and attention, facility room cleanliness, timing of birth, and location of birth.

CONCLUSIONS

Results from the study indicate the decline in exclusive breastfeeding rates in the WHO European Region during the COVID-19 pandemic. Using the socio-ecological model to identify factors associated with breastfeeding outcomes facilitates an integrated and holistic approach to address breastfeeding needs among women across the region. These findings demonstrate the need to augment breastfeeding support and to protect exclusive breastfeeding among mother-infant dyads, in an effort to reverse the declining exclusive breastfeeding rates. The study highlights the need to educate mothers and their families about the importance of exclusive breastfeeding, reduce maternal-infant separation, increase professional breastfeeding support, and follow evidence-based practice guidelines to promote breastfeeding in a comprehensive and multi-level manner.

TRIAL REGISTRATION NUMBER

Clinical Trials NCT04847336.

Quality of health care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Norway and trends over time

OBJECTIVE

To describe maternal perception of the quality of maternal and newborn care (QMNC) in facilities in Norway during the first year of COVID-19 pandemic.

METHODS

Women who gave birth in a Norwegian facility from March 1, 2020, to October 28, 2021, filled out a structured online questionnaire based on 40 WHO standards-based quality measures. Quantile regression analysis was performed to assess changes in QMNC index over time.

RESULTS

Among 3326 women included, 3085 experienced labor. Of those, 1799 (58.3%) reported that their partner could not be present as much as needed, 918 (29.8%) noted inadequate staff numbers, 183 (43.6%) lacked a consent request for instrumental vaginal birth (IVB), 1067 (34.6%) reported inadequate communication from staff, 78 (18.6%) reported fundal pressure during IVB, 670 (21.7%) reported that they were not treated with dignity, and 249 (8.1%) reported experiencing abuse. The QMNC index increased gradually over time (3.68 points per month, 95% CI, 2.83-4.53 for the median), with the domains of COVID-19 reorganizational changes and experience of care displaying the greatest increases, while provision of care was stable over time.

CONCLUSION

Although several measures showed high QMNC in Norway during the first year of the COVID-19 pandemic, and a gradual improvement over time, several findings suggest that gaps in QMNC exist. These gaps should be addressed and monitored.

Quality of maternal and newborn care around the time of childbirth for migrant versus nonmigrant women during the COVID-19 pandemic: Results of the IMAgiNE EURO study in 11 countries of the WHO European region

OBJECTIVE

To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe.

METHODS

Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women.

RESULTS

Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P = 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P = 0.001), lack of timely care (14.7% vs 13.0%; P = 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P = 0.004), inadequate number of women per room (9.4% vs 8.6%; P = 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P = 0.011), or suffering abuse (14.5% vs 12.7%; P = 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P = 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P = 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women.

CONCLUSION

Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all.

Women's perspectives on the quality of hospital maternal and newborn care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina

OBJECTIVE

To assess the quality of maternal and newborn care (QMNC) in countries of the former Yugoslavia.

METHOD

Women giving birth in a facility in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina between March 1, 2020 and July 1, 2021 answered an online questionnaire including 40 WHO standards-based quality measures.

RESULTS

A total of 4817 women were included in the analysis. Significant differences were observed across countries. Among those experiencing labor, 47.4%-62.3% of women perceived a reduction in QMNC due to the COVID-19 pandemic, 40.1%-69.7% experienced difficulties in accessing routine antenatal care, 60.3%-98.1% were not allowed a companion of choice, 17.4%-39.2% reported that health workers were not always using personal protective equipment, and 21.2%-53.8% rated the number of health workers as insufficient. Episiotomy was performed in 30.9%-62.8% of spontaneous vaginal births. Additionally, 22.6%-55.9% of women received inadequate breastfeeding support, 21.5%-62.8% reported not being treated with dignity, 11.0%-30.5% suffered abuse, and 0.7%-26.5% made informal payments. Multivariate analyses confirmed significant differences among countries, with Slovenia showing the highest QMNC index, followed by Croatia, Bosnia-Herzegovina, and Serbia.

CONCLUSION

Differences in QMNC among the countries of the former Yugoslavia during the COVID-19 pandemic were significant. Activities to promote high-quality, evidence-based, respectful care for all mothers and newborns are urgently needed.

CLINICALTRIALS

gov Identifier: NCT04847336.

Rates of instrumental vaginal birth and cesarean and quality of maternal and newborn health care in private versus public facilities: Results of the IMAgiNE EURO study in 16 countries

OBJECTIVE

To explore the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic by facility type among 16 European countries, comparing rates of instrumental vaginal birth and cesarean.

METHODS

Women who gave birth in the WHO European Region from March 1, 2020, to February 7, 2022, answered a validated online questionnaire. Rates of instrumental birth, instrumental vaginal birth, and cesarean, and a QMNC index were calculated for births in public versus private facilities.

RESULTS

Responses from 25 206 participants were analyzed. Women giving birth in private compared with public facilities reported significantly more frequent total cesarean (32.5% vs 19.0%; aOR 1.70; 95% CI 1.52-1.90), elective cesarean (17.3% vs 7.8%; aOR 1.90; 95% CI 1.65-2.19), and emergency cesarean before labor (7.4% vs 3.9%; aOR 1.39; 95% CI 1.14-1.70) (P < 0.001 for all comparisons), with analyses by country confirming these results. QMNC index results were heterogeneous across countries and regions in the same country and were largely affected by geographical distribution of regions rather than by type of facility alone.

