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Problem: Restrictions during the COVID-19 pandemic compromised maternal and newborn care., Background: Countries in the German speaking area share several clinical care guidelines but differed significantly in the strictness of COVID-19 protective measures., Aim: To investigate the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic in the German-speaking area and explore associations between the reorganisational changes due to COVID-19 and QMNC, as described with WHO Standards-based Quality Measures., Methods: As part of the IMAgiNE EURO study (ClinicalTrials.gov: NCT04847336), we conducted an online survey on the QMNC in the German-speaking area, including women who gave birth in Germany, Switzerland, and Austria. Descriptive statistics, Spearman rank correlation coefficient and multivariable quantile regression were used., Findings: Out of a total of 70,721 women accessing the online questionnaire, 1,875 were included (Germany: n = 1,053, Switzerland: n = 494, Austria: n = 328). Significant differences across countries were found in Quality Measures. In Switzerland, women scored Quality Measures more favourable than in Germany and Austria in all four sub-indexes of QMNC. In Austria, Quality Measures gaps in the sub-index 'Experience of care' were higher. The sub-index 'Reorganisational changes due to COVID-19' correlated weakly to strongly with the other sub-indexes (between r = 0.33 and r = 0.62, p < 0.001 for all correlations)., Discussion: Midwives and other health professional should pay particular attention to the provision of respectful, high-quality care., Conclusion: To effectively improve QMNC, further research is essential to monitor the quality of care and develop targeted interventions beyond the COVID-19 pandemic addressing inherent challenges in the organisation and delivery of care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: To examine quality of maternal and newborn care (QMNC) around childbirth in facilities in Belgium during the COVID-19 pandemic and trends over time., Design: A cross-sectional observational study., Setting: Data of the Improving MAternal Newborn carE in the EURO region study in Belgium., Participants: Women giving birth in a Belgian facility from 1 March 2020 to 1 May 2023 responded a validated online questionnaire based on 40 WHO standards-based quality measures organised in four domains: provision of care, experience of care, availability of resources and organisational changes related to COVID-19., Primary and Secondary Outcome Measures: Quantile regression analysis was performed to assess predictors of QMNC; trends over time were tested with the Mann-Kendall test., Results: 897 women were included in the analysis, 67% (n=601) with spontaneous vaginal birth, 13.3% (n=119) with instrumental vaginal birth (IVB) and 19.7% (n=177) with caesarean section. We found overall high QMNC scores (median index scores>75) but also specific gaps in all domains of QMNC. On provision of care, 21.0% (n=166) of women who experienced labour reported inadequate pain relief, 64.7% (n=74) of women with an instrumental birth reported fundal pressure and 72.3% (n=86) reported that forceps or vacuum cup was used without their consent. On experience of care, 31.1% (n=279) reported unclear communication, 32.9% (n=295) reported that they were not involved in choices,11.5% (n=104) stated not being treated with dignity and 8.1% (n=73) experienced abuse. Related to resources, almost half of the women reported an inadequate number of healthcare professionals (46.2%, n=414). Multivariable analyses showed significantly lower QMNC scores for women with an IVB (-20.4 in the 50th percentile with p<0.001 and 95% CI (-25.2 to -15.5)). Over time, there was a significant increase in QMNC Score for 'experience of care' and 'key organisational changes due to COVID-19' (trend test p< 0.05)., Conclusions and Relevance: Our study showed several gaps in QMNC in Belgium, underlying causes of these gaps should be explored to design appropriate interventions and policies., Trial Registration Number: NCT04847336., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Introduction: Maternal-neonatal healthcare services were severely disrupted during the COVID-19 pandemic in even high-income countries within the World Health Organization (WHO) European Region. The objective of this study was to compare trends in the quality of maternal and neonatal care (QMNC) in Sweden and Norway to 12 other countries from the WHO European Region during the COVID-19 pandemic, and to identify domains for improvement., Material and Methods: This cross-sectional study included women giving birth in Europe from March 1, 2020 to December 31, 2022. Women answered an online, anonymous questionnaire which included 40 WHO Standard-based Quality Measures collectively scored as the total QMNC index (0-400) and separately in four subdomains (0-100): provision of care, experience of care, availability of human and physical resources, and reorganizational changes due to COVID-19. To assess reported QMNC changes over time, we used adjusted quantile regression models., Clinicaltrials: gov Identifier: NCT04847336., Results: Of the 45151 women included in the study, 13 117 (29.1%) were from Sweden and Norway and 32034 (70.9%) from the 12 WHO European countries. The total QMNC index for Sweden and Norway (median: 325, IQR: 285-355) was higher than the 12 WHO European countries (median: 315, IQR: 265-350, p < 0.001) as were trends in QMNC index over time (Sweden and Norway median: 310-345; 12 WHO European countries median: 305-340). Sweden and Norway also had higher scores in three-of-four QMNC subdomains, with the 12 WHO European countries scoring higher only for reorganizational changes due to COVID-19. In adjusted quantile models of the total QMNC index, Sweden and Norway had higher scores, with largest differences in the lower quantiles (p < 0.001 in all percentiles)., Conclusions: Across Europe, there are significant gaps in the quality of maternal-neonatal healthcare