Access to maternal healthcare services is an essential pre-requisite for improving women’s health. However, due to poor access and underutilization, women in developing countries remain vulnerable to various complications. Evaluation of quality maternal healthcare services in any country must include the opinions of the women being as a key stakeholder utilizing maternal healthcare services.The present study was designed to evaluate the experiences, perceptions and expectations of pre-birth and post-birth women regarding utilization and delivery of maternal healthcare services in Pakistan.n = 9) and post-birth women (n = 9). All interviews were recorded after getting permission from the respondents. The interviews were transcribed verbatim and were then subjected to thematic analysis.A qualitative study design was used. Snow ball sampling technique was adopted to identify the respondents. Interviews were conducted using semi-structures interview guide till saturation point was achieved. The sample size at saturation point for different respondents was: pre-birth women (The age group for the pre-birth respondents was 23–43 years while for post-birth group it was 23–32 years. Most of the respondents from both groups were from urban setting. Most of them were either first time pregnant or were having experience of one pregnancy. Thematic analysis of the interviews yielded different themes and sub-themes including birth experience, maternal treatment pathway, identified barriers for quality maternal care, involvement in healthcare decision-making, impact of Covid 19, payment dynamics, role of digital health and recommendations for improving maternal care services.The results of the present study concluded that the overall quality of the maternal care services provided in Pakistan was not up to the mark. High rate of caesarian section was prevalent. Majority of the women were not involved in the decision-making process or provided with any birth plan or counselling regarding birth signs, family planning, danger and birth signs. The cost of maternal care was quite high and not affordable for all. Access to integrated, evidence-based and cost-effective maternal health services for reducing maternal and child mortality have remained a priority goal in the healthcare systems throughout the world . DeliverAccess to maternal healthcare services is an essential pre-requisite for improving women’s health. However, due to poor access and underutilization, women in developing countries remain vulnerable to various complications . VariousMaternal mortality ratio (MMR) in Pakistan has decreased from 276 deaths per 100,000 live births as per Pakistan Demographic and Health Survey of 2006–2007 to 186 per 100,000 live births in 2017, still being highest in the South Asian region. Approximately 65% of the pregnant women in Pakistan seek routine antenatal care, half of the deliveries occur in absence of a skilled maternal care provider and less than 50% seek post-partum healthcare services . DespiteA qualitative study was designed to evaluate the experiences, perceptions and expectations of pre-birth and post-birth women regarding utilization and delivery of maternal healthcare services in Pakistan.Study site for this research included household, universities and healthcare facilities located in twin cities, i.e., Islamabad and Rawalpindi of Pakistan. Study respondents included pre-birth and post-birth women willing to participate in the study.n = 9) and post-birth women (n = 9).Snow ball sampling technique was adopted as it is the best way of identifying the respondents having common characteristics. Interviews were conducted till saturation point was achieved. The sample size at saturation point for different respondents was: pre-birth women  from both groups were from urban setting. Most of them  were either first time pregnant or were having experience of one pregnancy. Nearly half of the total respondents  from both groups were working women. Furthermore, healthcare cost of majority of the total respondents  was covered by medical insurance. C-section rate was seen quite high among the respondents and all of them were using smartphone “My last experience has been very good so I am expecting the same level of service this time too”(Pre-B 05)“I had difficulty in finding the doctor as I was very scared because of my previous miscarriage. However, I chose the doctor during my second pregnancy on recommendation of my aunt”(Pos-B 02)“I had great difficulty in finding the right doctor. Then, I chose this doctor due to good feedback provided by my friends”(Pos-B 05)Preparedness for birth“I feel myself ready for the birth as this is my third time and I do not have any stress or fear”(Pre-B 01)“I am a bit confused at the moment and do not feel myself ready for the birth”(Pre-B 02)“I was not prepared for the birth and was scared till the end”(Pos-B 06)“As it was my second pregnancy so I felt ready as I knew all the process”(Pos-B 09)“My expectations from the healthcare system is that I receive quality care. My doctor calls me monthly for checkup and prescribe me tests such as blood CP, urine RE on different visits”(Pre-B 01)“My expectations from the healthcare system are high in terms of quality and care from my doctor. I am called every month by my doctor up till now as this is my sixth month of pregnancy. She prescribes different tests namely blood CP, glucose, anomaly scan, hepatitis testing and ultrasound on every visit”(Pre-B 04)“My doctor used to call me every month on the same date. My blood pressure, blood glucose level and ultrasound were performed on every visit while complete blood count and hemoglobin were checked after every two months”(Pos-B 01)“My doctor used to call me every month for checkup for two trimesters, then I was called after 15 days during the last trimester. I went to one doctor during first trimester then changed my doctor as a friend suggested another one who was rated better than this one. Ultra sound was performed regularly, however, complete blood count was done after second trimester”(Pos-B 03)Almost all the pre-birth as well the post-birth respondents stated that they were regularly called by their doctor every month for checkup. They were prescribed tests including blood CP, urine RE and ultrasound on every visit.Nearly all the pre-birth as well as post-birth respondents stated that they faced difficulty in finding the right doctor. They usually chose doctor based on the recommendation of friends, family members, colleagues and/or internet reviews. Few of the pre-birth and post-birth respondents highlighted that they were not able to give proper feedback and the healthcare facility also lack follow-up. Almost all of the pre-birth and post-birth respondents were of the view that they were not involved in the decision-making process.Finding a doctor“Yes, I had difficulty in searching the right doctor. Although, my family members recommended another doctor but I selected this doctor myself on the basis of reviews. There should be some sort of database of gynecologists which could be reviewed by the patients for in terms of ratings and reviews of previously treated patients as this can help to choose the right doctor”(Pre-B 02)“It is a bit difficult to search for a good doctor specially during the Covid period as one cannot go freely to the hospitals and get information. I choose my doctor on recommendations of my family and friends”(Pre-B 07)“I had difficulty in finding this doctor as I was very scared because of my previous miscarriage. However, during my second pregnancy I chose the doctor based on the recommendation of my aunt”(Pos-B 02)“I had great difficulty in finding the right doctor. I chose this doctor based on the feedback of my friends. There should be an app for finding the doctor”(Pos-B 05)Mechanism for feedback and follow-up“No, I am not able to give feedback. The hospital doesn’t have a very good feedback mechanism. Although, they have a complaint box in which one can drop their complaint and then they contact the complainant”(Pre-B 01)“Yes, I am able to give feedback to my doctor. At times I feel very anxious regarding pregnancy complications or delivery and get panic but my doctor console me well”(Pre-B 07)“No, I was not able to give feedback as doctor never listened to my complaints. Even I was guided wrong about estimated due date (EDD)”(Pos-B 05)“Yes, I was able to give feedback. I was concerned regarding my gestational diabetes and got panic but she consoled me well”(Pos-B 07)Informed decision-making“No, I haven't been able to make choices myself. My doctor makes the choices”(Pre-B 02)“No, I don’t feel able to make informed choices”(Pre-B 07)“I was not involved in decision-making at all”(Pos-B 02)“No, I was not able to make informed choices neither involved in decision-making”(Pos-B 03)“My doctor guides me about the available choices. I follow her recommendations”(Pre-B 08)“I don’t have a say in my healthcare. I followed the doctor’s recommendations as it is. The doctor mainly makes the decision. Beside this, my husband makes the decisions for my healthcare”(Pre-B 02)“I was not involved in the decision-making at all. All the decisions were made by my doctor”(Pos-B 08)“No, I didn’t have a say in my healthcare. I followed the instructions of my doctor”(Pos-B 09)Nearly all the pre-birth respondents reported that even if they have choice in healthcare decision-making still they follow their doctor’s recommendations for every decision or their family members makes decisions for them. On the other hand, all the post-birth respondents were not involved in decision-making or provided with any birth plan or counselling regarding birth signs.“I search queries related to pregnancy on the internet or mobile apps and also ask my doctor through WhatsApp”(Pre-B 05)“I search queries on google, Facebook and mobile apps and also ask my doctor through WhatsApp”(Pre-B 09)“I used to ask doctor on my appointment or use to call her. Moreover, I use to search internet for information but never used any helpline”(Pos-B 01)“Although, I used to ask my doctor via WhatsApp but still used to search google and YouTube for information but never used any helpline”(Pos-B 04)Nearly all the pre-birth as well as the post-birth respondents highlighted that the most common source for gathering information used was via google followed by Facebook, WhatsApp group and/or their doctor.“I have not been given any information on danger signs and family planning till now”(Pre-B 01)“No, I have not been counseled on warning signs and family planning”(Pre-B 04)“I did not receive any birth plan or was guided about birth risks or family planning”(Pos-B 05)“I did not receive any birth plan or was guided about birth risks”(Pos-06)Almost all the pre-birth as well as the post-birth respondents indicated that they did not receive any counselling from their doctor due to her excessive workload. The respondents highlighted that counselling regarding family planning, danger signs and birth signs were not provided to them.