Midwives' experiences with providing home-based postpartum care during the COVID-19 pandemic: A qualitative study.

AIM: To explore midwives' experiences with providing home-based postpartum care during the COVID-19 pandemic in Norway. DESIGN: A descriptive and explorative qualitative study. METHODS: The study is based on semi-structured individual interviews with 11 midwives experienced in offering home-based postpartum care. We explored their experiences of such care during the first wave of the COVID-19 pandemic. Data collection occurred from October through November 2020. An inductive thematic analysis was performed using Systematic Text Condensation (STC) by Malterud (2012). RESULTS: The following two main results emerged from the analyses: (1) the midwives adapted quickly to changes in postpartum care during the pandemic and (2) midwives saw the experience as an opportunity to re-evaluate their practices. CONCLUSION: This study highlights midwives' resilience and adaptability during the first wave of COVID-19 pandemic. It emphasises the crucial role of face-to-face interactions in postpartum care, while recognising the value of technology when direct access is limited. By shedding light on midwives' experiences, this research contributes to improving postpartum care in unforeseen circumstances. It underscores the significance of interdisciplinary integration in planning postpartum care services and the lasting influence of lessons learned on addressing future challenges. IMPLICATIONS FOR PRACTICE: The valuable insights gained from lessons learned during the COVID-19 pandemic may have a lasting influence on the postpartum care system, empowering it to tackle unforeseen challenges both today and in the future. IMPACT: The current study addressed midwives' experience with providing home-based postpartum care during the COVID-19 pandemic in Norway. Midwives received an opportunity to re-evaluate their own practices and valued being included when changes were implemented. The current findings should alert policy makers, leaders and clinicians in postpartum care services when planning future practice.

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.

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.

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.

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.

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors.

OBJECTIVE: To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway. DESIGN: Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region. MAIN OUTCOME: Epidural analgesia for labour pain. RESULTS: Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds. CONCLUSION: The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use.

Somali women's experiences of antenatal care: A qualitative interview study.

OBJECTIVE: To explore Somali women's experiences of antenatal care in Norway. DESIGN: A qualitative study based on individual semi-structured interviews conducted either face-to-face or over the phone. SETTING: Norway. PARTICIPANTS: Eight Somali-born women living in Norway. KEY FINDINGS: Four themes were generated from the analysis. From their experiences of antenatal care in Norway, the Somali women described: 1) when care was provided in a way that gained their trust, they made better use of the available health services, 2) the importance of continuity of care and of sharing commonalities with the caregiver, 3) a need for accessible information, specifically tailored to the needs of Somali women and 4) how culturally insensitive caregivers had a negative impact on the quality of care. CONCLUSION AND IMPLICATIONS FOR PRACTICE: The Somali women in this study were grateful for the care provided, although the quality of antenatal care did not always meet their needs. This study should serve as a reminder of the importance of establishing trust between the pregnant woman and the caregiver, strengthening interpretation services and assuring tailored information is available to Somali women at an early stage. The findings further suggest that antenatal care for Somali women may be improved by offering continuity of care and improving clinical and cultural skills in clinicians. Suggestions for practice, and future research, include initiating group antenatal care especially tailored to Somali women.

Solo Mothers After Assisted Conception and Their Experiences with Postnatal Care.

PURPOSE: To explore solo mothers' postnatal caring experiences. PATIENTS AND METHODS: A qualitative interview study including nine solo mothers living in six different counties in Norway. The mothers had a total of twelve children conceived through assisted fertilization and donor sperm. Systematic text condensation was used to analyze the data. RESULTS: The first theme described how the decision to be a solo mother entailed responsibility and rendered solo mothers vulnerable. Secondly, it was valuable, but sometimes surprising, to be met with care and interest, but, and finally, bending standard rules and regulation of the postnatal ward proved necessary to fit the needs of solo mothers. CONCLUSION: Solo mothers see themselves as different from other mothers, and the results of this study underline that solo mothers' individual needs are not always met in postnatal care.

Emergency medical technicians' experiences with unplanned births outside institutions: A qualitative interview study.

AIM: To explore emergency medical technicians' experiences with unplanned births outside institutions. DESIGN: A qualitative interview study. METHODS: Individual semi-structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material. RESULTS: Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out-of-hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women.

Women's experiences with giving birth before arrival.

OBJECTIVE: To explore women's experiences with giving birth before arrival. DESIGN: A qualitative interview study. SETTING: Individual semi structured interviews with women from Western Norway conducted in their homes in 2015. PARTICIPANTS: 10 women who experienced BBA-births in 2014, or the beginning of 2015. Two primiparous and eight multiparous women participated in the study. KEY FINDINGS: Three themes were generated from the analysis. In the encounter with the healthcare services, the women described midwives as gatekeepers defining active labour. Giving birth before arrival was dramatic, but at some point fear of giving birth alone was replaced by feelings of coping, and in hindsight they felt empowered. The women described giving birth before arrival to be a special experience, but this was not always acknowledged by the midwives. CONCLUSION AND IMPLICATIONS FOR PRACTICE: The findings in this study question the cost-benefit of today's maternity care system pointing towards a more differentiated and decentralised care. To enhance patient safety adequate capacity of midwives in the maternity care is essential. Furthermore, good communication skills are key to improving practice and enhancing safety. Further research must be conducted.