services. Although women giving birth in Sweden and Norway reported higher QMNC scores in all subdomains except for "reorganizational changes due to COVID-19," there is room for improvement and shared learning across Europe. Policymakers should prioritize long-term investments in maternal and neonatal healthcare, ensuring that facilities are adequately equipped during public health crises and that all women have access to high-quality, evidence-based, equitable, and respectful care., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: The COVID-19 pandemic had an important psychological impact on children and their families. This study aims to explore paediatric health services users' perceptions of quality of care (QOC) and COVID-19-related fears, and their evolution over time in relation to COVID-19 pandemic., Methods: In a multicentre cross-sectional study involving 11 public hospitals providing paediatric care across the Italian territory, we collected data from services users through a validated questionnaire. We analysed four indicators-(1) QOC perceived in relation to COVID-19; (2) overall QOC perceived; (3) fear of accessing health services due to COVID-19; (4) fear of contracting COVID-19 in hospital-and calculated Spearman's correlation indexes (ρ) with the number of COVID-19 new cases over time. Subgroup analyses were conducted by macroregions and single facility., Results: Data from 956 services users were analysed. QOC indicators were stable over time at values close to the maximum (range 77-100 and median 100 for COVID-19 QOC, range 74-98 and median 80 for overall QOC), and no correlations were found with the COVID-19 new cases (ρ=-0.073 and -0.016, respectively). Fear of accessing care and fear of contracting the infection varied over time in between 0%-52% and 0%-53%, respectively, but did not correlate directly with number of COVID-19 new cases (ρ=0.101, 0.107 and 0.233, 0.046, respectively). At subgroup analyses, significantly higher frequencies of fear (p values <0.05) and lower QOC (p values <0.001) were reported in South Italy, and three facilities showed moderate correlation between these indicators., Conclusions: COVID-19-related fears and perceived QOC may be mediated by more complex cultural and facility/regional-level factors, than simply by epidemic peaks. Subgroup analyses can help unpack major differences within the same country., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: There is little experience in the use of the WHO Standards for improving the quality of care (QOC) for children at the facility level. We describe the use of 75 WHO Standard based Quality Measures to assess paediatric QOC, using service users as a source of data, in Italy., Study Design: In a cross-sectional study including 12 hospitals, parents/caregivers of admitted children completed a validated questionnaire including 75 Quality Measures: 40 pertinent to the domain of experience of care; 25 to physical/structural resources; 10 to COVID-19 reorganisational changes. Univariate and multivariate analyses were conducted., Results: Answers from 1482 service users were analysed. Physical resources was the domain with the higher frequency of reported gaps in QOC, with key gaps (higher rates of responders reporting need for improvement and low variability across centres) being: (1) quality of meals (48.1%; range across facilities: 35.3%-61.7%); (2) presence of cooking areas (50.9%; range: 34.6%-70.0%); (3) spaces for family/friends (51.3%; range: 31.8%-77.4%). For experience of care , the most critical gap was the information on the rights of the child (76.6%; range: 59.9%-90.4%), with most other Quality Measures showing an overall frequency of reported need for improvement ranging between 5% and 35%. For reorganisational changes due to COVID-19 an improvement was felt necessary by <25% of responders in all Quality Measures, with low variability across centres. At the multivariate analyses, factors significantly associated with the QOC Index largely varied by QOC domain., Conclusions: The use of the 75 prioritised Quality Measures, specific to service users' perspective, enabled the identification of both general and facility-specific gaps in QOC. Based on these findings, quality improvement initiatives shall focus on a core list of selected Quality Measures common to all facilities, plus on an additional list of Quality Measures as more relevant in each facility., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The COVID-19 pandemic has challenged the provision of maternal care. The IMAgiNE EURO study investigates the Quality of Maternal and Newborn Care during the pandemic in over 20 countries, including Switzerland., Aim: This study aims to understand women's experiences of disrespect and abuse in Swiss health facilities during the COVID-19 pandemic., Methods: Data were collected via an anonymous online survey on REDCap®. Women who gave birth between March 2020 and March 2022 and answered an open-ended question in the IMAgiNE EURO questionnaire were included in the study. A qualitative thematic analysis of the women's comments was conducted using the International Confederation of Midwives' RESPECT toolkit as a framework for analysis., Findings: The data source for this study consisted of 199 comments provided by women in response to the open-ended question in the IMAgiNE EURO questionnaire. Analysis of these comments revealed clear patterns of disrespect and abuse in health facilities during the COVID-19 pandemic. These patterns include non-consensual care, with disregard for women's choices and birth preferences; undignified care, characterised by disrespectful attitudes and a lack of empathy from healthcare professionals; and feelings of abandonment and neglect, including denial of companionship during childbirth and separation from newborns. Insufficient organisational and human resources in health facilities were identified as contributing factors to disrespectful care. Empathic relationships with healthcare professionals were reported to be the cornerstone of positive experiences., Discussion: Swiss healthcare facilities showed shortcomings related to disrespect and abuse in maternal care. The pandemic context may have brought new challenges that compromised certain aspects of respectful care. The COVID-19 crisis also acted as a magnifying glass, potentially revealing and exacerbating pre-existing gaps and structural weaknesses within the healthcare system, including understaffing., Conclusions: These findings should guide advocacy efforts, urging policy makers and health facilities to allocate adequate resources to ensure respectful and high-quality maternal care during pandemics and beyond., (© 2024. The Author(s).)