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

Abstract

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.

Keywords: COVID-19; IMAgiNE EURO; Portugal; childbirth; maternal care; newborn care; quality of care; respectful maternity care.

FIGURE 1

Study flow diagram. ^aPercentage of missing data for each woman was calculated over 45 mandatory questions, including the 40 key quality measures and five key sociodemographic variables: date of birth, age, education, parity, whether a woman gave birth in the same country where she was born.

FIGURE 2

Domain of provision of care indicators by region of childbirth (Two panels for women who experienced labor and women with prelabor cesarean) (Supporting Information Table S3). Abbreviations: HCP, healthcare provider; IVB, instrumental vaginal birth; VB, vaginal birth. Data are reported as percent frequency on the total sample (gray dot) and as percent frequency on the sample of women giving birth in each region (colored dots); horizontal gray line represents the range of the regional frequencies. All the indicators in the domain of provision of care are directly based on WHO standards. Indicators identified with letters (e.g. 3a, 3b) were tailored to take into account different mode of birth (i.e. noninstrumental VB, IVB, and cesarean). These were calculated on subsamples (e.g. 3a was calculated on non‐instrumental VB; 3b was calculated on IVB). Alentejo, Madeira, and Azores regions are reported in this descriptive analysis but results should be regarded only as exploratory findings due to the low sample size enrolled in these regions.

FIGURE 3

Domain of experience of care by region of childbirth (Two panels for women who underwent labor and women with prelabor cesarean) (Supporting Information Table S4). Abbreviations: HCP, healthcare provider; IVB, instrumental vaginal birth; VB, vaginal birth. Data are reported as percent frequency on the total sample (gray dot) and as percent frequency on the sample of women giving birth in each region (colored dots); horizontal gray line represents the range of the regional frequencies. All the indicators in the domain of experience of care are directly based on WHO standards. Indicators identified with letters (e.g. 2a, 2b) were tailored to take into account different mode of birth (i.e. noninstrumental VB, IVB, and cesarean). These were calculated on subsamples (e.g. 2a was calculated on noninstrumental VB; 2b was calculated on IVB). Alentejo, Madeira, and Azores regions are reported in this descriptive analysis, but results should be regarded only as exploratory findings due to the low sample size enrolled in these regions.

FIGURE 4

Availability of human and essential physical resources by region of childbirth (Two panels for women who experienced labor and women with prelabor cesarean) (Supporting Information Table S5). Abbreviations: HCP, healthcare provider. Data are reported as percent frequency on the total sample (gray dot) and as percent frequency on the sample of women giving birth in each region (colored dots); horizontal gray line represents the range of the regional frequencies. All the indicators in the domain of human and physical resources are directly based on WHO standards. Alentejo, Madeira, and Azores regions are reported in this descriptive analysis, but results should be regarded only as exploratory findings due to the low sample size enrolled in these regions.

FIGURE 5

Reorganizational changes due to the COVID‐19 pandemic by region of childbirth (Two panels for women who experienced labor and women with prelabor cesarean) (Supporting Information Table S6). Abbreviations: HCP, healthcare provider; PPE, personal protective equipment; QMNC, quality of maternal and newborn care. Data are reported as percent frequency on the total sample (gray dot) and as percent frequency on the sample of women giving birth in each region (colored dots); horizontal gray line represents the range of the regional frequencies. Alentejo, Madeira, and Azores regions are reported in this descriptive analysis, but results should be regarded only as exploratory findings due to the low sample size enrolled in these regions.

FIGURE 6

QMNC indexes: Provision of care, experience of care, availability of human and physical resources, reorganizational changes due to the COVID‐19 pandemic and total QMNC index by region of childbirth (Supporting Information Table S8). Alentejo, Madeira, and Azores regions are reported in this descriptive analysis, but results should be regarded only as exploratory findings due to the low sample size enrolled in these regions.