Abstract
Background and Problem
Aim
Methods
Findings
Conclusion
Abbreviations:
CS (Caesarean section), COVID-19 (Coronavirus disease 2019), IMAgINE-Euro (Improving Maternal Newborn Care in Europe), QMNC (Quality of maternal and newborn care), WHO (World Health Organization)Keywords
1. Introduction
Mödrahälsovård, Sexuell och Reproduktiv Hälsa – SFOG. Available at: https://www.sfog.se/natupplaga/ARG76web4a328b70-0d76-474e-840e-31f70a89eae9.pdf [Accessed 10 Aug 2021].
Mödrahälsovård, Sexuell och Reproduktiv Hälsa – SFOG. Available at: https://www.sfog.se/natupplaga/ARG76web4a328b70-0d76-474e-840e-31f70a89eae9.pdf [Accessed 10 Aug 2021].
World Health Organization. Global strategy for women’s, children’s and adolescent’s health 2016-2030. Available: http://www.who.int/life-course/partners/global-strategy/global-strategy-2016-2030/en/ [Accessed 10 Aug 2021].
- Lazzerini M.
- Covi B.
- Mariani I.
- Drglin Z.
- Arendt M.
- Nedberg I.H.
- et al.
2. Participants, methods and ethics
2.1 Study design and participants
IMAgiNE EURO Improving Maternal Newborn Care in the European Region. Available at: https://www.burlo.trieste.it/ricerca/imagine-euro-improving-maternal-newborn-care-euro-region (Accessed 10 Aug, 2021).
2.2 Data collection tool
- World Health Organization Regional office for Europe
- World Health Organization Regional office for Europe
National Institute of Health and Care Excellence (NICE). Intrapartum care for healthy women and babies. (NICE clinical guideline 190). Published: 01/12/2014. Available at https://www.nice.org.uk/guidance/cg190/resources/intrapartum-care-for-healthy-women-and-babies-pdf-35109866447557 (Accessed 10 Aug 2021).
2.3 Statistical analyses
3. Results
Total women, N = 5003 n (%, 95%CI) | Women who underwent labour, N = 4528 n (%, 95%CI) | Women with prelabour Caesarean section, N = 475 n (%, 95%CI) | P value | ||
---|---|---|---|---|---|
Year of giving birth | 2020 | 4290 (85.7, 84.2−86.1) | 3894 (86.0, 85−87) | 396 (83.4, 80.0−86.7) | 0.462 |
2021 | 446 (8.9, 8.1−9.7) | 408 (9.0, 8.2−9.8) | 38 (8.0, 5.6−10.4) | 0.119 | |
Missing | 267 (5.3, 4.7−6.0) | 226 (5.0, 4.4−5.6) | 41 (8.6, 6.1−11.2) | 0.001 | |
Mother born in Sweden | Yes | 4416 (88.3, 87.3−89.1) | 4015 (88.7, 87.7−89.6) | 401 (84.4, 81.2−87.7) | 0.006 |
No | 337 (6.7, 6.0−7.4) | 302 (6.7, 5.9−7.4) | 35 (7.4, 5.0−9.7) | 0.563 | |
Missing | 250 (5.0, 4.4−5.6) | 211 (4.7, 4.0−5.3) | 39 (8.2, 5.7−10.7) | 0.001 | |
Age (years) | 18−24 | 243 (4.9, 4.3−5.4) | 231 (5.1, 4.5−5.7) | 12 (2.5, 1.1−3.9) | 0.013 |
25−30 | 2082 (41.6, 40.2−42.9) | 1941 (42.9, 41.4−44.3) | 141 (29.7, 25.6−33.8) | <0.001 | |
31−35 | 1838 (36.7, 35.4−38.0) | 1644 (36.3, 34.9−37.7) | 194 (40.8, 36.4−45.3) | 0.051 | |
36−39 | 482 (9.6, 8.8−10.4) | 418 (9.2, 8.4−10.1) | 64 (13.5, 10.4−16.5) | 0.003 | |
≥40 | 111 (2.2, 1.8−2.6) | 86 (1.9, 1.5−2.3) | 25 (5.3, 3.3−7.3) | <0.001 | |
Missing | 247 (4.9, 4.3−5.5) | 208 (4.6, 4.0−5.2) | 39 (8.2, 5.7−10.7) | 0.001 | |
Educational level | None | 3 (0.1, 0.0−0.1) | 3 (0.1, 0.0−0.1) | 0 (0.0, 0.0−0.0) | >0.999 |
Elementary school | 2 (0.0, 0.0−0.1) | 1 (0.0, 0.0−0.1) | 1 (0.2, 0.0−0.6) | 0.181 | |
