Women’s suggestions on how to improve the quality of maternal and newborn hospital care: a qualitative study in Italy using the WHO standards as framework for the analysis

Health 2020, the World Health Organisation (WHO) policy framework and strategy for the European Region [1], identifies quality of maternal and newborn care (QMNC) as a key determinant of maternal and newborn health outcomes, of health services expenditures, and as a crucial aspect of human rights. The importance of QMNC - which includes the dimension of patient-centred care - is also recognised by many other policy documents, including the WHO Global Strategy for women and children, the agenda for Sustainable Development Goals (SDGs), and it is in general is widely accepted by many other groups and organizations [2‐5]. In the recent years there has been an increasing recognition on the fact that cross the world many women experience low quality care, and often disrespectful, abusive, or neglectful treatment during childbirth in facilities [6‐10]. The importance on providing a good “experience of care” during childbirth is now emphasized in many recent documents, such as the “WHO Guidelines of Intrapartum Care for a Positive Childbirth Experience” [11].

Despite high-income countries in the European Region, including Italy [6], are characterized by low maternal and newborn mortality when compared to resources settings, yet several challenges in the QMNC persist. Current evidence suggests that in many high-income countries within the European Region the implementation of good practices based on evidence is still unsatisfactory [12‐17], with a diffuse tendency to overmedicalisation [12, 15‐17], and, frequently, a culture of “paternalism”, with low participation of women in decision making [17]. In general, even in high-income countries, such as Italy mothers’ qualitative perception of the experience of care is very not included in the routine assessment of the QMNC, and not considered for health services planning purposes [6].

Among the many initiatives aiming at improving the QMNC, in 2015 the WHO developed a framework which defines clearly key components of quality services for the mother and the newborn [18]. The WHO framework identifies the following three key dimensions of the QMNC: 1) “provision of care”, including evidence-based practices, efficient information and referral systems; 2) “experience of care” including effective communication, respect, dignity and emotional support; 3) the availability of resources, including “competent, motivated human resources” and “appropriate physical resources” [18]. Based on these eight key dimensions of the framework [18], WHO developed eight Standards for improving the QMNC in health facilities”, further declined into 31 quality statements, and over 300 quality measures, in an attempt of defining what health care planners, managers and care providers should ensure to guarantee high-quality care around the time of birth [19]. The WHO Standards were developed based on the existing literature and through a large consultation with experts and represent a very comprehensive set of measures related to the QMNC [19]. However, as documented in a recent systematic review [20], what matters to women during childbirth is still relatively poorly documented. Specifically, among 35 studies identified by the systematic review [20], all had a very small sample (ie, maximum 35 women), with the only exception being a study in Sweden (908 women), one in Australia (202 women), and one in India (85 women) [21‐23]. Additionally, these studies did not documented suggestions of women, collected after delivery, on how to improve QMNC, but rather expectations before delivery [21, 22] or changes in cultural belief through generations [23]. None study from Italy has ever reported women’s suggestions on how to improve the QMNC [20]. This qualitative study aimed at exploring the suggestions provided by women, after hospital delivery in Italy, on how to improve the QMNC.

This study showed that collecting women’s suggestions on how to improve QMNC at hospital level in Italy was feasible and extremely relevant, highlighting critical inputs on aspects of care that should be improved in the opinion of service-users. Most of mothers provided more than one inputs and requests for improving the QMNC. This is the first study in Italy documenting views of women, after giving birth in a hospital, on how to improve the QMNC: we were able to identify three previous research reporting on the women’s experience of care during childbirth in Italy, but these did not include practical suggestions, as expressed by women, on how to improve it [25, 29, 30]. Additionally, this is the first study utilising the WHO Standards [19] as framework for the thematic analysis on women’s suggestions on how to improve the QMNC, and may serve as model for future research. Strengths of the study include that had a relatively large sample size, when compared overall to existing literature [20, 21].

Findings of this study are in line with existing evidences on women’s requests on QMNC, as reported by other investigations. The most frequent women’s request emerged in this study, ie, increase presence of a companion (made by about one third of women in our study) has been largely documented, together with the fear of being alone, in previous systematic reviews [20, 31]. Key aspects of “experience of care”, such as a request for privacy and confidentiality, effective communication and information, respect, empathy and continuity of care have been also widely documented [20, 31]. Other themes relevant to the “resources” domain, such as the need for a safe and supportive environment, and the expectation for health professionals to be skilled, competent, sensitive and kind, in the delicate moment of childbirth, have emerged as key themes in studies conducted both in low-income and high-income countries [20, 31]. Taken together this literature calls for more investments in establishing routine systems for collecting patients’ suggestions on how to improve QMNC, as already recommended by WHO and others [19, 32]. Data collected should be used in practice for planning intervention to improve QMNC (19.32). This pilot study may be used as a model for future projects, aiming at improving women participation into health care planning.

