Perinatal Outcomes and Level of Labour Difficulty in Deliveries with Right and Left Foetal Position-A Preliminary Study.

BACKGROUND: Many studies have shown the negative influence of the foetus's occiput posterior position during birth on the final perinatal outcome. This study aims to add to the discussion on the impact of foetus positioning on the course of labour and subjective assessment of the level of labour difficulty. METHODS: The cross-sectional study took place from February 2020 to September 2021, and consisted of filling out observation forms and the assessment by the midwives and women of the level of labour difficulty. This study is based on the observation of 152 labours in low-risk women. FINDINGS: When compared to left foetal positioning, labours in which the foetus was in the right position were longer and more frequently failed to progress (in 11.3% vs. 37.5%), and epidural was more frequently administrated (in 30.4% vs. 52.7%). Both women and midwives subjectively evaluated deliveries with a foetus in the right position as more difficult. CONCLUSIONS: The right positioning of the foetus was related to greater labour difficulty and worse perinatal outcomes. The position of the foetus' head in relation to the pelvis should be considered as an indicator of the difficulty of labour and a support plan for the woman should be offered accordingly.

A jump into the deep end - Women's strategies on the way to VBAC in Poland.

PROBLEM: In Poland, as in other high-income countries, the rate of caesarean sections (CS) is alarmingly high. Promoting vaginal birth after caesarean section (VBAC) is one of the ways that may help to decrease CS rate. Despite the recommendations by the Polish Association of Gynaecologists and Obstetricians that one previous CS should not be an indication for a subsequent one and VBAC should be promoted, the rate of VBAC in Poland remains low. BACKGROUND: Research shows that in countries with high VBAC rates women felt supported by healthcare personnel to have VBAC. AIM: This study aims to explore the elements of Polish maternity services that contribute to or hinder women's chances of having a VBAC. METHODS: The study used qualitative methods of research based on semi-structured interviews. We interviewed 22 women. Each woman was interviewed twice, once during pregnancy and then between 6 and 12 weeks after she had given birth. FINDING: Women who planned vaginal birth after one previous CS engaged in various strategies such as seeking supportive personnel, opting for fee-for-service dedicated midwifery care or traveled long distances to give birth in facilities supporting VBAC. CONCLUSIONS: Polish maternity services do not support women on the way to vaginal birth after surgery. Access to VBAC in Poland is highly unequal and dependent on women's social and financial resources such as access to private care, place of residence, or social relationships. Efforts should be made to make access to VBAC more universal.

Using Robson classification to analyze cesarean section and induction rates in relation to changes in the standards of perinatal care in one hospital in Poland.

BACKGROUND: Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten-Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions. METHODS: We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time. RESULTS: The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period. CONCLUSIONS: The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct.

Investment in the peace of mind? How private services change the landscape of maternity care in Poland.

For over two decades midwifery research advocated for the continuity of care and the ability to establish a relationship between care providers and care users as an important features of quality maternity services. In many countries, while unavailable through public services, continuity of care became commercialized and can be access as a private service. In Poland, private prenatal consultations and dedicated midwifery care allow women to access continuity and establish personal relationships with care providers. In this study, we explore, how accessing these private services, impact the rates of medical interventions and type of care women receive during labour and birth. We analyse data collected through an online questionnaire from 4402 first-time mothers in healthy pregnancy who had given birth in Poland between 2020 and 2021. We show that while private consultation did not translate into any significant differences in care, women who accessed private dedicated midwifery services experienced more attentive and less medicalized care, namely were more likely to give birth in vertical position, move freely during labour and less likely to experience emergency caesarean section. However, private dedicated midwifery care did not shield them from negative experience. While private care offers benefits for women who can afford it, it also contributes to inequalities in access to quality care and puts women with less social and financial resources in a vulnerable position. Efforts should be made to develop a more universal and equitable model of care that allows for building personal relationships between maternity care providers and women.

Parental experiences of prenatal education when preparing for labor and birth of infant with a lethal diagnosis.