“I do not feel safe during this time. I use my own car but still the hospital environment makes me scared during Covid 19”(Pre-B 05)“Yes, I feel safe traveling to the hospital during Covid 19 as I use my own vehicle. However, my doctor has advised me not to visit in the first few months of pregnancy due to Covid 19 until and unless it is necessary”(Pre-B 01)“No, it didn’t feel safe to go to the hospital during Covid 19, so I preferred that the doctor guided me over the phone call”(Pos-B 09)“I found it safe to travel to hospital during Covid 19”(Pos-B 08)Nearly all the pre-birth respondents except one stated that they did not feel safe travelling to the hospital during the COVID 19 pandemic, despite the necessary SoP being followed at the hospitals. Contrary to this, mix responses of post-birth respondents were seen regarding safety concerns for travelling to hospitals during Covid 19.All the pre-birth as well as post-birth respondents highlighted that the cost of maternal care was quite high and not affordable for all. Half of the pre-birth while all the post-birth respondents except one had their treatment covered through insurance. Moreover, all the pre-birth as well as post-birth respondents highlighted the need of reducing cost of care in order to make it easily affordable and accessible for all.Cost and mode of payment“Healthcare cost is a burden for us as we do not have any medical insurance nor we have planned to have one yet”(Pre-B 02)“Healthcare cost is quite high. My healthcare cost is fully paid by the insurance company at my workplace”(Pre-B 08)“Healthcare cost is an immense burden especially in case of C section. My healthcare is paid by insurance company at my workplace”(Pos-B 01)“It is a burden as the cost is very high for birth. We bear the cost ourselves. We do not have any intensions to go for insurance as the process is complicated”(Pos-B 09) Expected treatment cost“I expected it to be less than Rs. 60,000 but it is more than Rs. 80,000 for normal delivery and more than Rs.1,50,000 for a cesarean delivery”(Pre-B 03)“I expected to pay less than Rs. 30 thousand by the end”(Pre-B 09)“It should be free or less than Rs. 20,000 in order to be accessible and affordable for all”(Pos-B 07)“It should be less than Rs. 50,000 to be affordable for everyone”(Pos-B 04)“There should be a mobile app for asking queries and WhatsApp group could be effective”(Pre-B 03)“There should be a helpline and a WhatsApp group for mothers”(Pre B 05)“I think class training or WhatsApp group could be effective. Beside this, I think telemedicine could also be effective during this pandemic as counselling could be easily received at home”(Pos-B 02)“I think class training will be effective. Recorded videos might be played in the waiting areas. Moreover, I think telemedicine might also be effective to some extent keeping in view the literacy rate of Pakistan”(Pos-B 05)All the pre-birth as well as post-birth respondents acknowledged the role of digital health for improving maternal care. A mobile app was the most recommended option for improving maternal care followed by helpline/website and WhatsApp group by the pre-birth respondents while the post-birth women suggested class room training and telemedicine as the most effective digital health strategy for improving maternal care.“There is a need of counseling and guidance sessions by the doctor regarding treatment. Doctors should be empathetic and should motivate the mother. New mothers should know about the specific diet and danger signs and symptoms. There should be a separate counseling service within the hospital for guidance regarding diet and other pregnancy related queries”(Pre-B 01)“New mothers should be counseled about signs and symptoms of each stage of pregnancy. Diet counseling should also be provided. Treatments should be clearly explained. Husbands should be involved in the whole process and also be guided by the doctors. The facilities should be accessible to patients”(Pre-B 02)“Patient education and counselling should be available at every stage of pregnancy. Patients should be counseled regarding self-care and lactation. Dietary and post-partum depression counselling must be provided”(Pos-B 01)“Unnecessary tests and visits for checkup should be avoided to reduce cost. Gynecologist fee should be affordable for everyone. New mother must be counseled regarding OTC medicines intake, life style and diet”(Pos-B 04)All the pre-birth as well as post-birth respondents suggested to improve the maternal care services by establishing a database of gynecologists, providing birth plan and appropriate guidance/counselling to the new mothers regarding danger signs, miscarriage, life style modification, lactation, post-partum depression, birth signs and complications associated with pregnancy as well as delivery.During the past decade, a significant improvement has been observed in the quality and delivery of maternal healthcare services throughout the world by implementing specialized maternal child health programs focusing on nutrition, medical care, pre-partum and post-partum services. However, despite these interventions it has been recorded that more than half a million women die during pre-partum and post-partum phase, especially in the developing countries. The reasons might include poor access and reduced utilization of maternal care services along with various social, economic, and cultural factors contributing towards rising maternal morbidity and mortality in developing countries including Pakistan . It is iCounseling can help improve the utilization of healthcare services as well as might reduce maternal complications . The resThe emergence of Covid-19 pandemic has severely impacted the quality of healthcare services throughout the world. As pregnant women require specialized care, the delivery of such services due to pandemic has been negatively affected . The resAccess to quality evidence-based maternal care is necessary to reduce maternal mortality and morbidity. However, the cost of delivery and post-natal care can affect the utilization of these services . The resAs in any study, it is only possible to reflect the opinions and experiences of women who agree to participate. It is possible that the views of women who did not take part in this interview study may have differed from the views of those who did. Majority of the respondents were literate, from urban setting and moderate-income background, therefore, the experience and perceptions of the illiterate women or from rural areas and low social economic background might be different and were not captured by the study.The results of the present study concluded that the overall quality of the maternal care services provided in Pakistan was not up to the mark. High rate of caesarian section was prevalent. Majority of the women faced difficulty in finding the right doctor and were not prepared for the birth. They were not involved in the decision-making process or provided with any birth plan or counselling regarding birth signs, family planning and danger signs. The cost of maternal care was quite high and not affordable for all. The role of digital health for improving maternal care was acknowledged by the women. It was suggested by the respondents to improve the maternal care services by establishing a database of gynecologists, providing birth plan and appropriate guidance/counselling to the new mothers regarding danger signs, miscarriage, life style modification, lactation, post-partum depression, birth signs and complications associated with pregnancy as well as delivery. Thus, adequate support system should be in place at healthcare facilities to provide prenatal and post-natal support to all mothers to reduce maternal complications and promote early initiation of breastfeeding in Pakistan.


The birthing room is a major workplace for midwives but how it influences them in practice is not enough investigated.Purpose: This study aimed to explore midwives´ experiences of how the birthing room affects them in their work to promote a normal physiological birth.Methods: A phenomenological reflective lifeworld research approach was used and included individual interviews with 15 midwives working at four different hospitals in western Sweden, and of which two also assisted at homebirths. The analysis focused on the meanings of the study phenomenon.Results: A birthing room can by its design either support a normal physiological birth or support a risk approach to childbirth. Four opposing constituents complete the essential meaning of the birthing rooms, and to which the midwives need to relate in their roles as guardians for normal birth: i) a private or a public room; ii) a home-like or hospital-like room; iii) a room promoting activity or passivity; iv) a room promoting the midwife´s presence or absence.Conclusions: The birthing room mirrors a pathogenic-oriented care approach. A presupposition for the work to keep the birth bubble intact is to protect the mother from disturbing elements both inside and outside the room. The environment in which health care occurs has substantial effects on patient’s health, safety and effectiveness of care  or by the head of the unit in the department where they worked, with a request to participate in an individual interview. Those who showed interest in participating were contacted and given oral and written information about the study.Eighteen midwives were asked to participate of which three declined due to lack of time. The fifteen participating midwives worked at four different hospitals and at six different labour wards. Two of the midwives also assisted at homebirths. Their age varied between 36–61 years old (median 48 years), and they had worked as midwives between 3–30 years, (median 14 years). Six of the participants worked in the ward where the Room4Birth study is taking place and had therefore experience of working in a newly built test room, designed to offer changes according to a woman´s wishes. These experiences of working in different birthplaces and settings, were considered beneficial for providing broad variations of lived experiences on how the birthing room affects the midwife in her work.Each participating midwife received both verbal and written information about the study, and they were told that the interviews would be recorded, and that they could withdraw from the study at any time. Written informed consent was received prior to the interviews. Midwives were interviewed individually by either AA (n = 12), HD (n = 1) or MB (n = 2).how do you feel the birthing room affects your ability to promote a normal birth? The participants were encouraged to elaborate on experiences and concrete situations related to the study phenomenon. Follow-up questions were asked continuously, such as: can you give an example? and can you develop that more? The interviews were recorded and lasted between 28–64 minutes.All participants decided time and place for the interview. Each interview began with an open-ended question: The recorded interviews were transcribed verbatim and analysed according to the reflective lifeworld research approach. According to this approach, analysis is characterized by a constant movement between the whole-parts-the whole, focusing on meanings in each interview and the interview as a whole, as well as between each interview and all interviews together. The aim of the analysis was to explore and describe the essential structure of the phenomenon, which can be reached through understanding the variations of meaning. The process of analysis went from discovering meaning units to finding patterns of meaning, an essential structure, and finally, variations of the meaning patterns, described below as constituents  are midwives, which challenged us further to have an open attitude to the study phenomenon, instead of seeing what we usually see. As part of the bridling process, questions were repeatedly asked during the analysis about whether this was the best way to understand the phenomenon, or whether it should be understood differently. We also went back repeatedly to the original whole of interview texts, in an oscillation between the whole of the text, parts and a new whole that defined the essential meaning structure of the phenomenon.Finally, the