Challenging the status quo: Women's experiences of opting for a home birth in Andalucia, Spain

Objective: To explore the perceptions, beliefs and attitudes of women who opted for a home birth in Andalusia (Spain). Background: Home birth is currently an unusual choice among Spanish women. It is not an option covered by the Spanish National Health Service and women who opt for a home birth have to pay for an independent midwife. Design: A qualitative study with a phenomenological approach was adopted. All participants who took part in this study had chosen to have a home birth and given written consent to take part in the study. Methods: Data collection was conducted in 2015–16. Face-to-face, semi-structured interviews were undertaken with women who chose a home birth in the last 5 years. Findings: The sample consisted of thirteen women. Seven themes were created through analysis: 1. Getting informed about home birth; 2. Home birth as a choice, despite feeling unsupported; 3. The best way to have a personalized and a physiological birth; 4. Seeking a healing and empowering experience 5. The need for emotional safety, establishing a relationship and trusting the midwife; 6. Preparing for birth and working on fears; 7. Inequality of access (because of financial implications). Conclusions: Women opted to plan birth at home because they wanted a personalised birth and control over their decision-making in labour, which they felt would not have been afforded to them in hospital settings. Andalusian maternity care leaders should strive to ensure that all pregnant women receive respectful and high-quality personalised care, by appropriately trained staff, both in the hospital and in the community

Analysis of Caesarean Section Rates Using the Robson Classification System at a University Hospital in Spain

Background: The WHO recommends the use of the Robson ten-group classification system (RTGCS) as an effective monitoring and analysis tool to assess the use of caesarean sections (CS). The present study aimed to conduct an analysis of births using the RTGCS in La Ribera University Hospital over nine years and to assess the levels and trends of CS births. Methods: Retrospective study between January 1, 2010, and December 31, 2018. All eligible women were allocated in RTGCS to determine the absolute and relative contribution made by each group to the overall CS rate; linear regression and weighted least squares regression analysis were used to analyze trends over time. The risk of CS of women with induced versus spontaneous onset of labor was calculated with an odds ratio (OR) with a 95% CI. Results: 16,506 women gave birth during the study period, 19% of them by CS. Overall, 20.4% of women were in group 1 (nulliparous, singleton cephalic, term, spontaneous labor), 29.4% in group 2 (nulliparous, singleton cephalic, term, induced labor or caesarean before labor), and 12.8% in group 4 (multiparous, singleton cephalic, term, induced or caesarean delivery before labor) made the most significant contributions to the overall rate of CS; Conclusions: In our study, Robson Groups 1, 2, and 4, were identified as the main contributors to the hospital's overall CS rate. The RTGCS provides an easy way of collecting information about the CS rate, is a valuable clinical method that allows standardized comparison of data, and time point, and identifies the groups driving changes in CS rates

Proceso de adaptación cultural del “Questionnaire for Assesing the Childbirth Experience (QACE)”

Background: Negative experiences during delivery are associated with women disempowerment, postpartum depression, post-traumatic stress disorder, and low breastfeeding rates. The Questionnaire for Assessing the Childbirth Experience (QACE) is a 23-item screening tool useful for discovering women with a negative experience in their birth process and avoids future complications in following pregnancies or couple's relationships. Objective: The general objective is to adapt the Questionnaire for Assessing the Childbirth Experience (QACE) to the Spanish population and to obtain its psychometric characteristics.Methodology: The cultural adaptation process consisted of forwarding translation and back translation into Spanish, conceptual equivalence evaluation by a committee of judges, comprehensibility evaluation and cognitive interview to a postpartum group. Psychometric characteristics were obtained throughout the factorial analysis, Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity and Cronbach alpha level.Results: After complete the adaptation process, the committee of judges made several adjustments to achieve a better comprehension in the Spanish population, avoid misunderstandings or offensive words in the target language. 138 participants were needed to calculate factor analysis. The KMO (0.838) and Bartlett test (p < 0.001) confirmed the adequacy of factor analysis and the Scree plot showed 6 factors with the predictive power of 73.75% supported total variance. Internal consistency was assured using a Cronbach α of 0.896.Conclusions: Data from this study demonstrate that the Spanish version of QACE is a valid and reliable measure of childbirth experience in the Spanish population.Introducción: Las experiencias negativas durante el parto se han asociado con desempoderamiento de la mujer, depresión postparto, trastorno por estrés postraumático y bajas tasas de lactancia maternal, entre otros. El Questionnaire for Assessing the Childbirth Experience (QACE) es una herramienta de 23 ítems útil para identificar mujeres que han tenido una mala experiencia en su proceso de parto y evitar así futuras complicaciones en embarazos posteriores o en la relación de pareja.Objetivo: El objetivo general consiste en adaptar el Questionnaire for Assessing the Childbirth Experience (QACE) a la población española y obtener sus características psicométricas.Metodología: El proceso de adaptación cultural ha consistido en la traducción y retro traducción al español, evaluación de la equivalencia conceptual por un comité de jueces, evaluación de la comprensibilidad y una entrevista cognitiva a un grupo de mujeres puérperas. Las características psicométricas se han obtenido mediante el análisis factorial, los test de Kaiser-Meyer-Olkin (KMO) y Bartlett y el alfa de Cronbach.Resultados: Tras el proceso de adaptación transcultural, el grupo de expertos realizó las modificaciones necesarias para conseguir una mayor compresión del cuestionario en la población española, evitar malentendidos y palabras ofensivas en la lengua de destino. Se necesitaron 138 participantes para obtener el análisis factorial. El KMO (0,838) y el test de Bartlett (p < 0,001) confirmaron la adecuación del análisis factorial y el grafico de sedimentación mostró 6 factores con un poder predictivo del 73,75% del total de la varianza. La consistencia interna se obtuvo mediante un alfa de Cronbach de 0,896.Conclusiones: Los datos obtenidos en este estudio demuestran que la versión española del QACE es una herramienta válida y fiable para medir la experiencia en el nacimiento en la población española

