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The COVID-19 pandemic is a global traumatic experience for citizens, especially during sensitive time windows of heightened plasticity such as pregnancy and neonatal life. Pandemic-related stress experienced by mothers during pregnancy may act as an early risk factor for infants’ regulatory capacity development by altering maternal psychosocial well-being (e.g., increased anxiety, reduced social support) and caregiving environment (e.g., greater parenting stress, impaired mother–infant bonding). The aim of the present longitudinal study was to assess the consequences of pandemic-related prenatal stress on infants’ regulatory capacity. A sample of 163 mother–infant dyads was enrolled at eight maternity units in northern Italy. They provided complete data about prenatal stress, perceived social support, postnatal anxiety symptoms, parenting stress, mother–infant bonding, and infants’ regulatory capacity at 3 months of age. Women who experienced emotional stress and received partial social support during pregnancy reported higher anxious symptoms. Moreover, maternal postnatal anxiety was indirectly linked to the infants’ regulatory capacity at 3 months, mediated by parenting stress and mother–infant bonding. Dedicated preventive interventions should be delivered to mothers and should be focused on protecting the mother–infant dyad from the detrimental effects of pandemic-related stress during the COVID-19 healthcare emergency.

Policy Points The White House Blueprint for Addressing the Maternal Health Crisis report released in June 2022 highlighted the need to enhance equitable access to maternity care. Nationwide hospital maternity unit closures have worsened the maternal health crisis in underserved communities, leaving many birthing people with few options and with long travel times to reach essential care. Ensuring equitable access to maternity care requires addressing travel burdens to care and inadequate digital access. Our findings reveal socioeconomically disadvantaged communities in the United States face dual barriers to maternity care access, as communities located farthest away from care facilities had the least digital access. Context With the increases in nationwide hospital maternity unit closures, there is a greater need for telehealth services for the supervision, evaluation, and management of prenatal and postpartum care. However, challenges in digital access persist. We examined associations between driving time to hospital maternity units and digital access to understand whether augmenting digital access and telehealth services might help mitigate travel burdens to maternity care. Methods This cross‐sectional study used 2020 American Hospital Association Annual Survey data for hospital maternity unit locations and 2020 American Community Survey five‐year ZIP Code Tabulation Area (ZCTA)–level estimates of household digital access to telecommunication technology and broadband. We calculated driving times of the fastest route from population‐weighted ZCTA centroids to the nearest hospital maternity unit. Rural‐urban stratified generalized median regression models were conducted to examine differences in ZCTA‐level proportions of household lacking digital access equipment (any digital device, smartphones, tablet), and lacking broadband subscriptions by spatial accessibility to maternity units. Findings In 2020, 2,905 (16.6%) urban and 3,394 (39.5%) rural ZCTAs in the United States were located >30 minutes from the nearest hospital maternity units. Regardless of rurality, these communities farther away from a maternity unit had disproportionally lower broadband and device accessibility. Although urban communities have greater digital access to technology and broadband subscriptions compared to rural communities, disparities in the percentage of households with access to digital devices were more pronounced within urban areas, particularly between those with and without close proximity to a hospital maternity unit. Communities where nearest hospital maternity units were >30 minutes away had higher poverty and uninsurance rates than those with <15‐minute access. Conclusions Socioeconomically disadvantaged communities face significant barriers to maternity care access, both with substantial travel burdens and inadequate digital access. To optimize maternity care access, ongoing efforts (e.g., Affordable Connectivity Program introduced in the 2021 Infrastructure Act), should bridge the gaps in digital access and target communities with substantial travel burdens to care and limited digital access.

Abstract Background Inadequate prenatal care utilization (PCU) is involved in the higher risk of adverse maternal outcomes among migrant vs. native women. Language barrier may be a risk factor for inadequate PCU. We aimed to assess the association between this barrier and inadequate PCU among migrant women. Methods This analysis took place in the French multicentre prospective PreCARE cohort study, conducted in four university hospital maternity units in the northern Paris area. It included 10 419 women giving birth between 2010 and 2012. Migrants’ language barrier to communication in French were categorized into three groups: migrants with no, partial or total language barrier. Inadequate PCU was assessed by the date prenatal care began, the proportion of recommended prenatal visits completed and ultrasound scans performed. The associations between these language barrier categories and inadequate PCU were tested with multivariable logistic regression models. Results Among the 4803 migrant women included, the language barrier was partial for 785 (16.3%) and total for 181 (3.8%). Compared to migrants with no language barrier, those with partial [risk ratio (RR) 1.23, 95% confidence interval (CI) 1.13–1.33] and total (RR 1.28, 95% CI 1.10–1.50) language barrier were at higher risk of inadequate PCU. Adjustment for maternal age, parity and region of birth did not modify these associations, which were noted particularly among socially deprived women. Conclusion Migrant women with language barrier have a higher risk of inadequate PCU than those without. These findings underscore the importance of targeted efforts to bring women with language barrier to prenatal care.

