Scarce perinatal social support for women with OUD: Opportunities for doula services.

PROBLEM: Persons with opioid use disorder (OUD) often lack social support, which is associated with improved recovery outcomes. BACKGROUND: In the last two decades, the rate of opioid use disorder (OUD) among pregnant people has quadrupled. QUESTION: This study aimed to describe the prenatal and postpartum social support networks and needs of persons with OUD and assess perceived acceptability of community-based social supports such as doulas. METHODS: This mixed methods study utilized quantitative and qualitative data to understand social support structures and needs. Data was collected through surveys -demographics and social mapping; Adverse Childhood Experiences (ACE) tool; Connor Davidson Resilience 25-item (CDRS-25) scale- and a semi-structured interview. A total of 34 participants from a single urban opioid treatment program consented to participate. FINDINGS: Participants were on average 34.9 years old, White (64.7%), and unemployed (91.2%). Participants described small perinatal social support networks, which decreased in size from the prenatal to postpartum period. Only half (52.9%) reported adequate prenatal and postpartum social support. Doulas and peer recovery support specialists were perceived as valuable in perinatal health, social support, and recovery domains, with interest in doulas seen particularly amongst those with fewer reported supports. DISCUSSION: The scarcity of prenatal and postpartum social support among persons with OUD is critical to address, given the increased risk of relapse during the postpartum period which has implications for the maternal child dyad. CONCLUSION: Due to multiple disparities in prenatal and postpartum social support (small networks, inadequate support), doulas represent a trusted community-based support to be integrated into healthcare teams to address maternal morbidity/mortality associated with opioid use.

Maternal birthplace and experiences of perinatal healthcare in Belgium: Evidence from a cross-sectional survey.

BACKGROUND: Patient experience is an important part of perinatal care quality. Migrant women in high-income countries often report more negative experiences than non-migrants, but evidence in Europe is patchy. In this study, we compared the experiences of two migrant populations with non-migrants, taking into account socioeconomic characteristics. METHODS: We surveyed mothers born in Belgium, North-Africa, and Sub-Saharan Africa (n = 877) using an adapted version of the Migrant-Friendly Maternity Care Questionnaire. Two patient experience scores were created using multiple correspondence analyses: a) information and communication with healthcare professionals and overall satisfaction with pregnancy care, and b) patient-centred aspects and satisfaction with delivery care. Through descriptive analyses and multivariable logistic regressions we estimated the associations of maternal characteristics with each score. RESULTS: Overall, positive experiences were reported in terms of communication (83 %) and patient-centred care (86 %). North African immigrants with low language proficiency had higher odds of negative communication experience (especially problems understanding information) (ORa: 2.30, 95 %CI 1.17-4.50), regardless of socioeconomic position. Among women with language barriers, 88 % were never offered a professional interpreter, relying on family members for translation. Patient-centred care was not associated with maternal birth region but was rated more negatively by older mothers, those with longer residence in Belgium, and higher majority-language proficiency. CONCLUSION: In Belgium, perinatal care experiences were generally positive, although communication with immigrants was suboptimal. Language barriers, single motherhood, and unstable housing increased communication issues. Our findings underline the necessity to improve information-exchange with immigrants and socioeconomically vulnerable women.

Obstetrics and Gynecologic Hospitalists and Their Focus: Impact on Safety and Quality Metrics.

Obstetrics and gynecologic hospitalists play a pivotal role in the evolution of perinatal care. Hospitalists improve patient safety by providing on-site, reliable, high-quality care. Hospitalists help to reduce the rates of unnecessary cesarean deliveries and increase the rates of vaginal deliveries.

Release notice - Perinatal Health Indicators (PHI) Data Tool. / Avis de publication : Outil de données sur les indicateurs de la santé périnatale (ISP).

The Maternal and Infant Health Section of the Public Health Agency of Canada (PHAC) is pleased to announce an update to the Perinatal Health Indicators (PHI) Data Tool. The interactive Data Tool on the PHAC Infobase website presents statistics on maternal, fetal and infant health in Canada based on data from the Canadian Institute for Health Information's (CIHI) Discharge Abstract Database (DAD), the Canadian Community Health Survey (CCHS), and the Canadian Vital Statistics (birth, stillbirth and death databases). The data include 20 indicators grouped into four key health domains: health behaviours and practices, health services, maternal outcomes, and infant outcomes. For this update, five new indicators were added and three existing ones were modified. To access the latest Perinatal Health Indicators Data Tool, visit https://health-infobase.canada.ca/phi/.