Assessing the performance of maternity care in Europe: a critical exploration of tools and indicators

Background: This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care. Methods: A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions. Results: A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally. Conclusions: The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures.COST Action IS0907, ‘Childbirth Cultures, Concerns and Consequences: Creating a dynamic EU framework for optimal maternity care’COST Action IS1405, ‘Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH

Incidence of Perinatal Post-Traumatic Stress Disorder in Catalonia: An Observational Study of Protective and Risk Factors

Pregnancy and childbirth have a great impact on women's lives; traumatic perinatal experiences can adversely affect mental health. The present study analyzes the incidence of perinatal post-traumatic stress disorder (PTSD) in Catalonia in 2021 from data obtained from the Registry of Morbidity and Use of Health Resources of Catalonia (MUSSCAT). The incidence of perinatal PTSD (1.87%) was lower than in comparable studies, suggesting underdiagnosis. Poisson regression adjusting for age, income, gestational weeks at delivery, type of delivery, and parity highlighted the influence of sociodemographics, and characteristics of the pregnancy and delivery on the risk of developing perinatal PTSD. These findings underline the need for further research on the risk factors identified and for the early detection and effective management of PTSD in the perinatal setting

Maternidad, tecnología y relación asistencial

Durante la segunda mitad del siglo XX se produjo un proceso de medicalización de la vida y los partos que se asistían en el domicilio hasta la segunda mitad del siglo XX se institucionalizaron. Actualmente, la atención al parto dentro de centros sanitarios y la cada vez más alta dotación tecnológica ha facilitado que se legitime la medicalización para todos los procesos asistenciales, incluso para aquellos fisiológicos como puede ser un parto normal. Son numerosos los autores que han puesto en evidencia como el proceso de medicalización de la vida ha concebido el cuerpo femenino, durante embarazo y parto, como anárquico y necesitado de control; asumiendo que el uso de las modernas técnicas obstétricas se ha extendido de forma inseparable a un proceso de alienación impuesto a las mujeres reclamándose una atención humanizada, respetuosa con la fisiología y sin medicalización. Desde una línea de argumentación post-estructuralista se critica el discurso basado en que la atención no tecnificada, y respetuosa con la fisiología del parto, significará, sin más, un empoderamiento de la mujer, puesto que, al igual que la posición medicalizadora de la asistencia, implica también una visión esencialista que no tiene en cuenta los componentes éticos y sociales [...

Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial.

BACKGROUND: While cesarean sections (CSs) are a life-saving intervention, an increasing number are performed without medical reasons in low- and middle-income countries (LMICs). Unnecessary CS diverts scarce resources and thereby reduces access to healthcare for women in need. Argentina, Burkina Faso, Thailand, and Vietnam are committed to reducing unnecessary CS, but many individual and organizational factors in healthcare facilities obstruct this aim. Nonclinical interventions can overcome these barriers by helping providers improve their practices and supporting women's decision-making regarding childbirth. Existing evidence has shown only a modest effect of single interventions on reducing CS rates, arguably because of the failure to design multifaceted interventions effectively tailored to the context. The aim of this study is to design, adapt, and test a multifaceted intervention for the appropriate use of CS in Argentina, Burkina Faso, Thailand, and Vietnam. METHODS: We designed an intervention (QUALIty DECision-making-QUALI-DEC) with four components: (1) opinion leaders at heathcare facilities to improve adherence to best practices among clinicians, (2) CS audits and feedback to help providers identify potentially avoidable CS, (3) a decision analysis tool to help women make an informed decision on the mode of birth, and (4) companionship to support women during labor. QUALI-DEC will be implemented and evaluated in 32 hospitals (8 sites per country) using a pragmatic hybrid effectiveness-implementation design to test our implementation strategy, and information regarding its impact on relevant maternal and perinatal outcomes will be gathered. The implementation strategy will involve the participation of women, healthcare professionals, and organizations and account for the local environment, needs, resources, and social factors in each country. DISCUSSION: There is urgent need for interventions and implementation strategies to optimize the use of CS while improving health outcomes and satisfaction in LMICs. This can only be achieved by engaging all stakeholders involved in the decision-making process surrounding birth and addressing their needs and concerns. The study will generate robust evidence about the effectiveness and the impact of this multifaceted intervention. It will also assess the acceptability and scalability of the intervention and the capacity for empowerment among women and providers alike. TRIAL REGISTRATION: ISRCTN67214403

Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.