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA generally becomes undetectable in upper airways after a few days or weeks postinfection. Here we used a model of viral infection in macaques to address whether SARS-CoV-2 persists in the body and which mechanisms regulate its persistence. Replication-competent virus was detected in bronchioalveolar lavage (BAL) macrophages beyond 6 months postinfection. Viral propagation in BAL macrophages occurred from cell to cell and was inhibited by interferon-γ (IFN-γ). IFN-γ production was strongest in BAL NKG2r + CD8 + T cells and NKG2A lo natural killer (NK) cells and was further increased in NKG2A lo NK cells after spike protein stimulation. However, IFN-γ production was impaired in NK cells from macaques with persisting virus. Moreover, IFN-γ also enhanced the expression of major histocompatibility complex (MHC)-E on BAL macrophages, possibly inhibiting NK cell-mediated killing. Macaques with less persisting virus mounted adaptive NK cells that escaped the MHC-E-dependent inhibition. Our findings reveal an interplay between NK cells and macrophages that regulated SARS-CoV-2 persistence in macrophages and was mediated by IFN-γ., (© 2023. The Author(s).)

Background: Evidence has shown that restrictions during the COVID-19 pandemic have negatively affected breastfeeding support and outcomes in hospitals in many countries. The aims of the study were to describe exclusive breastfeeding rates and identify factors associated with exclusive breastfeeding at hospital discharge among women who gave birth during the COVID-19 pandemic in Israel., Methods: A cross-sectional online anonymous survey based on WHO standards for improving quality of maternal and newborn care in health facilities was conducted among a sample of women who gave birth to a healthy singleton infant in Israel during the pandemic (between March 2020 and April 2022). The socio-ecological approach was employed to examine intrapersonal, interpersonal, organizational, and community/society factors associated with exclusive breastfeeding at hospital discharge according to women perspectives., Results: Among the 235 Israeli participants, 68.1% exclusively breastfed, 27.7% partially breastfed, and 4.2% did not breastfeed at discharge. Results of the adjusted logistic regression model showed that factors significantly associated with exclusive breastfeeding were the intrapersonal factor of multiparity (adjusted OR 2.09; 95% Confidence Interval 1.01,4.35) and the organizational factors of early breastfeeding in the first hour (aOR 2.17; 95% CI 1.06,4.45), and rooming-in (aOR 2.68; 95% CI 1.41,5.07)., Conclusions: Facilitating early breastfeeding initiation and supporting rooming-in are critical to promoting exclusive breastfeeding. These factors, reflecting hospital policies and practices, along with parity, are significantly associated with breastfeeding outcomes and highlight the influential role of the maternity environment during the COVID-19 pandemic. Maternity care in hospitals should follow evidence-based breastfeeding recommendations also during the pandemic, promoting early exclusive breastfeeding and rooming-in among all women, with particular attention to providing lactation support to primiparous women., Trial Registration: Clinical Trials NCT04847336., (© 2023. The Author(s).)

Background: Recent evidence revealed significant gaps in the quality of maternal and newborn care in the World Health Organization (WHO) European Region (EUR) countries. Collecting and analyzing women's views on their needs and priorities is crucial for developing actions to improve the quality of maternal and newborn care. With this study from the IMAgiNE EURO Project, we aimed to add to previous quantitative studies by analysing emerging themes from women's suggestions on how to improve the quality of maternal and newborn care during facility-based birth in Italy during the COVID-19 pandemic., Methods: We collected data from mothers giving birth during the coronavirus 2019 (COVID-19) pandemic using a validated online anonymous WHO standard-based questionnaire consisting of open-ended questions. Using a word co-occurrence network (WCON), we analysed responses in Italian from women who gave birth between March 2020 and March 2022. This approach entails a graphical representation of word pairings that frequently co-occur across sentences and compose clusters., Results: The texts, produced by 2010 women participating in the study, consisted of 79 204 words and 3833 sentences. Eight clusters emerged with WCON, the three largest of which were related to companionship during childbirth, breastfeeding support, and physical resources. The term "swab", associated with other terms in the COVID-19 domain, had the highest degree of centrality, thus representing a core topic., Conclusions: The key emerging themes from women's suggestions can be used to shape policies to improve the quality of care for mothers and newborns. Our WCON analysis offers a valid approach to quickly screen large textual data on quality of care, providing a first set of major themes identified by clusters. As such, it could be used to improve documentation of service users' suggestions promoting the engagement of both researchers and policymakers., Registration: ClinicalTrials.gov: NCT04847336., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2023 by the Journal of Global Health. All rights reserved.)

