Impact of macro-socioeconomic determinants on sustainable perinatal health care in Portugal: a qualitative study on the opinion of healthcare professionals and experts

A qualitative approach was applied enabling to receive an in-depth understanding of the depicted problem. A purposive sampling technique was utilized to accomplish variability and balance in perspectives [17]. The study sample (n = 21) comprised: i) healthcare professionals (n = 14) such as neonatologists, paediatricians, obstetricians and nurses with work experiences in public and private care on prematurity before, during, and after the EAP implementation period; and ii) healthcare experts (n = 7) from the fields of politics, economy, sociology and pharmacy, of which some had been involved in health care policy and decision making during the same time period. The majority of healthcare professionals were female (n = 11) and the majority of healthcare experts were male (n = 6). The age of the participants ranged from 35 to 70 years (Table 4). The two major metropolitan areas of Portugal, Northern region and Lisbon and Tagus Valley, centralize most healthcare units with specialized differentiated perinatal care for VPT/VLBW infants in the country. They were therefore chosen as our study setting.

Participants were recruited via phone and email. Further contacts for data collection through individual interviewing was ended when inductive thematic saturation was attained [18]. That is, when the team of two researchers involved in collection, processing, and analysis of data agreed that new data tended to be redundant of data already collected and no new topics emerged from latest interviews. The saturation point was achieved after the preliminary analysis of 21 conducted interviews [19]. Data were collected between October 2018–July 2019. A face-to-face, in-depth semi-structured interview technique was chosen to deliver reliable and equivalent qualitative data while benefitting from an in-depth response of the participants [20]. The interviews lasted between 1 to 1 ½ hours.

A paper-based interview guide was developed and pilot tested covering the key questions to be answered within four main areas: a) Current health access and provision; b) Influence of EAP and crisis; c) Policy priorities on prematurity; d) Recommendations (Supplementary material 1). Inquired participants had been previously informed (verbally and in written format) about the study and provided with the interview guide. Participants were not financially compensated for the interviews. They were explicitly notified that the data would be processed as personal opinions of experienced professionals and experts in the subject and time period under study and not as representative of their current employment position and institution. Signed informed consent as well as prior permission for audio recording for analysis purposes was obtained from all participants. Appropriate ethical and consent procedures were taken according to the data protection guidelines of the General Data Protection Regulation (GDPR) [(EU) Regulation 2016/67] and Portuguese law regarding the non-sensitive nature of the data collected from study participants [21, 22].

The interviews were conducted in Portuguese and English language at times and locations chosen by the participants. Interviews were verbatim transcribed, maintaining original connotations, translated into English and verified by the same research team. Though informed on the right of providing insights on their transcripts and translations, none of the participants requested it and thus no transcript was returned to participants. All transcripts were anonymized. Transcripts were stored in a password encrypted file, which is protected in a dedicated storage at the research institution ISPUP and kept for a defined time period of 5 years. Publications and presentations from the study displayed anonymous findings and were subjected to a minimisation of identifiable data.

A thematic analysis was undertaken utilizing Nvivo2011 software, which provides tools for extracting, arranging, organizing, and comparing significant fragments of the transcriptions in a systematic way. The analysis was performed encompassing a five-step categorization procedure of coding refinement towards the definition of major emerged themes. The coding of the content was checked and matched independently by two researchers. Both researchers agreed upon the application of the same coding scheme (intercoder reliability). The five steps included: Identifying and ranking of key concepts by frequency (Step 1); Sorting ranked key concepts into minor sub-categories called codes (Step 2); Clustering codes into major categories called nodes (Step 3); Clustering nodes to identify major themes (Step 4); and Associating categorized major themes with the eight Quality Standards [QS] on maternal and newborn quality of care by the WHO [6] (Step 5) (Table 5). A graphic flowchart on the interplay between the EAP, the crisis, and the Quality Standards was constructed that emerged during the analysis (Supplementary material 2).