essential meaning that characterized the phenomenon was identified, and the clusters were abstracted to a higher level, grouped together, and made into constituents that described both the essential meaning and the phenomenon as a whole. This analysis was conducted by two of us (AA and MB), while HD and CB read, discussed and critiqued the emerging and final description, in the process known as “peer debriefing” . All procedures were in accordance with the 1964 Helsinki declaration and its later amendments  a private or a public room; ii) a home-like or hospital-like room; iii) a room promoting activity or passivity; iv) a room promoting the midwife´s presence or absence.In our descriptions the midwife is referred to as “she”, and the mother giving birth is also referred to as “she”.privacy and publicity. As guardians, the midwives want to encourage and promote the room to be private, thus protecting against publicity.One constituent structuring the meaning of the room concerns To make the birth public is the result of an institution focusing on risk, which includes the drive to have control over the process, thus allowing what is happening in the mother´s body to be available to everyone outside the room. This is the case with having Cardiotocography (CTG) monitors in the office, where everyone can observe what is going on inside the birthing room, with no need to step inside.he door has a central function on how the room is constituted in terms of keeping private or public. It is the way not only into and out of the birthing room, but gives access to the mother’s birth nest, to her space, her bubble, and to her body.Besides this, tIt is still their birth. We are the ones who are invited to the patient. We are involved as staff. And if you turn that perspective around a bit, it will be … the patient who should welcome us in for it to be really good. (P14)I will step into the room with reverence, for the woman. It should be her domain. She should be like a queen to whom I, as a midwife, should treat myself reverently. She will decide how it will be around her. (P8)In a room supporting privacy the door is closed, which gives the childbirth process protection from the outside world and allows for the mother to be in her “birth body”—her “bubble”. A closed door creates an atmosphere of peace, security, and emotional safety. The mother is not disturbed by activities out in the corridor. The privacy is preserved by the midwives knocking and waiting for answers before entering. It is a way to demonstrate that the space inside belongs to the mother who then gets to welcome the staff in:It is a very sensitive situation when a woman gives birth to a child, it has been known since time immemorial that when the birth was underway, the room was sealed, then anyone could not run in and out of there. It was they who were to take part in the birth and I have experienced that it still applies today, but we do not do that. (P4)If she [the mother] can focus on giving birth to her baby, if she can be in that bubble that you need to be in when giving birth, then it is very conducive to that hormonal play and also her ability to be in the bubble with as few breaks as possible. I think you need to have this focus in your childbirth bubble. If I now constantly say “I’m just going to go out and get a thing”, you force her out of this bubble every time you do that. (P5)In contrast, the door in a public birthing room is often open and the midwives, together with other staff at the ward, are often running in and out. It is like the room has no door, or that it is more like a revolving door, lacking handles. The staff have free access, they can just walk straight in. Also, the midwife and assistant nurse who work inside the room can easily move in and out, to pick up an aid, look after other mothers, join the rounds, or respond to an alarm. Every time the door opens, the world outside is remembered by those inside. It may be another light out there or other sounds that signal stress or danger. It can disturb the birthing process; the atmosphere and the bubble inside the birthing room blows up a little every time the midwife opens the door and goes out:To guard the normal, healthy, physiological birth in such a public room, including keeping the door closed, is hard work. Knowing that the door may swing open at any time, some midwives set up screens to further protect the mother´s privacy. They also try to warn the mother if someone is about to enter the room, i.e., a doctor or a colleague.And then I can only say: “No, stop”, at the door, “I do not want all of you in here. One person is enough now. We sound the alarm if we need more”. Because that’s also about integrity, calm. Because I think if you take in five, six people who start spinning around the room, what does it do to the woman and what does it do to her possible risk of bleeding? (P10)When something urgent happens, the door is wide open, everyone has access to it, and it is as though the door no longer exists. The room goes from being very private to becoming public. The mother then becomes exposed to all the people who run into the room. In these situations, one midwife describes that she may have to actively close the door to keep the staff out who are not needed at the moment. Otherwise, the situation may worsen:The bathtub: Privacy and publicity are also influenced by whether there is a bathtub in the birthing room or if it is placed elsewhere. If there is no bathtub in the birthing room, a mother that wants to take a bath will have to change rooms. This may cause her to refrain from bathing since it means that she has to leave her private space, move out in the corridor and into a new environment and into a new room that does not belong to her:Then you need to break this bubble in the room and go somewhere else, and if you go to another room I think many people also think “I have to go back from here later, back to the room where I will give birth” and then maybe you feel that you do not get any peace in it, “I have to leave here again, this is a bathroom ... I might take it up for someone else”. It’s easier to try it out too, it’s much easier if it’s there in your own room than to go through an entire corridor having pains, you may not be eager for that at all. (P5)What is going on outside the window may also disturb the privacy of the room. Sound from an ambulance, people working just outside the window, or if there are other buildings nearby from which one can see straight into the room, may cause the mother to feel uncomfortable. Knowing that there are people outside that may see or hear you birthing can be inhibitory. For the room to stay private and for the bubble to stay intact, there can be no risk of being seen or heard from the outside:Something I do not think contributes to that bubble is the environment outside the windows here. Partly that there are other windows enabling others to look into our windows even if far away … you may not feel completely protected … The integrity is disturbed by a crane outside the window that builds a new clinic next door. There is a truck driver two and a half meters outside … you might not want to share your birth with him. So, I think it bothers women, the environment outside the window. Or the feeling that you are not completely to yourself. (P3)home-like or hospital-like. A room that promotes childbirth is, according to the midwives, a room that provides emotional safety. And a room that feels emotionally safe is a room that feels homely. A hospital-like room is the opposite of home-like, it is a room that is designed according to the business and reflects the prevailing model of care and view of childbirth as a risk. Although it can never be like home in a hospital, there are aspects of the room that can either make it easier or harder for the midwives to create a homely environment for the mother.Next constituent is whether the room is Light, colours, nature, bedspread and personal items: One crucial element to make the room homely, is the lighting. If the lighting can be dimmed it creates a cozy, calm, and enclosing atmosphere. Earthy colours on the walls, nice pictures or green plants may also support a homely feeling. The environment should resemble a spa, it gives a safe and nice feeling (P12). In some hospitals, the birthing bed is covered with pretty duvet covers to make it more inviting. All such things help not only the mothers, but also the midwives to relax, which is positive for the birth process:I think it [the room] feels cozier and safer if it is not a very strong lighting … I think that partly it is for her who gives birth, but it is also the case that it is calmer for me to work in. A very bright light signals that it is a bit urgent. (P5)It is what the animals do, the mothers go to a safe place. If thunders and rains, or bombs or predators are coming to take them, then all contractions stop and they run and they wait until everything is calm and quiet and then let the babies out when they feel “Now I can let them out”. That’s how it is in the animal kingdom and I think it’s exactly the same, I do not let anything out until I feel that this is the right place. (P6)Nesting and taking possession of the room: To create a homely feeling, some mothers bring own personal items from home such as photographs, pieces of fabric shawls, their own pillow, or speakers so that they can listen to their own chosen music. The midwives welcome and encourage this nesting behaviour. If the mother can feel like home in the birthing room, it facilitates for her to take possession of the room. She doesn’t need to behave, asking for the midwife’s permission, instead she moves around as she pleases and uses all corners of the space. The room becomes her domain, just like home and the relationship between the mother and the midwife become more equal. For the midwives who work with assisting home births, they are guests and the one needing to adapt to the mother´s and her family´s domain.Then we have had couples here who have brought a lot of fabrics with them. They’ve hung things up. They have turned the lights off and were really nesting properly, so that they get what they want. And that is a great thing … Those couples have dared to take control, “We are the ones who come here. We are going to give birth. You will help us and support us”. They feel at home. (P13)It should be equal, that they should be able to talk to me, how they want it, and dare to do it. And that it is their experience that I really only get to follow. And that’s how it is if they come and decorate the room the way they want. I step in with them, instead of them being with me. So then it will be a different atmosphere. It will in a way be more equal then. (P9)[At a mother´s home] I adapt to the premises that are available. The person who is going to give birth does not have to adapt to me or the premises, because they are hers. She has an ownership there. (P8)Ahospital-like room, on the other hand, belongs to the staff, it is their domain. In such a room there will be more of a hierarchical order where the mother is subordinate to the midwife who controls and steers and focuses on performing her own duties. The midwives need to be in control and to be able to act quickly in case of emergency. There has to be enough floor space to move around, and a certain order—the cabinets should be marked with their contents, so it is easy to find items. If things are in the way of the midwife, she moves them:Should there be an emergency situation, we must be free to move around in the room ... Because it will be in the way, I decide ... to take out the walking