CONCLUSION

The study confirms that births in private facilities have higher odds of cesarean. It also suggests that QMNC should be closely monitored in all facilities to achieve high-quality care, independent of facility type or geographical distribution.

CLINICALTRIALS

GOV IDENTIFIER

NCT04847336.

Women's perspectives on the quality of maternal and newborn care in childbirth during the COVID-19 pandemic in Latvia: Results from the IMAgiNE EURO study on 40 WHO standards-based quality measures

OBJECTIVE

To investigate women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth during the COVID-19 pandemic in Latvia, comparing the years 2020 and 2021, among women who went into labor or had a prelabor cesarean.

METHODS

Women giving birth in healthcare facilities in Latvia from March 1, 2020, to October 28, 2021, answered an online questionnaire including 40 WHO standards-based quality measures. Descriptive and multivariate quantile regression analyses were performed to compare QMNC in 2020 and 2021.

RESULTS

2079 women were included in the analysis: 1860 women who went into labor (group 1) and 219 with prelabor cesarean (group 2). Among group 1, 66.4% (n = 99/149) of women received fundal pressure in an instrumental vaginal birth, 43.5% (n = 810) lacked involvement in choices, 17.4% (n = 317) reported suffering abuse, 32.7% (n = 609) reported inadequate breastfeeding support while 5.2% (n = 96) lack of early breastfeeding. A significant reduction in QMNC due to the COVID-19 pandemic was reported by 29.5% (n = 219) and 25.0% (n = 270) of respondents in 2020 and 2021, respectively (P = 0.045). Multivariate analyses highlighted a significantly lower QMNC index for 2020 compared with 2021 (P < 0.001).

CONCLUSION

This first study investigating QMNC in Latvia showed significant gaps in QMNC perceived by respondents, with slightly better results in 2021. Appropriate healthcare strategies to improve health care for women and newborns in Latvia are required.

CLINICALTRIALS

gov Identifier:NCT04847336.

Quality of maternal and newborn care in Switzerland during the COVID-19 pandemic: A cross-sectional study based on WHO quality standards

OBJECTIVE

To explore quality of maternal and newborn care (QMNC) in healthcare facilities during the COVID-19 pandemic in Switzerland.

METHODS

Women giving birth in Switzerland answered a validated online questionnaire including 40 WHO standards-based quality measures. QMNC score was calculated according to linguistic region and mode of birth. Differences were assessed using logistic regression analysis adjusting for relevant variables.

RESULTS

A total of 1175 women were included in the analysis. Limitations in QMNC during the pandemic were reported by 328 (27.9%) women. Several quality measures, such as deficient communication (18.0%, n = 212), insufficient number of healthcare professionals (19.7%, n = 231), no information on the newborn after cesarean (26.5%, n = 91) or maternal and newborn danger signs (34.1%, n = 401 and 41.4% n = 487, respectively) suggested preventable gaps in QMNC. Quality measures significantly differed by linguistic region and mode of birth. Multivariate analysis established a significantly lower QMNC for women in French- and Italian-speaking regions compared with the German-speaking region. Moreover, in several quality indicators reflecting communication with healthcare providers, women who did not answer the questionnaire in one of the Swiss national languages had significantly worse scores than others. A significant lower QMNC was also found for young and primiparous women and for those who experienced cesarean or instrumental vaginal birth.

CONCLUSION

Women giving birth in Switzerland during the pandemic reported notable gaps in QMNC. Providers should be attuned to women who are younger, primiparous, and those who had an emergency cesarean or instrumental vaginal birth given the lower QMNC reported by these groups. Women who did not respond in a Swiss national language may need improved communication strategies.

Women's assessment of the quality of hospital-based perinatal care by mode of birth in Romania during the COVID-19 pandemic: Results from the IMAgiNE EURO study

OBJECTIVE

To assess women's perceptions of the quality of maternal and newborn care (QMNC) received in hospitals in Romania during the COVID-19 pandemic by mode of birth.

METHODS

A validated anonymous online questionnaire based on WHO quality measures. Subgroup analysis of spontaneous vaginal birth (SVB), emergency cesarean, and elective cesarean and multivariate analyses were performed, and QMNC indexes were calculated. Maternal age, educational level, year of birth, mother born in Romania, parity, type of hospital, and type of professionals assisting the birth were used for multivariate analysis.

RESULTS

A total of 620 women completed the survey. Overall, several quality measures suggested gaps in QMNC in Romania, with the lowest QMNC indexes reported for provision of care and availability of resources. Women who had either elective or emergency cesarean compared with those who had SVB more frequently lacked early breastfeeding (OR 2.04 and 2.13, respectively), skin-to-skin contact (OR 1.73 and 1.75, respectively), rooming-in (OR 2.07 and 1.96, respectively), and exclusive breastfeeding at discharge (OR 2.27 and 1.64, respectively). Compared with elective cesarean, emergency cesarean had higher odds of ineffective communication by healthcare providers (OR 1.65), lack of involvement in choices (OR 1.58), insufficient emotional support (OR 2.07), and no privacy (OR 2.06). Compared with other modes of birth, a trend for lower QMNC indexes for emergency cesarean was observed for all domains, while for elective cesarean the QMNC index for provision of care was significantly lower.

