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

Abstract

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.

Keywords: COVID-19; European Region; WHO; facility; maternal; newborn; quality of care; questionnaire; respectful maternity care; survey.

Conflict of interest statement

Céline Miani's position as a post-doctoral researcher is funded by Bielefeld University. Catarina Barata had a PhD grant FCT/FSE (SFRH/BD/128600/2017) while she was voluntarily writing this article. She is board member, unpaid collaboration, of Associação Portuguesa pelos Direitos da Mulher na Gravidez e Parto (APDMGP). Daniela Drandić received a salary during the time she was volunteer-writing this article was from a grant from the Erasmus+ programme of the European Commission, regarding a project on parenting support and from a grant from the UNICEF Croatia, regarding a project on online education for pregnant women during COVID. She is a board member of an NGO called Human Rights in Childbirth, and has been for the entire time she worked on this paper. Dr Emma Sacks has received research funding from the World Health Organization related to the mistreatment of women and newborns in health facilities. The project has no impact on the present manuscript outside of similar topics. She is the former co-chair of the Newborn Health Working Group of the Global Respectful Maternity Care Council. Other authors have none to declare.

© 2021 The Author(s).

Figures

Figure 1

Flow diagram - Note: We used 45 key variables (40 key Quality Measures and five key socio-demographic questions).

Figure 2

Provision of care – Notes: Data are reported as median frequency on the total sample (grey dot) and as median frequency on the sample of women giving birth in each country (coloured dots); horizontal grey line represents the range of the median frequencies. All the indicators in the domain of provision of care are directly based on WHO standards. Indicators identified with letters (eg, 3a, 3b) were tailored to take into account different mode of birth (ie, spontaneous vaginal, instrumental vaginal, and caesarean section). These were calculated on subsamples (eg, 3a was calculated on spontaneous vaginal births; 3b was calculated on instrumental vaginal births). Abbreviations: CS = caesarean section; HCP = health care provider; IVB= instrumental vaginal birth; SVB = spontaneous vaginal birth.

Figure 3

Experience of care – Notes: Data are reported as median frequency on the total sample (grey dot) and as median frequency on the sample of women giving birth in each country (coloured dots); horizontal grey line represents the range of the median frequencies. All the indicators in the domain of experience of care are directly based on WHO standards. Indicators identified with letters (eg, 2a, 2b) were tailored to take into account different mode of birth (ie, spontaneous vaginal, instrumental vaginal, and caesarean section). These were calculated on subsamples (eg, 2a was calculated on spontaneous vaginal births; 2b was calculated on instrumental vaginal births). Abbreviations: ECS = emergency caesarean section; HCP = health care provider; IVB= instrumental vaginal birth; SVB = spontaneous vaginal birth.

Figure 4

Availability of physical and human resources – Notes: Data are reported as median frequency on the total sample (grey dot) and as median frequency on the sample of women giving birth in each country (coloured dots); horizontal grey line represents the range of the median frequencies. All the indicators in the domain of resources are directly based on WHO standards. Abbreviations: HCP = health care provider.

Figure 5

Reorganizational changes due to COVID-19 – Notes: Data are reported as median frequency on the total sample (grey dot) and as median frequency on the sample of women giving birth in each country (coloured dots); horizontal grey line represents the range of the median frequencies. Indicator 6 in both panels was defined as: at least one functioning and accessible hand-washing station (near or inside the room where the mother was hospitalised) supplied with water and soap or with disinfectant alcohol solution. Abbreviations: HCP = health care provider; PPE = personal protective equipment; QMNC = quality of maternal and newborn care.

Figure 6

QMNC Index by country of giving birth - Abbreviations: QMNC = quality of maternal and newborn care.

Figure 7

QMNC Index by other variables used in quantile regression analysis - Abbreviations: CS = caesarean section; IVB = instrumental vaginal birth; OB-GYN = obstetrics and gynaecology; QMNC = quality of maternal and newborn care; SVB = spontaneous vaginal birth.