How does person-centered maternity care relate to postpartum contraceptive counseling and use? Evidence from a longitudinal study of women delivering at health facilities in Ethiopia.

Objectives: This study examines the relationship between integrated, person-centered maternity care (PCMC), the provision of postpartum family planning (PPFP) services, and postpartum contraceptive use among women delivering at health facilities in Ethiopia. Study design: We analyze 2019-2021 longitudinal data from a representative sample of pregnant and recently postpartum women in Ethiopia. This study examines baseline, 6-week, and 6-month survey data collected from women who delivered at a health facility. Results: Maternity patients who reported more person-centered care were more likely to be counseled on postpartum contraceptive methods before discharge. Overall, 27.5% of women delivering in a health facility received family planning counseling before discharge, ranging from 15.2% in the lowest PCMC quintile to 36.3% in the highest PCMC quintile. The receipt of PPFP counseling was associated with increased odds of postpartum contraceptive use. Conclusions: Findings suggest dimensions of quality care are interlinked, and person-centered care is associated with greater integration of recommended PPFP services into predischarge procedures. However, even among women who report relatively high levels of person-centered care, our results highlight that family planning is not routinely discussed prior to discharge from delivery, and very few women receive a contraceptive method or referral prior to discharge. Implications: While most postpartum women report they wish to limit or space future pregnancies, the uptake of modern contraceptive methods in the postpartum period is low. As women increasingly opt to deliver in health facilities, further integration of family planning services into predischarge procedures within maternity care can improve contraceptive access. Data statement: The data used in these analyses were collected as part of the PMA Ethiopia study. Data are publicly available at https://www.pmadata.org/data/request-access-datasets.

Insights from Preventability Assessments Across 42 State and City Maternal Mortality Reviews in the United States.

BACKGROUND: The rising trend in maternal mortality over the past three decades sets the United States (U.S.) apart from all other high-income countries. Multidisciplinary state and city Maternal Mortality Review Committees (MMRCs) conduct comprehensive reviews of maternal deaths, including assessments of preventability and contributing factors. OBJECTIVE(S): Assess preventability of and contributing factors to maternal mortality in the U.S. STUDY DESIGN: This study is a secondary analysis of cross-sectional, population-based data from the most recent, publicly available MMRC data from 40 state and 2 cities in the U.S. Preventability was analyzed among all deaths during pregnancy or within one year postpartum from any cause (pregnancy-associated deaths, PAD) and deaths during pregnancy or within one year postpartum from causes related to pregnancy or its management, but not from accidental causes (pregnancy-related deaths, PRD). We also explored preventability by cause-of-death and contributing factors grouped as community, patient-family, provider, facility, and health system factors. RESULTS: Of deaths that occurred after 2010, between 53%-93.8% of PADs and 45%-100% of PRDs were deemed preventable across the 42 states and cities. Across the ten states reporting PRD preventability by cause-of-death, MMRCs deemed preventable >90% of deaths from preeclampsia-eclampsia and mental health conditions, >80% of deaths from hemorrhage and cardiovascular conditions, about 70% of deaths from infection and thrombotic embolism, and about 40% of deaths from amniotic fluid embolism and stroke. A total of 3,345 contributing factors were described in MMRC reports from 14 states in relation to 739 PRDs. While collectively patient-family and provider factors were most frequently noted as contributing to PRDs, the contribution of such factors varied between 6%-56% and 18%-42.3%, respectively, across the states. Based on data from 20 MMRCs with available information, racism or discrimination were noted in relation to 37.7% of PRDs. CONCLUSIONS: A large proportion of PADs and PRDs in the U.S. are preventable. However, likely due to differences in MMRC membership, available data, and judgement employed to determine preventability, wide variation exists in the proportion of deaths deemed preventable and factors identified as contributing to such deaths across states. There is need to reevaluate the definitions, structure, and outputs for maternal death preventability assessments currently employed by a majority MMRCs to adequately inform state and national programming and policies.

Is severe maternal morbidity a risk factor for postpartum hospitalization with mental health or substance use disorder diagnoses? Findings from a retrospective cohort study in Maryland: 2016-2019.

