Operationalising masculinities in theories and practices of gender-transformative health interventions: a scoping review.

Gender-transformative health interventions that involve men and boys are gaining global reach, adaptability to specific geographical, population and epidemiological contexts, public endorsement, and conceptual sophistication. However, the ways in which masculinities are conceptualised and operationalised in theory and practice across these interventions remains unclear. The purpose of this scoping review is to map intervention studies that conceptually grapple with masculinities and analyse: a) how the concept of masculinities is adapted and operationalised in gender-transformative interventions, with respect to intervention population and context, b) what the relationship between the concept of masculinities and its wider theoretical embedding is, and c) on which levels transformation can be observed when working with 'masculinities'.We conducted a search in APA Psych Articles, APA PsycINFO, and CINAHL via EBSCO, MedLine, PubMed, and Web of Sciences (December 2021) looking for peer-reviewed studies on gender-transformative health interventions which engaged with masculinities conceptually. There were no restrictions regarding language, publication date, or geography. Forty-two articles were included in this review. Our abductive analysis finds that 'hegemonic masculinities' is a central concept in almost all included studies. This shows how the concept is adaptable to a range of different intervention contexts. The review further identifies five theoretical approaches, that help operationalise masculinities on an analytical level: feminist framework, affect theory, critical pedagogy, theories of social change, and ecological approaches. Lastly, this review draws out six levels on which transformation can be observed in the intervention outcomes: relational level, symbolic level, material level, affective level, cognitive-behavioural level, and community-structural level. The discussion underlines that processes and practices of (gender) transformation also require engagement with theories of transformation more widely and advocates for theoretical pluralism. Lastly, implications for practice, including preventative, ecological and community-based care models, are drawn out.

Experiences of giving birth during the COVID-19 pandemic: a qualitative analysis of social media comments through the lens of birth integrity.

BACKGROUND: Social media offer women a space to discuss birth-related fears and experiences. This is particularly the case during the COVID-19 pandemic when measures to contain the spread of the virus and high rates of infection have had an impact on the delivery of care, potentially restricting women's rights and increasing the risk of experiencing different forms of mistreatment or violence. Through the lens of birth integrity, we focused on the experiences of women giving birth in Germany as shared on social media, and on what may have sheltered or violated their integrity during birth. METHODS: Using thematic analysis, we identified key themes in 127 comments and associated reactions (i.e. "likes", emojis) posted on a Facebook public page in response to the dissemination of a research survey on maternity care in the first year of the COVID-19 pandemic. RESULTS: Women contributing to the dataset gave birth during March and December 2020. They were most negatively affected by own mask-wearing -especially during the active phase of labour, not being allowed a birth companion of choice, lack of supportive care, and exclusion of their partner from the hospital. Those topics generated the most reactions, revealing compassion from other women and mixed feelings about health measures, from acceptation to anger. Many women explicitly formulated how inhumane or disrespectful the care was. While some women felt restricted by the tight visiting rules, those were seen as positive by others, who benefited from the relative quiet of maternity wards and opportunities for postpartum healing and bonding. CONCLUSION: Exceptional pandemic circumstances have introduced new parameters in maternity care, some of which appear acceptable, necessary, or beneficial to women, and some of which can be considered violations of birth integrity. Our research calls for the investigation of the long-term impact of those violations and the reassessment of the optimal conditions of the delivery of respectful maternity during the pandemic and beyond.

A critical review: developing a birth integrity framework for epidemiological studies through meta-ethnography.

Over the past decade, there has been growing evidence that women worldwide experience sub-standard care during facility-based childbirth. With this critical review, we synthesize concepts and measurement approaches used to assess maternity care conditions and provision, birth experiences and perceptions in epidemiological, quantitative research studies (e.g., obstetric violence, maternal satisfaction, disrespect or mistreatment during childbirth, person-centered care), aiming to propose an umbrella concept and framework under which the existing and future research strands can be situated. On the 82 studies included, we conduct a meta-ethnography (ME) using reciprocal translation, in-line argumentation, and higher-level synthesis to propose the birth integrity multilevel framework. We perform ME steps for the conceptual level and the measurement level. At the conceptual level, we organize the studies according to the similarity of approaches into clusters and derive key concepts (definitions). Then, we 'translate' the clusters into one another by elaborating each approach's specific angle and pointing out the affinities and differences between the clusters. Finally, we present an in-line argumentation that prepares ground for the synthesis. At the measurement level, we identify themes from items through content analysis, then organize themes into 14 categories and subthemes. Finally, we synthesize our result to the six-field, macro-to-micro level birth integrity framework that helps to analytically distinguish between the interwoven contributing factors that influence the birth situation as such and the integrity of those giving birth. The framework can guide survey development, interviews, or interventional studies.