Background: Little is known about women's experience of care and views on early breastfeeding during the COVID-19 pandemic in Norway., Methods: Women (n = 2922) who gave birth in a facility in Norway between March 2020 and June 2021 were invited to answer an online questionnaire based on World Health Organization (WHO) Standard-based quality measures, exploring their experiences of care and views on early breastfeeding during the COVID-19 pandemic. To examine associations between year of birth (2020, 2021) and early breastfeeding-related factors, we estimated odds ratios (ORs) with 95% confidence intervals (CIs) using multiple logistic regression. Qualitative data were analysed using Systematic Text Condensation., Results: Compared to the first year of the pandemic (2020), women who gave birth in 2021 reported higher odds of experiencing adequate breastfeeding support (adjOR 1.79; 95% CI 1.35, 2.38), immediate attention from healthcare providers when needed (adjOR 1.89; 95% CI 1.49, 2.39), clear communication from healthcare providers (adjOR 1.76; 95% CI 1.39, 2.22), being allowed companion of choice (adjOR 1.47; 95% CI 1.21, 1.79), adequate visiting hours for partner (adjOR 1.35; 95% CI 1.09, 1.68), adequate number of healthcare providers (adjOR 1.24; 95% CI 1.02, 1.52), and adequate professionalism of the healthcare providers (adjOR 1.65; 95% CI 1.32, 2.08). Compared to 2020, in 2021 we found no difference in skin-to-skin contact, early breastfeeding, exclusive breastfeeding at discharge, adequate number of women per room, or women's satisfaction. In their comments, women described understaffed postnatal wards, early discharge and highlighted the importance of breastfeeding support, and concerns about long-term consequences such as postpartum depression., Conclusions: In the second year of the pandemic, WHO Standard-based quality measures related to breastfeeding improved for women giving birth in Norway compared to the first year of the pandemic. Women's general satisfaction with care during COVID-19 did however not improve significantly from 2020 to 2021. Compared to pre-pandemic data, our findings suggest an initial decrease in exclusive breastfeeding at discharge during the COVID-19 pandemic in Norway with little difference comparing 2020 versus 2021. Our findings should alert researchers, policy makers and clinicians in postnatal care services to improve future practices., (© 2023. The Author(s).)

Introduction: The COVID-19 pandemic may increase women's vulnerability through violations of their integrity during birth. In a cross-sectional study (March 2020 to March 2022), we investigated how women giving birth experienced maternity care during the pandemic in Germany and which factors were associated with their birth integrity., Methods: In a survey (validated questionnaire and two open-ended questions), women ≥ 18 years described their experiences of maternity care. We conducted quantitative analyses using descriptive statistics and logistic regressions to investigate factors associated with dignified care and emotional support, which are understood as proxies of birth integrity. We analysed the open-ended questions through inductive content analysis., Results: We included data from 1271 participants and 214 comments. The majority of respondents felt emotionally supported (71%) and treated with dignity (76%). One third reported not always being involved in decision-making, while 14% felt they were subjected to physical, verbal or emotional abuse. For 57% of women, their companion of choice was absent or their presence limited. Those factors were all associated with the chances of feeling treated with dignity and emotionally supported. The qualitative comments provided an insight into what specifically women perceive as violating their integrity., Discussion: During the COVID-19 pandemic, the vulnerability of parturients lies in the violation of their birth integrity. Measures to promote respectful maternity care of women who give birth include comprehensive structural and political solutions as well as further research on the determinants of birth integrity., (© 2023. The Author(s).)

