Predictors of Pregnant Women's Decision to Opt for Cesarean Section in Romania.

INTRODUCTION: In Romania, the latest official report indicates that more than half of the births (80,890 cases, representing 52.88% of the total) are performed by cesarean, a rate significantly higher than the World Health Organization (WHO) recommendation of 15-20%. This study aims to identify the predictors associated with women's decisions to opt for cesarean in Romania. MATERIALS AND METHODS:  An analytical cross-sectional observational study was conducted in the general population of Romania. The study was carried out over the course of 2023, with a total duration of four months. During this period, researchers targeted pregnant women from various regions of the country, regardless of their place of residence, age, or education level. The primary data collection tool was a self-administered online questionnaire, distributed via Google Forms, an accessible and efficient platform that allows for automatic response collection. The questionnaire was distributed online, particularly on social media platforms frequented by pregnant women, such as Facebook, Instagram, and TikTok. RESULTS: A total of 1,301 participants were validated. Socio-demographic and clinical factors significantly influence women's decisions to give birth by cesarean. Among these participants, 435 expressed a preference for cesarean delivery. Key predictors include fear of pain and concern for the child's health. Fear of pain at birth is the first predictor in Romanian women to choose cesarean (OR=2.09; 95% CI: 1.62-2.68). Concerns about the child's health do not increase the likelihood of opting for a cesarean. CONCLUSION:  By utilizing valuable resources such as midwives and implementing strategies like birth plans, significant contributions can be made toward reducing the cesarean rate and improving the childbirth experience for women worldwide.

Exploring Factors Influencing Pregnant Women's Perceptions and Attitudes Towards Midwifery Care in Romania: Implications for Maternal Health Education Strategies.

BACKGROUND: Midwives are strong advocates for vaginal births. However, their visibility and accessibility are poorly perceived by women in Romania. Consequently, the women's options are limited to a single direction when pregnancy occurs, involving the family doctor, the obstetrician, and often an interventional technical approach at the time of birth. The aim of this research is to identify specific variables that affect the perceptions and attitudes of pregnant women towards the care provided by midwives. This knowledge could contribute to the development of more effective education and information strategies within maternal health services. METHODS: A cross-sectional observational analytical survey was conducted in Romania among pregnant women from the general population. Data were collected through a self-administered questionnaire, with informed consent obtained from each participating pregnant woman. The questionnaire was administered online using the cloud-based Google Forms platform and was available on the internet for seven months, from January to July 2023. The questionnaire was distributed through various media channels, both individually and in communication groups, in the form of a link. All questions were mandatory, and the questionnaire could only be submitted after answering all questions. RESULTS: A total of 1301 individual responses were collected. The analysis of the socio-demographic and obstetrical profile of the pregnant women revealed that approximately half, 689 (52.95%), of the participants were aged between 18-29 years, and 1060 (81.47%) of the participants were married. Among our group of 1301 pregnant women, 973 (74.78%) had higher education, and 987 (75.86%) had a regular job. A majority of the survey participants, 936 (71.94%), lived in an urban geographic area, while 476 (36.58%) had attended childbirth education courses, and 791 (60.79%) were in the third trimester of pregnancy. A total of 298 (22.9%) respondents did not want to give birth in a hospital, and one-third, 347 (26.67%), did not place significant importance on control over the childbirth process. CONCLUSIONS: The main factors influencing women's decisions regarding perinatal care and the importance of midwives as a component of the maternal-infant care team are modifiable, and thorough educational and psychological preparation would reduce the increasing predominance of preference for cesarean section, thereby promoting healthier and more woman- and child-centered perinatal care.

European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour - because words matter.

Substandard or disrespectful care during labour should be of serious concern for healthcare professionals, as it can affect one of the most important events in a woman's life. Substandard care refers to the use of interventions that are not considered best-practice, to the inadequate execution of interventions, to situations where best-practice interventions are withheld from patients, or there is lack of adequate informed consent. Disrespectful care refers to forms of verbal and non-verbal communication that affect patients' dignity, individuality, privacy, intimacy, or personal beliefs. There are many possible underlying causes for substandard and disrespectful care in labour, including difficulties in modifying behaviours, judgmental or paternalistic attitudes, personal interests and individualism, and a human tendency to make less arduous, less difficult, or less stressful clinical decisions. The term "obstetric violence" is used in some parts of the world to describe various forms of substandard and disrespectful care in labour, but suggests that it is mainly carried out by obstetricians and is a serious form of aggression, carried out with the intent to cause harm. We believe that this term should not be used, as it does not help to identify the underlying problem, its causes, or its correction. In addition, it is generally seen by obstetricians and other healthcare professionals as an unjust and offensive term, generating a defensive and less collaborative mindset. We reach out to all individuals and institutions sharing the common goal of improving women's experience during labour, to work together to address the underlying causes of substandard and disrespectful care, and to develop common strategies to deal with this problem, based on mutual comprehension, trust and respect.