Junior High school | 64 (1.3, 1.0−1.6) | 54 (1.2, 0.9−1.5) | 10 (2.1, 0.8−3.4) | 0.092 | |
High School | 1258 (25.1, 23.9−26.3) | 1144 (25.3, 24.0−26.5) | 114 (24.0, 20.2−27.8) | 0.545 | |
University degree | 2712 (54.2, 52.8−55.5) | 2470 (54.5, 53.1−56.0) | 242 (50.9, 46.5−55.4) | 0.134 | |
Postgraduate degree / Master /Doctorate or higher | 716 (14.3, 13.3−15.3) | 647 (14.3, 13.3−15.3) | 69 (14.5, 11.4−17.7) | 0.888 | |
Missing | 248 (5.0, 4.4−5.6) | 209 (4.6, 4.0−5.2) | 39 (8.2, 5.7−10.7) | 0.001 | |
Parity | 1 | 2820 (56.4, 54.9−57.7) | 2603 (57.5, 56.0−58.9) | 217 (45.7, 41.2−50.2) | <0.001 |
>1 | 1935 (38.7, 37.3−40.0) | 1716 (37.9, 36.5−39.3) | 219 (46.1, 41.6−50.6) | <0.001 | |
Missing | 248 (5.0, 4.4−5.6) | 209 (4.6, 4.0−5.2) | 39 (8.2, 5.7−10.7) | 0.001 | |
Type of health care providers who directly assisted childbirth | Midwife | 4684 (93.6, 92.8−94.2) | 4270 (94.3, 93.6−95.0) | 414 (87.2, 84.1−90.2) | <0.001 |
Nurse | 2236 (44.7, 43.3−46) | 1901 (42.0, 40.5−43.4) | 335 (70.5, 66.4−74.6) | <0.001 | |
A student (i.e. before graduation) | 1480 (29.6, 28.3−30.8) | 1370 (30.3, 28.9−31.6) | 110 (23.2, 19.4−27.0) | 0.002 | |
Obstetrics registrar / medical resident (under post-graduation training) | 844 (16.9, 15.8−17.9) | 656 (14.5, 13.5−15.5) | 188 (39.6, 21.0−28.7) | <0.001 | |
Obstetrics and Gynaecology doctor | 1451 (29.0, 27.7−30.2) | 1139 (25.2, 23.9−26.4) | 312 (65.7, 61.4−70.0) | <0.001 | |
I don’t know (health care providers did not introduce themselves) | 354 (7.1, 6.4−7.8) | 312 (6.9, 6.2−7.6) | 42 (8.8, 6.3−11.4) | 0.138 | |
Other | 1299 (26.0, 24.7−27.2) | 1169 (25.8, 24.5−27.1) | 130 (27.4, 23.4−31.4) | 0.497 | |
Which type of student assisted childbirth? | Midwife student | 1041 (20.8, 19.7−21.9) | 1012 (22.3, 21.1−23.6) | 29 (6.1, 4.0−8.3) | <0.001 |
Nurse student | 102 (2.0, 1.6−2.4) | 88 (1.9, 1.5−2.3) | 14 (2.9, 1.4−4.5) | 0.193 | |
Medical student | 337 (6.7, 6.0−7.4) | 270 (6.0, 5.3−6.7) | 67 (14.1, 11.0−17.2) | <0.001 | |
Birth mode | Vaginal spontaneous | 3736 (74.7, 73.4−75.8) | – | – | – |
Instrumental vaginal birth | 369 (7.4, 6.6−8.1) | – | – | – | |
Emergency Caesarean section during labour | 423 (8.5, 7.7−9.2) | – | – | – | |
Emergency Caesarean section before going into labour | 173 (3.5, 2.9−4.0) | – | – | – | |
Elective Caesarean section | 302 (6.0, 5.4−6.7) | – | – | – |

Provision of careb | n (%) | Experience of careb | n (%) | Availability of human and physical resourcesb | n (%) | COVID-19 pandemic | n (%) |
---|---|---|---|---|---|---|---|
N | 4528 | N | 4528 | N | 4528 | N | 4528 |
No pain relief in labour | 327 (7.2) | No liberty of movements in labour | 961 (21.2) | No timely care by health care providers at hospital arrivala | 483 (10.7) | Difficulties in antenatal care | 1352 (29.9) |
2a. Simple vaginal birth | 3736 (82.5) | No choice of birth position (vaginal birth) | 1321/3736 (35.4) | No maternal danger signs information | 2375 (52.5) | Access barriers | 1201 (26.5) |
2b. Instrumental vaginal birth | 369 (8.1) | No consent requested (instrumental vaginal birth) | 133/369 (36.0) | No newborn danger signs information | 2934 (64.8) | Inadequate info graphics | 230 (5.1) |
