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

Abstract

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 < 0.001). Over time, there was a significant monthly linear decrease in the QMNC index (P < 0.001), lacking correlation with the coronavirus disease 2019 (COVID-19) pandemic trends (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.

Figure 1

Flow diagram. Unfinished records are defined as records with missing data for 36 or more (≥90% of questions) quality measures (n = 40). QMNC – quality of maternal and newborn care.

Figure 2

Need for improvement in the provision of care domain. Data are reported as country frequencies (coloured dots) and range of country frequencies (horizontal black lines). All quality measures in the domain of the provision of care are directly based on WHO standards. 1 – for case management of healthy women/newborns, 2 – at least one training event in the last three years, 3 – only for maternal area: partogram, foetal well-being, unnecessary caesarean section; only for neonatal area: breastfeeding promotion, skin-to-skin, standards precautions, 4 – for case management of emergencies, 5 – only for maternal area: postpartum haemorrhage, eclampsia, shoulder dystocia, pregnant woman cardiovascular arrest; only neonatal area: newborn resuscitation.

Figure 4

Need for improvement in the availability of motivated and competent human and physical resources domain. Data are reported as country frequencies (coloured dots) and range of country frequencies (horizontal black lines). All quality measures in the domain of the availability of motivated and competent human and physical resources are directly based on WHO standards. 1 – for healthy women/newborns care, 2 – at least one training event in the last three years.

Figure 3

Need for improvement in the experience of care domain. Data are reported as country frequencies (coloured dots) and range of country frequencies (horizontal black lines). All quality measures in the domain of experience of care are directly based on WHO standards. 1 – at least one training event in the last three years; 2 – only for maternal area: regular orientation sections for women during pregnancy, written/digital material for consent before ceasarean section, induction of labour; only for neonatal area: regular orientation sections for women during pregnancy, written/digital material for consent before newborn vitamin K administration, newborn eye drops/ointment application; 3 – only for maternal area: pharmacological and non-pharmacological pain relief on labour; only for neonatal area: prevention/management of newborn’s pain.

Figure 5

Findings in the COVID-19 domain. Panel A. ‘Not always existing and/or not fully adequate’ OR ‘Never existed and/or never adequate since the beginning of pandemic up till now.’ Panel B. ‘Happened during the COVID-19 pandemic’ OR ‘Happened independently from the COVID-19 pandemic.’ Data are reported as country frequencies (coloured dots) and range of country frequencies (horizontal black lines). 1 – Frequency is calculated on seven indicators contributing to the same quality measure: increased medicalisation and/or limitations on companionship, restrictions on movements during labour, limitations on pain relief procedures, limitations on rooming-in practices without clinical indications, limitations on breastfeeding without clinical indications, limitations on skin to skin in the absence of clear medical indications. HW – health workers, PPE – personal protective equipment; QMNC – quality of maternal and newborn care.

Figure 6

QMNC Indexes by country and by domain. Data are reported using box plots (showing median and interquartile range), whiskers (representing 1.5 times the interquartile range) and dots (the extreme values) (n = 3093). QMNC – quality of maternal and newborn care.

Figure 7

Total QMNC index over time. The vertical grey dashed line shows the date of 27 April 2022, when was declared that the European Union was moving out of the emergency phase of the COVID-19 pandemic (Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions, COVID-19 - Sustaining EU Preparedness and Response: Looking ahead) [50]. MA – moving average, QMNC – quality of maternal and newborn care.