Introduction Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery. Material and methods We performed a national cross‐sectional population‐based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance. Results A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively). Conclusions Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices. In the French National Perinatal Survey, maternity unit characteristics in part and regional differences especially explained episiotomy rate variability.

Abstract Background Children born very preterm (VPT) have increased risks of multiple, sometimes complex health and neurodevelopmental difficulties (NDD), requiring long-term care. It is imperative to assess their health service use to investigate both expected and potentially suboptimal care. We described the health services used by VPT children at age 5, by neurodevelopmental and health needs, compared to term-born children. Methods We used data from Epipage2, a prospective population-based cohort of births <32 weeks’ gestation (WG) in all maternity units in 25 French regions over 6 to 8 months in 2011. Data was collected from medical records at birth and parental questionnaires and clinical exams at age 5. A reference sample of 585 children born at term (37-41 WG) in metropolitan France was obtained from the contemporary ELFE cohort. We defined cut-offs for high care use, and compared the services used and frequency of visits by subgroups of children defined by their gestational age, presence of NDD and health problems. Results Out of 3099 eligible VPT children, 2262 participated at 5 years; 15% had moderate/severe NDD and 52% had health problems. Reliance on specialist and therapeutical/paramedical services was high compared to term-born peers, especially among children born extremely preterm, with moderate/severe NDD, or health problems. Health service use varied widely: 25% of children with moderate/severe NDD saw no specialists in the past year, while 46% had >21 visits (to any provider, vs. 10% of term-born peers with >21 visits). Differences in emergency department visits and hospital care were smaller across subgroups. Conclusions Health service use is high among VPT-born children overall, yet some of them have not consulted relevant care providers in the past year, despite having health problems or NDD. These contrasts in care among children with similar level of impairment raise questions about care adequacy and its costs and consequences for children and their families. Key messages • Children born very preterm use a wider range of health services and have more visits than their term-born peers, especially if they have neurodevelopmental or health difficulties. • Health service use in very preterm children varied from no specialist care to over 21 visits in total; these contrasts raise questions about care adequacy and its impact on children and families.

Respectful maternity care (RMC) is essential for quality care, safety, and a fundamental right of women during childbirth. However, mistreatment during childbirth hinders global efforts to reduce maternal and perinatal deaths and birth-related injuries. In rapidly urbanizing Dar es Salaam, disrespectful care in overcrowded maternity units is concerning. To assess the prevalence and factors associated with women's experiences of RMC in four urban health facilities in Dar es Salaam. A 25-item locally co-created and validated measurement tool was administered to 838 postnatal women before discharge in a cross-sectional survey. Data were analyzed in Stata 14 to describe sociodemographic characteristics, birth outcomes, and birth experiences. Multivariable logistic regression identified factors associated with RMC. Satisfaction was reported by 96.4% (793/823) of women. Additionally, 84.3% (689/817) reported effective communication. However, 60.8% (503/827) shared hospital beds, 32.2% (253/785) experienced mistreatment, and 10.7% (89/829) had a birth companion. RMC was significantly less frequent among single women (aOR 0.56; 95% CI: 0.36-0.87) and those with childbirth complications (aOR 0.52; 95% CI: 0.35-0.78). Complications were reported less frequently when women had their own bed (aOR 0.51; 95% CI: 0.34-0.77). High satisfaction scores, despite mistreatment, bed-sharing, and lack of birth companionship highlight the need to raise awareness of rights-based care in communities. As urban growth strains healthcare systems, addressing structural constraints and overcrowding is crucial. Strengthening provider training in RMC and complications management, along with institutionalizing RMC measurements, can improve accountability, clinical outcomes, and women's experiences of care.