CONCLUSION

Quality indicators of perinatal care remain behind targets in Romania, with births by cesarean the most affected.

CLINICALTRIALS

GOV IDENTIFIER

NCT04847336.

Regional differences in the quality of maternal and neonatal care during the COVID-19 pandemic in Portugal: Results from the IMAgiNE EURO study

OBJECTIVE

To compare women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth across Nomenclature of Territorial Units for Statistics 2 (NUTS-II) regions in Portugal during the COVID-19 pandemic.

METHODS

Women participating in the cross-sectional IMAgiNE EURO study who gave birth in Portugal from March 1, 2020, to October 28, 2021, completed a structured questionnaire with 40 key WHO standards-based quality measures. Four domains of QMNC were assessed: (1) provision of care; (2) experience of care; (3) availability of human and physical resources; and (4) reorganizational changes due to the COVID-19 pandemic. Frequencies for each quality measure within each QMNC domain were computed overall and by region.

RESULTS

Out of 1845 participants, one-third (33.7%) had a cesarean. Examples of high-quality care included: low frequencies of lack of early breastfeeding and rooming-in (8.0% and 7.7%, respectively) and informal payment (0.7%); adequate staff professionalism (94.6%); adequate room comfort and equipment (95.2%). However, substandard practices with large heterogeneity across regions were also reported. Among women who experienced labor, the percentage of instrumental vaginal births ranged from 22.3% in the Algarve to 33.5% in Center; among these, fundal pressure ranged from 34.8% in Lisbon to 66.7% in Center. Episiotomy was performed in 39.3% of noninstrumental vaginal births with variations between 31.8% in the North to 59.8% in Center. One in four women reported inadequate breastfeeding support (26.1%, ranging from 19.4% in Algarve to 31.5% in Lisbon). One in five reported no exclusive breastfeeding at discharge (22.1%; 19.5% in Lisbon to 28.2% in Algarve).

CONCLUSION

Urgent actions are needed to harmonize QMNC and reduce inequities across regions in Portugal.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, 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 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on 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 medicalization of reproductive care.

Quality of maternal and newborn care around the time of childbirth in Luxembourg during the COVID-19 pandemic: Results of the IMAgiNE EURO study

OBJECTIVE

To investigate the quality of maternal and newborn care (QMNC) during childbirth in Luxembourg from women's perspectives.

METHODS

Women giving birth in facilities in Luxembourg between March 1, 2020, and July 1, 2021, answered a validated online WHO standards-based questionnaire as part of the multicountry IMAgINE EURO study. Descriptive and multivariate quantile regression analyses were performed.

RESULTS

A total of 493 women were included, representing 5.2% of women giving birth in the four maternity hospitals in Luxembourg during the study period. Most quality measures suggested high QMNC, although specific gaps were observed: 13.4% (n = 66) of women reported not being treated with dignity, 9.1% (n = 45) experienced abuse, 42.9% (n = 30) were not asked for consent prior to instrumental vaginal birth, 39.3% (n = 118) could not choose their birth position, 27% (n = 133) did not exclusively breastfeed at discharge (without significant differences over time), 20.5% (n = 101) reported an insufficient number of healthcare professionals, 20% (n = 25) did not receive information on the newborn after cesarean, and 41.2% (n = 203) reported lack of information on newborn danger signs before discharge. Multivariate analyses highlighted higher reported QMNC indexes among women born outside Luxembourg and delivering with a gynecologist, and significantly lower QMNC indexes in women with the highest education levels and those delivering in the hospital offering some private services.

CONCLUSIONS

Despite maternal reports suggesting an overall high QMNC in Luxembourg, improvements are needed in specific aspects of care and communication, mostly related to maternal autonomy, respect, and support, but also number and competencies of the health workforce.

Outcomes of induction versus spontaneous onset of labour at 40 and 41 GW: findings from a prospective database, Sri Lanka

Objectives

The World Health Organization recommends induction of labour (IOL) for low risk pregnancy from 41 + 0 gestational weeks (GW). Nevertheless, in Sri Lanka IOL at 40 GW is a common practice. This study compares maternal/newborn outcomes after IOL at 40 GW (IOL40) or 41 GW (IOL41) versus spontaneous onset of labour (SOL).

Methods

Data were extracted from the routine prospective individual patient database of the Soysa Teaching Hospital for Women, Colombo. IOL and SOL groups were compared using logistic regression.

Results

Of 13,670 deliveries, 2359 (17.4%) were singleton and low risk at 40 or 41 GW. Of these, 456 (19.3%) women underwent IOL40, 318 (13.5%) IOL41, and 1585 (67.2%) SOL. Both IOL40 and IOL41 were associated with an increased risk of any maternal/newborn negative outcomes (OR = 2.21, 95%CI = 1.75–2.77, p < 0.001 and OR = 1.91, 95%CI = 1.47–2.48, p < 0.001 respectively), maternal complications (OR = 2.18, 95%CI = 1.71–2.77, p < 0.001 and OR = 2.34, 95%CI = 1.78–3.07, p < 0.001 respectively) and caesarean section (OR = 2.75, 95%CI = 2.07–3.65, p < 0.001 and OR = 3.01, 95%CI = 2.21–4.12, p < 0.001 respectively). Results did not change in secondary and sensitivity analyses.

