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: NCT04847336This research was funded by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste Italy

The governance of justice and internal security in Scotland: Between the Scottish independence referendum and British decisions on the EU

This article examines how the governance of justice and internal security in Scotland could be affected by the outcome of the Scottish independence referendum in September 2014. The article argues that it is currently impossible to equate a specific result in the referendum with a given outcome for the governance of justice and internal security in Scotland. This is because of the complexities of the current arrangements in that policy area and the existence of several changes that presently affect them and are outside the control of the government and of the people of Scotland. This article also identifies an important paradox. In the policy domain of justice and internal security, a ‘no’ vote could, in a specific set of circumstances, actually lead to more changes than a victory of the ‘yes’ camp

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 0.05). 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. © (2024), (University of Edinburgh). All rights reserved.This study was supported by the Ministry of Health, Rome, Italy, in collaboration with the Institute for Maternal and Child Health, IRCCS ‘Burlo Garofolo,’ Trieste, Italy. Raquel Costa was supported by the Social European Fund and Foundation for Science and Technology under a post-doctoral grant (SFRH/BPD/117597/2016). Epidemiology Research Unit (EPIUnit) – UIDB/04750/2020, Laboratory for Integrative and Translational Research in Population Health (ITR) – LA/P/0064/2020, and Human-environment Interaction laboratory (HEI-Laboratory) – UIDB/05380/2020 (https://doi.org/10.54499/UIDP/05380/2020) are financed by Portuguese fundings through Fundação para a Ciência e a Tecnologia, Instituto publico

Assisted Reproductive Technologies in Europe. Usage and Regulation in the Context of Cross-Boarder Reproductive Care

This chapter reviews assisted reproductive technologies (ART) usage and policies across European countries, and scrutinizes emerging issues related to cross-border reproductive care (or “reproductive tourism”). Although Europe is currently the largest market for ART, the extent of usage varies widely across countries, largely because of differences in the laws, the affordability, the types of reimbursement, and the norms surrounding childbearing and conception. Since 2009, the regulation of ART has been expanding in Europe, and all countries now have some form of ART legislation. Countries where the treatments are completely covered by national health plans have the highest level of ART utilization. Being in a legal marriage or a stable union is often a prerequisite for access to ART. Currently, only half of European countries allow single women to use ART, and even fewer grant access to lesbian women. Surrogate motherhood is strictly prohibited in many countries in Europe, and where it is allowed, strong restrictions against commercial surrogacy are in place. While restrictive national legislation can be easily circumvented by crossing national boundaries for ART treatments, questions of equity of access have been raised, as not all prospective parents can afford to travel for treatment

LGBT Desires in Family Land: Parenting in Iceland, from Social Acceptance to Social Pressure

More than 20 years ago, Iceland opened civil union to same-sex couples with its confirmed partnership law (staðfest samvist, 1996). Since then, the country has attained a high level of equality between same-sex and different-sex couples in the domain of family law, and the law has strong provisions against discrimination toward LGBT people. The increasing visibility and acceptance of LGBT people is raising questions about the social process of integration. LGBT people are confronted with heterosexual norms, a confrontation that is difficult to bypass. In this context, some may find that they are losing their identity. Iceland is a familialist society, and a key entry into the social acceptance of homosexuality has been through marriage and parenting. There is a clear gender gap in family-making. Lesbians have access to ART whereas adoption is scarcely available and surrogacy still illegal, reducing access to parenthood for gay men. However, in Iceland’s small LGBT community, parenting desire has increasingly become a reality for both females and males. Based on a survey consisting of 30 interviews, the paper studies how parenthood meets a wide range of personal desires, but also how it has become a normative pressure