table. Now she does not have access to the walking table. And then I take in a Pilates ball and she has to sit on it for a while. So it will be me who decides. (P9)Childbirth can be completely normal from the first moment until you leave the room, but urgent things can also suddenly happen. Completely unexpected … where you need to move beds quickly, have the opportunity to be around the woman from all directions, that you do not have the bed against a wall or that you do not have access to the things you need, if needed! (P6)Ahospital-like birthing room is designed from arisk perspective. Such a room does not support birth since it does not signal that birth can be something normal. Instead the medical equipment indicates that giving birth is a risky event. To have an emergency table for the newborn child inside the room may have some advantages but “What does the table that stands there say? Well, something can happen to your child (P10).”It is precisely this medical, that you enter the birthing room and there is a lot of medical equipment in front, such as nitrous oxide tubes, CTG device, and drip stands. I think that is very negative. Because when you come in and are healthy and are about to give birth, it gives you the feeling that you are in hospital and … the feeling that a catastrophe can happen here. … this feeling is exactly the opposite of what you should feel when you go into the labour process, a sense of security. (P15)The interior in such a room gives a sterile impression with fluorescent lamps in the ceiling giving a strong light that cannot be regulated. The walls are often white coloured, and there are very few items that soften the atmosphere and make the room inviting to stay in. The bed is made with just a sheet and a plastic protective mat placed on top, which leaves the mother to wonder if birth is a messy event.“intrude too much on the couple, as it is their room. (P2),” it is difficult or even impossible for the mother to nest. Instead, they revert to the role of a patient—passive and docile—waiting for the midwife’s instructions and permission before doing anything such as changing position or going to the toilet:I think that very many [women and their companions] find it very difficult to make it their own … because they are patients in hospitals. They come into a hospital room and we as staff have a position of power in there, we control the birth very much. (P1)Such a hospital-like room makes the mother feel like a guest and it can even trigger fear of giving birth. Because even if the midwife is trying not to What I usually do, is that I explain when we enter the room what the different things are, so that they know. “That it’s not dangerous, it’s not strange, but this may be something you want eventually”. What the CTG device with the monitor is. That the computer is a work tool for me. That we have our baby’s table with a heat lamp over. And that we have an operating lamp in the ceiling if I need to suture after. Just so they know what it is they have around them. I think that creates more security than being thrown into a room where there are appliances you do not know what it is and what it is used for. (P11)In the hospital-like room the midwives must work hard to make the mother feel emotionally secure. They try to normalize what looks deplorable by explaining all the medical equipment and buttons in the room—what it is and what it might be used for, so there are no strange things that can create fear. Some midwives move medical equipment out of the way when not needed and some encourage the mothers to spread their things out just like they do at home.active or more passive during childbirth, both of which influence the midwives´ work. Aroom that promotes activity inspires the mother to movement. Preferably, it is the mother herself that takes the initiative to move and chooses which positions she wants to be in. This will strengthen her and give her influence over her birth, which may result in a better birth experience. In such rooms there is sufficient floorspace to move around. There are visible options, such as Pilates balls, walking trays, yoga mats, or a large bathtub inside the room. On the walls there may be pictures of different positions that can facilitate childbirth, which may serve as a source of inspiration. Since every mother is unique, the room offers several alternatives and adaptions:That she has a freedom of choice to find something that suits her, so that she feels that it is her birth, that she owns it. That she can choose. Not just because I say “Now I think you should kneel in bed”, but “No, I might want to hang my birth support rope here by the door”. So that she can get ideas to have more influence over her own birth which can hopefully lead to her having a positive birth experience. (P13)If you have things that promote that the woman is active, I think that it becomes a positive memory of being active in her birth, that it is not someone else who does it for you. My experience is that it can be experienced that someone else takes over, that you are just a machine that gets this child out! It’s like a human being giving birth to a child! For me it is an existential experience that I must be active to do myself, there is no one who can do it for me … And I think it promotes one’s experience, that “My body has given birth to children”. My goal as a midwife is for women to feel that “I did it!”, Not that I have done it for them. (P1)This constituent concerns whether the birth room is promoting the mother to be more the birth bed is the main feature, around which the midwives practice. Medical equipment, such as the CTG device, the nitrous oxide tubes, drip stands and infusion pumps, are placed around the head end of the bed. Its appearance, its placement, and the fact that there are few other comfortable options, such as a large bathtub or a sofa, indicates to the mother that the birth bed is where she should be. She becomes passive and in-active, and also more dependent on the midwives who in turn become more controlling in their efforts to encourage movement.The opposite, a room that is designed to promote passivity strengthens a risk perspective of childbirth. This room is not designed to encourage movement. In such a room As a midwife, if you have the bed … It is very easy to say “Yes, but lie down on the bed, and we will start by doing the CTG”. That’s how you start, you almost put the patient into the bed. (P15)… Then of course I want them in bed when they are about to give birth, so that I can see the perineum properly and see what the woman looks like and how the baby is coming. (P14)The descriptions show that the bed, for many midwives, is an important part of birthing. It is a central and safe place in the room and around which the midwives do their work such as comforting, connecting to CTG, performing vaginal examinations, observing the perineum during pushing, or managing a haemorrhage:If I am to carry out various interventions, I try not to be affected by her position. I can check when the woman is standing up at the edge of the bed, if possible. It’s not always possible, but I can always try it first. It may not be that she has to go to bed. I can put on a scalp electrode when she stands up at the edge of the bed and you can listen to fetal sounds in all sorts of different positions. You can give an injection when she sits up and stands up and so on. Or lying in the bathtub. I never tell a woman to get out of the bath for me to examine, for example. (P1)Generally, in a home birth, women do not use their beds until after the births … you are usually in the living room, the dining room, leaning over the table or leaning over the kitchen counter. Or lean back against the sofa, or you walk a lot more. And maybe most women who give birth at home nowadays want to bring a pool. You can see that when you have something as powerful as a birthing pool, it becomes the center of the room instead of the bed. But even at a home birth where there is no pool, I have never experienced that. The mother seeking out the bed. (P7)However, the midwives’ experiences of the birth bed contain contradictions. At the same time that they express the need for the bed in certain situations, they struggle with it in others. Once the mother has ended up in the bed, it can be very difficult to get her out. Therefore, different techniques are used to prevent the mother from entering the birth bed: One midwife describes how she usually raises the bed to maximum before she lets the mother into the room. Others try to re-furnish the room and move the bed aside, hiding it, although it can be a risky event since interfering with the order in the room may cause tension between the midwife and other colleagues. Another midwife states that she avoids instructing a mother to lie down when performing certain interventions. For the midwives working with home births, a bed is not a central thing for their practice, it is mostly used after the child is born.This constituent describes how the birthing room, and its surroundings, may either promote or hinder the midwife to be present, including both physical and mental presence. It also describes how the midwife´s presence in the birth room affects the mother´s ability to be in her own body—the birth´s inner room.presence and absence in the birthing room is influenced by activities out in the corridor, in the office or in another birthing room.Since the birth room at a hospital is not a separate unit, what is happening outside the room is somehow reflected on the inside. Much of the midwives´ maybe a small chair to sit on (P13).” However, by sitting down calmly, the midwives with their body language can convey that everything is going well, that the process is normal, and nothing dangerous is about to happen:If I can then sit on a Pilates ball and wiggle my toes and look generally calm, I can also convey that it is not dangerous because then I would not have been sitting here. Because then I would have been much more active in here. (P3)When the midwives´ presence is supported, the room provides space for them to just “be”. With their presence, the midwives signal that the mother is the focus of their attention. The midwives have little concern for their own comfort in the room, one midwife stated she didn´t need anything but ““see and hear and listen and taste the woman all the time (P11)”.When the midwives are present inside the birth room, they can gather information about the birth process, in order to discover small changes that can tell about what is happening in the woman´s body, they Because if she does not understand why she suddenly starts to feel a little poopy and thinks, “oh God, how embarrassing. This is very difficult. And I need to go poop”. And then comes this horror, “shall I poop on myself?” And so these negative fears are started in the body, which then suppresses the good hormones. Instead of understanding, “this is something natural. This is not something I need to be afraid of. It just tells me that the birth has gone very well, that this is happening, that I am starting to feel this way”. Then she has not become afraid of it and begun to tense up and work against her body. But it is also about seeing the woman’s body as a room. That this is where so much happens, in the woman’s body … not only the physical space around, which of course also affects. But so it’s about finding security in the body. (P11)Presence enables the midwives to encourage and support the mother to focus on giving birth, to be present in her own birthing body, just go with the flow and find her inner security. To achieve this, the