AIM: The aim of this study was to describe the unique experiences of parents facing a Life Limiting Fetal Conditions (LLFC) diagnosis, who chose to continue with their pregnancy, as they prepare for childbirth through individual and group prenatal education. DESIGN: A qualitative study. METHODS: We employed the phenomenological approach and the Colaizzi strategy to analyse semi-structured interviews. Thirteen persons were interviewed. The participants were couples (n = 6) and women (n = 7) who received LLFC and were preparing for birth. RESULTS: We described three main paths of prenatal education chosen by parents with LLFC: 'Searching for normality' concerned people participating in conventional prenatal classes (AC) who tried to avoid confronting the situation they faced; 'Searching for communitas' concerned the participation in special AC selected for the opportunity of sharing experiences; 'Searching for an individual way' concerned people who resorted to individual preparation for childbirth, often as a result of delayed planning. Parents should have a choice of various paths of birth preparation, that best meet their preferences.

Cooperation between midwives and doulas in the context of perinatal care - a integrative review of qualitative and quantitative studies.

BACKGROUND: A doula is a person who provides support to women in the perinatal period without providing medical services. During childbirth, the doula becomes a member of the interdisciplinary team. This integrative review aims to analyse the nature of the cooperation between doulas and midwives, its efficiency and challenges and ways of strengthening this cooperation. METHODS: A structured integrative review of empirical and theoretical studies written in English was conducted. The literature search included MEDLINE, Cochrane, Scopus, ProQuest, Science Direct, Web of Science, and Embase Health Source: Nursing/Academic Edition databases. The analysis included papers published in 1995-2020. Dedicated documents were searched for different combinations of terms and standard logical operators. A manual search of the studies was included for additional references. RESULTS: Twenty-three articles from 75 full-text records were analysed. Three main themes emerged. (1) doulas are needed to prop up the system (2) barriers in collaboration between midwives and doulas; and (3) how cooperation between midwives and doulas can be strengthened. None of the articles referred directly to the impact of collaboration between midwives and doulas on the quality of perinatal care. CONCLUSION: This is the first review to analyse the impact of collaboration between midwives and doulas on the quality of perinatal care. Ensuring adequate collaboration between doulas and midwives requires effort from both of these professional groups and the health care system. However, such collaboration is supportive for birthing women and the perinatal care system. Further research in terms of the impact of this collaboration on the quality of perinatal care is needed.

"This pregnancy makes sense": Experiences of women who have decided to continue pregnancy after lethal fetal diagnosis.

Lethal fetal diagnosis defines severe developmental disorders that lead to the death of a fetus or newborn. Using semi-structured interviews, we explored the experiences of women in Poland who actively decided to continue with the pregnancy after diagnosis. We thematically analyzed data collected from 10 women. We identified four themes: pregnancy as an experience of prenatal motherhood; the child as person; birth as encounter and farewell; and the mother experience in retrospect. This study was conducted while the termination of pregnancy due to the irreversible fetal abnormality was legal in Poland. Since October 2021, it is no longer legal.

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.

Prevalence and factors associated with postpartum pelvic girdle pain among women in Poland: a prospective, observational study.

BACKGROUND: Pelvic girdle pain (PGP) is a type of pregnancy-related lumbopelvic pain. This study aimed to examine the prevalence, severity, and factors associated with postpartum PGP in a selected group of postpartum women in Poland. METHODS: This was a prospective, observational study. In phase 1, 411 women were recruited 24-72 h postpartum. The prevalence of PGP was assessed by a physiotherapist using a series of dedicated tests. Pelvic floor muscle function and presence of diastasis recti were assessed via palpation examination. Age, education, parity, mode of delivery, infant body mass, body mass gain during pregnancy, the use of anesthesia during delivery and were recorded. In a phase 2, 6 weeks postpartum, the prevalence of PGP and its severity were assessed via a self-report. RESULTS: In phase 1 (shortly postpartum), PGP was diagnosed in 9% (n = 37) of women. In phase 2 (6 weeks postpartum), PGP was reported by 15.70% of women (n = 42). The univariable analyses showed a higher likelihood of PGP shortly postpartum in women who declared PGP during pregnancy (OR 14.67, 95% CI 4.43-48.61) and among women with abdominal midline doming (OR 2.05, 95% CI 1.04-4.06). The multivariable regression analysis showed significant associations in women with increased age (OR 1.12, 95% CI 1.01-1.21) and declaring PGP during pregnancy (OR 14.83, 95% CI 4.34-48.72). CONCLUSION: Although the prevalence of postpartum PGP among women in Poland is lower than reported in other countries, it is experienced by almost every tenth women shortly postpartum and every sixth can report similar symptoms 6 weeks later. Age, PGP during pregnancy and abdominal midline doming were associated with experiencing PGP shortly postpartum.