[Violated birth integrity during the COVID-19 pandemic in Germany: experiences of women with maternity care]. / Verletzte Geburtsintegrität während der COVID-19-Pandemie in Deutschland: Erfahrungen von Gebärenden mit der geburtshilflichen Versorgung.

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.

Un regard théorique sur l'intégrité à la naissance : médicalisation, théories du risque, embodiment et intersectionnalité.

INTRODUCTION: Recent quantitative research in public health indicates that women across the globe report suboptimal treatment during institutional deliveries. The most common approaches used to comprehend this abuse, violence, or mistreatment have not fully achieved a balance between theoretical perspectives and empirical assessment. To contribute to a more accurate account of the cultural driving forces, institutional conditions, direct expressions, and individual perceptions that undermine or preserve what we define as “integrity at birth”, we develop a new theoretical approach and a multi-level model. PURPOSE OF RESEARCH: We ground the terminology for integrity at birth upon theoretical foundations, referring to two theoretical discourses: medicalization and risk theory on the one hand, and embodiment and intersectionality theory on the other. We then contextualize this in a multi-level model in order to operationalize its potential for public health research. RESULTS: The concept and model of “integrity at birth” recognize that women in labor suffer from a number of gender-specific violations, which can be expressed at all levels (macro to micro) as implicit, inherent, normalized and invisible, or explicit, intentional, visible and socially accepted. In distinguishing six separate domains, we propose a theoretical contribution for obstetric care practices. CONCLUSION: Integrity at birth, as a multi-level and theoretically grounded approach, constitutes an important step towards raising awareness about this issue beyond the dimensions that have been studied to date in quantitative health research. Beyond available evidence of disrespectful and abusive practices constituting violations to integrity at birth, this study takes a step towards understanding gender-based violence and inequalities of health at childbirth.

Representation of gender in migrant health studies - a systematic review of the social epidemiological literature.

BACKGROUND: Gender as a social construct contributes to determine who migrates and which migration-related risks and opportunities emerge in all phases of the migration trajectory. Simultaneously, migration influences the individual as well as societal definition and perception of gender roles. An explicit gender perspective in migration-related epidemiological research can contribute to adequately analyse and interpret the health of migrants. This systematic review gives a comprehensive overview on how gender has been conceptualised, operationalised and measured in social epidemiologic studies aiming to assess the influence of gender on health among migrants. METHODS: We searched PubMed, Embase, CINAHL, the Cochrane Library, EconLit and PsycINFO and conducted backward reference searching. Reviewers independently selected studies, extracted data and conducted the quality assessment. Eligible studies actively aimed to understand, identify or explain the influence of gender on migrants' health, whereby the role of gender can encompass a variety of mechanisms, processes or states of differentiation, discrimination and/or inequality. RESULTS: Almost all of the 43 studies were cross-sectional and focussed on health outcomes in the post-migration phase. The most common theme of research was the health of male migrants in the US, and in particular of men who have sex with men (MSM). All studies treated gender as a binary variable (men vs. women), without discussing additional types of gender identities. A minority of studies differentiated clearly between sex and gender. Gender was mostly operationalised through attitudes toward gender roles and gender-based discrimination, experienced at the individual level. Community and societal level gender measures capturing structural gender determinants were underrepresented. CONCLUSIONS: The intersections of migration and gender suggested synergistic effects on health that only become visible when considering those two social determinants together. Future research needs to embrace a multilevel and non-binary understanding of gender and reflect on the influence of gender in the different phases of the migration journey. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019124698 .