OBJECTIVE: To determine the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed coronavirus disease 2019 (covid-19). DESIGN: Living systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 26 June 2020, along with preprint servers, social media, and reference lists. STUDY SELECTION: Cohort studies reporting the rates, clinical manifestations (symptoms, laboratory and radiological findings), risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed covid-19. DATA EXTRACTION: At least two researchers independently extracted the data and assessed study quality. Random effects meta-analysis was performed, with estimates pooled as odds ratios and proportions with 95% confidence intervals. All analyses will be updated regularly. RESULTS: 77 studies were included. Overall, 10% (95% confidence interval 7% to14%; 28 studies, 11 432 women) of pregnant and recently pregnant women attending or admitted to hospital for any reason were diagnosed as having suspected or confirmed covid-19. The most common clinical manifestations of covid-19 in pregnancy were fever (40%) and cough (39%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to report symptoms of fever (odds ratio 0.43, 95% confidence interval 0.22 to 0.85; I2=74%; 5 studies; 80 521 women) and myalgia (0.48, 0.45 to 0.51; I2=0%; 3 studies; 80 409 women) and were more likely to need admission to an intensive care unit (1.62, 1.33 to 1.96; I2=0%) and invasive ventilation (1.88, 1.36 to 2.60; I2=0%; 4 studies, 91 606 women). 73 pregnant women (0.1%, 26 studies, 11 580 women) with confirmed covid-19 died from any cause. Increased maternal age (1.78, 1.25 to 2.55; I2=9%; 4 studies; 1058 women), high body mass index (2.38, 1.67 to 3.39; I2=0%; 3 studies; 877 women), chronic hypertension (2.0, 1.14 to 3.48; I2=0%; 2 studies; 858 women), and pre-existing diabetes (2.51, 1.31 to 4.80; I2=12%; 2 studies; 858 women) were associated with severe covid-19 in pregnancy. Pre-existing maternal comorbidity was a risk factor for admission to an intensive care unit (4.21, 1.06 to 16.72; I2=0%; 2 studies; 320 women) and invasive ventilation (4.48, 1.40 to 14.37; I2=0%; 2 studies; 313 women). Spontaneous preterm birth rate was 6% (95% confidence interval 3% to 9%; I2=55%; 10 studies; 870 women) in women with covid-19. The odds of any preterm birth (3.01, 95% confidence interval 1.16 to 7.85; I2=1%; 2 studies; 339 women) was high in pregnant women with covid-19 compared with those without the disease. A quarter of all neonates born to mothers with covid-19 were admitted to the neonatal unit (25%) and were at increased risk of admission (odds ratio 3.13, 95% confidence interval 2.05 to 4.78, I2=not estimable; 1 study, 1121 neonates) than those born to mothers without covid-19. CONCLUSION: Pregnant and recently pregnant women are less likely to manifest covid-19 related symptoms of fever and myalgia than non-pregnant women of reproductive age and are potentially more likely to need intensive care treatment for covid-19. Pre-existing comorbidities, high maternal age, and high body mass index seem to be risk factors for severe covid-19. Preterm birth rates are high in pregnant women with covid-19 than in pregnant women without the disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020178076. READERS' NOTE: This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication

Assessing the performance of maternity care in Europe: A critical exploration of tools and indicators

Background: This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care. Methods: A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions. Results: A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally. Conclusions: The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures

Obstetric interventions in two groups of hospitals in Catalonia: A cross-sectional study

Background: Childbirth assistance in highly technological settings and existing variability in the interventions performed are cause for concern. In recent years, numerous recommendations have been made concerning the importance of the physiological process during birth. In Spain and Catalonia, work has been carried out to implement evidence-based practices for childbirth and to reduce unnecessary interventions. To identify obstetric intervention rates among all births, determine whether there are differences in interventions among full-term single births taking place in different hospitals according to type of funding and volume of births attended to, and to ascertain whether there is an association between caesarean section or instrumental birth rates and type of funding, the volume of births attended to and women's age. Methods: Cross-sectional study, taking the hospital as the unit of analysis, obstetric interventions as dependent variables, and type of funding, volume of births attended to and maternal age as explanatory variables. The analysis was performed in three phases considering all births reported in the MBDS Catalonia 2011 (7,8570 births), full-term single births and births coded as normal. Results: The overall caesarean section rate in Catalonia is 27.55% (CI 27.23 to 27.86). There is a significant difference in caesarean section rates between public and private hospitals in all strata. Both public and private hospitals with a lower volume of births have higher obstetric intervention rates than other hospitals (49.43%, CI 48.04 to 50.81). Conclusions: In hospitals in Catalonia, both the type of funding and volume of births attended to have a significant effect on the incidence of caesarean section, and type of funding is associated with the use of instruments during delivery. © 2014 Escuriet et al.; licensee BioMed Central Ltd