This theme reoccurred as the main dominant and interrelated theme throughout the analysis. The reduction of human resources with prohibition of hiring and replacing of manpower losses in order to limit non-essential healthcare costs were perceived to have a direct negative impact on perinatal healthcare provision [n = 20/21]. These measures aggravated the unequal distribution of human resources and shortage of staff across different health care divisions [QS8] [n = 20/21]; deficiencies to adequately provide evidence-based care [QS1] [n = 20/21]; restrictions in the functionality of the gatekeeping-system [QS3] [n = 20/21]; incomplete operating teams [n = 14/21]; delays in admitting women for delivery, which caused potential high risks to mothers and infants [n = 6/21]; and deteriorated staff motivations [QS7] [n = 20/21]. Indirect consequences of the lack of human resources were brain drain of healthcare professionals to the private sector or other countries [n = 20/21]; early retirements [n = 16/21]; lack of young healthcare professionals [n = 14/21]; delays in timely care provision and examinations [n = 19/21]; and reduced emotional support for mothers with VPT/VLBW infants in NICUs [QS6] [n = 15/21].

“Very delayed (appointments). Women who should have monthly consultations and sometimes are 2 months without getting consultations. […]”– Informant 21

The financial cuts enforced on the healthcare system had mostly impacted primary care facilities. Lack of healthcare professionals and namely lack of GPs to provide routine antenatal and postnatal care was linked to several problems [n = 17/21]. It impacted provided care by limiting time management for healthcare professionals [n = 20/21]. Major shortcomings in routine care for pregnant women were: increased waiting times to schedule appointments [n = 19/21]; limited timely antenatal consultations [n = 17/21]; time-consuming waiting periods at the respective health facility when attending appointments [n = 15/21]; reduced number of appointments as GPs were unable to adequately respond [n = 19/21]; and failures in patient referral to specialists [n = 18/21] [QS1]. Number and frequency of antenatal consultations was indicated to vary depending on the clinical situation but also on the limitations of the healthcare centres [n = 18/21]. Overall time assigned to each consultation decreased [n = 15/21], especially at the first consultation during pregnancy [n = 11/21]. Participants reported that 86% of pregnant women at one primary healthcare unit, which serves one of the largest populations in Great Lisbon region, had not yet been assigned to a GP (family doctor) in 2018 [n = 3/21]. In another primary care units with around 50,000 users, it was again reported that nearly 50% of their patients did not have an assigned GP in 2019 [n = 4/21].

“In relation to child health surveillance it was clear that people had to miss more surveillance appointments.” – Informant 5

At hospitals, lack of human resources caused challenges in support provision for VPT/VLBW infants [n = 13/21]. It adversely influenced care provided by clinicians and nurses in neonatology and obstetric departments [n = 17/21]. Lack of advanced healthcare professionals implied for remaining staff: to have less time to provide suitable formation to younger colleagues [n = 6/21]; to be overworked [n = 20/21]; to be left with too few operating staff [n = 8/21]; and to be faced with persisting work pressure [n = 20/21]. When the EAP implemented frozen salaries along with a 40-week-hour schedule extended to nurse professionals, recurrent strikes due to discontent by nurses with increased working hours and decreased base salaries, have further delayed the admission of women with planned caesarean sections [n = 6/21]. Medical doctors were less affected in their base salaries because they were treated according to the rules of collective contracts. They were confronted nonetheless with frozen careers, decreased supplementary payments and higher workload to compensate for staff shortages [n = 16/21]. Brain drain of middle-aged clinicians from intensive and intermediate care units of public hospitals during that period triggered further time and management issues in the operating teams that continue to date [n = 13/21]. Due to the re-instalment of the 35-week-hour schedule in the post-troika period, the impact of shortage in nurses has been felt to be even higher after the crisis [n = 17/21].