EUROPEAN ASSOCIATION OF PERINATAL MEDICINE (EAPM) EUROPEAN MIDWIVES ASSOCIATION (EMA) Joint position statement: Caesarean delivery rates at a country level should be in the 15-20 % range.

While cesarean deliveries performed for health indications can save lives, unnecessary cesareans cause unjustifiable health risks for the mother, newborn, and for future pregnancies. Previous recommendations for cesarean delivery rates at a country level in the 10-15% range are currently unrealistic, and the proposed concept that striving to achieve specific rates is not important has resulted in a confusing message reaching healthcare professionals and the public. It is important to have a clear understanding of when cesarean delivery rates are deviating from internationally acceptable ranges, to trigger the implementation of healthcare policies needed to correct this problem. Based on currently existing scientific evidence, we recommend that cesarean delivery rates at a country level should be in the 15-20% range. This advice is based on the demonstration of decreased maternal and neonatal mortalities when national cesarean delivery rates rise to circa 15%, but values exceeding 20% are not associated with further benefits. It is also based on real-world experiences from northern European countries, where cesarean delivery rates in the 15-20% range are associated with some of the best maternal and perinatal quality indicators in the world. With the increase in cesarean delivery rates projected for the coming years, experience in provision of intrapartum care may come under threat in many hospitals, and recovering from this situation is likely to be a major challenge. Professional and scientific societies, together with healthcare authorities and governments need to prioritize actions to reverse the upward trend in cesarean delivery rates observed in many countries, and to strive to achieve values as close as possible to the recommended range.

Psychological profile and mood disturbance of women who gave birth during the COVID-19 pandemic in Romania.

OBJECTIVE: This study aimed to outline the emotional profile and the mood disturbance of women who gave birth during Emergency and Alert states in Covid-19 pandemic. METHODS: A cross-sectional study was carried out to investigate how the emergency and alert states due to Covid-19 affected the emotional profile and the mood disturbance of pregnant women who gave birth during these times. We included 244 postpartum women, divided into two groups: 124 women during the State of Emergency and another 120 women during the State of Alert. After expressing their informed consent, they completed an anonymous questionnaire that collected demographic data and the Profile of Mood States Questionnaire, as well as a follow-up survey. Data analysis was performed using the statistical program SPSS 24.0. RESULTS: Out of the 300 questionnaires distributed, we collected 244 valid questionnaires. 45.2% of State of Emergency group and 53.3% of State of Alert group experienced Anxiety, 16.9% of State of Emergency group, respectively 18.3% of State of Alert group, Depression, and 25% of State of Emergency group respectively 34.2% of State of Alert group, Distress. Compared to the ideal Iceberg profile, the emotional profile of both groups presented an inverted graph for Anxiety and Depression and much lower values for Vigor. Only 35.5% of State of Emergency group and 16.7% of State of Alert group received information concerning the virus, symptoms, and evolution of the disease from the specialists who monitored their pregnancy and 25.8% of State of Emergency group respectively 11.7% of State of Alert group received information about measures to prevent contamination and infection. Psycho-emotional and mood disturbance was more pronounced among State of Alert group. CONCLUSIONS: There was a significant psycho-emotional alteration of surveyed women during the pandemic, worsened by the radical measures of the State of Emergency and associated with the major deficiency of care services in supplying valid information and counseling for pregnant women's safety in the State of Alert. There is a highlighted need to pay more attention to the psychological profile of pregnant women and to modernize the health services in this field and adapt them to pandemic situations with the use of modern virtual techniques. In addition, the Romanian health care system should round off the team responsible for the care of mother and child with midwives, internationally recognized very skilled in informing, monitoring, counseling, and support in this field.

Pregnancy in Teenage Romanian Mothers.