RÉSUMÉ: Résumé : La Section de la santé maternelle et infantile de l'agence de la santé publique du Canada (ASPC) a le plaisir d'annoncer une mise à jour de données sur les indicateurs de la santé périnatale (ISP). L'outil de données interactif se trouve sur le site Web de l'Infobase de l'ASPC et présente les statistiques sur la santé maternelle, foetale et infantile au Canada fondées sur les données de la Base de données sur les congés des patients (BDCP) de l'Institut canadien d'information sur la santé (ICIS), de l'Enquête sur la santé dans les collectivités canadiennes (ESCC) et de la Base canadienne de données de l'état civil (bases de données sur les naissances, les mortinaissances et les décès). Les données comprennent 20 indicateurs regroupés en quatre principaux domaines de la santé: comportements et pratiques en santé, services de santé, santé maternelle et santé infantile. Dans le cadre de cette mise à jour, cinq nouveaux indicateurs ont été ajoutés et trois indicateurs existants ont été modifiés. Pour accéder au plus récent outil de données sur les indicateurs de la santé périnatale, consultez le : https://sante-infobase.canada.ca/isp/.

Perinatal mental health service use in a representative sample of US women.

PROBLEM/BACKGROUND: Mental health problems are prevalent during the perinatal period and mental health service use is lower among perinatal women compared to the general population. AIM: This study examined the prevalence and variables associated with mental health service use (MHSU) among pregnant and postpartum women with a past-year mental disorder. METHODS: We analyzed nationally representative data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (N = 36,309). Our study sample included all women aged 18 - 55 with a past year mental disorder (n = 6,295). Semi-structured interviews assessed past-year DSM-5 mental disorders, which were categorized into four groups: depressive/bipolar, anxiety, posttraumatic stress disorder, and substance use. Logistic regressions examined rates and variables associated with MHSU across perinatal status, adjusting for key sociodemographic characteristics. FINDINGS: Compared to non-perinatal women 18-55 with a past-year mental disorder (38.5 %), postpartum women had reduced odds of MHSU (23.6 %; AOR = 0.56, p < 0.05), and pregnant women also sought services less than non-perinatal women (32.6 %; AOR = 0.89 p > 0.05). All groups had increased odds of MHSU when individuals had a greater number of mental disorders (AORs = 1.78 - 2.75, p = 0.01 and p < 0.001). Physical health conditions were also associated with increased odds of MHSU among all groups, except postpartum women (AORs = 1.26 - 1.62, p = 0.05, p < 0.001). DISCUSSION/CONCLUSION: Results highlight that over 60 % of perinatal women with mental disorders do not receive mental health services. This emphasizes the importance of mental health screening for perinatal women, particularly in the postpartum period.

Nurses' Perspectives Regarding Challenges of Providing Perinatal/Neonatal End-of-Life Care in a Regional Hospital: An Exploratory Qualitative Study.

AIM: This qualitative study aimed to explore nurses' perspectives regarding the challenges of providing perinatal/neonatal end-of-life care in a regional hospital. METHODS: This exploratory qualitative study was conducted with 20 nurses working in Turkey. Study data were collected through in-depth and semi-structured individual interviews. The interviews were then submitted to thematic analysis. RESULTS: Three themes emerged from analyses of the interviews: (1) inadequate support for delivery of palliative care, (2) perceptions of family readiness, and (3) providing information/education to the family. The most prominent difficulties experienced by nurses were inadequacy of unit and equipment and lack of trained personnel. Another important issue that stood out was families' not accepting the end-of-life care decision for the fetus or the neonate and their having unrealistic expectations. CONCLUSION: Study results have provided important considerations for regional isolated neonatal and perinatal units, and they will be used to inform clinical practice improvements, staff education support, policies/procedures, family support, and further research relating to end-of-life care provision for the most vulnerable babies and their families.

Health system responsiveness and its associated factors for intrapartum care in conflict affected areas in Amhara region, Ethiopia: a cross-sectional study.