Conclusions

Both IOL groups were associated with higher risk of negative outcomes compared to SOL. Findings, potentially explained by selection bias, local IOL protocols and CS practices, are valuable for Sri Lanka, particularly given contradictory findings from other settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04800-1.

Quality of Informed Consent Practices around the Time of Childbirth: A Cross-Sectional Study in Italy

Background: Few studies have explored consent request practices during childbirth. Objective: We explored consent request practices during childbirth in a referral hospital and research centre in Italy, capturing both women and health workers’ perspectives. Methods: Data were collected using self-administrated questionnaires between December 2016 and September 2018. Nine key maternal and newborn procedures were analysed. Associations between consent requests and women characteristics were explored by multiple logistic regression. Results: Among 1244 women, the rate of consent requests varied widely, with caesarean section (CS) showing the highest rate (89.1%) and neonatal conjunctivitis prophylaxis presenting the lowest rate (11.4%). Information provided on “risks/benefits” and “reasons” for procedures by health staff was most often not comprehensive for procedures of interest (range 18.6–87.4%). The lack of informed consent is not specifically linked to any pattern of women characteristics. According to 105 health workers, adequate protocols and standard forms for consent requests were available in 67.6% and 78.1% of cases, respectively, while less than one third (31.4%) reported having received adequate training and supportive supervision on how to deliver informed consent. Conclusions: Study findings align with previous evidence showing that consent request practices during childbirth need to be largely improved. More research is needed to investigate effective strategies for improvement.

WHO Standards-based questionnaire to measure health workers' perspective on the quality of care around the time of childbirth in the WHO European region: development and mixed-methods validation in six countries

OBJECTIVES

Develop and validate a WHO Standards-based online questionnaire to measure the quality of maternal and newborn care (QMNC) around the time of childbirth from the health workers' perspective.

DESIGN

Mixed-methods study.

SETTING

Six countries of the WHO European Region.

PARTICIPANTS AND METHODS

The questionnaire is based on lessons learnt in previous studies, and was developed in three sequential phases: (1) WHO Quality Measures were prioritised and content, construct and face validity were assessed through a Delphi involving a multidisciplinary board of experts from 11 countries of the WHO European Region; (2) translation/back translation of the English version was conducted following The Professional Society for Health Economics and Outcomes Research guidelines; (3) internal consistency, intrarater reliability and acceptability were assessed among 600 health workers in six countries.

RESULTS

The questionnaire included 40 items based on WHO Standards Quality Measures, equally divided into four domains: provision of care, experience of care, availability of human and physical resources, organisational changes due to COVID-19; and its organised in six sections. It was translated/back translated in 12 languages: Bosnian, Croatian, French, German, Italian, Norwegian, Portuguese, Romanian, Russian, Slovenian, Spanish and Swedish. The Cronbach's alpha values were ≥0.70 for each questionnaire section where questions were hypothesised to be interrelated, indicating good internal consistence. Cohen K or Gwet's AC1 values were ≥0.60, suggesting good intrarater reliability, except for one question. Acceptability was good with only 1.70% of health workers requesting minimal changes in question wording.

CONCLUSIONS

Findings suggest that the questionnaire has good content, construct, face validity, internal consistency, intrarater reliability and acceptability in six countries of the WHO European Region. Future studies may further explore the questionnaire's use in other countries, and how to translate evidence generated by this tool into policies to improve the QMNC.

TRAIL REGISTRATION NUMBER

NCT04847336.

WHO standards-based tool to measure women's views on the quality of care around the time of childbirth at facility level in the WHO European region: development and validation in Italy

OBJECTIVES

A comprehensive WHO standards-based tool to measure women's perceived quality of maternal and newborn care (QMNC) in health facilities is needed to allow for comparisons of data across settings and over time. This paper describes the development of such a tool, and its validation in Italy.

DESIGN

A multiphase, mixed-methods study involving qualitative and quantitative research methods.

SETTING

Nine health facilities in Italy.

METHODS

The questionnaire was developed in six phases: (1) Defining the scope, characteristics and a potential list of measures for the tool; (2) initial content and construct validation; (3) first field testing to assess acceptability and perceived utility for end-users (1244 women, 35 decision makers) and further explore construct validity; (4) content optimisation and score development; (5) assessment of face validity, intrarater reliability and internal consistency and (6) second field testing in nine maternity hospitals (4295 women, 78 decision-makers).

RESULTS

The final version of the tool included 116 questions accounting for 99 out of the 350 of the extended lists of WHO Quality Measures. Observed face validity was very good, with 100% agreement for 101 (87%) questions and Kappa exceeding 0.60 for remaining ones. Reliability was good, with either high agreement or Kappa exceeding 0.60 for all items. Cronbach alpha values ranged from 0.84 to 0.88, indicating very good internal consistency. Acceptability across seven hospitals was good (mean response rate: 57.4%, 95% CI 44.4% to 70.5%). The questionnaire proved to be useful, driving the development of actions plan to improve the QMNC in each facility.

CONCLUSIONS

Study findings suggest that the tool has good content, construct, face validity, intrarater reliability and internal consistency, while being acceptable and useful. Therefore, it could be used in health facilities in Italy and similar context. More research should investigate how effectively use the tool in different countries for improving the QMNC.

Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic: online survey investigating maternal perspectives in 12 countries of the WHO European Region

BACKGROUND

Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID-19 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.

FINDINGS

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 significant 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.

INTERPRETATION

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.

STUDY REGISTRATION

ClinicalTrials.gov Identifier: NCT04847336.

Quality of care at childbirth: findings of IMAgiNE EURO in Italy during the first year of the COVID‐19 pandemic

Objective

Investigate the quality of maternal and newborn care (QMNC) during childbirth in the first year of COVID‐19 pandemic in Italy, from the mothers' perspective, as key service users.

Methods

Women who gave birth in an Italian facility from March 1, 2020 to February 29, 2021 answered an online questionnaire including 40 WHO Standard‐based Quality Measures. Descriptive and multivariate quantile regression analyses were performed.

Results

In total, 4824 women were included, reporting heterogeneity of practices across regions: among 3981 women who underwent labour 78.4% (63.0%–92.0%) were not allowed a companion of choice, 44.6% (28.9%–53.3%) had difficulties in attending routine antenatal visits, 36.3% (24.9%–61.1%) reported inadequate breastfeeding support, 39.2% (23.3%–62.2%) felt not involved in medical choices, 33.0% (23.9%–49.3%) experienced unclear communication from staff, 24.8% (15.9%–39.4%) were not always treated with dignity and 12.7% (10.1%–29.3%) reported abuses. Findings in the group of women who did not experience labour were substantially similar. Multivariate analyses confirmed a significant lower QMNC index for regions in southern Italy compared to North and Central regions.

Conclusion

Mothers reported substantial inequities in the QMNC across Italian regions. Future studies should monitor QMNC over time. Meanwhile, actions to ensure high QMNC for all mothers and newborns across Italy are urgently required.

Mothers giving birth in the first year of the COVID‐19 pandemic reported substantial inequities across Italian regions in the QMNC around the time of childbirth.

Large gaps in the quality of healthcare experienced by Swedish mothers during the COVID-19 pandemic: a cross-sectional study based on WHO standards

Background and Problem

Existing healthcare systems have been put under immense pressure during the COVID-19 pandemic. Disruptions in essential maternal and newborn services have come from even high-income countries within the World Health Organization (WHO) European Region.

Aim

To describe the quality of care during pregnancy and childbirth, as reported by the women themselves, during the COVID-19 pandemic in Sweden, using the WHO ‘Standards for improving quality of maternal and newborn care in health facilities’.

Methods

Using an anonymous, online questionnaire, women ≥18 years were invited to participate if they had given birth in Sweden from March 1, 2020 to June 30, 2021. The quality of maternal and newborn care was measured using 40 questions across four domains: provision of care, experience of care, availability of human/physical resources, and organisational changes due to COVID-19.

Findings

Of the 5003 women included, n = 4528 experienced labour. Of these, 46.7% perceived a poorer quality of maternal and newborn care due to the COVID-19. Fundal pressure was applied in 22.2% of instrumental vaginal births, 36.8% received inadequate breastfeeding support and 6.9% reported some form of abuse. Findings were worse in women undergoing prelabour Caesarean section (CS) (n = 475). Multivariate analysis showed significant associations of the quality of maternal and newborn care to year of birth (P < 0.001), parity (P < 0.001), no pharmacological pain relief (P < 0.001), prelabour CS (P < 0.001), emergency CS (P < 0.001) and overall satisfaction (P < 0.001).

Conclusion

Considerable gaps over many key quality measures and deviations from women-centred care were noted. Findings were worse in women with prelabour CS. Actions to promote high-quality, evidence-based and respectful care during childbirth for all mothers are urgently needed.

Problem-based learning for in-service training on breastfeeding in Friuli Venezia Giulia, Italy

Background

Problem-Based Learning (PBL) is extensively used in pre- and post-graduate teaching programmes. However, it has been seldom used for in-service training and continuing medical education. We aimed to develop a PBL curriculum for a short in-service training on breastfeeding for maternal and child health professionals, and to assess the effect of these courses on their knowledge and skills. Also, the project aimed at increasing exclusive breastfeeding rates and duration in an Italian region.

Methods

After initial training on PBL and an assessment of the learning needs of about 400 health professionals, a small working group developed learning objectives, designed a curriculum, produced manuals, and shaped assessment tools for a new PBL course on breastfeeding. The field test of the new course allowed selection of the tutors for the scaling up of the training to the whole region. During this extension phase, participants were asked to complete an evaluation questionnaire. In addition, the health professionals who attended the PBL courses in 2019 were asked to complete an online survey to assess knowledge, attitudes and practices (KAP) just before, soon after the course, and 4–6 months later.

Results

The new 29 − hour PBL course, to be delivered in four days over four consecutive weeks, gives priority to tutorial groups and practical activities (71% of the total time). Supervised clinical practices absorb 16% of time. Ethics, communication and woman-centred clinical management content run throughout the four days and all activities. The three manuals, for tutors, participants and practical activities, facilitate the tasks and performance of tutors and participants. After the field test, 32 regional tutors ran courses for 562 health professionals. The analysis of the evaluation showed a high level of satisfaction for perceived effectiveness, relevance to practice, and educational quality. The KAP questionnaires indicated a general improvement after the course and retention after 4–6 months.

