Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

Objective: To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic. Methods: Online anonymous survey of women who gave birth in 2020–2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level. Results: Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P< 0.001). Country-level variables contributed to explaining some of the variance between countries. Conclusion: We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care

Regional differences in the quality of maternal and neonatal care during the COVID-19 pandemic in Portugal: results from the IMAgiNE EURO study

Objective: To compare women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth across Nomenclature of Territorial Units for Statistics 2 (NUTS-II) regions in Portugal during the COVID-19 pandemic. Methods: Women participating in the cross-sectional IMAgiNE EURO study who gave birth in Portugal from March 1, 2020, to October 28, 2021, completed a structured questionnaire with 40 key WHO standards-based quality measures. Four domains of QMNC were assessed: (1) provision of care; (2) experience of care; (3) availability of human and physical resources; and (4) reorganizational changes due to the COVID-19 pandemic. Frequencies for each quality measure within each QMNC domain were computed overall and by region. Results: Out of 1845 participants, one-third (33.7%) had a cesarean. Examples of high-quality care included: low frequencies of lack of early breastfeeding and rooming-in (8.0% and 7.7%, respectively) and informal payment (0.7%); adequate staff professionalism (94.6%); adequate room comfort and equipment (95.2%). However, substandard practices with large heterogeneity across regions were also reported. Among women who experienced labor, the percentage of instrumental vaginal births ranged from 22.3% in the Algarve to 33.5% in Center; among these, fundal pressure ranged from 34.8% in Lisbon to 66.7% in Center. Episiotomy was performed in 39.3% of noninstrumental vaginal births with variations between 31.8% in the North to 59.8% in Center. One in four women reported inadequate breastfeeding support (26.1%, ranging from 19.4% in Algarve to 31.5% in Lisbon). One in five reported no exclusive breastfeeding at discharge (22.1%; 19.5% in Lisbon to 28.2% in Algarve). Conclusion: Urgent actions are needed to harmonize QMNC and reduce inequities across regions in Portugal.info:eu-repo/semantics/publishedVersio

Quality of health care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Norway and trends over time

Objective: To describe maternal perception of the quality of maternal and newborn care (QMNC) in facilities in Norway during the first year of COVID-19 pandemic. Methods: Women who gave birth in a Norwegian facility from March 1, 2020, to October 28, 2021, filled out a structured online questionnaire based on 40 WHO standards-based quality measures. Quantile regression analysis was performed to assess changes in QMNC index over time. Results: Among 3326 women included, 3085 experienced labor. Of those, 1799 (58.3%) reported that their partner could not be present as much as needed, 918 (29.8%) noted inadequate staff numbers, 183 (43.6%) lacked a consent request for instrumental vaginal birth (IVB), 1067 (34.6%) reported inadequate communication from staff, 78 (18.6%) reported fundal pressure during IVB, 670 (21.7%) reported that they were not treated with dignity, and 249 (8.1%) reported experiencing abuse. The QMNC index increased gradually over time (3.68 points per month, 95% CI, 2.83– 4.53 for the median), with the domains of COVID-19 reorganizational changes and experience of care displaying the greatest increases, while provision of care was stable over time. Conclusion: Although several measures showed high QMNC in Norway during the first year of the COVID-19 pandemic, and a gradual improvement over time, several findings suggest that gaps in QMNC exist. These gaps should be addressed and monitored

Birth integrity through the lens of medicalization, risk, embodiment and intersectionality

Batram-Zantvoort S, Razum O, Miani C. Birth integrity through the lens of medicalization, risk, embodiment and intersectionality. European Journal of Public Health . 2021;31(Suppl. 3):534.Background Women globally report suboptimal conditions during facility-based childbirth. Most approaches that capture abuse, violence or mistreatment in epidemiology do not reflect a theoretical perspective in their measurement. In order to contribute to a more valid consideration of the cultural drivers, institutional conditions, direct expressions and individual perceptions that violate or preserve what we define as “birth integrity”, we developed a new theory-informed approach and an accompanying multilevel framework. Methods We theoretically substantiated birth integrity, referring to medical anthropology, sociology, social epidemiology and a critical-feminist theory, in particular: risk and medicalization of childbirth, social embodiment and intersectionality. We then contextualized birth integrity within a multilevel framework to operationalize its potential for epidemiological research. Results We present a six-field theoretical framework to operationalise and measure birth integrity violations, from institutional discrimination, to gender norms structuring labour room interactions and restrictions on autonomy. It allows to measure birth integrity violations that women experience at the macro-to-micro level as implicit, invisible and normalized, or explicit, visible and societally accepted. Conclusions Our new multilevel framework, based on a theory-informed construct of birth integrity, allows to measure drivers of health inequality and gender-based violence in more dimensions than so far represented in epidemiological research. Key messages The birth integrity concept integrates theories of medicalization, risk, embodiment and intersectionality into a multilevel framework. Our birth integrity framework is useful in epidemiological approaches to explicitly acknowledge and integrate cultural drivers of gender-based violence and inequalities in maternity care research

