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.

A History of the Midwifery Profession in the Republic of Croatia.

INTRODUCTION: It can be said that midwifery is as old as humankind because there has always been someone who accompanied women in childbirth. The purpose of this article is to present the history of midwifery on the present-day territory of the Republic of Croatia, from prehistoric ages to the present. METHOD: Historical methodologies were used for the study. An analysis of available literature and archives was carried out. RESULTS: For many centuries, midwifery was in the hands of formally uneducated but skilled women. Midwives had professional autonomy until the 1960s when obstetricians took full control of maternal care, and midwives became their assistants. DISCUSSION: Although midwives in the Republic of Croatia are more educated today than at any time in history, in practice, they do not have professional autonomy in the field of work that they are entitled to under Directive 2005/36/EC.

Women's perspectives on the quality of hospital maternal and newborn care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina.

OBJECTIVE: To assess the quality of maternal and newborn care (QMNC) in countries of the former Yugoslavia. METHOD: Women giving birth in a facility in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina between March 1, 2020 and July 1, 2021 answered an online questionnaire including 40 WHO standards-based quality measures. RESULTS: A total of 4817 women were included in the analysis. Significant differences were observed across countries. Among those experiencing labor, 47.4%-62.3% of women perceived a reduction in QMNC due to the COVID-19 pandemic, 40.1%-69.7% experienced difficulties in accessing routine antenatal care, 60.3%-98.1% were not allowed a companion of choice, 17.4%-39.2% reported that health workers were not always using personal protective equipment, and 21.2%-53.8% rated the number of health workers as insufficient. Episiotomy was performed in 30.9%-62.8% of spontaneous vaginal births. Additionally, 22.6%-55.9% of women received inadequate breastfeeding support, 21.5%-62.8% reported not being treated with dignity, 11.0%-30.5% suffered abuse, and 0.7%-26.5% made informal payments. Multivariate analyses confirmed significant differences among countries, with Slovenia showing the highest QMNC index, followed by Croatia, Bosnia-Herzegovina, and Serbia. CONCLUSION: Differences in QMNC among the countries of the former Yugoslavia during the COVID-19 pandemic were significant. Activities to promote high-quality, evidence-based, respectful care for all mothers and newborns are urgently needed. CLINICALTRIALS: gov Identifier: NCT04847336.

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.