Conclusions

Despite some predictable shortcomings, this new PBL approach for short in-service training courses on breastfeeding showed encouraging results as far as participants’ satisfaction and KAP are concerned. The possible effects on rates and duration of exclusive breastfeeding need further research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00439-4.

Antenatal screening practices in the WHO European Region: a mixed methods study

Background

Literature suggests an increasing trend towards more screening tests, while awareness of potential harms of screenings has been reported to be sub-optimal. This paper aimed to characterize ANC screening practices within the 53 countries of the WHO Europe Region and compare these to evidenced-based recommendations from WHO and from other key reference sources.

Methods

From January 2019 to July 2019 we conducted a survey among key informants (KIs) in the 53 countries of the WHO European Region and a systematic review of literature. KIs were invited to answer an online structured questionnaire, available both in English and Russian. Published and unpublished guidelines, policies or cross-sectional studies on ANC screening practices were searched for in four electronic databases (MEDLINE, Global Health Library, Web of Science, Google) and also sent by KIs. Data obtained from both methods were analysed and triangulated by two independent authors.

Results

Overall 42 countries participated in the survey. Among these, 36 (86%) reported national guidelines on ANC screening, but only 26 (61.9%) reported up-to-date and comprehensive guidelines. All countries reported supplemental use other guidelines, with 19 (45.2%) using more than three. When looking at current evidence-based recommendations, only one (ultrasound before 24 weeks) was reported to be implemented in all countries. Overall, 35 (83.3%) countries reported using at least five not-recommended ANC screening practices, with 21 (50%) implementing ≥10 not-recommended ANC screening practices. The systematic review resulted in 11871 records, with 111 (90 guidelines, 4 policies, 17 cross-sectional studies) matching inclusion criteria. Findings from the systematic review were largely consistent with those of the online survey: among the most comprehensive national guidelines identified, only six (24%) had a concordance ≥75% with the reference recommendations, independently from their publication date, while the few existing cross-sectional studies highlighted large heterogeneity in the implementation of ANC practices among countries.

Conclusions

Guidance on and implementation of evidenced-based recommendations on ANC screening is suboptimal in the WHO European Region. It is necessary to increase the availability of evidence-based high-quality national guidelines and their concrete use in routine practice.

Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool

BACKGROUND

Increasing efforts toward quality improvement (QI) are necessary in low- and middle-income countries (LMICs) to reduce maternal and perinatal mortality and morbidity and to promote respectful care. In Brazil, perinatal health indicators are below targets in several states despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce.

OBJECTIVES

We assessed the effects of a 1-year comprehensive QI cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented QIs obtained after a 1-year comprehensive QI cycle.

METHODS

Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil, accounting for 29 128 live births in 2014. A standards-based and participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level was used. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits.

RESULTS

At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery and in neonatal care.

CONCLUSIONS

A systematic participatory approach based on a WHO tool produced important QIs in a relatively short time and should be considered for use for large-scale QI programs in Brazil and other LMICs. Its comprehensive, peer-to-peer and action-oriented nature and its capability to document QI over time and to build a QI culture represent important comparative advantages over other QI interventions.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 1: Review of implementation features and observed quality gaps in 25 countries

BACKGROUND

A substantial proportion of maternal and neonatal mortality and morbidity is attributable to gaps in quality of care. A systematic, standard-based tool for quality assessment and improvement for maternal and neonatal hospital care (QA/QI MN tool) was developed in 2009 by the World Health Organization (WHO). The tool guides the assessment process along the whole continuum from admission to discharge, collects the views of the recipients of care and engages hospital mangers and staff in identifying gaps and drafting an action plan.

METHODS

Publications describing use of the WHO QA/QI MN tool from 2009 to 2017 and reports retrievable from WHO or other development partners' websites were searched and considered for inclusion in the review. Only assessments of hospitals were considered. Quality gaps were classified as regarding case management in maternal care, case management in neonatal care, hospital infrastructure, hospital policies and according to severity and frequency. Quotations from women regarding key issues in effective communication, respect and dignity, emotional support and costs incurred were selected.

RESULTS

In the period 2009-2017, use of the WHO QA/QI MN tool was documented in 25 countries, belonging to Central and Eastern Europe (8), Central Asia (4), Sub-Saharan Africa (11), Latin America (1) and Middle East (1). Overall, 133 hospitals were assessed. The tool allowed to identify in great detail serious quality gaps including: insufficient or incomplete adherence to recommended evidence-based procedures for normal childbirth and maternal and neonatal complications; excess of inappropriate or unnecessary interventions; insufficient infection control; failure to provide respectful care, adequate communication and emotional support to mothers and babies; poor use of information generated locally to analyse processes and outcomes. These gaps were observed in all countries. Significant differences were observed among facilities belonging to the same health systems, ie, with very similar staffing, infrastructure and equipment.

CONCLUSIONS

The experience made, the largest of this kind, provides comprehensive and detailed insight into the existing quality gaps in a wide variety of settings. QI cycles at facility level should be primarily based on assessments made by multidisciplinary teams of professionals to identify the parts of the care pathways which require improvement through a participatory approach involving managers, staff and patients.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change

BACKGROUND

Information about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change.