2c. Caesarean section (CS) | 423 (9.3) | No information on newborn (emergency CS) | 183/423 (43.3) | Bad room comfort and equipment | 315 (7.0) | Inadequate wards reorganisation | 1754 (38.7) |
3a. Episiotomy (vaginal birth) | 242/3736 (6.5) | No clear/effective communication | 1199 (26.5) | Inadequate number of women per rooms | 435 (9.6) | Inadequate room reorganisation | 1424 (31.4) |
3b. Fundal pressure (instrumental vaginal birth) | 82/369 (22.2) | No involvement in choices | 1387 (30.6) | Bad room cleaning | 278 (6.1) | Inadequate hand-washing station | 202 (4.5) |
3c. No pain relief after CS | 96/423 (22.7) | Limited companionship hours | 2297 (50.7) | Bathroom inadequacy | 500 (11.0) | Health care providers not always use personal protective equipment | 2828 (62.5) |
No skin to skin | 131 (2.9) | Not treated with dignity | 833 (18.4) | Inadequate partner visiting hours | 2452 (54.2) | Number of health care providers inadequate | 1651 (36.5) |
No early breastfeeding | 338 (7.5) | No emotional support | 910 (20.1) | Number of health care providers inadequate | 1123 (24.8) | Inadequate communication | 1765 (39.0) |
Inadequate breastfeeding support | 1666 (36.8) | No privacy | 717 (15.8) | Lack of professionality by health care providers | 230 (5.1) | Reduction in quality of maternal and newborn care due to COVID-19 | 2113 (46.7) |
No rooming-in | 764 (16.9) | Abuse (physical/verbal/emotional) | 311 (6.9) | ||||
Not allowed to stay with the baby as wished | 437 (9.7) | Informal payment | 6 (0.1) | ||||
No exclusive breastfeeding at discharge | 1144 (25.3) | ||||||
No immediate attention when needed | 1373 (30.3) |
Provision of care | n (%) | Experience of care | n (%) | Availability of human and physical resources | n (%) | COVID-19 pandemic | n (%) |
---|---|---|---|---|---|---|---|
N | 475 | N | 475 | N | 475 | N | 475 |
Type of Caesarean section (CS) | No vaginal examination consent request | 57 (12.0) | No maternal danger signs information | 262 (55.2) | Difficulties in antenatal care | 161 (33.9) | |
1a. Emergency CS before labour | 173 (36.4) | No information on newborn (CS) | 164 (34.5) | No newborn danger signs information | 310 (65.3) | Access barriers | 161 (33.9) |
1b. Prelabour CS | 302 (63.6) | No clear/effective communication | 180 (37.9) | Bad room comfort and equipment | 62 (13.1) | Inadequate info graphics | 27 (5.7) |
No pain relief after CS | 95 (20.0) | No involvement in choices | 196 (41.3) | Inadequate number of women per rooms | 23 (4.8) | Inadequate wards reorganisation | 214 (45.1) |
No skin to skin | 79 (16.6) | Limitations in companionship | 246 (51.8) | Bad room cleaning | 39 (8.2) | Inadequate room reorganisation | 141 (29.7) |
No early breastfeeding (within 2 h of birth) | 100 (21.1) | Not treated with dignity | 133 (28.0) | Bathroom inadequacy | 52 (10.9) | Inadequate hand-washing station | 24 (5.1) |
Inadequate breastfeeding support | 219 (46.1) | No emotional support | 132 (27.8) | Inadequate partner visiting hours | 265 (55.8) | Health care professionals not always use personal protective equipment | 311 (65.5) |