Background: Exclusive breastfeeding is the optimal infant nutrition, providing infants immunoprotection against many diseases including SARS-CoV-2 infection. Restrictions during the COVID-19 pandemic may have negatively affected breastfeeding practices in maternity care facilities. The aims of the study were to examine exclusive breastfeeding rates at discharge over time and to identify factors associated with exclusive breastfeeding during the pandemic., Methods: A cross-sectional survey was conducted among mothers who gave birth in a maternity care facility in the World Health Organization (WHO) European Region countries during the COVID-19 pandemic. The socio-ecological model was employed to examine intrapersonal, interpersonal, organizational, and community/society factors associated with maternal report of exclusive breastfeeding at the time of discharge., Results: There were 26,709 participating mothers from 17 European Region countries who were included in the analysis. Among the mothers, 72.4% (n = 19,350) exclusively breastfed and 27.6% (n = 7,359) did not exclusively breastfeed at discharge. There was an overall decline in exclusive breastfeeding rates over time (p = 0.015) with a significantly lower rate following the publication of the WHO breastfeeding guidelines on 23 June 2020 (AOR 0.88; 95% CI 0.82, 0.94). Factors significantly associated with exclusive breastfeeding outcomes in the logistic regression analysis included maternal age, parity, education, health insurance, mode of birth, inadequate breastfeeding support, lack of early breastfeeding initiation, lack of full rooming-in, birth attendant, perceived healthcare professionalism and attention, facility room cleanliness, timing of birth, and location of birth., Conclusions: Results from the study indicate the decline in exclusive breastfeeding rates in the WHO European Region during the COVID-19 pandemic. Using the socio-ecological model to identify factors associated with breastfeeding outcomes facilitates an integrated and holistic approach to address breastfeeding needs among women across the region. These findings demonstrate the need to augment breastfeeding support and to protect exclusive breastfeeding among mother-infant dyads, in an effort to reverse the declining exclusive breastfeeding rates. The study highlights the need to educate mothers and their families about the importance of exclusive breastfeeding, reduce maternal-infant separation, increase professional breastfeeding support, and follow evidence-based practice guidelines to promote breastfeeding in a comprehensive and multi-level manner., Trial Registration Number: Clinical Trials NCT04847336., (© 2022. The Author(s).)

Objective: To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe., Methods: Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women., Results: Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P = 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P = 0.001), lack of timely care (14.7% vs 13.0%; P = 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P = 0.004), inadequate number of women per room (9.4% vs 8.6%; P = 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P = 0.011), or suffering abuse (14.5% vs 12.7%; P = 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P = 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P = 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women., Conclusion: Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To investigate the quality of maternal and newborn care (QMNC) during childbirth in Luxembourg from women's perspectives., Methods: Women giving birth in facilities in Luxembourg between March 1, 2020, and July 1, 2021, answered a validated online WHO standards-based questionnaire as part of the multicountry IMAgINE EURO study. Descriptive and multivariate quantile regression analyses were performed., Results: A total of 493 women were included, representing 5.2% of women giving birth in the four maternity hospitals in Luxembourg during the study period. Most quality measures suggested high QMNC, although specific gaps were observed: 13.4% (n = 66) of women reported not being treated with dignity, 9.1% (n = 45) experienced abuse, 42.9% (n = 30) were not asked for consent prior to instrumental vaginal birth, 39.3% (n = 118) could not choose their birth position, 27% (n = 133) did not exclusively breastfeed at discharge (without significant differences over time), 20.5% (n = 101) reported an insufficient number of healthcare professionals, 20% (n = 25) did not receive information on the newborn after cesarean, and 41.2% (n = 203) reported lack of information on newborn danger signs before discharge. Multivariate analyses highlighted higher reported QMNC indexes among women born outside Luxembourg and delivering with a gynecologist, and significantly lower QMNC indexes in women with the highest education levels and those delivering in the hospital offering some private services., Conclusions: Despite maternal reports suggesting an overall high QMNC in Luxembourg, improvements are needed in specific aspects of care and communication, mostly related to maternal autonomy, respect, and support, but also number and competencies of the health workforce., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To assess the quality of maternal and newborn care (QMNC) in countries of the former Yugoslavia., Method: Women giving birth in a facility in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina between March 1, 2020 and July 1, 2021 answered an online questionnaire including 40 WHO standards-based quality measures., Results: A total of 4817 women were included in the analysis. Significant differences were observed across countries. Among those experiencing labor, 47.4%-62.3% of women perceived a reduction in QMNC due to the COVID-19 pandemic, 40.1%-69.7% experienced difficulties in accessing routine antenatal care, 60.3%-98.1% were not allowed a companion of choice, 17.4%-39.2% reported that health workers were not always using personal protective equipment, and 21.2%-53.8% rated the number of health workers as insufficient. Episiotomy was performed in 