"I knew there has to be a better way": Women's pathways to freebirth in Poland.

BACKGROUND: Each year a small number of women decide to birth at home without midwifery and medical assistance despite the availability of maternity services in the country. This phenomenon is called freebirth and can be used as a lens to look into shortcomings of maternity care services. AIM: By exploring women's pathways to freebirth, this article aims to examine the larger context of maternity services in Poland and identify elements of care contributing to women's decision to birth without midwifery and medical assistance. METHODS: A qualitative methodology was used employing elements of ethnographic fieldwork, including digital ethnography. Semi-structured interviews with twelve women who freebirth, analysis of online support groups, secondary sources of information and elements of participant observation were used. FINDINGS: Women's decisions to freebirth were born out of their previous negative experiences with maternity care. Persistent use of medical technology and lack of respect from maternity care providers played a major role in pushing women away from available Polish maternity services. While searching for a better environment for themselves and their babies for the subsequent births, women experienced a rigidity of both mainstream and homebirth services and patchy availability of the latter that contributed to their decisions to freebirth. CONCLUSIONS: Freebirth appears to be a consequence of inadequate maternity services both mainstream and homebirth rather than a preference. Women's freebirth experiences can be used to improve maternity care in Poland and inform similar contexts globally.

Oxytocin administration for induction and augmentation of labour in polish maternity units - an observational study.

BACKGROUND: There is not enough data regarding practices and protocols on the dose of oxytocin administrated to women during labour. Empirical evidence indicates that compliance with the guidelines improves the quality of healthcare and reduces adverse effects. The study aimed to evaluate practices of oxytocin provision for labour induction and augmentation in two maternity units in Poland. METHODS: The article presents a prospective observational study. Data from 545 (n = 545) labours was collected in two maternity units. First, the total dose (the total amount of oxytocin provided from the beginning in the labour ward until delivery including the III and IV stage of labour) and cumulative dose of oxytocin (the amount of oxytocin given until the birth of the neonate) administered to women during labour was calculated. Then, the relationship between the cumulative dose of oxytocin and short term perinatal outcomes (mode of delivery, use of epidural anaesthesia, Apgar scores, birth weight and postpartum blood loss) was analysed. Finally, the compliance of oxytocin supply during labour with national guidelines in the following five criteria: medium, start dose, escalation rate, interval, the continuation of infusion after established labour was examined. RESULTS: The average cumulative dose of oxytocin administrated to women before birth was 4402 mU following labour induction and 2366 mU following labour augmentation. The actual administration of oxytocin deviated both from the unit and national guidelines in 93.6% of all observed labours (mainly because of continuation of infusion after established labour). We found no statistically significant correlation between the cumulative dose of oxytocin administered and mode of delivery, immediate postpartum blood loss or Apgar scores. There was no observed effect of cumulative dose oxytocin on short-term perinatal outcomes. The two units participating in the study had similar protocols and did not differ significantly in terms of total oxytocin dose, rates of induction and augmentation - the only observed difference was the mode of delivery. CONCLUSIONS: The study showed no effect of the mean cumulative oxytocin dose on short-term perinatal outcomes and high rate of non-compliance of the practice of oxytocin administration for labour induction and augmentation with the national recommendations. Cooperation between different professional groups of maternity care providers should be considered in building national guidelines for maternity care.. Further studies investigating possible long-term effects of the meant cumulative dose of oxytocin and the reasons for non-compliance of practice with guidelines should be carried out.