OBJECTIVE: In Ethiopia, information about health system responsiveness (HSR) in conflict-affected areas is limited. No previous local study was conducted on the assessment of HSR at the community level. Hence, the study assessed HSR for intrapartum care in conflict-affected areas in Amhara region, Ethiopia. DESIGN: Community-based cross-sectional study design. SETTING: Wadila, Gayint and Meket districts, Amhara region, Ethiopia. PARTICIPANTS: The participants were 419 mothers who gave birth in conflict-affected areas within the last 6 months. The study included all mothers who gave birth at health facilities but excluded those who delivered at home, critically ill or unable to hear. OUTCOME: HSR was the outcome variable. In this regard, the study assessed how mothers were treated and the situation in which they were cared for in relation to their experience during the conflict. METHODS: We conducted the study in the community, where we analysed eight domains of HSR to identify 30 measurement items related to intrapartum care responsiveness. The domains we looked at were dignity (4), autonomy (4), confidentiality (2), communication (5), prompt attention (5), social support (3), choice (3) and basic amenities (4). We used a multiple linear regression model to analyse the data, and in this model, we used an unstandardized ß coefficient with a 95% CI and a p value of less than 0.05 to determine the factors significantly associated with HSR. RESULTS: The findings of our study revealed that the overall proportion of HSR in intrapartum care was 45.11% (95% CI: 40.38 to 49.92). The performance of responsiveness was the lowest in the autonomy, choice and prompt attention domains at 35.5%, 49.4% and 52.0%, respectively. Mothers living in urban areas (ß=4.28; 95% CI: 2.06 to 6.50), government employees (ß=4.99; 95% CI: 0.51 to 9.48), those mothers stayed at the health facilities before delivery/during conflict (ß=0.22; 95% CI: 0.09 to 0.35), those who were satisfied with the healthcare service (ß=0.69; 95% CI: 0.08 to 1.30) and those who perceived the quality of healthcare favourable (ß=0.96; 95% CI: 0.72 to 1.19) were more likely to rate HSR positively. On the other hand, joint decision-making for health (ß=-2.46; 95% CI: -4.81 to -0.10) and hospital delivery (ß=-3.62; 95% CI: -5.60 to -1.63) were negatively associated with HSR. CONCLUSION: In the Amhara region of Ethiopia, over 50% of mothers living in areas affected by conflict reported that health systems were not responsive with respect to intrapartum care. Therefore, all stakeholders should work together to ensure that intrapartum care is responsive to conflict-affected areas, with a focus on providing women autonomy and choice.

Spatial Access to Continuous Maternal and Perinatal Health Care Services in Low-Resource Settings: Cross-Sectional Study.

BACKGROUND: Maternal and perinatal health are fundamental to human development. However, in low-resource settings such as sub-Saharan Africa (SSA), significant challenges persist in reducing maternal, newborn, and child mortality. To achieve the targets of the sustainable development goal 3 (SDG3) and universal health coverage (UHC), improving access to continuous maternal and perinatal health care services (CMPHS) has been addressed as a critical strategy. OBJECTIVE: This study aims to provide a widely applicable procedure to illuminate the current challenges in ensuring access to CMPHS for women of reproductive age. The findings are intended to inform targeted recommendations for prioritizing resource allocation and policy making in low-resource settings. METHODS: In accordance with the World Health Organization guidelines and existing literature, and taking into account the local context of CMPHS delivery to women of reproductive age in Mozambique, we first proposed the identification of CMPHS as the continuum of 3 independent service packages, namely antenatal care (ANC), institutional delivery (ID), and postnatal care (PNC). Then, we used the nearest-neighbor method (NNM) to assess spatial access to each of the 3 service packages. Lastly, we carried out an overlap analysis to identify 8 types of resource-shortage zones. RESULTS: The median shortest travel times for women of reproductive age to access ANC, ID, and PNC were 2.38 (IQR 1.38-3.89) hours, 3.69 (IQR 1.87-5.82) hours, and 4.16 (IQR 2.48-6.67) hours, respectively. Spatial barriers for women of reproductive age accessing ANC, ID, and PNC demonstrated large variations both among and within regions. Maputo City showed the shortest travel time and the best equity within the regions (0.46, IQR 0.26-0.69 hours; 0.74, IQR 0.47-1.04 hours; and 1.34, IQR 0.83-1.85 hours, respectively), while the provinces of Niassa (4.07, IQR 2.41-6.63 hours; 18.20, IQR 11.67-24.65 hours; and 7.69, IQR 4.74-13.05 hours, respectively) and Inhambane (2.69, IQR 1.49-3.91 hours; 4.43, IQR 2.37-7.16 hours; and 10.76, IQR 7.73-13.66 hours, respectively) lagged behind significantly in both aspects. In general, more than 51% of the women of reproductive age, residing in 83.25% of Mozambique's land area, were unable to access any service package of CMPHS in time (within 2 hours), while only about 21%, living in 2.69% of Mozambique's land area, including Maputo, could access timely CMPHS. CONCLUSIONS: The spatial accessibility and equity of CMPHS in Mozambique present significant challenges in achieving SDG3 and UHC, especially in the Inhambane and Niassa regions. For Inhambane, policy makers should prioritize the implementation of a decentralization allocation strategy to increase coverage and equity through upgrading existing health care facilities. For Niassa, the cultivation of well-trained midwives who can provide door-to-door ANC and PNC at home should be prioritized, with an emphasis on strengthening communities' engagement. The proposed 2-step procedure should be implemented in other low-resource settings to promote the achievement of SDG3.