Rights-based Respectful Maternity Care (RMC) is crucial for quality of care and improved birth outcomes, yet RMC measurements are rarely included in facility improvement initiatives. We aimed to (i) co-create a routine RMC measurement tool (RMC-T) for congested maternity units in Dar es Salaam, Tanzania, and (ii) assess the RMC-T's acceptability among women and healthcare stakeholders. We employed a participatory approach utilizing multiple mixed methods. This included a scoping review, stakeholder engagement involving postnatal women, healthcare providers, health leadership, and global researchers through interviews, focus groups, and two surveys involving 201 and 838 postnatal women. Cronbach's alpha and factor analysis were conducted for validation using Stata 15. Theories of social practice and Thematic Framework of Acceptability guided the assessment of stakeholder priorities and tool acceptability. The multi-phased iterative co-creation process produced the 25-question RMC-T that measures satisfaction, communication, mistreatment (including physical, verbal, and sexual abuse; neglect; discrimination; lack of privacy; unconsented care; post-birth clean-up; informal payments; and denial of care), supportive care (such as food intake and mobility), birth companionship, post-procedure pain relief, bed-sharing, and newborn respect. The pragmatic validation process prioritized stakeholder feedback over strict statistics, lowering Cronbach's alpha from 0.70 in version 1 to 0.57 for the RMC-T. Women valued the opportunity to share their experiences. The RMC-T is contextualized, validated, and acceptable for measuring women's experiences of RMC. Routine use in facility-based quality improvement initiatives, along with targeted actions to address gaps, will advance rights-based RMC. Further validation and community-based studies are needed.

Disrespect and abuse in maternity services in South Africa has been described over several decades and are rooted in the country's complex socio-political landscape and unequal health system which places strain on public sector health professionals. Strategies to improve the quality of health care typically involve once-off didactic teaching or outside technical consultants focused on improving specific health programmes. These approaches fail to encourage self-reflection or to establish learning cultures. Participatory learning processes, embedded in routine service delivery, are a potentially powerful way to improve ownership and accountability for health system performance. We describe the process followed to develop the Strengthening Teamwork and Respect (STAR) intervention which is being implemented in nine district hospitals in two rural districts of KwaZulu-Natal. The intervention approach draws on a conceptual framework for learning health systems, with intervention strategies informed by participatory learning and action theory. The intervention design was an iterative process informed by literature reviews, formative data collection, consultation with provincial, district and hospital management stakeholders, expert reviewer inputs and piloting of proposed activities. This process produced the STAR intervention approach and toolkit, consisting of: identification and training of champions, creation of STAR teams, convening of learning sessions to work through STAR toolkit activities, identification, implementation and monitoring of change projects, and onsite and virtual mentorship from the STAR development team. Endline cross-sectional surveys and a parallel process evaluation will advance the evidence base for interventions to improve respectful care and cultures of teamwork and learning within maternity units in rural low- and middle-income settings.

Purpose - The aim of this research is to determine the effect of changes in servicescape on the service quality perceptions of maternity ward patients in a private hospital.Design methodology approach - A quasi-experimental design was used. An experimental and control group (of patients) was surveyed before the changes in servicescape took place, and a further experimental and control group of patients was surveyed after changes in the servicescape. Each group was surveyed using a SERVPERF instrument to determine perceptions of service quality.Findings - The changes in servicescape which took place in the experimental context resulted in a significant change in service quality perceptions among the experimental group. This change was not seen in all service quality dimensions, however, with statistical significance seen only in the tangible, reliability and responsiveness dimensions.Research limitations implications - Four different groups of respondents took part in the quasi-experiment (two experimental groups and two control groups) specifically in a medical setting, and the ability to generalise these findings needs to be investigated.Practical implications - Management needs to take greater notice of the effect of servicescape, as well as any changes in the servicescape on the perceptions of service quality.Originality value - There is agreement that the servicescape affects perceptions of service quality and this study bears out this conclusion.

Hospital cleaning has been shown to impact on rates of healthcare-associated infections (HCAIs) and good environmental hygiene is critical to quality care, yet those tasked with the role of ensuring a safe and clean environment often go unrecognised as members of the healthcare workforce. Sepsis is a leading cause of maternal and newborn death, a significant proportion of these cases are estimated to be due to HCAIs. Deliveries in health institutions have now reached 75% globally, and in low and middle income countries the corresponding increased pressure on facilities  has impacted both quality of care provided and quality of the birth environment in terms of infection prevention and control (IPC) and HCAIs. The paper discusses the neglected role of health facility cleaners, providing evidence from the literature and from needs assessments conducted by The Soapbox Collaborative and partners in Bangladesh, India, The Gambia and Zanzibar. While not the primary focus of the assessments, common themes emerged consistently pointing to institutional neglect of cleaning and cleaners. The paper argues that low status within facilities, wider societal marginalisation, lack of training, and poor pay and working conditions contribute to the lack of prioritisation placed on health facility environmental hygiene. With increased international attention focused towards health facility water, sanitation and hygiene and a growing focus on IPC, now is the time to address the neglect of this frontline healthcare workforce. We propose that provision of and improved training can enable the recognition of the valuable role cleaning staff play, as well as equipping these staff with the tools required to perform their job to the highest standard. In addition to training, wider systems changes are necessary to establish improvements in environmental hygiene and the role of cleaning staff, including addressing resource availability, supportive supervision, and an increased emphasis on preventative healthcare.