Quality of Care at childbirth during the COVID-19 pandemic: findings of the IMAgiNE EURO study in Belgium (preprint)

Objectives To examine quality of maternal and newborn care (QMNC) around childbirth in facilities in Belgium during the COVID-19 pandemic and trends over time. Design A cross-sectional observational study. Setting Data of the IMAgiNE EURO study in Belgium. Participants Women giving birth in a Belgian facility from March 1, 2020, to May 1, 2023, responded a validated online questionnaire based on 40 WHO standards-based quality measures organised in four domains: provision of care, experience of care, availability of resources, and organizational changes related to COVID 19. Primary and secondary outcome measures Quantile regression analysis was performed to assess predictors of QMNC; trends over time were tested with the Mann Kendall test. Results 897 women were included in the analysis, 67%(n=601) with spontaneous vaginal birth, 13.3%(n=119) with instrumental vaginal birth and 19.7%(n=177) with cesarean section. We found high QMNC scores but also specific gaps in all domains of QMNC. On provision of care, 21.0%(n=166) of women who experienced labor and 14.7%(n=26) of women with a cesarean reported inadequate pain relief; 64.7%(n=74) of women with an instrumental birth reported fundal pressure and 72.3% (n=86) reported that forceps or vacuum cup was used without their consent. On experience of care, 31.1%(n=279) reported unclear communication, 32.9%(n=295) reported that they were not involved in choices,11.5%(n=104) stated not being treated with dignity and 8.1%(n=73) experienced abuse. Related to resources, almost half of the women reported an inadequate number of healthcare professionals (46.2%, n=414). The multivariable analyses showed significantly lower QMNC scores for women with an instrumental vaginal birth. Over time there was a significant increase in QMNC score for experience of care and key organizational changes due to COVID-19. Conclusions and relevance Although overall QMNC scores were high, findings also suggest gaps in QMNC. Underlying causes of these gaps should be explored to design appropriate interventions and policies.

Utilisation of services along the continuum of maternal healthcare during the COVID-19 pandemic in Lubumbashi, DRC: findings from a cross-sectional household survey of women (preprint)

Introduction:The continuum of maternal care along antenatal (ANC), intrapartum, and postnatal care (PNC) is fundamental for protecting women’s and newborns’ health. The COVID-19 pandemic and accompanying mitigation measures interrupted the provision and use of these essential services globally. This study examines maternal healthcare utilisation along the continuum during the COVID-19 pandemic in the Democratic Republic of the Congo, and explores factors associated with use of the full continuum.Methods:This is a cross-sectional study using data collected on a survey of 599 households in Lubumbashi using stratified random sampling. We included 604 women (15-49 years) who were pregnant between March 2020-May 2021. A structured interview involved questions on sociodemographic characteristics, attitudes regarding COVID-19, and maternal service use and cost. Complete continuum of care was defined as receiving ANC 4+ consultations, skilled birth attendance, and at least one PNC check for both mother and newborn. Data were analysed in SPSS using descriptive statistics and multivariable logistic regression.Results:Of the women who gave birth during the COVID-19 pandemic, 61% had ANC 4+ consultations, most had a skilled birth attendant (97%), and more than half (55%) had a PNC check for themselves and the newborn. One-third (36%) of women completed the continuum of maternal healthcare. Factors significantly associated with completing the continuum included higher education (aOR=2.6; p-value<0.001) and positive attitude towards the COVID-19 vaccination (aOR=1.9; p-value=0.04). Reasons for not seeking maternal care included lack of money and avoiding COVID-19 vaccination.Conclusion:During the COVID-19 pandemic, maternal healthcare seeking behaviours were shaped by vaccine hesitancy and care unaffordability in Lubumbashi. By disproportionately affecting women and vulnerable populations, the pandemic could exacerbate pre-existing structural barriers to maternal healthcare utilisation. Addressing the high cost of maternal healthcare and vaccine hesitancy appear essential to avoid deepening pre-existing socio-economic inequalities.

How COVID-19 challenged care for women and their newborns: a qualitative case study of the experience of Belgian midwives during the first wave of the pandemic (preprint)

In this article, we describe the results of a rapid qualitative study conducted between May 19 and June 25, 2020 on the work experience of midwives during the first wave of the COVID-19 pandemic in Brussels and Wallonia (Belgium). Using semi-structured interviews conducted with fifteen midwives working in hospitals or practicing privately, we investigated the impact of the first COVID-19 wave on their work experience, the woman-midwife relationship, and midwife-perceived changes in quality of care. Findings include high levels of stress and insecurity related to the lack of resources and personal protective equipment, feelings of distrust from midwives towards the Belgian State and public health authorities, as well as structural and organizational challenges within maternity wards which negatively affected quality of care. Moreover, based on the midwives’ experiences, we demonstrate the need to recognise the views of all stakeholders involved in maternal and newborn care provision, and share five essential lessons learned from this study: 1) it is crucial to acknowledge the central role of midwives for maintaining maternal and newborn care amidst the pandemic and beyond; 2) creating unified national guidelines could support ensuring best practice; 3) efforts must be put in place to diminish the climate of mistrust towards health authorities and to repair the relationship between midwives and decision-makers which was damaged during the pandemic; 4) caring for front-line healthcare workers’ mental health is critical, and 5) quality of maternal care can be improved, even in the midst of a pandemic, through team effort and creative solutions tailored to the needs and demands of each setting.