Models of care: Opportunities and challenges.

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

Building Capacity of Community Health Centers to Improve the Provision of Postpartum Care Services Through Data-Driven Health Information Technology and Innovation.

Maternal morbidity and mortality remain significant challenges in the United States, with substantial burden during the postpartum period. The Centers for Disease Control and Prevention, in partnership with the National Association of Community Health Centers, began an initiative to build capacity in Federally Qualified Health Centers to (1) improve the infrastructure for perinatal care measures and (2) use perinatal care measures to identify and address gaps in postpartum care. Two partner health center-controlled networks implemented strategies to integrate evidence-based recommendations into the clinic workflow and used data-driven health information technology (HIT) systems to improve data standardization for quality improvement of postpartum care services. Ten measures were created to capture recommended care and services. To support measure capture, a data cleaning algorithm was created to prioritize defining pregnancy episodes and delivery dates and address data inconsistencies. Quality improvement activities targeted postpartum care delivery tailored to patients and care teams. Data limitations, including inconsistencies in electronic health record documentation and data extraction practices, underscored the complexity of integrating HIT solutions into postpartum care workflows. Despite challenges, the project demonstrated continuous quality improvement to support data quality for perinatal care measures. Future solutions emphasize the need for standardized data elements, collaborative care team engagement, and iterative HIT implementation strategies to enhance perinatal care quality. Our findings highlight the potential of HIT-driven interventions to improve postpartum care within health centers, with a focus on the importance of addressing data interoperability and documentation challenges to optimize and monitor initiatives to improve postpartum health outcomes.

'It's just one step too far': Negotiating physical activity for perinatal mental health.

BACKGROUND: Physical activity is recommended as a self-help strategy for some mild to moderate perinatal mental illnesses. Despite this, we know very little about how women remain active, or take up physical activity, in the context of changing family life and perinatal mental illness. We seek to explore: a) how women negotiate physical activity for their mental health during transitions into parenthood and the early years; and b) the experiences of women with perinatal mental illness in relation to physical activity. METHODS: An anonymous UK-wide qualitative online survey was used to better understand how physical activity may be used for perinatal mental health, barriers to activity and changes over time. 186 women with babies and children up to four years completed the survey. Reflexive thematic analysis was used to analyse the qualitative data and generate themes. RESULTS: Themes generated from this data were: 1) negotiating being active for perinatal mental health (the benefits and how these women remained active); 2) barriers to PA associated with mental illness (some women were active but still experienced general barriers to further PA, and there were several emotional barriers from mental illness); and 3) PA, guilt and the importance of valuing walking (guilt about not being active enough, guilt and feelings of failure exacerbated by questions about PA levels without support offered; regular walking not valued as PA exacerbating feelings of guilt). CONCLUSIONS AND IMPLICATIONS: This study provides new empirical data on the experiences of new mothers', physical activity and mental health with important implications for physical activity messaging and support for women during this time through maternity care. Individualised conversations are important and the value of walking and incidental activity from activities that mothers and families find enjoyable should be promoted.

Timeliness and quality of peripartum care provision during a health system strengthening initiative in rural Guinea-Bissau: a qualitative situation analysis.