Interestingly, in this study only a minority of mothers (11.5%) made suggestions related to the domain of “provision of care”, which includes all technical aspects of evidence-based care (such as mode of delivery, type of practices experienced). Exiting similar studies conducted in high-income countries [19, 22] seem to confirm that women tend to make few suggestions related to medical practices. For example, in an Australian study [22], women reported as unique expectation related to “provision of care” the desire of a vaginal birth (when compared to operative delivery or caesarean section), and other important aspects (eg, induction of labour, episiotomy etc) were not mentioned at all. The observation that in our study as well as in others [16] few mothers made suggestions related to the “provision of care” may have multiple explanations, including: lack of knowledge among mothers on “technical aspects” of care; cultural factors including different types of stereotypes (eg, tendency to low autonomy in these domains); low importance attributed by mothers to these aspects when compared to others (eg, newborn well-being); overall good practices with low need for improving the QMNC. Each of these factors may play a different role in a different contest. More studies should document factors affection women’s opinion on “provision of care” in different settings.

This study identified, among overall women’s requests, 16.4% themes currently not included in the WHO Standards, such as a request for more privacy, and for more flexible rooming in (ie, not strictly 24/24 h) to allow the mother to rest or shower. These findings should be interpreted based on the characteristics of the setting and in the light of other women’s suggestions - such as the request for higher presence of a companion, and better comfort in the rooms, suggesting that the problem is not rooming-in per se, but rather the lack of other adequate support systems for the mother in the immediate post-delivery-. Currently, there is little experience on the use of the WHO Standards [19], no standardized data collection tool for high-income countries, nor pre-defined data sources. Our results, in line with existing literature [11, 32] call for further research in this area. If confirmed by other studies, consideration should be given on whether to include the additional themes emerged in this study as important for women, among the WHO Standards.

We acknowledge that this study was conducted in one single facility in Italy, and as such findings are not generalizable to other Italian hospitals. Previous studies reported clear differences in practices (such as caesarean section rate) as well as in the experience of care among different geographical regions in Italy, and even among nearby facilities in the same region [6, 29]. For example, it is possible that the maternal and newborn outcomes influenced indirectly the perception of the QMNC with Halo effect, ie, the behavior, usually unconscious, of using evaluations based on things unrelated, to make judgments about something or someone [33, 34].

Additionally, we acknowledge that this study, due to lack on interpreter, did not to capture views of migrant women unable of talking the local language (Italian). Recent studies pointed out how the need of migrant women may focus on specific topics, such as: the need for information on how to access health services, the availability of trained interpreters, and developing capacities health care providers on how to respond to the health needs of women with different backgrounds, in a culturally appropriate way [35, 36]. Similarly, women younger than 18 years were not included in the study, which therefore does not represent the views of adolescent mothers.

Finally, we acknowledge that the data collection tool (open questions to be filled on a voluntary basis) and the timing of administration (immediate post-partum) may have affected results. For example, some answers suggested that mothers may have much more to say, and this would deserve different data collection methods (eg. focus group). Additionally, soon after childbirth mothers may be more concentrated on the joy of having a baby than on the quality of care received. A Halo effect, with negative experiences being temporarily overshadowed in the immediate post-delivery by the excitement and joy of the moment, and later looming as time goes and memories become more realistic, has been previously described among women after delivery [33]. Additionally, although there were no major differences between mothers who provided their views and those who did not (Supplementary Table 2), we cannot exclude a selection bias. For example, it is possible that mothers who provided their views were those with more to say. However, it is also possible that women’s’ response rate was affected by other factors, such as individual psychological traits (eg, willingness to contribute, trust in the institution); contingency (eg, availability of time) or other factors. The ideal timing, tools and data collection methods for these types of studies have not been establish yet. Further research is needed to explore how mothers’ views may vary over time, depending on the timing and types of questions asked, and maternal and newborn health outcomes. In general, more studies should be conducted to further explore mothers’ suggestions and requests on how to improve QMNC in different regions in Italy, as well as in other countries.

Most importantly, data emergency from this and from similar studies should be used to improve QMNC. Efforts should be made for establishing routine systems for monitoring patients experience of care, and for ensuring that data collected are used for improving the quality of health services, as recommended by WHO and others [19, 32]. Still there is little evidence exploring the drivers of poor experience if care and even fewer studies documenting interventions to prevent it. As highlighted also by others [32], although studies and measurement remain important, we need to move beyond collecting data, and drive efforts for increasing accountability and for tracking and achieving change.

Collecting the women’s views on how to improve the QMNC after hospital delivery highlighted critical inputs on aspects of care that should be improved in the opinion of service-users. More investments should be made for establishing routine systems for monitoring patients experience of care. Data collected should be used un practice to improve health service quality. WHO Standards may be further optimized by adding items emerging as relevant for women in high-income countries.