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Objective: To investigate women's perspectives on the quality of maternal and new-born 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 signifi-cantly 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 health-care strategies to improve health care for women and newborns in Latvia are required.

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.

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.

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 = 4 87, 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.

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.

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 question- naire 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 profession-alism (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 noninstru- mental 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.

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: NCT04847336 This research was funded by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste Italy.

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. ClinicalTrials.gov Identifier: NCT04847336.

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 to March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based quality measures. Findings: 21,027 women were included in the analysis. Among those who experienced labour (N=18,063), 49·9% (37·2%-60·7%) perceived a reduction in QMNC due to the COVID-19 pandemic, 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 health workers not always using protective personal equipment, and 31·8% (17·8%-53·1%) rated the number of health workers 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. Findings were significantly worst among women with elective caesarean (CS) and emergency CS during labour (N=2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significant lower QMNC Indexes; younger women and those with operative births also had significant lower QMNC Indexes. Interpretation: Findings reveal large inequities in the QMNC across countries of the WHO European Region. Actions to reduce these inequities and promote high-quality, evidence-based, patient-centred respectful care for all mothers and newborns are urgently needed. Trial Registration: Study registration ClinicalTrials.gov Identifier: NCT04847336. Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy. Declaration of Interest: None to declare. Ethical Approval: The study was approved by the Institutional Review Board of the coordinating centre: the IRCCS Burlo Garofolo Trieste (IRB-BURLO 05/2020 15.07.2020). The study protocol was also reviewed and approved by the ethical committees of three other countries to comply with local regulations: Portugal (Instituto de Saude Publica da Universidade do Porto, CE20159); Norway (Norwegian Regional Committee for Medical Research Ethics, 2020/213047) and Germany (Bielefeld University ethics committee, 2020-176).