mother needs to understand what is happening, otherwise she may become frightened:Some [mothers] may have concern for their partner, that the partner should be comfortable. And if there is no place where he or she can lie down, they may find it unwelcoming and strange … for the partners are their security and it [the room] must be just as inviting for them. (P4)The room should also support the presence of the mother´s companion. He or she needs to have the space to support the mother, but also have room for rest and recovery. There should preferably be a place in the room where the couple can have a physical presence, for example, a sofa where they can sit together, since physical contact creates security and promotes oxytocin production.The biggest hurdle to the midwives´ presence in the birthing room is that they have to take care of more than one mother in the labour and birthing process at the same time. The care is not organized in such a way that there is one midwife per mother giving birth. There are several physical attributes in the birthing room and on the ward that support and enable this care model to function.the CTG device, with tracings that are displayed on a monitor, both inside the delivery room and outside in the office. The CTG monitoring can thus facilitate the midwives’ work because they can keep track of the baby’s health even if they are not in the room, but at the same time monitoring creates a culture that leads the midwives away from the birthing room. One midwife shared that she sometimes has more than one CTG on display inside a delivery room, which signals that she is divided:I may have to have the other CTG curve [displayed] on her curve, so that I see both sometimes. And then they can also be stressed by the fact that they see that I have two that I must keep an eye on. That my attention is not only on them, but I must keep an eye on one more. (P13)But it’s also this thing that here we are talking about how the health care system views a birth, right? The care clearly shows that the focus should be on the CTG graph because we can sit in the coffee room and look at our curves. It can take us away from the woman. We do not have to be in there to listen every 15 minutes. Because we can be in the coffee room and look at the screen instead. (P7)One such physical attribute is And they say, “Here it [the contractions] comes. Here it comes. Here it comes.” And then I can sometimes show them how they can put a hand on their stomach and feel it coming. (P7)Inside the birthing room, the CTG device takes focus away from the mother at the same time it prevents her from being present in her birth body. When everyone in the room looks at the CTG monitor, what happens there becomes the centre of the childbirth. Somehow what is shown on the monitor becomes more important than what the birth body is showing, which may cause the mothers to doubt their body and their ability to give birth. When that occurs, the midwives may need to actively turn the monitor away so that the mother does not see it. If the companions are too much focused on the CTG monitor, one midwife explained how she sometimes encourages them to put their hand on the mothers´ stomach instead and feel when the contraction comes:the alarm system. Inside each delivery room, there is an alarm system that those in the room can use to call attention and signal that they need help. In some cases, the alarms go out in viewfinders carried by each staff member, in other cases it rings on a telephone, or the room that alarms is shown on a display on the wall. The alarm system means that the staff hear all the alarms in the entire labour ward, even from the rooms for which they are not responsible, and the women they care for can also hear, which is disturbing for them:There are different signals that penetrates the room. Maybe I have my viewfinder in my pocket that sounds out load and then they [the mother and her companion] ask me why it beeps, if the ward is very busy and if it is stressful outside the room. (P4)Another physical attribute that discourages the midwives from being present in the room, both mentally and physically, is The ringing of the alarm system is disturbing for the midwives as it indicates others’ needs in the wider labour ward. This can cause stress for the midwife, which can also be transmitted to the mother who may lose the concentration on her body and disturb her birthing bubble.This study shows that the birthing room either supports or hinders midwives to do their job as guardians for a healthy, normal physiological birth. The birthing rooms have the power to optimize or hinder this work. The labour wards where the interviewed midwives worked were mainly organized to reduce risks and treat complications and were thus dominated by a pathogenic-orientation to care. This was also mirrored in the birthing rooms which had a clinical, disease-oriented design and interiors. There was often bright fluorescent light, the birthing bed was placed in the centre with medical equipment around it, and there were few elements that created a warm and inviting atmosphere.A pathogenic oriented healthcare focusses on detecting and treating pathological conditions, and classifies patients as “healthy or not”, or as being at a certain risk level. This is the opposite to salutogenic oriented healthcare, which emphasizes that humans are continuously, in daily life, moving between the two endpoints dis-ease and ease/health, and that healthcare should support patients to grasp their general resistance resources that promotes a move towards health and well-being (Mittelmark et al., Antonovsky, the father of the salutogenic theory, concluded already in the mid-1990s that society is entirely rooted in pathogenic thinking with disease prevention via risk factor reduction (Antonovsky, Antonovsky was convinced that the pathogenic orientation would continue to dominate the healthcare arena. To promote health optimally, his hope was that salutogenesis and pathogenesis would exist side by side on equal and complementary terms (Antonovsky, Other studies have shown similar difficulties for midwives. An interview study with midwives working at a modern, centralized and high-technology hospital in Norway shows that there was an ideological battle in the birthing rooms between a biomedical and a sensual knowledge tradition, and which included a battle played out between active treatment and more natural treatment of childbirth. This battle affected the midwives’ way of doing midwifery, including their way of being in the birthing room and their thinking about the body and on safety (Blaaka & Schauer Eri, The midwives in our study tried to manage these contradictory perspectives of care by adapting and changing the interior, and eliminating disturbing activities occurring both inside and outside the birthing room. These findings echo a study in Australia and the UK of midwives working in labour wards, birth centres and homes, and who considered it to be important to create the right ambiance and space conducive to birth. Even though an appropriate ambiance could be created in any birth setting, the hospital labour ward provided the most challenges, partly due to clinical features such as visible medical equipment and bright lights but also because of the noise and the lack of privacy for the birthing women (Davis & Homer, One of the four opposing constituents completing the essential meaning of the birthing room for the midwives in our study was `a private or a public room´. Similar to the midwifery guardianship described in the theory of “Birth Territory” (Fahy & Parratt, The next opposing constituent about the meaning of the birthing room was whether it was `home-like or hospital-like´. To feel “at home” in the birthing room for a mother in birth implies that she can relate to it as her own, having the freedom to use it as she wishes without concern for other´s opinions. This can, according to Roxberg et al, be difficult to achieve for many women since the private space existing in one´s home is lost when entering the hospital environment (Roxberg et al., For the birthing room to become more home-like, the midwives encouraged a “nesting” behaviour, which meant that the mother and her companion arranged the birth room to their preferences aiming at creating an emotionally safe birthplace. A mother´s nesting-behaviour during birth has been found Walsh,  to incluThe third opposing constituent forming part of the essential meaning of the birthing room for the midwives in our study was whether the `room promoted activity or passivity´. In general, the midwives felt that the unfamiliar, sterile, and high-tech environment in the birthing room could cause mothers to become docile and passive. The birthing bed took over as the main focus, encouraging women to lie down in labour. For some midwives, the birth bed had become the safe place in the room, around which they conducted care. The bed was used for convenience. This is contrary to the global recommendation for the use of upright positions to enhance normal labour (Zang et al., The fourth and final opposing constituent about the meaning of the birthing room was whether it was a room promoting the midwife´s “presence or absence´. The midwives” own comfort in the birthing room has, in an Australian study, been highlighted as a factor that may influence her presence in the birthing room. Lack of privacy and personal space can make the midwife more willing to leave the woman and sit in another part of the ward (Hammond et al., A main finding in our study was that the medical equipment such as the CTG and the alarm system interfered with the midwives´ presence in the birthing room. The CTG compensated for the midwives´ presence in terms of observation of the foetal condition, but also made the mother public by putting the workings of her body on display in the office, allowing all staff to keep track of some signs of the birthing process. As described in an ethnographic study from the UK (Lankshear et al., For us three midwives we tried hard to reach a high level of self-awareness about our preunderstanding, and according to the method—to avoid a risk of bias—adopted a “bridling” attitude throughout the whole process. This approach increases the possibility that the researcher remains open to the studied phenomenon (Dahlberg et al., The midwives gave rich descriptions of their experiences; however, a limitation of the study is the generalizability, as it comprises the experiences of a small group of midwives working at only six labour wards in Sweden. In addition, six of the 15 participants had experience of the Room4Birth adaptable birthing room, so the extent, scope and range of their descriptions were probably greater than any other group of midwives would have had. This improves the scale, breadth and detail of the study. We do not suggest that the participants are representative of all midwives and all labour wards in Sweden, or in other countries. However, we believe that findings can be applicable in similar contextsOur interview study shows that the birthing rooms, as part of labour wards, have the power to optimize or hinder midwives to do their job as guardians for a healthy, normal physiological birth. Most birthing rooms mirror a pathogenic-oriented care approach, and such rooms make it more difficult for midwives to protect the women so they can remain in an intact birth bubble. To counteract these effects, midwives need to be present, to make the room private and home-like, to support the mothers to be active, and to protect them from disturbing elements both inside and outside the room.