BACKGROUND: Perinatal mental health conditions and substance use are leading causes, often co-occurring, of pregnancy-related and pregnancy-associated deaths in the United States. This study compares odds of hospitalization with a mental health condition or substance use disorder or both during the first year postpartum between patients with and without severe maternal morbidity (SMM) during delivery hospitalization. Methods: Data are from the Maryland's State Inpatient Database and include patients with a delivery hospitalization during 2016-2018 (n = 197,749). We compare rate of hospitalization with a mental health condition or substance use disorder or both at 42 days and 42 days to 1 year postpartum by occurrence of SMM during the delivery hospitalization. We use multivariable logistic regression to derive the odds of hospitalization with each outcome for patients by SMM status, adjusted for patient sociodemographic characteristics, presence of mental health condition or substance use disorder diagnoses during the delivery hospitalization, and delivery outcome. SMM, mental health conditions, and substance use disorders are identified using ICD-10 diagnosis and procedure codes. RESULTS: Overall, 5,793 patients (2.9%) who delivered during 2016-2018 experienced hospitalization in the year following delivery. Among these patients, 24.3% (n = 1,410) had a mental health condition diagnosis, 10.6% (n = 619) had a substance use disorder diagnosis, and 9.8% (n = 570) had co-occurring mental health condition and substance use disorder diagnoses. Patients with SMM had 3.7 times the odds (95% CI 2.7, 5.2) of hospitalization with a mental health condition diagnosis, 2.7 times the odds (95% CI 1.6, 4.4) of a hospitalization with substance use disorder diagnosis, and 3.0 times the odds (95% CI 1.8, 4.8) of hospitalization with co-occurring mental health condition and substance use disorder diagnoses during the first-year postpartum adjusting for covariates. CONCLUSION: Patients who experience SMM during their delivery hospitalization had higher odds of hospitalization with a mental health condition, substance use disorder, and co-occurring mental health condition and substance use disorder in the one-year postpartum period. Treatment and support resources for mental health and substance use providers --including enhanced screening and warm handoffs -- should be made available to patients with SMM upon discharge after delivery, and evidence-based interventions to improve mental health and reduce substance use should be prioritized in these patients.

Complexities of implementing Maternal and Perinatal Death Surveillance and Response in crisis-affected contexts: a comparative case study.

BACKGROUND: Maternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts - where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts. METHODS: Descriptive case studies were conducted on the implementation of MPDSR in Cox's Bazar refugee camps in Bangladesh, refugee settlements in Uganda, South Sudan, Palestine, and Yemen. Desk reviews of case-specific MPDSR documentation and in-depth key informant interviews with 76 stakeholders supporting or directly implementing mortality surveillance interventions were conducted between December 2021 and July 2022. Interviews were recorded, transcribed, and analyzed using Dedoose software. Thematic content analysis was employed to understand the adoption, penetration, sustainability, and fidelity of MPDSR interventions and to facilitate cross-case synthesis of implementation complexities. RESULTS: Implementation of MPDSR interventions in the five humanitarian settings varied in scope, scale, and approach. Adoption of the interventions and fidelity to established protocols were influenced by availability of financial and human resources, the implementation climate (leadership engagement, health administration and provider buy-in, and community involvement), and complex humanitarian-health system dynamics. Blame culture was pervasive in all contexts, with health providers often facing punishment or criminalization for negligence, threats, and violence. Across contexts, successful implementation was driven by integrating MPDSR within quality improvement efforts, improving community involvement, and adapting programming fit-for-context. CONCLUSIONS: The unique contextual considerations of humanitarian settings call for a customized approach to implementing MPDSR that best serves the immediate needs of the crisis, aligns with stakeholder priorities, and supports health workers and humanitarian responders in providing care to the most vulnerable populations.

Centering Equity and Fostering Stakeholder Collaboration and Trust-Pillars of the Maternal Health Innovation Program in Maryland.

Objective: To describe two main pillars of the Maryland Maternal Health Innovation Program (MDMOM): (1) centering equity and (2) fostering broad stakeholder collaboration and trust. Methods: We summarized MDMOM's key activities and used severe maternal morbidity (SMM) surveillance and program monitoring data to quantify MDMOM's work on the two pillars. We developed measures of hospital engagement with MDMOM (participation in quality improvement [QI] activities, participation in check-in meetings, staff involvement) and with other partners (participation in QI activities, representation in state-level groups). We examined Bonferroni-adjusted correlations between these hospital engagement measures and with key hospital characteristics: level of maternity care, annual delivery volume, and SMM rate. Results: Over 100 national and state organizations and individual stakeholders contributed to our building the MDMOM program and implementing key activities centering equity: hospital-based SMM surveillance in 20 of Maryland's 32 hospitals; almost 5,000 trainings offered to perinatal health care providers; two telemedicine/telehealth interventions; training of home visitors and community-based organization staff. Birthing hospitals represent MDMOM's main implementation partners. The strength of their participation in MDMOM QI activities is positively correlated to their participation in check-in meetings and with the degree of involvement by physicians in such activities. Higher engagement in MDMOM QI activities is also positively correlated to hospitals' participation in other state-level maternal health initiatives or groups. Conclusion: Our experience with the MDMOM program demonstrates that an equity focus and broad stakeholder collaboration building strong relationships and providing implementation support can lead to high levels of engagement in innovative maternal health interventions.

Implementation of maternal and perinatal death surveillance and response and related death review interventions in humanitarian settings: A scoping review.