Un regard théorique sur l’intégrité à la naissance : médicalisation, théories du risque, embodiment et intersectionnalité

Batram-Zantvoort S, Miani C, Razum O. Un regard théorique sur l’intégrité à la naissance : médicalisation, théories du risque, embodiment et intersectionnalité. Santé Publique. 2021; 33(5):645-654

Potential of standard perinatal data for measuring maternal integrity in childbirth

Miani C, Batram-Zantvoort S, Razum O. Potential of standard perinatal data for measuring maternal integrity in childbirth. In: 16th World Congress on Public Health 2020. Public Health for the future of humanity: analysis, advocacy and action. European Journal of Public Health. Vol 30. Oxford: Oxford Univ Press; 2020: V157

Experiences of giving birth during the COVID-19 pandemic: a qualitative analysis of social media comments through the lens of birth integrity

Abstract Background Social media offer women a space to discuss birth-related fears and experiences. This is particularly the case during the COVID-19 pandemic when measures to contain the spread of the virus and high rates of infection have had an impact on the delivery of care, potentially restricting women’s rights and increasing the risk of experiencing different forms of mistreatment or violence. Through the lens of birth integrity, we focused on the experiences of women giving birth in Germany as shared on social media, and on what may have sheltered or violated their integrity during birth. Methods Using thematic analysis, we identified key themes in 127 comments and associated reactions (i.e. “likes”, emojis) posted on a Facebook public page in response to the dissemination of a research survey on maternity care in the first year of the COVID-19 pandemic. Results Women contributing to the dataset gave birth during March and December 2020. They were most negatively affected by own mask-wearing –especially during the active phase of labour, not being allowed a birth companion of choice, lack of supportive care, and exclusion of their partner from the hospital. Those topics generated the most reactions, revealing compassion from other women and mixed feelings about health measures, from acceptation to anger. Many women explicitly formulated how inhumane or disrespectful the care was. While some women felt restricted by the tight visiting rules, those were seen as positive by others, who benefited from the relative quiet of maternity wards and opportunities for postpartum healing and bonding. Conclusion Exceptional pandemic circumstances have introduced new parameters in maternity care, some of which appear acceptable, necessary, or beneficial to women, and some of which can be considered violations of birth integrity. Our research calls for the investigation of the long-term impact of those violations and the reassessment of the optimal conditions of the delivery of respectful maternity during the pandemic and beyond

Operationalising masculinities in theories and practices of gender-transformative health interventions: a scoping review

Zielke J, Batram-Zantvoort S, Razum O, Miani C. Operationalising masculinities in theories and practices of gender-transformative health interventions: a scoping review. International Journal for Equity in Health. 2023;22(1): 139.Gender-transformative health interventions that involve men and boys are gaining global reach, adaptability to specific geographical, population and epidemiological contexts, public endorsement, and conceptual sophistication. However, the ways in which masculinities are conceptualised and operationalised in theory and practice across these interventions remains unclear. The purpose of this scoping review is to map intervention studies that conceptually grapple with masculinities and analyse: a) how the concept of masculinities is adapted and operationalised in gender-transformative interventions, with respect to intervention population and context, b) what the relationship between the concept of masculinities and its wider theoretical embedding is, and c) on which levels transformation can be observed when working with ‘masculinities’. We conducted a search in APA Psych Articles, APA PsycINFO, and CINAHL via EBSCO, MedLine, PubMed, and Web of Sciences (December 2021) looking for peer-reviewed studies on gender-transformative health interventions which engaged with masculinities conceptually. There were no restrictions regarding language, publication date, or geography. Forty-two articles were included in this review. Our abductive analysis finds that ‘hegemonic masculinities’ is a central concept in almost all included studies. This shows how the concept is adaptable to a range of different intervention contexts. The review further identifies five theoretical approaches, that help operationalise masculinities on an analytical level: feminist framework, affect theory, critical pedagogy, theories of social change, and ecological approaches. Lastly, this review draws out six levels on which transformation can be observed in the intervention outcomes: relational level, symbolic level, material level, affective level, cognitive-behavioural level, and community-structural level. The discussion underlines that processes and practices of (gender) transformation also require engagement with theories of transformation more widely and advocates for theoretical pluralism. Lastly, implications for practice, including preventative, ecological and community-based care models, are drawn out