30.9%-62.8% of spontaneous vaginal births. Additionally, 22.6%-55.9% of women received inadequate breastfeeding support, 21.5%-62.8% reported not being treated with dignity, 11.0%-30.5% suffered abuse, and 0.7%-26.5% made informal payments. Multivariate analyses confirmed significant differences among countries, with Slovenia showing the highest QMNC index, followed by Croatia, Bosnia-Herzegovina, and Serbia., Conclusion: Differences in QMNC among the countries of the former Yugoslavia during the COVID-19 pandemic were significant. Activities to promote high-quality, evidence-based, respectful care for all mothers and newborns are urgently needed., Clinicaltrials: gov Identifier: NCT04847336., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To explore the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic by facility type among 16 European countries, comparing rates of instrumental vaginal birth and cesarean., Methods: Women who gave birth in the WHO European Region from March 1, 2020, to February 7, 2022, answered a validated online questionnaire. Rates of instrumental birth, instrumental vaginal birth, and cesarean, and a QMNC index were calculated for births in public versus private facilities., Results: Responses from 25 206 participants were analyzed. Women giving birth in private compared with public facilities reported significantly more frequent total cesarean (32.5% vs 19.0%; aOR 1.70; 95% CI 1.52-1.90), elective cesarean (17.3% vs 7.8%; aOR 1.90; 95% CI 1.65-2.19), and emergency cesarean before labor (7.4% vs 3.9%; aOR 1.39; 95% CI 1.14-1.70) (P < 0.001 for all comparisons), with analyses by country confirming these results. QMNC index results were heterogeneous across countries and regions in the same country and were largely affected by geographical distribution of regions rather than by type of facility alone., Conclusion: The study confirms that births in private facilities have higher odds of cesarean. It also suggests that QMNC should be closely monitored in all facilities to achieve high-quality care, independent of facility type or geographical distribution., Gov Identifier: NCT04847336., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To explore quality of maternal and newborn care (QMNC) in healthcare facilities during the COVID-19 pandemic in Switzerland., Methods: Women giving birth in Switzerland answered a validated online questionnaire including 40 WHO standards-based quality measures. QMNC score was calculated according to linguistic region and mode of birth. Differences were assessed using logistic regression analysis adjusting for relevant variables., Results: A total of 1175 women were included in the analysis. Limitations in QMNC during the pandemic were reported by 328 (27.9%) women. Several quality measures, such as deficient communication (18.0%, n = 212), insufficient number of healthcare professionals (19.7%, n = 231), no information on the newborn after cesarean (26.5%, n = 91) or maternal and newborn danger signs (34.1%, n = 401 and 41.4% n = 487, respectively) suggested preventable gaps in QMNC. Quality measures significantly differed by linguistic region and mode of birth. Multivariate analysis established a significantly lower QMNC for women in French- and Italian-speaking regions compared with the German-speaking region. Moreover, in several quality indicators reflecting communication with healthcare providers, women who did not answer the questionnaire in one of the Swiss national languages had significantly worse scores than others. A significant lower QMNC was also found for young and primiparous women and for those who experienced cesarean or instrumental vaginal birth., Conclusion: Women giving birth in Switzerland during the pandemic reported notable gaps in QMNC. Providers should be attuned to women who are younger, primiparous, and those who had an emergency cesarean or instrumental vaginal birth given the lower QMNC reported by these groups. Women who did not respond in a Swiss national language may need improved communication strategies., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

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., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

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., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To assess women's perceptions of the quality of maternal and newborn care (QMNC) received in hospitals in Romania during the COVID-19 pandemic by mode of birth., Methods: A validated anonymous online questionnaire based on WHO quality measures. Subgroup analysis of spontaneous vaginal birth (SVB), emergency cesarean, and elective cesarean and multivariate analyses were performed, and QMNC indexes were calculated. Maternal age, educational level, year of birth, mother born in Romania, parity, type of hospital, and type of professionals assisting the birth were used for multivariate analysis., Results: A total of 620 women completed the survey. Overall, several quality measures suggested gaps in QMNC in Romania, with the lowest QMNC indexes reported for provision of care and availability of resources. Women who had either elective or emergency cesarean compared with those who had SVB more frequently lacked early breastfeeding (OR 2.04 and 2.13, respectively), skin-to-skin contact (OR 1.73 and 1.75, respectively), rooming-in (OR 2.07 and 1.96, respectively), and exclusive breastfeeding at discharge (OR 2.27 and 1.64, respectively). Compared with elective cesarean, emergency cesarean had higher odds of ineffective communication by healthcare providers (OR 1.65), lack of involvement in choices (OR 1.58), insufficient emotional support (OR 2.07), and no privacy (OR 2.06). Compared with other modes of birth, a trend for lower QMNC indexes for emergency cesarean was observed for all domains, while for elective cesarean the QMNC index for provision of care was significantly lower., Conclusion: Quality indicators of perinatal care remain behind targets in Romania, with births by cesarean the most affected., Gov Identifier: NCT04847336., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