No rooming-in | 90 (18.9) | No privacy | 87 (18.3) | Number of health care professions inadequate | 124 (26.1) | 8. Number of health care professions inadequate | 193 (40.6) |
Not allowed to stay with the baby as wished | 50 (10.5) | Abuse (physical/verbal/emotional) | 44 (9.3) | Lack of professionality by health care professionals | 27 (5.7) | Inadequate communication | 227 (47.8) |
No exclusive breastfeeding at discharge | 213 (44.8) | Informal payment | 0 (0) | Inadequate wards reorganisation | 214 (45.1) | Reduction in quality of maternal and newborn care due to COVID-19 | 239 (50.3) |
No immediate attention when needed | 204 (42.9) | ||||||
No timely care by health care professionals at hospital arrival | 50 (10.5) |
Provision of care | Adj OR (95% CI) | P-value | Experience of care | Adj OR (95% CI) | P-value | Availability of human and physical resources | Adj OR (95% CI) | P-value | COVID-19 pandemic | Adj OR (95% CI) | P-value |
---|---|---|---|---|---|---|---|---|---|---|---|
3c. No pain relief after CS | 0.9 (0.6; 1.2) | 0.381 | 2c. No information on newborn (ECS) | 0.7 (0.5; 0.9) | 0.028 | No timely care by health care providers at hospital arrival | 0.9 (0.7; 1.3) | 0.683 | 1. Difficulties in antenatal care | 1.3 (0.9; 1.5) | 0.054 |
No skin to skin | 7.3 (5.2; 10.1) | <0.001 | No clear/effective communication | 1.7 (1.4; 2.2) | <0.001 | No maternal danger signs information | 1.1 (0.9; 1.4) | 0.106 | 2. Access barriers | 1.4 (1.1; 178) | 0.006 |
No early breastfeeding | 3.5 (2.7; 4.6) | <0.001 | No involvement in choices | 1.6 (1.3; 2.0) | <0.001 | No newborn danger signs information | 1.1 (0.9; 1.3) | 0.528 | 3. Inadequate info graphics | 1.0 (0.8; 1.3) | 0.955 |
Inadequate breastfeeding support | 1.7 (1.3; 2.0) | <0.001 | Limited companionship hours | 1.1 (0.9; 1.3) | 0.361 | Bad room comfort and equipment | 2.1 (1.5; 2.8) | <0.001 | Inadequate wards reorganisation | 1.4 (1.1; 1.7) | 0.002 |
No rooming-in | 1.2 (0.9; 1.5) | 0.152 | Not treated with dignity | 1.8 (1.4; 2.2) | <0.001 | Inadequate number of women per rooms | 0.5 (0.3; 0.8) | 0.001 | Inadequate room reorganisation | 0.9 (0.7; 1.1) | 0.327 |
Not allowed to stay with the baby as wished | 0.98 (0.7; 1.4) | 0.927 | No emotional support | 1.5 (1.2; 1.9) | <0.001 | Bad room cleaning | 1.4 (0.9; 2.0) | 0.109 | Inadequate hand-washing station | 1.2 (0.8; 1.9) | 0.462 |
No exclusive breastfeeding at discharge | 2.5 (2.0; 3.1) | <0.001 | No privacy | 1.2 (0.9; 1.6) | 0.136 | Bathroom inadequacy | 1.0 (0.7; 1.4) | 0.887 | Health care providers not always use personal protective equipment | 1.3 (1.0; 1.6) | 0.024 |
No immediate attention when needed | 1.8 (1.5; 2.3) | <0.001 | Abuses (physical /verbal /emotional) | 1.5 (1.1; 2.1) | 0.021 | Inadequate partner visiting hours | 1.2 (0.9; 1.5) | 0.084 | Number of health care providers inadequate | 1.3 (1.0; 1.6) | 0.016 |
Informal payment | NA | NA | Number of health care professionals inadequate | 1.2 (0.9; 1.5) | 0.186 | Inadequate communication | 1.5 (1.3; 1.9) | <0.001 | |||