METHODS

All documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators.

RESULTS

Changes were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members.

CONCLUSIONS

The use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

Association between maternal satisfaction and other indicators of quality of care at childbirth: a cross-sectional study based on the WHO standards

OBJECTIVES

This study aimed to explore the association between maternal satisfaction and other indicators of quality of care (QoC) at childbirth, as defined by WHO standards.

DESIGN

Cross-sectional study.

SETTING

Referral hospital in Northeast Italy.

PARTICIPANTS

1244 consecutive mothers giving birth in the hospital participated in a survey.

DATA COLLECTION AND ANALYSIS

Univariate analyses were performed to evaluate the association between maternal satisfaction and 61 variables, including measures of 'provision of care', 'experience of care', 'availability of resources' and other maternal characteristics. Exploratory factor analysis was performed to create groups of correlated variables, which were used in multivariate analysis.

RESULTS

Overall, 509 (40.9%) of women were >35 years of age, about half (52.7%) were highly educated, most (95.2%) were married/living with partner and employed (79.3%) and about half (52.9%) were primiparous. Overall, 189 (15.2%) were not born in Italy and 111 (8.9%) did not have Italian citizenship. Most women (84.2%) were highly satisfied (score ≥7/10) with the care received. Among the 61 variables explored, 46 (75.4%) were significantly associated with women's satisfaction, 33 with higher satisfaction and 13 with lower satisfaction. Multivariate analysis largely confirmed univariate findings, with six out of eight groups of correlated variables being statistically significantly associated with women's satisfaction. Factors most strongly associated with women's satisfaction were 'effective communication, involvement, listening to women's needs, respectful and timely care' (OR 16.84, 95% CI 9.90 to 28.61, p<0.001) and 'physical structure' (OR 6.51, 95% CI 4.08 to 10.40, p<0.001). Additionally, 'victim of abuse, discrimination, aggressiveness' was inversely associated with the wish to return to the facility or to recommend it to a friend (OR 0.35, 95% CI 0.17 to 0.70, p<0.003).

CONCLUSION

This study suggested that many variables are strongly associated with women's satisfaction with care during childbirth and support the use of multiple measures to monitor the QoC at childbirth.

Implementation of the WHO manual for Robson classification: an example from Sri Lanka using a local database for developing quality improvement recommendations

OBJECTIVES

This study aimed at describing the use of a prospective database on hospital deliveries for analysing caesarean section (CS) practices according to the WHO manual for Robson classification, and for developing recommendations for improving the quality of care (QoC).

DESIGN

Observational study.

SETTING

University Obstetric Unit at De Soysa Hospital for Women, the largest maternity unit in Sri Lanka.

DATA COLLECTION AND ANALYSIS

For each childbirth, 150 variables were routinely collected in a standardised form and entered into a database. Data were routinely monitored for ensuring quality. Information on deliveries occurring from July 2015 to June 2017 were analysed according the WHO Robson classification manual. Findings were discussed internally to develop quality improvement recommendations.

RESULTS

7504 women delivered in the hospital during the study period and at least one maternal or fetal pathological condition was reported in 2845 (37.9%). The CS rate was 30.0%, with 11.9% CS being performed prelabour. According to the Robson classification, Group 3 and Group 1 were the most represented groups (27.0% and 23.1% of population, respectively). The major contributors to the CS rate were group 5 (29.6%), group 1 (14.0%), group 2a (13.3%) and group 10 (11.5%). The most commonly reported indications for CS included abnormal cardiotocography/suspected fetal distress, past CS and failed progress of labour or failed induction. These suggested the need for further discussion on CS practices. Overall, 18 recommendations were agreed on. Besides updating protocols and hands-on training, activities agreed on included monitoring and supervision, criterion-based audits, risk management meetings and appropriate information for patients, and recommendations to further improve the quality of data.

CONCLUSIONS

This study provides an example on how the WHO manual for Robson classification can be used in an action-oriented manner for developing recommendations for improving the QoC, and the quality of data collected.

Use of WHO standards to improve quality of maternal and newborn hospital care: a study collecting both mothers' and staff perspective in a tertiary care hospital in Italy

Background

WHO developed a list of standards for improving maternal and newborn hospital care. However, there is little experience on their use, and no precise guidance on their implementation. This study aimed at documenting the use of the WHO standards for improving the quality of maternal and neonatal care (QMNC) in a tertiary hospital, Northeast Italy.

Methods

The study was conducted between May 2016 and May 2018, in three phases: phase I—sensitisation and training of health professionals; phase II—data collection on the WHO standards through a survey among service users and providers; phase III—based on the findings of phase II, development of recommendations for improving the QMNC.

Results

Overall, 101 health professionals were successfully trained. 1050 mothers and 105 hospital staff participated in the survey. Key indicators of QMNC (and related prevalence) from the mothers survey included: caesarean section (23.1%); episiotomy (18.3%); restrictions to free movements during labour (46.5%), lithotomy position for staff choice (69.3%); skin to skin (80.8%); early breast feeding (67.2%); information on newborn danger signs (47.2%); high satisfaction with QMNC (68.8%). Only 1.2% and 0.7% of women respectively reported discrimination or abuse. Key indicators (and prevalence) reported from staff included: availability of clinical protocols (37%); regular training (14%); health information system used for quality improvement (16.3%); training on effective communication (9.7%) and on emotional support (19.6%); protocols to prevent mistreatment and abuse (6.9%). On several indicators, the opinions of mothers on QMNC was better than those of staff. Overall, 55 quality improvement recommendations were agreed.