They were assessed for childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression (PPD). Clinically relevant symptoms of PPD and PTSD were high before the pandemic and showed no significant change during the pandemic . We found a notable increase in the frequency of obstetric violence (p = 0.015) during the pandemic, which, in turn, has a strong correlation with birth-related PTSD and PPD. The problem of ethical communication with patients among maternal healthcare professionals is acute in Russia, and it has been exacerbated by the pandemic. Family and doula support during labor can be a potential protective factor against obstetric violence.The aim of the study is to investigate the changes in the maternal healthcare system during the pandemic and their associations with maternal mental health in Russia. A sample of Russian women who gave birth during the first year of the COVID-19 pandemic ( The pandemic has had a dramatic effect on the healthcare system around the globe, including maternal and childbirth practices. In 2020–2021 women have faced the threat of COVID-19 during pregnancy, labor, and after delivery. In January 2020, the Russian government introduced multiple anti-covid measures which varied across the regions [A growing body of research shows that mothers who gave birth during the pandemic had more clinically acute stress responses in comparison to those who had children in previous years ,4,5. In In the qualitative study in Canada, women identified their hospital birth experience during the pandemic as important for their mental health . AlteratThe presence of a partner and a personal midwife or doula at birth has previously been associated with fewer medical interventions . Higher Childbirth-related PTSD may have long-term effects on maternal mental health . Dikmen-To our knowledge, this is the first study presenting data on maternal mental health and changes in the childbirth context due to the COVID-19 pandemic in the Russian Federation. We conducted the first study of the birth conditions, postpartum depression, and PTSD in Russia before the pandemic in January–February 2020. The following year we organized the follow-up study during the pandemic and investigated the changes in birth experience in Russia as well as their associations with birth-related PTSD and postpartum depression (PPD). While many circumstances that may affect maternal perinatal mental health are out of human control, such as pandemic and obstetrical complications, those related to proper support during labor and ethical considerations of the medical personnel may be modified. Therefore, it is important to study the possible risk factors for postpartum PTSD and depression and shed light on the situation in Russia. Thus, the aim of our research is to investigate the changes in birth experience, symptoms of postpartum PTSD and depression, and frequency of medical interventions and obstetric violence instances, due to the restrictive COVID-19 measures and COVID-19 disease diagnosis.The study included two stages: before the pandemic (January–February 2020) and during the pandemic (February–March 2021). During the period from January to February 2020 and February to March 2021, women received an invitation to participate in the study via thematic online and offline communities for expecting and new parents and childbirth education classes. The findings are based on the responses of a cross-sectional sample of 611 mothers of infants aged 0–13 months (M = 6.37) before the pandemic, and 1645 mothers of infants aged 0–14 months (M = 6.93) during the pandemic, who consented to participate in the study and completed the online survey. The participants were included in the study if they were 18 years old and over, were able to read and write in Russian, and had given birth within 14 months prior to the study.The study was conducted in accordance with the Declaration of Helsinki. Both study follow-ups were approved by the Ethical Committee of the Russian Psychological Society, Lomonosov Moscow State University. All women participated voluntarily and signed informed consent. The assessments were performed online via Google Forms tool.The survey included questions regarding the participants’ age at the time of testing, education level , place of residence and labor , and marital status (married/cohabiting with partner/single). Respondents also answered questions regarding the pregnancy, such as parity, wellbeing during pregnancy, gestational age, time since birth, and delivery mode . Participants were asked to report the medical interventions during labor and their types. episiotomyamniotomyuse of synthetic oxytocinepidural anesthesiaThere was an option to add information about medical interventions. We asked the participants to mark the types of obstetric violence during the current childbirth, if they faced any. There was an option for the participants to add information about the obstetric violence experience.medical interventions without patient’s consent and approvalverbal aggression and bullyingphysical aggression threats and accusationsKristeller maneuverpain relief denialignoring the needs of the birthing womanWe also collected information about the presence of a support person during labor (none/partner/doula or private midwife/partner + doula or private midwife). Moreover, the follow-up survey also included questions about the COVID-19 diagnosis: whether any of the family members and/or the respondents themselves were diagnosed with COVID-19 during pregnancy, labor, or after delivery. The question about separation from the baby right after birth due to a positive COVID-19 test was also included.We used the Russian version of the City Birth Trauma Scale (CBTS)  to assesThe EPDS  was deveWe used maternal age at testing, level of education, family status, time after childbirth, gestational age, parity, and place of childbirth as covariates.Spearman’s correlation coefficient was used to estimate the relationship between postpartum PTSD and PPD symptoms as well as between these variables and the covariates listed above.We explored the association between the PPD and postpartum PTSD symptoms and birth experience factors  using generalized linear models. Multiple linear regression analysis examined the association between postpartum depressive and PTSD symptoms and the number of medical interventions and obstetric violence experiences. Pearson Chi-square tests were performed to compare the demographic and obstetric characteristics between the first and second follow-ups as well as to assess the associations between medical interventions and obstetric violence experience and the symptoms of postpartum depression and PTSD.All analyses were performed using SPSS 25 software .p-values for all > 0.3). However, we found that participants who gave birth during the pandemic were more often married , more often gave birth in a specialized birth hospital under state insurance , more often gave birth for the first or second time , more often gave birth via cesarean , and, on average, longer time passed after the childbirth . The majority of participants came from the capital Moscow region and big Russian cities  participants who had the test-confirmed diagnosis during pregnancy, 35 (1.6%) participants who had it in the hospital during labor and the immediate postpartum period, and 121 (5.4%) women who reported contracting the infection after giving birth.p > 0.10) (p = 0.034). > 0.10) . Howeverp = 0.017) and during  the pandemic.p = 0.015). While the increase in the instances of medical interventions without consent, threats and accusations, denial of pain relief, and use of Kristeller maneuver did not reach statistical significance (p > 0.066), women reported significantly more experiences of verbal aggression and bullying when giving birth during the pandemic  and fewer instances of ignoring their needs during labor .p = 0.014) and during  the pandemic.p = 0.64) or depression  during the pandemic in comparison to the pre-pandemic levels. PPD and postpartum PTSD symptoms were significantly correlated both before  and during pandemic .There were no notable changes in the prevalence of clinically significant symptoms of either postpartum PTSD  and during pandemic . Although to a lesser extent, there was also a positive correlation between PPD symptoms and the number of interventions both before  and during pandemic  (= 0.002) .p < 0.001) and during the pandemic . Similarly, symptoms of PPD increased the more instances of obstetric violence there were both in the first  and second follow-up .p-values for all > 0.19, data not shown). After adjustment for covariates, having a confirmed COVID-19 diagnosis was associated with more symptoms of PPD, if tested positive in the hospital during labor  or after delivery , but not during pregnancy . There were no associations between having the COVID-19 infection at any stage with symptoms of birth-related PTSD, nor were there significant associations with the COVID-19 status of family members at any stage .There were no significant associations between having a support person present during labor and symptoms of postpartum PTSD and depression in either cohort  taking place at the hospitals. Such high figures might reflect the highly medicalized birth culture in Russia which was not affected by the pandemic in either direction. Our results show significant associations between the number of medical interventions and postpartum depression and PTSD. A number of medical interventions can be necessary in case of birth complications, which, in turn, are related to posttraumatic stress . HoweverThe levels of obstetric violence before the pandemic in Russia were rather high with roughly every fourth woman experiencing at least one type of obstetric violence, according to our data. Sadly, the overall frequency of obstetric violence has further grown by more than 5% during the pandemic. Our research indicates a significant increase in bullying from the medical personnel, with 11.3% of women having faced bullying before the pandemic and 15.6% reporting such experience in the follow-up. One of the factors that may explain this increase is the COVID-19 related restrictions for the presence of support persons during labor. Our previous study showed that women with accompaniment experienced significantly less obstetric aggression in comparison to those giving birth without support . AnotherIt is intriguing, however, that despite the overall increase in cases of obstetric violence experience, there were fewer instances of ignoring the needs of the women who were giving birth during the pandemic in comparison to the previous year. This result contradicts the worldwide data, where women report less care from medical staff during the pandemic . We suggOne of the strongest effects of the COVID-19 related changes on birth experience is related to the possibility of the support person’s presence during labor. While in the Russian birth culture, the most common situation was hospital birth without any assistance of the partner or birth doula, there was an increasing trend of having a support person during labor . Our stuContracting COVID-19 infection has also affected maternal mental health directly. In our study testing positive for COVID-19 at the hospital or after delivery was associated with PPD, while it did not have such an effect during pregnancy, or when the infection was detected in a family member at any stage. We suggest that women, diagnosed with COVID-19 at maternity hospital before and after labor, could be anxious about separating from the infant right after birth, which may put them at risk for developing mental health problems. This result corresponds with the global data, where women name restriction for visitors after delivery (59%), the baby contracting COVID-19 (59%), lack of support during delivery (55%), and COVID-19 causing changes to the delivery plan (41%) as the main causes for anxiety . AnotherThe pandemic has remarkably changed the conditions of giving birth in Russia. There are significant differences in birth accompaniment and rates of obstetric violence. Our data shows that COVID-19 disease is not only a threat to maternal health and well-being per se, but it also presents a risk for poorer postpartum mental health due to restrictive measures which are introduced for the protection and prevention of the disease. Although there is a global discussion about the rates of violence against women during the pandemic, to date the evidence on the topic is scarce ,42. Our Strengths of our study include considerable sample sizes of the two follow-ups, use of validated questionnaires, and thorough investigation of birth experiences. Furthermore, the inclusion of the questions regarding the COVID-19 diagnosis allows us to evaluate its prevalence and direct effect on maternal mental health in the follow-up. However, there are several limitations that should be taken into account when interpreting our results. First, we have collected data for both follow-ups exclusively online, with no direct contact of the researchers and the participants, which may have affected the women’s level of trust and, consequently, the reliability of their responses. Second, all the data is based on self-reports and lacks objective information on the participants’ health, including mental health and COVID-19 status, and obstetric history or medication use, which may limit their validity. Moreover, as we did not have access to the objective information on the clinical diagnosis of depression, we chose the commonly used EPDS score cut-off value of 10 or higher to estimate the prevalence of PPD in our samples. However, this cut-off point may be oversensitive and presents the risk of exaggerating the rate of PPD ,44. TherOverall, our study results show that the pandemic had a negative impact on birth experience in Russia. However, it remains unclear whether it was the effect of the COVID-19 infection itself, or rather of the restrictive measures which contributed to the already existing problem of maternal mental health in Russia. While there was no significant change in the rates of clinically relevant symptoms of postpartum depression and PTSD as they had been high already before the pandemic, we found a notable increase in the frequency of obstetric violence, which, in turn, has a strong correlation with birth-related PTSD and PPD. Our results indicate that the presence of support persons was associated with lower rates of obstetric violence and medical interventions. However, the restrictions due to the pandemic have limited the opportunity for having support during labor. The problem of ethical communication with patients among maternal healthcare professionals is acute in Russia, and it has been exacerbated by the pandemic. Family and doula support during labor can be a potentially protective factor against obstetric violence. Furthermore, the separation or threat of separation of mothers and their newborns due to the COVID-19 positive status of the mother should be re-evaluated as it may have a stronger long-term negative effect on their health than the infection itself. Therefore, the introduction of restrictive measures should take into account potential mental health risks for mothers and their children.