Guinea-Bissau has among the world's highest maternal and perinatal mortality rates. To improve access to quality maternal and child health (MCH) services and thereby reduce mortality, a national health system strengthening initiative has been implemented. However, despite improved coverage of MCH services, perinatal mortality remained high. Using a systems-thinking lens, we conducted a situation analysis to explore factors shaping timeliness and quality of facility-based care during labour, childbirth, and the immediate postpartum period in rural Guinea-Bissau. We implemented in-depth interviews with eight peripartum care providers and participant observations at two health facilities (192 h) in 2021-22, and analysed interview transcripts and field notes using thematic network analysis. While providers considered health facilities as the only reasonable place of birth and promoted facility birth uptake, timeliness and quality of care were severely compromised by geographical, material and human-resource constraints. Providers especially experienced a lack of human resources and materials (e.g., essential medicines, consumables, appropriate equipment), and explained material constraints by discontinued donor supplies. In response, providers applied several adaptation strategies including prescribing materials for private purchase, omitting tests, and delegating tasks to birth companions. Consequences included financial barriers to care, compromised patient and occupational safety, delays, and diffusion of health worker responsibilities. Further, providers explained that in response to persisting access barriers, women conditioned care seeking on their perceived risk of developing birthing complications. Our findings highlight the need for continuous monitoring of factors constraining timeliness and quality of essential MCH services during the implementation of health system strengthening initiatives.

Perinatal care among Hispanic birthing people: Differences by primary language and state policy environment.

OBJECTIVE: The study aims to examine maternal care among Hispanic birthing people by primary language and state policy environment. DATA SOURCES AND STUDY SETTING: Pooled data from 2016 to 2020 Pregnancy Risk Assessment Monitoring System surveys from 44 states and two jurisdictions. STUDY DESIGN: Using multivariable logistic regression, we calculated adjusted predicted probabilities of maternal care utilization (visit attendance, timeliness, adequacy) and quality (receipt of guideline-recommended care components). We examined outcomes by primary language (Spanish, English) and two binary measures of state policy environment: (1) expanded Medicaid eligibility to those <133% Federal Poverty Level, (2) waived five-year waiting period for pregnant immigrants to access Medicaid. DATA COLLECTION/EXTRACTION METHODS: Survey responses from 35,779 postpartum individuals with self-reported Hispanic ethnicity who gave birth during 2016-2020. PRINCIPAL FINDINGS: Compared to English-speaking Hispanic people, Spanish-speaking individuals reported lower preconception care attendance and worse timeliness and adequacy of prenatal care. In states without Medicaid expansion and immigrant Medicaid coverage, Hispanic birthing people had, respectively, 2.3 (95% CI:0.6, 3.9) and 3.1 (95% CI:1.6, 4.6) percentage-point lower postpartum care attendance and 4.2 (95% CI:2.1, 6.3) and 9.2 (95% CI:7.2, 11.2) percentage-point lower prenatal care quality than people in states with these policies. In states with these policies, Spanish-speaking Hispanic people had 3.3 (95% CI:1.3, 5.4) and 3.0 (95% CI:0.9, 5.1) percentage-point lower prenatal care adequacy, but 1.3 (95% CI:-1.1, 3.6) and 2.7 (95% CI:0.2, 5.1) percentage-point higher postpartum care quality than English-speaking Hispanic people. In states without these policies, those same comparisons were 7.3 (95% CI:3.8, 10.8) and 7.9 (95% CI:4.6, 11.1) percentage-points lower and 9.6 (95% CI:5.5, 13.7) and 5.3 (95% CI:1.8, 8.9) percentage-points higher. CONCLUSIONS: Perinatal care utilization and quality vary among Hispanic birthing people by primary language and state policy environment. States with Medicaid expansion and immigrant Medicaid coverage had greater equity between Spanish-speaking and English-speaking Hispanic people in adequate prenatal care and postpartum care quality among those who gave birth.

Education professionals' perceptions on perinatal mental health education in Australian and New Zealand medical and pharmacy curricula.

INTRODUCTION: Primary healthcare workers, including doctors and pharmacists, are well-positioned to detect and support women experiencing mental health disorders in the perinatal period. However, research exploring their education and training to fulfil these roles is limited. This study aimed to examine the perspectives of medical and pharmacy educational program representatives on perinatal mental health education in medical and pharmacy curricula at Australian and New Zealand universities. METHODS: A web-based search (e.g., Australian Health Practitioner Regulation Agency) was used to identify potentially relevant medical and pharmacy educational program representatives. Eligible participants were invited to participate in audio-recorded semi-structured interviews which were transcribed verbatim. Data regarding perinatal mental health content within each program were extracted and tabulated for comparisons. Thematic analysis of participants' perspectives on perinatal mental health education was conducted. RESULTS: Fifty medical and pharmacy educational program representatives were invited to participate (December 2022-March 2023), of which 13 participated representing 14 programs. The extent and content of perinatal mental health education varied considerably across programs. Thematic analysis resulted in four themes: How much perinatal mental health content is enough?; Reflections on perinatal mental health related content; Perinatal mental health education in and beyond the classroom; Challenges associated with delivering perinatal mental health content. CONCLUSIONS: Participants acknowledged the importance of perinatal mental health content for medical and pharmacy students; however, limited time and lack of opportunities for students to complete placements were key challenges to curricular integration.

