There is little research on how financial incentives and penalties impact national cesarean section rates. In January 2018, Georgia introduced a national cesarean section reduction policy, which ...imposes a financial penalty on hospitals that do not meet their reduction targets. The aim of this study was to assess the impact of this policy on cesarean section rates, subgroups of women, and selected perinatal outcomes.
We included women who gave birth from 2017 to 2019 registered in the Georgian Birth Registry (n = 150 534, nearly 100% of all births in the country during this time). We then divided the time period into pre-policy (January 1, 2017, to December 31, 2017) and post-policy (January 1, 2018, to December 31, 2019). An interrupted time series analysis was used to compare the cesarean section rates (both overall and stratified by parity), neonatal intensive care unit transfer rates, and perinatal mortality rates in the two time periods. Descriptive statistics were used to assess differences in maternal socio-demographic characteristics.
The mean cesarean section rate in Georgia decreased from 44.7% in the pre-policy period to 40.8% in the post-policy period, mainly among primiparous women. The largest decrease in cesarean section births was found among women <25 years of age and those with higher education. There were no significant differences in the neonatal intensive care unit transfer rate or the perinatal mortality rate between vaginal and cesarean section births in the post-policy period.
The cesarean section rate in Georgia decreased during the 2-year post-policy period. The reduction mainly took place among primiparous women. The policy had no impact on the neonatal intensive care unit transfer rate or the perinatal mortality rate. The impact of the national cesarean section reduction policy on other outcomes is not known.
Background
Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID19 pandemic, as defined by WHO Standards, are lacking.
Methods
Women who gave birth in 12 ...countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures.
Results
21,027 mothers were included in the analysis. Among those who experienced labour (N = 18,063), 41.8% (26.1%- 63.5%) experienced difficulties in accessing antenatal care, 62% (12.6%-99.0%) were not allowed a companion of choice, 31.1% (16.5%-56.9%) received inadequate breastfeeding support, 34.4% (5.2%-64.8%) reported that health workers were not always using protective personal equipment, and 31.8% (17.8%-53.1%) rated the health workers' number as "insufficient". Episiotomy was performed in 20.1% (6.1%-66.0%) of spontaneous vaginal births and fundal pressure applied in 41.2% (11.5% -100%) of instrumental vaginal births. In addition, 23.9% women felt they were not treated with dignity (12.8%-59.8%), 12.5% (7.0%-23.4%) suffered abuse, and 2.4% (0.1%-26.2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N = 2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significantly lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes.
Conclusions
Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed.
Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
Introduction
According to the World Health Organization, the medicalisation of birth tends "to undermine the woman's own capability to give birth and negatively impacts her childbirth experience". ...The COVID-19 pandemic has disrupted maternity care, with potential increase in the medicalisation of birth and in occurrences of disrespectful maternity care. We aim to investigate potential associations between individual and country-level factors and medicalisation of birth in 15 European countries during the COVID-19 pandemic.
Methods
We collected data through an online, anonymous survey for women who gave birth in 2020-2021. We ran multivariable, multi-level logistic regression models estimating associations between indicators of medicalisation (caesarean section (CS), instrumental vaginal birth (IVB), episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country-level.
Results
Among 27173 women, 24.4% had a CS, and 8.8% an IVB. Among women with IVB, 41.9% reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalisation. For example, women who reported having CS, IVB and episiotomy reported not feeling treated with dignity more frequently than women who didn't have those interventions (respectively: OR: 1.37; OR: 1.61; OR: 1.51; all: p < 0.001). Country-level variables contributed to explaining some of the variance between countries.
Conclusions
We recommend a greater emphasis in health policies on the promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor the medicalisation of reproductive care.
Speakers/Panellists
Emanuelle Pessa Valente
WHO Collaborating Centre, Institute for Maternal and Child Health IRCCS, Trieste, Italy
The Republic of Georgia implemented COVID-19-related restrictions starting on 31 March 2020, when it imposed a 1-month strict lockdown, after which the country continued with some form of ...restrictions for 1 year. These restrictions created barriers to healthcare access, affected healthcare services, caused severe economic degradation, and changed reproductive behavior. The aim of this study was to explore the impact of COVID-19-related restrictions on pregnancy and abortion rates in Georgia.
Information on pregnancy, abortion, and related variables was extracted from the Georgian Birth Registry from January 2018 through April 2022. The final study sample included 232,594 pregnancies and 86,729 abortions. We used interrupted time series analysis to study the impact of COVID-19-related restrictions.