The lack of articulation between health information systems was classified as a restraining aspect for quality of care [n = 6/21]. Participants rated health information systems as ineffective due to serious deficiencies such as technological failures [n = 14/21] and poor articulation between actionable information systems [QS 2] [n = 14/21]. It was stated that the patient must either have had one prior consultation or been admitted to that particular health facility in order for healthcare professionals to be able to access past medical information and report exchange. The proper functioning of each healthcare facility information system depended on healthcare facility management [n = 5/21], human resources availability [n = 18/21], and user subscriptions [n = 4/21]. It was specified that actionable information systems did not function homogeneously across the country [n = 14/21].

“Yeah, and when you look for indicators in more bureurifical [outer] regions, you’ll realise that the number [of health care units] drops drastically. So, the problem is not the number [of healthcare units] itself, it is the distribution. […] With the troika, the Government and policy makers realised that there was a need to cut public expending […] again, decisions became more centralised.” – Informant 20

Geographically scattered and unequal distribution of primary care and hospital facilities was perceived to have obstructed timely access and adequate care provision for patients [n = 20/21]. Consequences for mothers were lower accessibility, increased inequalities in the availability of appointments, higher dependency on transport and longer waiting times [n = 15/21]. This has aggravated differential outcome and potential survival of preterm infants [n = 8/21]. The plan for the creation of reference centres by the EAP has not been completely implemented in all healthcare units until today [n = 11/21]. Moreover, an autonomously organized structure persisted in many units, which caused structural issues that have been impairing communication and coordination of care [n = 8/21].

Follow-up was perceived as a challenge [n = 18/21] due to: i) delays in follow-up exams on account of capacity issues [n = 9/21], ii) non-availability, incompleteness and incoordination of follow-up exams due to lack of specialized healthcare professionals (e.g., physiotherapy, social therapies) [n = 13/21], iii) incoherency in the gatekeeping-system as mothers without assigned GP were consulted by different clinicians in each consultation [n = 20/21] and iv) loss of referral continuity [n = 8/21]. The lack of coordination in follow-up care reflected prior crisis-existent structural and organizational issues of the gatekeeping-system [n = 15/21], which were then aggravated by insufficiency in human resources [n = 20/21]. Its deficiency hampered articulation and communication [n = 14/21] and homogenous functioning [n = 13/21] which impeded adequate tracking of the development of infants [n = 8/21]. It further occasioned uncoordinated and overlapped postpartum appointments in health facilities [n = 11/21] and ultimately over use of emergency care rooms [n = 19/21].

“No, we don’t coordinate together. Everything is separated in terms of follow up.” Informant 2

As already stated, the impossibility to hire additional staff during the EAP led to a disproportionate nurse- and medical doctor-ratio per patient [n = 20/21], particularly in primary care facilities. Regarding antenatal consequences, numerous mothers were not assigned to a GP which ended up in their exclusion from the referral system [n = 12/21] or in delayed referral to specialists [QS3] [n = 13/21] with consequences for diagnosis of potential complications for preterm birth (e.g., preeclampsia, diabetes) [n = 5/21].

The economic crisis directly influenced women with a lower socioeconomic status (SES) [n = 20/21] and the year 2010/2011 was pointed out as a social break point [n = 20/21]. Women with a lower SES, residing in areas distanced from main centres or deficient in health care provision capacity, attended perinatal consultations less frequently [n = 15/21]. Due to centralization and reallocation of care facilities, many pregnant women experienced accessibility constraints [n = 11/21]. Though pregnant women and children are exempt from NHS user fees [n = 16/21], they faced increased difficulties with time-consuming travel distances and transport costs [n = 14/21].

Lack of motivation, dissatisfaction and productivity loss due to the budget cuts and cost savings by the EAP were among the main identified issues [n = 18/21] [QS7]. Healthcare professionals in general earned less than 10 years ago [n = 16/21]. The 11% retirement deduction frequently led to the uptake of double shifts between public and private care [n = 16/21]. Principal demotivation factors pointed by participants were salary cuts associated with additional working hours (e.g., 12 h night shifts) along with a reduction in additional hourly payment [n = 19/21]. Additional stated reasons were: the reinforcement of contracts per hour “Recibos Verdes” with lack of employment benefits (e.g., disability income protection, annual bonus, extra hour and retirement benefits); withdrawal of working conditions such as paid meal provision during continuous shifts or personnel resting areas; and the lack of human and physical resources [n = 18/21].