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., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To investigate women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth during the COVID-19 pandemic in Latvia, comparing the years 2020 and 2021, among women who went into labor or had a prelabor cesarean., Methods: Women giving birth in healthcare facilities in Latvia from March 1, 2020, to October 28, 2021, answered an online questionnaire including 40 WHO standards-based quality measures. Descriptive and multivariate quantile regression analyses were performed to compare QMNC in 2020 and 2021., Results: 2079 women were included in the analysis: 1860 women who went into labor (group 1) and 219 with prelabor cesarean (group 2). Among group 1, 66.4% (n = 99/149) of women received fundal pressure in an instrumental vaginal birth, 43.5% (n = 810) lacked involvement in choices, 17.4% (n = 317) reported suffering abuse, 32.7% (n = 609) reported inadequate breastfeeding support while 5.2% (n = 96) lack of early breastfeeding. A significant reduction in QMNC due to the COVID-19 pandemic was reported by 29.5% (n = 219) and 25.0% (n = 270) of respondents in 2020 and 2021, respectively (P = 0.045). Multivariate analyses highlighted a significantly lower QMNC index for 2020 compared with 2021 (P < 0.001)., Conclusion: This first study investigating QMNC in Latvia showed significant gaps in QMNC perceived by respondents, with slightly better results in 2021. Appropriate healthcare strategies to improve health care for women and newborns in Latvia are required., Clinicaltrials: gov Identifier:NCT04847336., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background and Problem: Existing healthcare systems have been put under immense pressure during the COVID-19 pandemic. Disruptions in essential maternal and newborn services have come from even high-income countries within the World Health Organization (WHO) European Region., Aim: To describe the quality of care during pregnancy and childbirth, as reported by the women themselves, during the COVID-19 pandemic in Sweden, using the WHO 'Standards for improving quality of maternal and newborn care in health facilities'., Methods: Using an anonymous, online questionnaire, women ≥18 years were invited to participate if they had given birth in Sweden from March 1, 2020 to June 30, 2021. The quality of maternal and newborn care was measured using 40 questions across four domains: provision of care, experience of care, availability of human/physical resources, and organisational changes due to COVID-19., Findings: Of the 5003 women included, n = 4528 experienced labour. Of these, 46.7% perceived a poorer quality of maternal and newborn care due to the COVID-19. Fundal pressure was applied in 22.2% of instrumental vaginal births, 36.8% received inadequate breastfeeding support and 6.9% reported some form of abuse. Findings were worse in women undergoing prelabour Caesarean section (CS) (n = 475). Multivariate analysis showed significant associations of the quality of maternal and newborn care to year of birth (P < 0.001), parity (P < 0.001), no pharmacological pain relief (P < 0.001), prelabour CS (P < 0.001), emergency CS (P < 0.001) and overall satisfaction (P < 0.001)., Conclusion: Considerable gaps over many key quality measures and deviations from women-centred care were noted. Findings were worse in women with prelabour CS. Actions to promote high-quality, evidence-based and respectful care during childbirth for all mothers are urgently needed., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: Investigate the quality of maternal and newborn care (QMNC) during childbirth in the first year of COVID-19 pandemic in Italy, from the mothers' perspective, as key service users., Methods: Women who gave birth in an Italian facility from March 1, 2020 to February 29, 2021 answered an online questionnaire including 40 WHO Standard-based Quality Measures. Descriptive and multivariate quantile regression analyses were performed., Results: In total, 4824 women were included, reporting heterogeneity of practices across regions: among 3981 women who underwent labour 78.4% (63.0%-92.0%) were not allowed a companion of choice, 44.6% (28.9%-53.3%) had difficulties in attending routine antenatal visits, 36.3% (24.9%-61.1%) reported inadequate breastfeeding support, 39.2% (23.3%-62.2%) felt not involved in medical choices, 33.0% (23.9%-49.3%) experienced unclear communication from staff, 24.8% (15.9%-39.4%) were not always treated with dignity and 12.7% (10.1%-29.3%) reported abuses. Findings in the group of women who did not experience labour were substantially similar. Multivariate analyses confirmed a significant lower QMNC index for regions in southern Italy compared to North and Central regions., Conclusion: Mothers reported substantial inequities in the QMNC across Italian regions. Future studies should monitor QMNC over time. Meanwhile, actions to ensure high QMNC for all mothers and newborns across Italy are urgently required., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Although great improvements in child survival were achieved in the past two decades, progress has been uneven within and across countries, and the COVID-19 pandemic threatens to reverse previous advances. Demographic and epidemiological transitions around the world have resulted in shifts in the causes and distribution of child death and diseases, and many children are living with short-term and long-term chronic illnesses and disabilities. These changes, plus global threats such as pandemics, transnational and national security issues, and climate change, mean that regular monitoring of child health and wellbeing is essential if we are to achieve the Sustainable Development Goals. This Health Policy describes the three-phased process undertaken by the Child Health Accountability Tracking technical advisory group (CHAT) to develop a core set of indicators on child health and wellbeing for global monitoring purposes, and presents CHAT's research recommendations to address data gaps. CHAT reached consensus on 20 core indicators specific to the health sector, which include 11 impact-level