Lack of professionality by health care providers | 1.2 (0.8; 1.7) | 0.480 | Reduction in quality of maternal and newborn care due to COVID-19 | 1.2 (1.0; 1.5) | 0.027 |
25th percentile | 50th percentile (median) | 75th percentile | ||||
---|---|---|---|---|---|---|
Coefficient (95%CI) | P- value | Coefficient (95%CI) | P- value | Coefficient (95%CI) | P- value | |
Age | ||||||
18−24 | −5 (−12.5; 2.5) | 0.194 | −5 (−11.7; 1.7) | 0.141 | 1.1 (−5; 7.2) | 0.720 |
25−30 | Ref | Ref | Ref | |||
31−35 | 5 (0.6; 9.4) | 0.026 | 0 (−2.6; 2.6) | >0.999 | 1.7 (−1.1; 4.4) | 0.235 |
36−39 | 7.5 (3.3; 11.7) | 0.001 | 5 (−0.4; 10.4) | 0.067 | 5 (1.4; 8.6) | 0.006 |
≥40 | 7.5 (−1.8; 16.8) | 0.114 | 0 (−8.3; 8.3) | >0.999 | 1.7 (−4.1; 7.4) | 0.572 |
Mother born in Sweden | ||||||
Yes | Ref | Ref | Ref | |||
No | −2.5 (−10; 5) | 0.514 | −5 (−11.2; 1.2) | 0.114 | 0 (−4.8; 4.8) | >0.999 |
Year of giving birth | ||||||
2020 | Ref | Ref | Ref | |||
2021 | 15 (9.3; 20.7) | <0.001 | 10 (6.7; 13.3) | <0.001 | 8.9 (6; 11.8) | <0.001 |
Parity | ||||||
1 | Ref | Ref | Ref | |||
>1 | 2.5 (−1.3; 6.3) | 0.194 | 5 (2.5; 7.5) | <0.001 | 1.7 (−0.7; 4.1) | 0.173 |
Educational level | ||||||
Junior high school or lower | −2.5 (−11.4; 6.4) | 0.583 | −5 (−18.4; 8.4) | 0.465 | −5 (−11.2; 1.2) | 0.114 |
High school | Ref | Ref | Ref | |||
University or higher | 0 (−3.9; 3.9) | >0.999 | 0 (−2.7; 2.7) | >0.999 | −1.1 (−2.3; 4.5) | 0.526 |
Birth mode | ||||||
Spontaneous vaginal birth | Ref | Ref | Ref | |||
Instrumental vaginal birth | 0 (−8.6; 8.6) | >0.999 | 0 (−5.7;5.7) | >0.999 | 1.7 (−4.7; 8) | 0.606 |
Emergency Caesarean section | −15 (−21.1; −8.9) | <0.001 | −15 (−19.6; 10.4) | <0.001 | −12.2 (−17.0; −7.5) | <0.001 |
Prelabour Caesarean section | −30 (−44.6; −15.4) | <0.001 | −25 (−30.1; 19.9) | <0.001 | −7.8 (−27.5; 12.0) | 0.440 |
Pain relief | ||||||
Yes | Ref | Ref | Ref | |||
No | −27.5 (−35.4; −19.6) | <0.001 | −20 (−25.1; −14.9) | <0.001 | −20 (−25.5; −14.5) | <0.001 |
Satisfaction | ||||||
Very positive | Ref | Ref | Ref | |||
Positive | −60 (−63.7; −56.3) | <0.001 | −50 (−52.7; 47.3) | <0.001 | −43.9 (−46.3; −41.5) | <0.001 |
Negative | −130 (−136.1; −123.9) | <0.001 | −115 (−120.2; −109.8) | <0.001 | −103.9 (−110; −97.8) | <0.001 |
Obstetrics and Gynaecology doctor in the team who directly assisted childbirth | ||||||
No | Ref | Ref | Ref | |||
Yes | 2.5 (−2.3; 7.3) | 0.307 | 0 (−3.1; 3.1) | >0.999 | 0.6 (−2.8; 3.9) | 0.743 |
Intercept | −330 (325.9; 334.1) | <0.001 | 350 (347; 353) | <0.001 | 376.2 (363.5; 371) | <0.001 |
4. Discussion
WHO recommendations Intrapartum care for a positive childbirth experience. Available at: https://apps.who.int/iris/bitstream/handle/10665/272447/WHO-RHR-18.12-eng.pdf (Accessed 10 Aug 2021).
Hansson M. A meaningful work in a strained context - exploring midwives’ work situation and professional role. Doctoral thesis. Sahlgrenska Academy, University of Gothenburg. 9-nov-2021. ISBN 978-91-8009-462-7 (PRINT), 978-91-8009-463-4 (PDF). URI: http://hdl.handle.net/2077/69310.
5. Conclusions
Ethical statement
Funding
Conflict of interest
Authorship contributions
Acknowledgement
Appendix A. Supplementary data
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