The infant in case 2 managed to survive through severe prematurity secondary to hydrops fetalis. However, complications followed soon as tracheal granulation tissue was formed with neurodevelopmental impairment. The infant in case 3 was born recently and her clinical course was less remarkable without severe complications, despite having the least gestational age and birthweight among the three patients. The improved care protocols for extremely low birthweight infants over these years through experiential learning including that with cases 1 and 2 may have ensured the better outcome of case 3. Accumulating evidence and recording the experience of such cases with continuous constructive discussion can contribute to better outcomes and appropriate parental counseling for extremely small babies in the future.Reports on the birth of infants weighing <300 g are quite rare and little is known about the best practices in treating such micropreemies. Therefore, we report here on three cases of low birthweight infants weighing <300 g, of whom two infants survived. The birthweights and gestational ages were ranging 279–293 g and 22 + 6/7 – 23 + 6/7 weeks, respectively. All the infants had severe fetal growth restriction and prematurity. The infant in case 1 died of hepatic rupture, perhaps due to birth trauma, which emphasized the need for less invasive obstetric procedures including  The survival rate of extremely low birthweight infants (ELBWIs) has been improving over the past few decades , 2. HoweWe conducted medical record review at the University of Tokyo Hospital between January 2011 and December 2020. During this period, it was well-accepted in Japan to provide neonatal resuscitation for babies born with gestational age (GA) ≥22 weeks. However, there have been no definitive consensus criteria for resuscitation with respect to birthweight. During this period, there were 10,219 babies ≥22 gestational weeks were born including 82 stillbirths in our hospital. All the stillbirths were intrauterine fetal deaths; thus, no deaths occurred in the delivery room. Three infants weighed <300 g at birth (2.3% of ELBWIs) and their parents hoped for their survival. Neonatal and maternal characteristics are shown in SURFACTEN® 120 mg/kg/dose) is administrated for respiratory distress syndrome. The initial mode of mechanical ventilation is synchronized intermittent mandatory ventilation (SIMV). When hypoxemia or hypoventilation develops, the ventilation mode is switched to high-frequency oscillatory ventilation (HFOV). Umbilical vessels are the first choice for the arterial line and blood access, considering the skin fragility. A peripherally inserted central catheter (PICC) and/or a peripheral arterial catheter is inserted, if umbilical catheterization is unsuccessful. Dopamine and dobutamine are administrated for systemic hypotension. The first dose of prophylactic indomethacin  is administered for prevention of intraventricular hemorrhage (IVH) within 6 h after birth, if there are no contraindications such as persistent pulmonary hypertension of the newborn (PPHN). Routine ultrasound is performed every 8 h until 3 days of life (DOL). The second or third dose of the prophylactic indomethacin is withheld, if closure of the arterial duct is confirmed. Parenteral nutrition is started on 0 DOL. The dose of amino acids is initially about 1 g/kg/day, which is gradually increased to 2–3 g/kg/day. Intravenous administration of fatty acids is usually started on 2 to 4 DOL, which is often abandoned due to hyperglycemia. Probiotics and glycerin enema are started on 1–3 DOL. We insist on giving breastmilk as the initial enteral feeding. Routine sedation is not applied; when sedative is needed, usually phenobarbital and, occasionally, fentanyl are given. Blood samples were collected by heel-prick methods after removal of the arterial catheter.There are no standardized care protocols for extremely premature infants with birthweight below 300 g in Japan. Our standard practice for extremely preterm infants born below 25 weeks of GA is as follows. Endotracheal intubation is performed immediately after birth with a 2.0- or 2.5-mm endotracheal tube. Bovine lung-derived surfactant .A 43-year-old primipara presented with severe hypertensive disorder of pregnancy and fetal growth restriction (FGR) at 19 gestational weeks. At 23 6/7 gestational weeks, an emergency cesarean section was conducted due to worsened hypertensive disorders of pregnancy (HDP) and a non-reassuring fetal status. “En caul” delivery could not be achieved because of the thick uterine wall. The caul refers to the amniotic membrane. To be born in a caul (en caul) means to be born with the head covered by the amnion (or be born within an intact unruptured amnion). A male infant with a birthweight of 293 g was born without any apparent trauma. Endotracheal intubation and surfactant replacement were performed immediately after birth in the delivery room. The umbilical venous catheter (UVC) and the peripheral arterial catheter were successfully placed, while umbilical arterial catheter (UAC) insertion was unsuccessful. Initial examination revealed anemia (hemoglobin level: 10.8 g/dl), disseminated intravascular coagulation (DIC), and the presence of slight ascites on ultrasonography, suggesting intra-abdominal bleeding. Intensive treatment, including HFOV, inotropes, steroids, and massive blood and plasma transfusion for the progressive anemia and DIC, was started. However, liver and adrenal bleeding gradually became evident on ultrasonography  and he cen caul delivery. Endotracheal intubation and surfactant replacement were performed immediately after birth in the delivery room. We successfully placed the UVC and the peripheral arterial catheter, whereas the UAC could not be inserted. Severe general edema was detected at birth and continued for a long time , no therapy was required. She is now 8 months of corrected age and stays healthy in the outpatient clinic without signs of developmental delay; she already sits, rolls over, and pulls up to standing.A 40-year-old primipara woman was diagnosed with FGR at 19 gestational weeks. She was transferred to our hospital at 22 gestational weeks due to severe HDP. A female infant was born at 22+6/7 gestational weeks with a birthweight of 279 g after an emergency We share our experiences with three extremely preterm infants with birthweight <300 g including two survivors. The survival rate of ELBWIs has improved over the past few decades , 2. HoweCase 1 illustrates the fragility of the smallest babies with hepatic rupture. Although we could not determine the exact cause of liver hemorrhage in this case study, fetal birth traumas can occur anytime during and after delivery and this may be one of the limitations associated with their survival. Recently, in the delivery of the preemies, more Japanese obstetricians adopt the “en caul” cesarean section technique, in which the babies are delivered wrapped in amniotic fluids and membranes to avoid birth traumas . AdditioCase 2 was complicated, with the patient having progressive hydrops antenatally and suffering from severe respiratory and circulatory instability after birth. Later, he had tracheal granulation tissue, perhaps due to prolonged intubation and the need for repeated surgery. Although no evidence of PVL or IVH was found, neurodevelopmental impairment was evident during follow-up. Hence, it was surmised that achieving intact survival in the most severe micropreemies still remains critically challenging.Case 3 was born most recently. Her clinical course was less remarkable without severe complications despite having the lowest GA and the smallest birthweight among the three patients. The accumulation of experience on ELBWIs over these years, including that with cases 1 and 2, may have played a role in improving the outcome. Her neurological prognosis is yet unknown and we will continue to follow-up.Each case had difficulties with respect to blood access due to the small size of the infants. In cases 1 and 2, UAC insertion was unsuccessful and in case 3, the UVC was unavailable. In case 1, an arterial catheter could be placed, but the wave of the artery was not displayed because of imperfect circulation. For case 2, the peripheral arterial line was placed with difficulties, but the procedure worsened the skin erosions. For case 3, the peripherally inserted central venous catheters, not the UVC, were successfully placed and the clinical course was uncomplicated. More secure and less invasive blood access procedures are required for the smallest preemies. However, the small medical devices available are limited. For example, from 2.5 to 5.0 Fr single lumen UAC are available in our hospital. On the other hand, available double-lumen UVC is only one size. For endotracheal tube, the inner diameter of the smallest one available is 2.0 mm , 16. HowThere are many arguments about the ethical aspect, considering the long-term outcome. Currently, there are many options for the treatment in the NICU: surfactant, HFOV, iNO, cyclooxygenase inhibitors for PDA, minimally invasive PDA surgery, ultrasound-guided circulatory management, prophylaxis of IVH with indomethacin, probiotics, etc. –21. All Further accumulation of experience on these cases and continuation of constructive discussion are required.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This case study was approved by the Ethics Committee of the University of Tokyo Hospital . The parents of patients provided their written informed consent for participation in this case study and a written informed consent was obtained from the parents of the infants for the publication of this case study with any identifiable data or images.YS was in charge of these case studies and wrote the first draft of manuscript. SK and TM were in charge of the patients in this case study and also supervised the drafting, reviewed, and revised the manuscript. KK and MK took care of the patients and provided access to the patients and also helped to write the draft. NT supervised the data analysis and critically reviewed the manuscript. All the authors approved the final manuscript for submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