Conclusions

Information on the WHO standards can be collected from both services users and providers and can be proactively used for planning improvements on QMNC.

Effectiveness of an action-oriented educational intervention in ensuring long term improvement of knowledge, attitudes and practices of community health workers in maternal and infant health: a randomized controlled study

BACKGROUND

The potential role of Community Health Workers (CHWs) in improving maternal and child health outcomes, particularly in low and middle-income countries and in disadvantaged communities, is receiving increased attention. Adequate and focused training is among the key requisites for enhancing CHWs performances and research is necessary to identify effective training methods.

METHODS

A randomized controlled study was designed to assess the effectiveness of a training course in improving knowledge, attitudes and practices (KAP) of CHWs regarding maternal and infant health. Seventy-eight CHWs belonging to Family Health Units in the city of Recife, Brazil were randomly allocated to intervention and control groups. The intervention group took part in a four-day interactive training course based on an action-oriented guide to perform home visits to pregnant women and their infants throughout pregnancy and infancy until 9 months of age. KAP in intervention group after training and after 1 year were compared to control group and to baseline.

RESULTS

Fifty-nine CHWs completed all KAP assessments (31 in intervention and 28 in control group). Baseline characteristics were similar in both groups. At 1 year from training, the intervention group had higher overall KAP score (120.65 vs. 108.19, p <  0.001) as well as knowledge (47.45 vs. 40.54, p <  0.001), practice (53.45 vs. 49.11, p <  0.001) and attitudes scores (19.74 vs. 18.81, p = 0.047) than the control group. Moreover, at 1 year from training, the intervention group maintained significant improvements in overall KAP score (120.65 vs. 106.55, p <  0.001) as well as in knowledge (45.45 vs. 42.13, p <  0.001), and practice (53.45 vs. 45.29, p <  0.001) scores with respect to baseline. In the control group, overall KAP (106.59 vs. 108.19, p = 0.345) as well as separate knowledge, attitudes and practices scores remained unchanged.

CONCLUSIONS

A four-day interactive training course on action-oriented home visits to pregnant women and infants produced a sustained improvement of CHWs' KAP and may represent a model to ensure retention of acquired competences.

TRIAL REGISTRATION

RBR-9gchqr . Date registered: July 21, 2018 (Retrospectively registered).

Innovating home visiting to mothers and infants by community health workers: an action-oriented guide

Abstract Objectives: to describe the process of development and the structure of an action-oriented guide for home visits (HVs) to mothers and infants by Community Health Workers (CHWs). The guide was adopted in a controlled trial aimed at assessing its efficacy in improving CHWs' performance. Methods: steps to develop the guide included: 1) Review of international and national standards and recommendations for community interventions for maternal and child care; 2) Assessment of perceived needs of CHWs and other Family Health professionals regarding prenatal and postnatal HVs; 3) Identification of elements to construct the guide. Results: the Guide provides action-oriented instructions for 10 HVs during prenatal and postnatal period up to 9 months instead of the 18 HVs currently recommended by Ministry of Health. Specific tasks for each visit including assessment and promotion of early child development (ECD) and an action-oriented risk classification are introduced as standardized operational practice. Conclusions: the described approach to guide construction allows adapting the guide contents to the health system context in Brazil and other countries interested in improving quality of HVs by CHWs. The guide, by identifying tasks to be carried out and actions to be taken at each HV, provides an innovative approach and represents a requisite for a more efficient and effective use of their time.

Activation of Toll-like receptor-2 by glycosylphosphatidylinositol anchors from a protozoan parasite

Glycosylphosphatidylinositol (GPI) anchors and glycoinositolphospholipids (GIPLs) from parasitic protozoa have been shown to exert a wide variety of effects on cells of the host innate immune system. However, the receptor(s) that are triggered by these protozoan glycolipids has not been identified. Here we present evidence that Trypanosoma cruzi-derived GPI anchors and GIPLs trigger CD25 expression on Chinese hamster ovary-K1 cells transfected with CD14 and Toll-like receptor-2 (TLR-2), but not wild-type (TLR-2-deficient) Chinese hamster ovary cells. The protozoan-derived GPI anchors and GIPLs containing alkylacylglycerol and saturated fatty acid chains or ceramide were found to be active in a concentration range of 100 nM to 1 microM. More importantly, the GPI anchors purified from T. cruzi trypomastigotes, which contain a longer glycan core and unsaturated fatty acids in the sn-2 position of the alkylacylglycerolipid component, triggered TLR-2 at subnanomolar concentrations. We performed experiments with macrophages from TLR-2 knockout and TLR-4 knockout mice, and found that TLR-2 expression appears to be essential for induction of IL-12, TNF-alpha, and NO by GPI anchors derived from T. cruzi trypomastigotes. Thus, highly purified GPI anchors from T. cruzi parasites are potent activators of TLR-2 from both mouse and human origin. The activation of TLR-2 may initiate host innate defense mechanisms and inflammatory response during protozoan infection, and may provide new strategies for immune intervention during protozoan infections.