Assessing the Gap Between Women's Expectations and Perceptions of the Quality of Intrapartum Care in Jordan: A Two-Stage Study Using the SERVQUAL Model.

INTRODUCTION: Although Jordan has made significant progress toward expanding the utilization of facility-based intrapartum care, prior research highlights that poor service quality is still persistent. This study aimed to identify quality gaps between women's expectations and perceptions of the actual intrapartum care received, while exploring the contributing factors. METHODS: Utilizing a pre-post design, quality gaps in intrapartum care were assessed among 959 women pre- and postchildbirth at a prominent tertiary hospital in northern Jordan. Data were gathered using the SERVQUAL scale, measuring service quality across reliability, responsiveness, tangibles, assurance, and empathy dimensions. RESULTS: The overall mean gap score between women's expectations and perceptions of the quality of intrapartum care was -0.60 (±0.56). The lowest and highest mean gap scores were found to be related to tangibles and assurance dimensions, -0.24 (±0.39) and -0.88 (±0.35), respectively. Significant negative quality gaps were identified in the dimensions of assurance, empathy, and responsiveness, as well as overall service quality (p < 0.001). The MLR analyses highlighted education (ß = 0.61), mode of birth (ß = -0.60), admission timing (ß = -0.41), continuity of midwifery care (ß = -0.43), physician's gender (ß = -0.62), active labour duration (ß = 0.37), and pain management (ß = -0.33) to be the key determinants of the overall quality gap in intrapartum care. CONCLUSION: Our findings underscore the importance of fostering a labour environment that prioritizes enhancing caregivers' empathetic, reassuring, and responsive skills to minimize service quality gaps and enhance the overall childbirth experience for women in Jordan. PATIENT OR PUBLIC CONTRIBUTION: This paper is a collaborative effort involving women with lived experiences of childbirth, midwives, and obstetrics and gynaecologist physicians. The original idea, conceptualization, data generation, and coproduction, including manuscript editing, were shaped by the valuable contributions of stakeholders with unique perspectives on intrapartum care in Jordan.

Suboptimal factors in maternal and newborn care for refugees: Lessons learned from perinatal audits in the Netherlands.

INTRODUCTION: Refugees and their healthcare providers face numerous challenges in receiving and providing maternal and newborn care. Research exploring how these challenges are related to adverse perinatal and maternal outcomes is scarce. Therefore, this study aims to identify suboptimal factors in maternal and newborn care for asylum-seeking and refugee women and assess to what extent these factors may contribute to adverse pregnancy outcomes in the Netherlands. METHODS: We conducted a retrospective analysis of national perinatal audit data from 2017 to 2019. Our analysis encompassed cases with adverse perinatal and maternal outcomes in women with a refugee background (n = 53). Suboptimal factors in care were identified and categorized according to Binder et al.'s Three Delays Model, and the extent to which they contributed to the adverse outcome was evaluated. RESULTS: We identified 29 suboptimal factors, of which seven were related to care-seeking, six to the accessibility of services, and 16 to the quality of care. All 53 cases contained suboptimal factors, and in 67.9% of cases, at least one of these factors most likely or probably contributed to the adverse perinatal or maternal outcome. CONCLUSION: The number of suboptimal factors identified in this study and the extent to which they contributed to adverse perinatal and maternal outcomes among refugee women is alarming. The wide range of suboptimal factors identified provides considerable scope for improvement of maternal and newborn care for refugee populations. These findings also highlight the importance of including refugee women in perinatal audits as it is essential for healthcare providers to better understand the factors associated with adverse outcomes to improve the quality of care. Adjustments to improve care for refugees could include culturally sensitive education for healthcare providers, increased workforce diversity, minimizing the relocation of asylum seekers, and permanent reimbursement of professional interpreter costs.