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.

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.

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.

Racism in public health services: A research agenda.

Despite racism and its impact on health inequities being increasingly studied in health care settings, racism in public health services has so far been neglected in public health research. Studying racism in public health services provides many opportunities to explore the relationship between racism and health protection. We identify several research themes to be explored on (1) non-stigmatizing and community-driven risk communication, (2) surveillance by public health authorities of racialized minority groups, (3) racism experiences in everyday interactions with public health authorities, (4) legal consequences of encounters with public health authorities and (5) public health infrastructure, structural racism and the intersectionality of marginalization. Tackling these research themes will help to start building an evidence base on how racism interferes with equitable health protection and how to dismantle it.

Corrigendum: How Can Schools of Public Health Actively Promote Peace?

[This corrects the article DOI: 10.3389/phrs.2021.1604459.].

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.

Decomposing intersectional inequalities in subjective physical and mental health by sex, gendered practices and immigration status in a representative panel study from Germany.

BACKGROUND: The mapping of immigration-related health inequalities remains challenging, since immigrant populations constitute a heterogenous socially constructed group whose health experiences differ by social determinants of health. In spite of the increasing awareness that population mobility and its effects on health are highly gendered, an explicit gender perspective in epidemiology is often lacking or limited. METHODS: To map inequalities in self-reported physical and mental health in Germany at the intersections of sex, gendered practices and immigration status, we used data from the German Socioeconomic Panel (SOEP) and applied an intercategorical intersectional approach conducting multilevel linear regression models. We differentiated between sex (male/female) as reported in the survey and gendered social practices, quantified through a gender score (on a femininity-masculinity continuum). RESULTS: We included 20,897 participants in our analyses. We saw an intersectional gradient for physical and mental health. Compared to the reference group, i.e. non-immigrant males with masculine gendered practices, physical and mental health steadily decreased in the intersectional groups that did not embody one or more of these social positions. The highest decreases in health were observed in the intersectional group of immigrant females with feminine gendered practices for physical health (-1,36; 95% CI [-2,09; -0,64]) and among non-immigrant females with feminine practices for mental health (-2,51; 95% CI [-3,01; -2,01]). CONCLUSIONS: Patterns of physical and mental health vary along the intersectional axes of sex, gendered practices and immigration status. These findings highlight the relevance of intersections in describing population health statuses and emphasise the need to take them into account when designing public health policies aiming at effectively reducing health inequalities.

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.

Development of a gender score in a representative German population sample and its association with diverse social positions.

Background: Gender as a relational concept is rarely considered in epidemiology. However, an in-depth reflection on gender conceptualisation and operationalisation can advance gender analysis in quantitative health research, allowing for more valid evidence to support public health interventions. We constructed a context-specific gender score to assess how its discriminatory power differed in sub-groups defined by social positions relevant to intersectional analyses, i.e., sex/gender, race, class, age and sexual attraction. Methods: We created a gender score with the help of multivariable logistic regression models and conditional probabilities based on gendered social practices and expressed on a masculinity-femininity continuum, using data of the German Socioeconomic Panel. With density plots, we exploratively compared distributions of gendered social practices and their variation across social groups. Results: We included 13 gender-related variables to define a gender score in our sample (n = 20,767). Variables on family and household structures presented with the highest weight for the gender score. When comparing social groups, we saw that young individuals, those without children, not living with a partner or currently living in a same-sex/gender partnership, showed more overlap between feminine/masculine social practices among females and males. Conclusions: The distribution of gendered social practices differs among social groups, which empirically backs up the theoretical notion of gender being a context-specific construct. Economic participation and household structures remain essential drivers of heterogeneity in practices among women and men in most social positions. The gender score can be used in epidemiology to support concerted efforts to overcome these gender (in)equalities-which are important determinants of health inequalities.

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.

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 .

Correction to: ASPHER statement on racism and health: racism and discrimination obstruct public health's pursuit of health equity.

Authors would like to correct the error in author names spotted in their original publication. Naomi Limaro corrected to Naomi Limaro NATHAN and Rhanjeet Dhonkal corrected to Ranjeet Dhonkal by this correction article.

Small-Area Factors and Their Impact on Low Birth Weight-Results of a Birth Cohort Study in Bielefeld, Germany.

Introduction: The location of residence is a factor possibly contributing to social inequalities and emerging evidence indicates that it already affects perinatal development. The underlying pathways remain unknown; theory-based and hypothesis-driven analyses are lacking. To address these challenges, we aim to establish to what extent small-area characteristics contribute to low birth weight (LBW), independently of individual characteristics. First, we select small-area characteristics based on a conceptual model and measure them. Then, we empirically analyse the impact of these characteristics on LBW. Material and methods: Individual data were provided by the birth cohort study "Health of infants and children in Bielefeld/Germany." The sample consists of 892 eligible women and their infants distributed over 80 statistical districts in Bielefeld. Small-area data were obtained from local noise maps, emission inventory, Google Street View and civil registries. A linear multilevel analysis with a two-level structure (individuals nested within statistical districts) was conducted. Results: The effects of the selected small-area characteristics on LBW are small to non-existent, no significant effects are detected. The differences in proportion of LBW based on marginal effects are small, ranging from zero to 1.1%. Newborns from less aesthetic and subjectively perceived unsafe neighbourhoods tend to have higher proportions of LBW. Discussion: We could not find evidence for negative effects of small-area factors on LBW, but our study confirms that obtaining adequate sample size, reliable measure of exposure and using available data for operationalisation of the small-area context represent the core challenges in this field of research.