Science and beyond science in the reporting of quality of facility-based maternal and newborn care during the COVID-19 pandemic.

We are concerned with science and beyond science issues regarding the paper published in the Lancet on the quality of facility-based maternal and newborn care during the COVID-19 pandemic.

As acknowledged by the authors, online surveys may be compromised by bias. According to the official national data from the “Instituto Nacional de Estatística”, in 2020, Portugal had 36.3% of C-sections and 18.8% of instrumental-vaginal-births (IVB). Similar numbers may be inferred, from March 2020 to March 2021, from the “Consórcio Português de Dados Obstétricos (CPDO)”, which provides on-line data from nearly one third of the public maternities. This suggests that the 33.9% of C-sections and the 23.7% of IVB presented in the paper are, respectively, too low, and too high. Moreover, the episiotomy rate in non-IVB was 31.2% according to the CPOD, while it was 40.7% in the study, probably as a result of an overrepresentation of the IVB. These discrepancies should be put in perspective.

As acknowledged by the authors, the survey lacked “more information on maternal and newborn characteristics and outcomes”. Therefore, it would be essential to provide information regarding maternal and perinatal mortalities, and on admission to the intensive care unit, avoiding just reliance on the C-section or IVB rates. Similarly, the episiotomy rate should be analysed with the rate of fourth- and third-degree perineal tears. In Portugal, for example, the obtained episiotomy rate was significantly higher than in Sweden, but that should be faced up with persistently higher rates of fourth- and third- degree perineal tears in the latter, that have been reported as high as 4.0% in non-IVB, in year 2016.

Moreover, the 95% CI show that in the “prelabour-C-section” group Portugal was always statistically similar (43.9%) or better (56.0%) than the median of the twelve countries under study. Furthermore, the variables were statistically similar (64.9%) or significantly better (24.3%) in the “prelabour-C-section” group compared to the “Women who underwent labour”. It is quite disturbing to consider that Portugal has too high C-section rates and, simultaneously, conclude that women were more prone to rate better the quality of care in the C-section group. We do not want to take precipitated conclusions, but rather emphasize that complex problems require broader discussion.

Research papers may have beyond science side effects that can be harmful. The Portuguese main TV channel commented on The Lancet's paper, using the following headline, in bold capital letters: “Obstetrical violence rates in Portugal above the European average”. The message was repeated, over and over again, by other channels, newspapers and magazines. However, the 95% CI show that for the 86 analyzed variables in the study, Portugal was in 81,3 of the times statistically similar (34.8%) or better (46.5%) than the median of the countries included in the research. Furthermore, Portugal was in the third position pertaining to the QMNC index after the multivariate analysis conducted by the authors. Promoting dignity in maternal care should not rely on alarming soundbites, widely spread in the media, as they can cause unnecessary anxiety to the population.

In what matters dignity and respect in maternal care one should not point out only things that are wrong in Europe, but also present what is going on in a world where basic human rights are violated and where maternal and perinatal mortality rates may be 50 times higher. It also matters to have an integrated view of the healthcare consumers and the professionals so often disrespected by “working shifts to cover ‘24/7’ service availability and dealing with anxious people and subtle diagnosis, as well as life and death emergencies”.

Contributors

The authors have contributed equally to this work, JB as senior authorship.

Declaration of interests

JB is president of the Portuguese College of Obstetricians and Gynaecologists from Portuguese Medical Association (Ordem dos Médicos), representing all the O&G specialists in Portugal. AR declares no competing interests.