The impact of COVID-19 on the provision of respectful maternity care: findings from a global survey of health workers (preprint)

Background Significant adjustments to the provision of maternity care in response to the COVID-19 pandemic and the direct impacts of COVID-19 can compromise the quality of maternal and newborn care. Aim To explore how the COVID-19 pandemic affected frontline health workers’ ability to provide respectful maternity care globally. Methods We conducted a global online survey of health workers to assess the provision of maternal and newborn healthcare during the COVID-19 pandemic. We collected quantitative and qualitative data between July and December 2020 and conducted a qualitative content analysis to explore open-ended responses. Findings Health workers (n=1,127) from 71 countries participated; and 120 participants from 33 countries provided qualitative data. The COVID-19 pandemic negatively affected the provision of respectful maternity care in multiple ways. Six central themes were identified: less family involvement, reduced emotional and physical support for women, compromised standards of care, increased exposure to medically unjustified caesarean section, and staff overwhelmed by rapidly changing guidelines and enhanced infection prevention measures. Further, respectful care provided to women and newborns with suspected or confirmed COVID-19 infection was severely affected due to health workers’ fear of getting infected and measures taken to minimise COVID-19 transmission. Discussion Multidimensional and contextually-adapted actions are urgently needed to mitigate the impacts of the COVID-19 pandemic on the provision and continued promotion of respectful maternity care globally in the long-term. Conclusions The measures taken during the COVID-19 pandemic disrupted the quality of care provided to women during labour and childbirth generally, and respectful maternity care specifically.

A double-edged sword - Telemedicine for maternal care during COVID-19: Findings from a global mixed methods study of healthcare providers (preprint)

IntroductionThe COVID-19 pandemic has led to a rapid and wide implementation of telemedicine for provision of maternal and newborn health care worldwide. Studies conducted before the pandemic, mainly deriving from high-income countries, showed telemedicine was a safe and cost-effective tool for delivering healthcare under certain conditions. The objective of this study was to document the experiences of healthcare professionals globally with the provision of telemedicine for maternal and newborn healthcare during the COVID-19 pandemic. MethodsWe analysed responses received to the second round of a global, online survey of maternal and newborn health professionals, disseminated through professional networks and social media in 11 languages. Data were collected between July 5, 2020 and September 10, 2020. The questionnaire included questions regarding background, preparedness for and response to COVID-19 and experiences with providing telemedicine during the pandemic. Descriptive statistics and qualitative thematic analysis were used concurrently to analyse responses, disaggregated by country income level. ResultsResponses from 1,060 maternal and newborn health professional were analysed. Among the sample, 58% reported using telemedicine, with the lowest proportion reported by professionals working in low-income countries (24%). Two fifths of telemedicine users reported not receiving guidelines on the provision of care through technology. Key practices along the continuum of maternal and newborn healthcare provided through telemedicine included online group birth preparedness classes, antenatal and postnatal care by video/phone, setting up a COVID-19 helpline at maternity wards, and online psychosocial counselling. Challenges reported technological barriers, lack of technological literacy, financial and language barriers, lack of nonverbal feedback, and distrust from patients. Maternal and newborn health providers considered telemedicine to be an important alternative to in-person consultations to maintain care provision during the COVID-19 pandemic. However, they also emphasized the lower quality of care and risk of increasing the already existing inequalities in access to healthcare. ConclusionsTelemedicine has been applied globally to address the disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. Pitfalls of health care provision by telemedicine include exacerbated inequalities in access to care, patient-provider communication problems, and a financial burden for certain healthcare workers and women. More research regarding the effectiveness, efficacy, and quality of telemedicine for maternal health care in different contexts is highly needed before considering long-term adaptations in provision of care away from face to face interactions. Clear guidelines for care provision and approaches to minimising socio-economic and technological inequalities in access to care are urgently needed. Summary boxO_ST_ABSWhat is already known?C_ST_ABSO_LITelemedicine is the delivery of healthcare services by healthcare professionals from distance through using information and communication technologies for the exchange of valid and correct information. C_LIO_LITelemedicine for maternal and newborn health can safely be used to deliver certain components of care in highly controlled settings where the technology is available and accessible to patients C_LIO_LITelemedicine has been applied rapidly and on a wide scale during the COVID-19 pandemic to replace face to face visits along the continuum of maternal and newborn health care. C_LI What are the new findings?O_LIMaternal and newborn healthcare providers globally considered telemedicine of benefit during the pandemic and applied it on a wide scale for different aspects of maternal and newborn healthcare. C_LIO_LIThe rapid adaptation to provision of care via telemedicine was not optimally supported by guidelines, training for health providers, adequate equipment, reimbursement for cost of connectivity and insurance payments for care provided remotely. C_LIO_LIHealthcare providers reported not being able to reach a substantial group of families by telemedicine and encountered different barriers in providing high quality maternity care by telemedicine due to challenges present worldwide, but more prominent in low- and middle-income countries. C_LI What do the new findings imply?O_LIPre-existing inequalities in terms of access to high quality care might have increased by the large scale and rapid implementation of telemedicine during the COVID-19 pandemic in different settings. C_LIO_LIAccess to telemedicine for women was hampered by various factors such as internet connection problems, lack of the necessary equipment, digital illiteracy and distrust. C_LIO_LIIn-depth research is needed to formalise evidence-based guidelines for the implementation of telemedicine along the continuum of maternal and newborn care as lessons learned for building back beyond the COVID-19 pandemic and also for future emergency preparedness. C_LI