When the part geometry scaling down from macro to microscale level, the size-induced surface effect becomes significant in the injection molding process. The adhesion between polymer and nickel (Ni) mold insert during the process can lead to defects in necking, warping and deformation of microstructure. In this study, the self-assembled monolayers (SAMs) with low surface energy were deposited on the Ni surface to reduce the adhesion and further improve the demolding quality of the microstructure. Results show that the alkyl mercaptan SAMs with chemical bonds and close alignment can be successfully deposited on the surface of Ni by the solution deposition method. The contact angle, surface free energy, and friction coefficient before and after anti-adhesion treatment on the surface of mold insert were measured. In addition, the anti-adhesion properties of different alkyl mercaptan materials and the correspondingly replication quality of microstructure parts after injection molding were analyzed. It is found that the Ni mold insert treated by the perfluorodecanethiol has the best wear resistance and still shows good reproducibility at the 100th demolding cycle. Injection molding technology is a common method to fabricate plastic products in biomedicine ,2,3, cheWhen the size of the structure is down to micrometer or nanometer, microscale factors including the mold surface roughness may obviously affect the adhesion characteristics of the interface between polymer and mold insert . StormonIn order to eliminate the demolding defects in injection molding process, Douglas et al.  treated It is demonstrated from the previous studies that the deposition of appropriate coatings on metal or nonmetal materials can effectively reduce the adhesion between interfaces and improve the performance ,25,26. HThe microstructure with quadrangular column arrays was designed in this study . The aspDue to the excellent mechanical properties, Ni was selected as the insert material for the injection molding of the parts with microstructure arrays . Figure 2 was used for the first 30 min. The current density was increased to 4 A/dm2 for 20 h to improve the electroforming efficiency. The Ni coating was then electroformed as the mold insert for the following injection molding process. A self-designed electroforming device , as shown in The reagents used in the preparation of anti-adhesion SAMs were decanethiol (DT), decanedithiol (DDT) and perfluorodecanethiol (PFDT). The basic attribute parameters are shown in the In the preparation of SAMs, the Ni mold insert was immersed in the solution containing the self-assembled molecule. The active groups of organic molecules would spontaneously adsorb on the surface to form the dense and ordered SAMs. The self-assembly of Ni mold insert in PFDT solution was shown in Prior to that, the Ni mold insert was pre-treated to remove the grease, organic and inorganic impurities in an ultrasonic cleaner 15 min. The insert was then treated with the plasma cleaning device  for 200 s to remove the oxide and generate the hydrophilic groups that was conducive to the deposition of alkyl mercaptan molecules on the Ni surface. Benzene was selected as the solvent in this experiment, as this non-polar solvent will not react with metal matrix. Therefore, 20 mL benzene was mixed with three kinds of alkyl mercaptan reagents individually, with the concentration of 0.1 mol/L. After the alkyl mercaptan solution was magnetic stirred at room temperature for 3 h, the pre-treated insert was immersed in alkyl mercaptan solution for 24 h. Finally, the insert in the alkyl mercaptan solution was taken out, washed with deionized water, and then blown dried at 100 °C for 30 min. The drying process was conducive to enhancing the adhesion between the self-assembled molecules and the mold insert. The precision injection molding machine  was used to prepare the polymer parts with surface quadrangular column array. During the experiment, the mold temperature controller  and the cooling system  was used to control the temperature of the mold and the injection machine. Polypropylene , with excellent filling performance, high mechanical strength and melt flow rate, was selected as the experimental material. The prepared Ni mold insert was installed in the fixed mold cavity, and the effect of anti-adhesion treatment on the demolding quality of the microstructure was explored. The standard process parameters were used to study the demolding quality of polymer parts by comparing the quality without anti-adhesion treatment and after alkyl mercaptan treatment, as shown in The laser confocal microscope  was used to analyze the morphology of the microstructure on both mold insert and the replicated products.The AFM  in tapping mode was used to measure the morphology of the SAMs, with the scanning range of 1 μm × 1 μm. Contact angle meter  was used to measure the static contact angles. The droplet was set to 4 μL in each test. The contact angle of water droplets on the Ni surface was affected by the small temperature change, which was the cause of the error. In addition, 120 measurements of each sample were performed in the measurement of contact angle.3N4 ball, with a diameter of 6 mm. The normal load, the radius of wear track and the linear sliding speed were 1 N, 2.5 mm and 5 mm/s, respectively, and the rotation angular speed was 60 rpm. The surface of each sample was tested for at least three cycles, and each test was rubbed for 100 cycles.The friction and wear properties of SAMs on the insert surface were measured by the precision friction and wear tester  at room temperature. The equipment can be applied with a loading range of 1–20 N, and friction mode is ball/pin disc. The friction pair was a standard SiThe microstructure arrays on Si master and the Ni mold insert manufactured in this study were shown in The three-dimensional morphology and surface roughness with no coating and the SAMs with different alkyl mercaptans were shown in The static contact angles of three different positions were measured with water drops on each surface, and the average contact angles of three sampling points were taken. The contact angles of Ni surface treated with different alkyl mercaptans were shown in The static water contact angle of the surface of Ni insert was 73.74°. However, the static water contact angle increased significantly after deposition of alkyl mercaptan SAMs, indicating that alkyl mercaptan self-assembly molecules were successfully deposited on the surface of Ni mold insert, which made the contact angle of Ni mold insert surface increased.3N4 ball and the oxide on the Ni surface that acted as the lubricant [The friction coefficient on Ni surface was shown in ubricant . The friubricant . It is d3N4 ball. The SAMs lost their lubricating effect and showed dry friction with Si3N4 ball. Therefore, the wear resistance of DT SAMs was poor. In the whole friction process, the friction coefficient of DDT SAMs was much higher than that of DT SAMs. After 40 s, the friction, Si3N4 ball almost wore through DDT SAMs. At the later stage of friction, dry friction occurred between Si3N4 ball and Ni surface, and the friction coefficient fluctuates around 0.7, which was basically the same as that of Ni surface without SAMs. The friction coefficient of PFDT SAMs was lower than that of the other two SAMs at 100 s, and the SAMs began to wear rapidly after 60 s. The results showed that the PFDT SAMs had a good wear resistance and good lubricity in early time, which was due to the low surface energy of trifluoromethyl in PFDT. In the first 20 s of friction test, the friction coefficient of Ni surface with DT SAMs was less than 0.2. The friction coefficient then increased slowly to 0.53 and fluctuated with the increase of time. It means that DT SAMs have been worn through by SiThe injection-molded product after the first demolding was selected to observe the microstructure by the laser confocal microscope. The three-dimensional morphology of the microcolumn arrays was shown in The cross-section of a microcolumn was intercepted, and the profile curve was shown in In order to quantitatively analyze the demolding quality of microcolumn, the deviation percentage in height and width of the profiles were defined to describe the deviation between the profile of the injection-molded microstructure and the microcavity in Ni insert. The calculation formulas were as follows:In total of fifty microcolumns were randomly selected to calculate the deviation percentage. The calculation results were shown in It is shown that the height deviation of microcolumn profile was positive, which indicated that microcolumn had an elongation deformation after demolding from Ni mold insert under all conditions. When the DDT and PFDT SAMs were deposited on the surface of the mold insert, the height deviation of the microcolumn profile was relatively small. When there was no self-assembled coating on the insert surface, the width deviation was negative, which indicated that the microstructure has a shrinkage deformation. When the alkyl mercaptan layer was deposited on the insert surface, the width deviation was positive, which indicated that the microstructure had expansion deformation.It could be found that when the SAMs were not deposited on the surface of the Ni mold insert, the microcolumn was relatively small, and most of the microcolumns were not fully replicated, and when the SAMs of alkyl mercaptan were deposited on the surface of Ni mold insert, the demolded parts had better reproducibility, especially PFDT SAMs, compared with the Ni mold insert without SAMs as shown in the When the PFDT SAMs were deposited on the insert surface, the microcolumn showed high replication quality in the twentieth demolding cycles, as shown in As shown in It is seen that PFDT SAMs have the best wear resistance and could effectively reduce the friction and adhesion between PP and Ni mold insert, which was consistent with the friction coefficient measured by friction test. As shown in In this work, the SAMs of alkyl mercaptan were successfully prepared on the surface of Ni insert. The results show that alkyl mercaptan could greatly reduce the surface energy of Ni insert and therefore reduce the adhesion during the demolding. Without the SAMs, the microcolumns had defects in elongation in height, depression at the top and neck shrinkage. The widths and heights of the microcolumn were obviously smaller than these of the microcavity. When the SAMs of alkyl mercaptan were deposited on the surface of Ni insert, the defects of the injection-molded columns were greatly improved. Each microcolumn had high homogeneity in three-dimensional morphology, which could reproduce the morphology of the microcavity. However, the wear resistance of the DT and DDT SAMs was relatively poor, and its effective life in microinjection molding was less than five cycles. On the other hand, the self-assembled perfluorocarbon coating had an excellent wear resistance. The microcolumn could still show high replication quality after twenty demolding cycles. When there were no SAMs on the insert surface, the width deviation of the microcolumn profile was negative, and the microstructure had a shrinkage deformation. When the alkyl mercaptan SAMs were deposited on the insert surface, the width deviation of the microcolumn was positive, and the microstructure expanded.


OBJECTIVES/GOALS: Preterm birth is the most common birth complication in the United States. To date, there are no effective public health strategies to reduce the burden of prematurity. Using geospatial information system (GIS) mapping, we identified the most salient risk factors of preterm birth across US counties targetable for future interventions. METHODS/STUDY POPULATION: Risk factors of preterm birth were identified from the perinatal health nonprofit organization, March of Dimes, and included factors such as obesity, smoking, insurance coverage and poverty. US 2013 county-level data on sociodemographic characteristics, behavioral risk factors and preterm birth were extracted and combined from the American Census, Center for Disease Control, and US Health Resources and Services Administration. Spatial autocorrelation and multivariate spatial regression were used to determine the risk factors most strongly associated with preterm birth. These models were adjusted for race, given well-documented race disparities for preterm birth. As a case-study comparison, we mapped risk factors in the two states with the highest and lowest proportion of preterm births in 2013. RESULTS/ANTICIPATED RESULTS: In our preliminary analysis, obesity was the factor most strongly associated with preterm birth  at the US county-level. Surprisingly, smoking was not found to be significantly associated with preterm birth. In 2013, Vermont had the lowest prevalence of preterm birth at 7.6% and Mississippi had the highest prevalence of preterm birth at 13.1%. Health insurance coverage and obesity were the two risk factors that differed between Vermont and Mississippi. The median proportion of uninsured individuals in Mississippi counties was four times higher than that of Vermont counties . Similarly, the median obesity prevalence in Mississippi counties was significantly higher than the median obesity prevalence in Vermont counties (38.8% vs. 25.2%). DISCUSSION/SIGNIFICANCE OF IMPACT: Public health efforts aimed at reducing obesity and increasing health insurance coverage may have the greatest impact at addressing the US burden of preterm birth. Further, geospatial mapping is a powerful analytic tool to identify regions in the US where preterm birth interventions would be most beneficial.