Background and purpose Teenage pregnancy is associated with an increased risk of adverse pregnancy outcomes. The objective of this research is to determine the profile of the pregnant teenager and the medical complications associated with pregnancy at this young age. Materials and methods A cross-sectional study based on a 29-item questionnaire was conducted in 2019 and 2020 in Ploiești, Romania. The participants were divided into two groups, namely, Group A, consisting of 100 minor, teenage childbearing women under the age of 18, and Group B, consisting of 100 childbearing women over 18 years of age. Results Group A had a mean age of 16.56 ± 1.65. The percentage of births in very young girls (13-15 years) from group A is 28%. In 65 adolescents, sexual intercourse began at the age of 14. Pregnancy monitoring, expressed by the number of medical examinations, shows significant differences between the studied groups. The Short Assessment of Health Literacy (SAHL) test applied to both groups revealed a low level of health literacy in group A. Also in this group A, teenagers gave birth to low-birth-weight children, the percentage is statistically significant (14% vs. 4%). The gestational age in this group had an average of 36.88 ± 2.13 weeks, compared to the gestational age in the control group of 38.41 ± 1.57 weeks. In Romania, there are teenagers who became mothers at an early age. There should be educational programs in rural and urban schools and communities. Poverty leads to inadequate medical supervision with significant consequences for the health of the mother and child, lack of education (school dropout, illiteracy), and inability to find a job. The midwife can play a key role in rural communities through health education conducted on specific communication channels and with different forms of presentation of messages, adapted to their needs. A good target would be the parents of adolescent mothers and better communication with them.

Prenatal screening for Down syndrome: popularity, perceptions and factors associated with acceptance or refusal of testing.

BACKGROUND: Prenatal screening tests for aneuploidies have become increasingly used in maternal and fetal medicine. Given that all pregnancies associate a potential risk of Down syndrome, adequate knowledge of the tests, and their characteristics as well as facilitating decision-making autonomy are fundamental rights that must be respected. OBJECTIVES: Identification of the popularity of the tests, their perception and the factors associated with the acceptance or refusal to perform them. METHODS: A cross-sectional study was carried out in the South-East region of Romania, between April and September 2016. The data were collected from 275 postpartum women. The instrument used was a self-administered questionnaire and the data obtained were processed using the IBM SPSS 20.0 statistical software (IBM Corp., Armonk, NY, USA). The normality of the distribution was analyzed with Chi-square, Kolmogorov-Smirnov and Shapiro-Wilk tests. Factorial Analysis was carried out for the Principal Components of the scales for the reasons for performing and not performing. RESULTS: The 2nd Trimester Morphology had the popularity as well as the highest rate of accomplishment (98.2% respectively 67.6%) among the investigated women. It is also the preferred recommendation of the specialists (81.1%). The least popular test was the TPNI, only 13.1% of the participants heard about it, as it was recommended in only 2% of the situations. Most of the participants perceived the screening tests as essential and useful, but 43.3% considered that they become mandatory if the doctor recommends them. The acceptance of the child with DS and the misperception of the risk were the main factors associated with the refusal of the test and the compliance with the recommendation of the specialist (system confidence), and social influence (non-acceptance of the Down syndrome by the society) were the main factors associated with the acceptance. CONCLUSIONS: The number of women who made the decision to accept the test was greater than the ones who refused. The amendment is that acceptance was based on the custom of socio-economic-medical compliance and responsibility. For many women, the motivation of acceptance meant alignment with the normality directed by the society and the system. Even the popularity of the tests carries the imprint of the beliefs and values of the system and the specialists involved. For an adequate perception and an autonomous and informed choice of women, the screening program must include adequate information and communication services by involving specialists responsible for multidisciplinary competencies. The percentage of completion and the type of test performed almost perfectly align with the recommendations received.

Human Papillomavirus Infection at the Time of Delivery.