Health Care Providers' Perceptions of Quality of Childbirth and Its Associated Risks in Poland.

OBJECTIVE: To describe Polish maternity care providers' cognitive frames of quality of childbirth and how they relate to providers' perceptions of childbirth using Baranowska's model of quality of care. DESIGN: Mixed-methods, cross-sectional. SETTING: Twenty-four hospitals and outpatient clinics that provide maternity care located in two central districts of Poland. PARTICIPANTS: Obstetricians or resident physicians in obstetrics (n = 50) and midwives (n = 676) who were actively engaged in the provision of maternity care. METHODS: Participants completed a survey that included two tasks. The first was a sentence completion technique that we used as a projective method to investigate participants' preconceived attitudes about quality of childbirth. Depending on the number of perspectives (as in Baranowska's model) included in the statements, participants' perceptions were categorized as strongly narrowed (zero perspectives), narrow (one perspective), intermediate (two perspectives), or holistic (three perspectives). In the second task, we asked participants to choose one statement out of three that best represented their beliefs about childbirth. RESULTS: Participants had mostly intermediate (n = 436, 60%) or narrow (n = 183, 25%) perceptions of quality of childbirth. Those with less work experience tended to have more encompassing perspectives. More than half of the participants perceived childbirth as a physiologic process requiring no medical interventions (n = 385, 53%). Only 9% (n = 65) of the participants reported that childbirth is always associated with great risk. There was a main effect of work experience on the number of perspectives included in the definition of quality of childbirth with F(2, 720) = 5.532, p = .004. Participants with less work experience included more perspectives in their statements. There were no statistically significant differences in the perception of quality of childbirth between obstetricians and midwives, with F(1, 724) = .000, p = 0.991, or between participants from different workplaces, with F(3, 719) = 1.742, p = .157. CONCLUSION: Only a small share of participants had holistic perceptions of quality of childbirth consistent with Baranowska's model. This may not only contribute to the medicalization of maternity care in Poland, but it also contrasts with participants' declarations that childbirth is a physiologic process with no need for medical interventions. Considering the greater rates of medical interventions in maternity care in Poland, the latter finding requires further research.

Private Services and the Fragmentation of Maternity Care in Poland.

As a result of reforms aimed at adjusting it to the market economy, the Polish health care system has become a complicated mix of public and private services. Using as an example maternity services, I show how private services allow a subtle process of patient selection to emerge, contributing to the fragmentation of public care. The process of selection is based on social relations formed between health care providers and patients through the use of private services. This has a negative impact on women who do not have the social or financial resources to engage in private services.W wyniku reform majacych na celu dostosowanie do gospodarki rynkowej, opieka zdrowotna w Polsce przeksztalcona zostala w skomplikowana mieszanine uslug publicznych i prywatnych. Na podstawie swiadczen polozniczych, pokazuje, w jaki sposób prywatne uslugi zdrowotne staly sie "oknami" pozwalajacymi na subtelna selekcje pacjentów. Selekcja ta oparta jest na relacjach spolecznych nawiazywanych pomiedzy lekarzem/polozna a pacjentka przy okazji korzystania z prywatnych uslug i prowadzi do fragmentaryzacji opieki publicznej. Proces ten szczególnie negatywnie wplywa na kobiety, których zasoby spoleczne i finansowe nie pozwalaja na korzystanie z prywatnych uslug zdrowotnych.

Polish maternity services in times of crisis: in search of quality care for pregnant women and their babies.

The current COVID-19 pandemic put a burden on healthcare services around the globe and impacted many areas of care delivery, including maternity services. Prioritizing ringfenced community care to keep women away from hospitals may be the best strategic response to ensure pregnant and laboring women receive optimal care. By analyzing the structure of maternity services in Poland and their response to the current crisis, we show that while the available model allows to provide large share of prenatal services outside hospital settings, it allows no alternative to hospital births. In addition, medicalization, inequalities in access and fragmentation of care hinder services' ability to respond in a way it ensures best possible care.