“I think the quality of care is still good, but with the cost of the health of professionals.” – Informant 2

The EAP cost reduction measure included offering less stable hospital contracts and resulted in a less specialized and cheaper labour workforce which contributed to the fragility of working teams [n = 6/21]. Younger healthcare professionals were not sufficiently supported and faced issues in their career perspective [n = 4/21]. Young nurses indicated to have done their specialization aside from their work time for which they neither got time allocated nor were accordingly paid for [n = 4/21]. Young clinicians declared that they were often not hired after their specialization because there were no vacancies [n = 8/21].

“What changed most was in terms of human resources and wages, as I was saying. It changes in terms of satisfaction, in terms of availability, in terms of burn-out, but not in terms of practice.” –  Informant 6

The reduction in human and physical resources while increasing working hours amplified their efforts to maintain quality of care at pre-crisis level but with a higher workload [n = 20/21]. The majority of healthcare professionals felt pressurized and overwhelmed with their work [n = 20/21]. It led to stress, burn out, 10% absenteeism at work, earlier retirements, and brain drain to the private sector or other European countries [n = 20/21]. The impact of the working environment of healthcare professionals was summarized in a three-stage effect chain (Fig. 2).

Two major issues on parents support provision were described: i) insufficient formal postnatal support provision by the NHS, and ii) refusal of psychological support by mothers after birth. Psychological support after preterm birth was declared to be available on request [n = 11/21] and offered by at least one psychologist in the immediate postnatal period at the public hospitals [n = 15/21]. Healthcare professionals and experts claimed that frequently mothers did not remember that emotional support was offered to them as they were overwhelmed with the situation [n = 12/21]. Some mothers refused emotional support especially when birth was perceived as a traumatic event or when the infant was born with major physical or cognitive limitations [n = 13/21]. Parental leave for parents with VPT/VLBW infants was perceived as inadequate as it equals the support time of parents with a term born infant [n = 18/21]. Participants recommended to expand parental leave for parents with VPT/VLBW infants [n = 13/21].

“In the early days of internment, the situation is so heavy that, often, though we offer support they refuse. And then they do not even remember that they refused. I think the situation is too intense, first, for us, professionals, to be able to judge it. […] they often do not remember at all that we’ve talked to them about this or that [...].” – Informant 2

Higher stress levels among healthcare professionals and less available time to provide accurate explanations on care procedures, blocked effective interactions with staff [QS4]. It further inhibited information exchange between patients and healthcare professionals [QS5] [n = 17/21]. Participants considered that care provided did not always meet the needs of their patients and the required emotional support, which also led to greater demotivation [n = 19/21]. Healthcare professionals needed to prioritize their working time on mainly the immediate postnatal care (defined as the first month after birth) [n = 6/21] due to time constraints [n = 16/21]. Antenatal follow-up exams were either not provided in the obligatory frequency or to a lesser extent than mothers required [n = 7/21].

The EAP reduced equipment (e.g., computers) and stopped the substitution of technology to achieve resource savings that impacted significant essential physical resources [QS8]. Primary care units experienced higher material deficiencies compared to hospitals [n = 17/21]. Insufficient maintenance and replacement of equipment and medical necessities were pointed out [n = 17/21]. The shortage of material was defined as: i) lack of equipment and materials to carry out certain activities during the consultations [n = 19/21]; ii) outdated and slow-functioning computers computer systems that led to system failures and caused technical errors, significantly slowed the entry of medical data, and caused delays in consultations and examinations [n = 14/21]; iii) outdated or defective devices and technical resources (e.g., diagnostic devices, CATscan, MRT, ultrasound devices); iv) worn hospital beds; v) lack of simple tools (e.g., gloves, needles, paper); and vi) no resting places for parents and medical doctors [n = 18/21].