indicators and nine outcome-level indicators that cover the topics of: acute conditions and prevention; health promotion and child development; and chronic conditions, disabilities, injuries, and violence against children. An additional six indicators (three impact and three outcome) that capture information on child health issues such as malaria and HIV are recommended; however, these indicators are only relevant to high-burden regions. CHAT's four research priorities will require investments in health information systems and measurement activities. These investments will help to increase data on children aged 5-9 years; develop standard metadata and data collection processes to enable cross-country comparisons and progress assessments over time; reach a global consensus on essential interventions and associated indicators for monitoring emerging priority areas such as child development, chronic conditions, disabilities, and injuries; and implement strategies to increase the uptake of data on child health to improve evidence-based planning, programming, and advocacy efforts., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 World Health Organization. Published by Elsevier Ltd. All rights reserved. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Develop and validate a WHO Standards-based online questionnaire to measure the quality of maternal and newborn care (QMNC) around the time of childbirth from the health workers' perspective., Design: Mixed-methods study., Setting: Six countries of the WHO European Region., Participants and Methods: The questionnaire is based on lessons learnt in previous studies, and was developed in three sequential phases: (1) WHO Quality Measures were prioritised and content, construct and face validity were assessed through a Delphi involving a multidisciplinary board of experts from 11 countries of the WHO European Region; (2) translation/back translation of the English version was conducted following The Professional Society for Health Economics and Outcomes Research guidelines; (3) internal consistency, intrarater reliability and acceptability were assessed among 600 health workers in six countries., Results: The questionnaire included 40 items based on WHO Standards Quality Measures, equally divided into four domains: provision of care, experience of care, availability of human and physical resources, organisational changes due to COVID-19; and its organised in six sections. It was translated/back translated in 12 languages: Bosnian, Croatian, French, German, Italian, Norwegian, Portuguese, Romanian, Russian, Slovenian, Spanish and Swedish. The Cronbach's alpha values were ≥0.70 for each questionnaire section where questions were hypothesised to be interrelated, indicating good internal consistence. Cohen K or Gwet's AC1 values were ≥0.60, suggesting good intrarater reliability, except for one question. Acceptability was good with only 1.70% of health workers requesting minimal changes in question wording., Conclusions: Findings suggest that the questionnaire has good content, construct, face validity, internal consistency, intrarater reliability and acceptability in six countries of the WHO European Region. Future studies may further explore the questionnaire's use in other countries, and how to translate evidence generated by this tool into policies to improve the QMNC., Trail Registration Number: NCT04847336., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

BackgroundVery few studies describe factors associated with COVID-19 diagnosis in children.AimWe here describe characteristics and risk factors for COVID-19 diagnosis in children tested in 20 paediatric centres across Italy.MethodsWe included cases aged 0-18 years tested between 23 February and 24 May 2020. Our primary analysis focused on children tested because of symptoms/signs suggestive of COVID-19.ResultsAmong 2,494 children tested, 2,148 (86.1%) had symptoms suggestive of COVID-19. Clinical presentation of confirmed COVID-19 cases included besides fever (82.4%) and respiratory signs or symptoms (60.4%) also gastrointestinal (18.2%), neurological (18.9%), cutaneous (3.8%) and other unspecific influenza-like presentations (17.8%). In multivariate analysis, factors significantly associated with SARS-CoV-2 positivity were: exposure history (adjusted odds ratio (AOR): 39.83; 95% confidence interval (CI): 17.52-90.55; p < 0.0001), cardiac disease (AOR: 3.10; 95% CI: 1.19-5.02; p < 0.0001), fever (AOR: 3.05%; 95% CI: 1.67-5.58; p = 0.0003) and anosmia/ageusia (AOR: 4.08; 95% CI: 1.69-9.84; p = 0.002). Among 190 (7.6%) children positive for SARS-CoV-2, only four (2.1%) required respiratory support and two (1.1%) were admitted to intensive care; all recovered.ConclusionRecommendations for SARS-CoV-2 testing in children should consider the evidence of broader clinical features. Exposure history, fever and anosmia/ageusia are strong risk factors in children for positive SARS-CoV-2 testing, while other symptoms did not help discriminate positive from negative individuals. This study confirms that COVID-19 was a mild disease in the general paediatric population in Italy. Further studies are needed to understand risk, clinical spectrum and outcomes of COVID-19 in children with pre-existing conditions.

Essential health, education and other service disruptions arising from the COVID-19 pandemic risk reversing some of the hard-won gains in improving child survival over the past 40 years. Although children have milder symptoms of COVID-19 disease than adults, pandemic control measures in many countries have disrupted health, education and other services for children, often leaving them without access to birth and postnatal care, vaccinations and early childhood preventive and treatment services. These disruptions mean that the SARS-CoV-2 virus, along with climate change and shifting epidemiological and demographic patterns, are challenging the survival gains that we have seen over the past 40 years. We revisit the initiatives and actions of the past that catalyzed survival improvements in an effort to learn how to maintain these gains even in the face of today's global challenges.