Health workers' perspectives on the quality of maternal and newborn health care around the time of childbirth: Results of the Improving MAternal Newborn carE in the EURO Region (IMAgiNE EURO) project in 12 countries of the World Health Organization European Region.

Background: Health workers' (HWs') perspectives on the quality of maternal and newborn care (QMNC) are not routinely collected. In this cross-sectional study, we aimed to document HWs' perspectives on QMNC around childbirth in 12 World Health Organization (WHO) European countries. Methods: HWs involved in maternal/neonatal care for at least one year between March 2020 and March 2023 answered an online validated WHO standards-based questionnaire collecting 40 quality measures for improving QMNC. A QMNC index (score 0-400) was calculated as a synthetic measure. Results: Data from 4143 respondents were analysed. For 39 out of 40 quality measures, at least 20% of HWs reported a 'need for improvement', with large variations across countries. Effective training on healthy women/newborns management (n = 2748, 66.3%), availability of informed consent job aids (n = 2770, 66.9%), and effective training on women/newborns rights (n = 2714, 65.5%) presented the highest proportion of HWs stating 'need for improvement'. Overall, 64.8% (n = 2684) of respondents declared that HWs' numbers were insufficient for appropriate care (66.3% in Portugal and 86.6% in Poland), and 22.4% described staff censorship (16.3% in Germany and 56.7% in Poland). The reported QMNC index was low in all countries (Poland median (MD) = 210.60, interquartile range (IQR) = 155.71, 273.57; Norway MD = 277.86; IQR = 244.32, 308.30). The 'experience of care' domain presented in eight countries had significantly lower scores than the other domains (P < 0.001). Over time, there was a significant monthly linear decrease in the QMNC index (P < 0.001), lacking correlation with the coronavirus disease 2019 (COVID-19) pandemic trends (P > 0.05). Multivariate analyses confirmed large QMNC variation by country. HWs with <10 years of experience, HWs from public facilities, and midwives rated QMNC with significantly lower scores (P < 0.001). Conclusions: HWs from 12 European countries reported significant gaps in QMNC, lacking association with COVID-19 pandemic trends. Routine monitoring of QMNC and tailored actions are needed to improve health services for the benefit of both users and providers. Registration: ClinicalTrials.gov NCT04847336.

Maternal self-conception and mental wellbeing during the first wave of the COVID-19 pandemic. A qualitative interview study through the lens of "intensive mothering" and "ideal worker" ideology.

Mothers tended to be responsible for most of the (additional) caregiving and domestic tasks during the COVID-19 pandemic while simultaneously having to pursue their work duties. Increased role conflicts, parenting stress, and exhaustion predict adverse mental health. We aimed to examine how women referred to and made sense of dominant gender norms in their arrangements of pandemic daily life and how these beliefs impacted their maternal self-conception. Qualitative interviews with 17 women were analyzed through the lens of "intensive mothering" ideology and "ideal workers" norms, emphasizing notions of maternal guilt rising from a perceived mismatch between the ideal and actual maternal self-conception. We found that mothers' notions of guilt and their decreases in health link to dominant discourses on motherhood and intersect with "ideal worker" norms. As such, these norms amplify the burden of gendered health inequalities.

Self-reported mental well-being of mothers with young children during the first wave of the COVID-19 pandemic in Germany: A mixed-methods study.

OBJECTIVES: Mothers of young children have been identified as a particularly vulnerable group during the COVID-19 pandemic. We aimed to explore how occupational, psychosocial and partnership-related factors were associated with their self-reported mental well-being during the first COVID-19 wave. METHODS: Five hundred fifty participants of the BaBi cohort study (est. 2013, Bielefeld, North-Rhine Westphalia, Germany) were invited to complete an online survey and to take part in email interviews (April-May 2020). With survey data, we assessed self-reported mental well-being through validated instruments (eight-item Patient Health Questionnaire; short version of the Symptom Checklist) and ran linear regression models for occupational, psychosocial and partnership-related factors. We performed content analysis on the interviews' data to further understand the determinants of the women's mental well-being. RESULTS: One hundred twenty-four women participated in the survey; of which 17 also participated in the interviews. A perceived lack of support in childcare was associated with higher levels of depressive symptoms, while having a higher internal locus of control was associated with lower levels. Psychological distress was higher in those reporting lack of emotional or childcare support. Interviews confirmed the interplay of potential stressors and highlighted the difficulties to reconcile different expectations of motherhood. DISCUSSION: Occupational, psychosocial and partner-related factors can act (to varying degree) both as resources and stressors to the self-reported mental well-being of mothers of young children. These impacts took different forms and created opportunities or challenges, depending on specific life circumstances, such as work or family situations, relationships and own psychosocial resources. Although not representative, our study contributes to building the COVID-19 evidence base, delineating the mental health toll of the pandemic on mothers of young children and the factors that contribute to it.