There were slightly decreasing trends in pregnancy and abortion rates in the pre-pandemic period (1 January 2018-31 March 2020). During the 1-month strict lockdown (1 April-30 April 2020), pregnancy and abortion rates decreased in all investigated age groups. There were no substantial differences in pregnancy or abortion rates in the pandemic period (for pregnancies: 1 April 2020-30 June 2021; for abortions: 1 April 2020-30 April 2022) compared to the pre-pandemic period. The precision of all estimates suggested that both small increases and decreases in pregnancy and abortion rates are reasonably compatible with our data.
Despite the 1-year-long COVID-19-related restrictions, our results did not indicate substantial long-term changes in pregnancy or abortion rates during the study period for any age group. This may indicate that the restrictions did not substantially influence access to contraception, abortion services, or reproductive behavior.
Kudoa thyrsites
is a myxosporean parasite (Cnidaria, Myxozoa) that infects the skeletal and cardiac muscle of Northeast Atlantic (NEA) mackerel (
Scomber scombrus
). Heavy infections are associated ...with
post-mortem
myoliquefaction of the host skeletal muscle which reduces the quality of the fish product. The biological infection characteristics of the parasite in NEA mackerel are poorly known. This study examined the distribution of
K. thyrsites
in various organs of NEA mackerel from the northern North Sea, and elucidates the relationship between density of infection, developmental stage and parasite distribution in the musculature, and the extent of visible flesh myoliquefaction. Quantitative polymerase chain reaction (qPCR) data showed that
K. thyrsites
is unevenly distributed in the somatic musculature of the fish host, with highest density in the anterior ventral muscle sections—the belly flaps. A weak positive correlation was observed between the level of myoliquefaction and the parasite density in the fish host muscle. This relationship was also reflected by the amount and distribution of parasite developmental stages seen during histological examinations. Histological findings indicate an association between the dispersion of free myxospores and the level of myoliquefaction of the fish host muscle. Visceral organs were also found infected using qPCR, although at lower densities compared to the musculature.
The World Health Organization recommends exclusive breastfeeding for six months, defined as no other solids or liquids besides breast milk and essential vitamins or medicines. Data about exclusive ...breastfeeding are limited in Georgia, and the information that exist are provided by national surveys, that present inconsistent numbers. Georgia has recently established a national birth registry, which includes information about early postpartum breastfeeding. The objective of this study was to identify factors associated with exclusive breastfeeding of term newborns at hospital discharge in Georgia, using national registry data.
All live, singleton, term births registered in the Georgian Birth Registry in November and December 2017 were included, with a final study sample of 7134 newborns. Newborns exclusively breastfed at hospital discharge were compared with those who were not, and potential factors were assessed with logistic regression analysis. Hospital discharge normally occurred between 2 and 5 days postpartum.
The study identified several factors associated with nonexclusive breastfeeding of term newborns at hospital discharge in Georgia: maternal higher education compared to secondary education or less (Adjusted Odds Ratio AOR 0.75; 95% CI 0.59, 0.97), caesarean delivery compared to vaginal or assisted vaginal delivery (AOR 0.47; 95% CI 0.37, 0.60), birthweight < 2500 g compared to 3000-3499 g (AOR 0.51; 95% CI 0.27, 0.97), and admission to neonatal intensive care unit after delivery (AOR 0.02; 95% CI 0.02, 0.03). None of the following factors were associated with exclusive breastfeeding at discharge: mother's age, marital status, Body Mass Index (BMI), parity, in vitro fertilization, maternal intrapartum complications and the sex of the newborn.
To the authors' knowledge, this is the first time determinants of exclusive breastfeeding at hospital discharge have been studied in Georgia. Several factors associated with nonexclusive breastfeeding at discharge were identified, most noteworthy were caesarean delivery and admission to neonatal intensive care unit. These findings are of importance to the Georgian health authorities and maternal/child non-governmental organizations.
Little is known about women's experience of care and views on early breastfeeding during the COVID-19 pandemic in Norway.
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.
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.
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.
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
Synopsis
Births in private facilities consistently had higher odds of cesarean, while overall quality of care was heterogeneous both across and within countries.
Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic, as defined by WHO Standards, are lacking.
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.
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.
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.
The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
ClinicalTrials.gov Identifier: NCT04847336
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