“And the equipment that needed to be replaced, especially the ultrasound equipment, their approval was long overdue. The difficulties felt were in fact in the staff and the equipment. “ – Informant 4

Paradoxical and counterproductive problems due to lack of essential physical recourses were classified in peripheral hospitals [n = 6/21]. Even though deliveries have declined within the last decade, the number of nurses and medical doctors has also decreased due to the cuts of the EAP [n = 7/21]. VPT/VLBW new-born transferral was hampered because nurses could not accompany the inter-facilities-transport [n = 15/21]. It prevented the entry of preterm infants who needed an incubator or special treatment (e.g., hydrocephaly requiring neurosurgery or diaphragmatic hernia requiring cardiac thoracic surgery) and affected access to adequate care in NICUs [n = 13/21]. The transferral of infants to a HAPD without medical necessity increased [n = 14/21]. This was caused by frequent referrals of infants from HAP to HAPD because HAP did not have sufficient capacity [n = 14/21]. It led at times to the transferral of other infants who were in a slightly better condition from HAPD back to HAP [n = 17/21]. Participants recalled two situations in which infants were too early referred from HAPD back to HAP and deterioration in their health was observed [n = 4/21].

Capacity issues (e.g., lack of incubators, cots) led to the closure of available rooms with incubators at NICUs [n = 7/21]. Lack of cots and isolation spaces led to perinatal infections in one NICU [n = 6/21]. The lack of capacity in intensive care units NICUs and maternity units remained overcrowded and space in wards and beds remained deficient [n = 18/21]. Capacity problems were exacerbated due to the simultaneous ongoing closure of maternity units of under 1500 births per year in 2000–2012 [n = 7/21]. The need for larger intensive care units and intermediate wards [n = 8/21] and the recruitment of additional nurses at the HAPD [n = 20/21] was recommended.

“ […] And we have a room [in NICU] closed because we don't have enough nurses. This room has been closed for 1-2 years. [...]. Even now, with the entrance of additional nurses we cannot open it, there are not enough yet.“ –  Informant 6

Drug attainment has become cheaper since the EAP reinforced generics through prescribing the active substance instead of the commercial name [n = 21/21]. At the end of the Troika period, the generic market represented around 30 to 50% [n = 13/21]. The EAP also cut freely available therapeutic methods and birth control measures at primary care centres [QS 8] [n = 8/21]. Women with lower SES often bought only parts of medical prescriptions and rather chose the less expensive drugs [n = 8/21]. Participants indicated that pregnant women stated that they had stopped taking or limited buying certain medications as they could not afford all prescribed medicine due to a general inferior financial situation [n = 7/21].

A limitation depicts a relative low generalizability of study findings due to the nature of a qualitative study. Yet, as our study focused on the two main metropolitan areas of Portugal where the majority of health care units are concentrated, the findings are still of high importance and partially generalizable. A minor limitation is that the participants might have been more susceptible towards the study as they communicated their interest and availability.

The added value is the disclosure of an in-depth understanding on the interrelation of macro-socioeconomic determinants and healthcare permitting a distinct representation from quantitative methods. The non-linearity between policy response and expected outcomes chiefly complements its comprehension and demonstrates its relevance for further research on assessing effects of austerity measures.

Firstly, we would recommend a higher focus on the inclusion of social policies into health policies in order to mitigate the effects of the economic crisis and the EAP. Secondly, we would consider the prolonging of the exclusive maternal leave period as predominantly necessary to strengthen maternity protection and encourage motherhood in a cost-effective way. Thirdly, we recommend that greater attention should be placed on the equal geographical distribution of primary care facilities to allow timely antenatal care and perinatal screening possibilities. Finally, a greater transparency and equity on regulations and professional wages between the private and public sector would maximize quality of care and balance human resources distribution throughout the health care system.