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. GOV IDENTIFIER: NCT04847336.

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 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.

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.

Measurement of gender as a social determinant of health in epidemiology-A scoping review.

BACKGROUND: The relevance of gender as a social determinant of health and its role in the production of health inequalities is now broadly acknowledged. However, the plethora of existing approaches to capture gender, which often stem from disciplines outside of epidemiology, makes it difficult to assess their practicality and relevance for a given research purpose. We conducted a scoping review to 1) map the evidence of how gender can be operationalised in quantitative epidemiology and 2) design a tool to critically evaluate the measures identified. METHODS: We identified peer-reviewed articles in electronic databases (PubMed, Embase and PsycINFO). Eligible sources described the quantitative operationalisation of the social dimension of gender. With the help of a newly developed checklist, we assessed their relevance from an analytical perspective (e.g. intersectionality) and their potential for implementation in epidemiology. RESULTS: Gender measures principally assessed gender roles and norms, gender-based discrimination and violence, and structural gender (in)equality. Of the 344 measures included in this review, the majority lacked theoretical foundation, and tended to reinforce the binary understanding of gender through stereotypes of femininity and masculinity. Only few measures allowed for an intersectional approach and a multilevel understanding of gender mechanisms. From a practical point of view, gender measures demonstrated potential for use in varied populations and contexts. CONCLUSIONS: A range of gender measures are readily available for epidemiological research, addressing different levels and dimensions of gender as a social construct. With our theory-informed, practice-driven scoping review, we highlighted strengths and limitations of such measures and provided analytical tools for researchers interested in conducting intersectional, gender-sensitive analyses.

Potential of Standard Perinatal Data for Measuring Violation of Birth Integrity.

Background: Measuring the phenomenon of violation of birth integrity (vBI) (e.g., obstetric violence) relies in part on the availability and content of maternity care providers' data. The population coverage and linkage possibilities that these data provide make for a yet untapped potential. Although vBI is a complex phenomenon best measured with dedicated instruments, we argue that maternity care providers' data could contribute to enhance our knowledge of the manifestations and frequency of vBI, and allow for analyses across different sub-groups of the population. Looking into the German standardized perinatal data, we investigate which variables are relevant to vBI-related research, and how complete their reporting is. Methods: First, we analyse state-of-the-art frameworks and recommendations, and, for each vBI-related domain, we search for and list corresponding variables in the perinatal data which could contribute to a better understanding of vBI issues. Second, we use an example and analyse the content of perinatal data obtained between 2013 and 2016 in the context of the BaBi birth cohort study set in Bielefeld, Germany. We use descriptive statistics to assess the completeness of the data. Results: The vBI-related variables can be classified in three main categories: discrimination based on specific patient socio-demographic attributes (e.g., height and weight to calculate BMI before pregnancy, foreign origin), indication for medical interventions (i.e., medicalization-related variables: indication for cesarean sections and induction), and supportive care, in particular the mobilization dimension (e.g., continuous fetal heartbeat monitoring). The data analyses included 876 births, of which 601 were vaginal birth. We found poor reporting on demographic variables in terms of completeness. Medicalization and mobilization variables are better documented, although limited in scope. Conclusions: Putting more emphasis on the completeness of standardized data could increase their potential for vBI-related research. Perinatal data alone are insufficient to assess vBI, but a broader, theory-informed discussion of indicators to be included in standardized datasets would contribute to capturing the different aspects of integrity violation in a more systematic way and expand the evidence-base on different types of vBI.