Human papillomavirus (HPV) is one of the most encountered viral etiologies of genital infections that are transmitted through the sexual route in sexually active females. In the genital area, condylomata acuminate warts and the Buschke-Loewenstein tumor (giant condyloma acuminatum) are described. These lesions are associated with benign HPV6 and HPV 11 types. Condylomata acuminate may appear as exophytic growth similar to a cauliflower and is usually asymptomatic. The Buschke-Loewenstein tumor appears as ulcerated cauliflower-like lesions, often associated with fistulas and abscesses. They present exophytic and endophytic growth, local invasion, and high recurrence rates. This type of lesion may be associated with malignant HPV types. Here we present the case of a 34-year-old year pregnant woman who presented herself at the emergency room in labor with no previous medical evaluation during the pregnancy. The local examination revealed normal pubic hair, vulvar hyperpigmentation, and tonic and continent anal sphincter. At the vulvar level, a bulky cauliflower-like formation appeared. All routine investigations were normal. Immunological tests revealed the presence of antibodies anti-HPV immunoglobulin M (IgM) and immunoglobulin G (IgG). Treponema pallidum hemagglutination (TPHA) and HIV tests were negative. Samples collected from the genital lesions tested positive for both 6 and 11 DNA/HPV. The patient was diagnosed with condylomata acuminate and C-section was indicated as the methodology of birth so HPV infection of the newborn was avoided. We believe that HPV infection during pregnancy must be documented and treated when detected in order to avoid transmitting it to the newborn baby in a manner similar to TORCH testing. In pregnant women and women that want to conceive, in order to avoid transmission of infectious diseases from the mother to the newborn baby, TORCH testing is recommended. TORCH represents an acronym that includes: toxoplasmosis, other infectious diseases, rubella, cytomegalovirus infection, and herpes simplex infection.

Teenage Pregnancies and Childbirth Experience in Romania From the Midwives Point of View.

In Romania, in 2017, the infant mortality rate was eight per thousand; with 41,000 women who had no medical visits during pregnancy; 18,500 were teenagers. Our objective was to analyze how many teen pregnancies were in an Obstetrics and Gynaecology Hospital from Romania over a two-year period and underline the role that midwives have in preventing teenage pregnancies. A descriptive study of a group of 343 childbearing teenagers out of 7020 childbearing women who gave birth in 2017-2018 is presented. The teenagers were evaluated by age, the number of pregnancies, birth complications, way of delivery, and place of origin. The involvement of the midwife was highlighted. From the total of 7020 analyzed cases, 4.8% (n=343) were teen pregnancies. Within this group, 4.37%(n=15)were already at the third birth and 89.79 (n=308)were un-investigated during the entire pregnancy. Sixty-eight point fifty-one percent (68.51%; n=235)of the teenagers gave birth with the aid of a midwife while 4.66 (n=16) gave birth with no medical attendance and experienced homebirth. All the teenagers that gave birth at home were from rural areas and not married. High teenage pregnancy rates are determined in Romania by the low level of information about sexuality and family planning at young ages. The midwives have the ability to help to resolve these problems if they were more allowed to be involved in these programs, especially in rural areas.

Attitude, knowledge and informed choice towards prenatal screening for Down Syndrome: a cross-sectional study.

BACKGROUND: Down Syndrome screening test is a bridge between knowledge and uncertainty, safety and risk, unpredictability and desire to know in order to gain control. It may be accepted either not to have a baby with Down syndrome, or to prepare to have a baby with this condition. Every woman should understand that it is an option and should be encouraged to make their own decisions based on information and personal values. The implications and possible subsequent scenarios differentiate this type of test from the common biochemical tests performed during pregnancy, of paramount importance being the right to make informed choices. The aim of this study was to investigate the knowledge and attitude towards prenatal Down syndrome screening in order to asses to what extent the Romanian women make informed choices in this area. METHODS: A cross-sectional study was carried out that included 530 postpartum women, clients of Romania' south-east region maternities, during April-September 2016. The level of knowledge and the attitude concerning the Down syndrome screening were evaluated using a questionnaire. Data were analyzed using SPSS version 20.0. RESULTS: 48.1% of the women have never heard about any tests for Down Syndrome and from those 51.9% who have heard, only 14.2% made an informed choice, 78.9% had a positive attitude for screening, 88% were classified as having insufficient knowledge and 68.3% made a value-consistent decision to accept or decline prenatal screening. A higher knowledge level was associated with a higher education level and the urban residence. The information satisfaction and confidence in the overall value of screening were predictive factors of positive attitude. More informed choices were made by women monitored by an obstetrician in a private practice. CONCLUSIONS: The prenatal screening tests for Down Syndrome were mostly unknown and the women who accepted or not to perform a test were insufficiently knowledgeable that means that the ethical concept of the informed choice wasn't followed. In our opinion the Romanian Health System needs to improve the antenatal policy by developing an adequate information strategy at the reproductive population level based on a network of trained specialists.