Background: The global population impacted by humanitarian crises continues to break records each year, leaving strained and fractured health systems reliant upon humanitarian assistance in more than 60 countries. Yet little is known about implementation of maternal and perinatal death surveillance and response (MPDSR) within crisis-affected contexts. This scoping review aimed to synthesise evidence on the implementation of MPDSR and related death review interventions in humanitarian settings. Methods: We searched for peer-reviewed and grey literature in English and French published in 2016-22 that reported on MPDSR and related death review interventions within humanitarian settings. We screened and reviewed 1405 records, among which we identified 25 peer-reviewed articles and 11 reports. We then used content and thematic analysis to understand the adoption, appropriateness, fidelity, penetration, and sustainability of these interventions. Results: Across the 36 records, 33 unique programmes reported on 37 interventions within humanitarian contexts in 27 countries, representing 69% of the countries with a 2023 United Nations humanitarian appeal. Most identified programmes focussed on maternal death interventions; were in the pilot or early-mid implementation phases (1-5 years); and had limited integration within health systems. While we identified substantive documentation of MPDSR and related death review interventions, extensive gaps in evidence remain pertaining to the adoption, fidelity, penetration, and sustainability of these interventions. Across humanitarian contexts, implementation was influenced by severe resource limitations, variable leadership, pervasive blame culture, and mistrust within communities. Conclusions: Emergent MPDSR implementation dynamics show a complex interplay between humanitarian actors, communities, and health systems, worthy of in-depth investigation. Future mixed methods research evaluating the gamut of identified MPDSR programmes in humanitarian contexts will greatly bolster the evidence base. Investment in comparative health systems research to understand how best to adapt MPDSR and related death review interventions to humanitarian contexts is a crucial next step.

Educating Families on Urgent Maternal Warning Signs: Learning From a Pilot to Improve Training and Tools for Maternal and Child Home Visiting Programs.

Early recognition of the warning signs of pregnancy-related complications and provision of timely, quality care could prevent many maternal deaths. We piloted a maternal warning signs education intervention with five Maryland-based maternal, infant, and early childhood home visiting programs serving populations disproportionately affected by adverse maternal outcomes. The intervention included a 1.5-hr online training for home visitors, monthly collaborative calls with program managers, and a client education toolkit with a 3-min video, illustrated handout of 15 urgent maternal warning signs, magnet with the same, and discussion guide for home visitor-client interactions. A mixed-methods formative evaluation assessed the acceptability, feasibility, and utilization of different components of the intervention. Home visiting program staff reported that the materials were highly acceptable and easily understood by diverse client populations. They valued the illustrations, simple language, and translation of materials in multiple languages. Program managers found implementation a relatively simple process, feasible for in-person and remote visits. Despite positive reception, not all components of the toolkit were used consistently. Program managers and staff also identified the need for more guidance and tools to help clients communicate with health care providers and advocate for their health care needs. Feedback from pilot sites was used to adapt the training and tools, including adding content on patient self-advocacy. Home visiting programs have a unique ability to engage families during pregnancy and the postpartum period. This pilot offers lessons learned on strategies and tools that home visiting programs can use to improve early recognition and care-seeking for urgent maternal warning signs.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity.

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

Assessing the neonatal health policy landscape in low- and middle-income countries: Findings from the 2018 WHO SRMNCAH policy survey.

Background: We aimed to describe the availability of newborn health policies across the continuum of care in low- and middle-income countries (LMICs) and to assess the relationship between the availability of newborn health policies and their achievement of global Sustainable Development Goal and Every Newborn Action Plan (ENAP) neonatal mortality and stillbirth rate targets in 2019. Methods: We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) Policy Survey and extracted key newborn health service delivery and cross-cutting health systems policies that align with the WHO health system building blocks. We constructed composite measures to represent packages of newborn health policies for five components along the continuum of care: antenatal care (ANC), childbirth, postnatal care (PNC), essential newborn care (ENC), and management of small and sick newborns (SSNB). We used descriptive analyses to present the differences in the availability of newborn health service delivery policies by World Bank income group in 113 LMICs. We employed logistic regression analysis to assess the relationship between the availability of each composite newborn health policy package and achievement of global neonatal mortality and stillbirth rate targets by 2019. Results: In 2018, most LMICs had existing policies regarding newborn health across the continuum of care. However, policy specifications varied widely. While the availability of the ANC, childbirth, PNC, and ENC policy packages was not associated with having achieved global NMR targets by 2019, LMICs with existing policy packages on the management of SSNB were 4.4 times more likely to have reached the global NMR target (adjusted odds ratio (aOR) = 4.40; 95% confidence interval (CI) = 1.09-17.79) after controlling for income group and supporting health systems policies. Conclusions: Given the current trajectory of neonatal mortality in LMICs, there is a dire need for supportive health systems and policy environments for newborn health across the continuum of care. Adoption and implementation of evidence-informed newborn health policies will be a crucial step in putting LMICs on track to meet global newborn and stillbirth targets by 2030.

Postpartum Opioid-Related Mortality in Patients With Public Insurance.

OBJECTIVE: To assess the incidence and risk factors for postpartum opioid overdose death and describe other causes of postpartum death in individuals with opioid use disorder (OUD). METHODS: We conducted a cohort study that used health care utilization data from the Medicaid Analytic eXtract linked to the National Death Index in the United States from 2006 to 2013. All pregnant individuals with live births or stillbirths and continuous enrollment for 3 months before delivery were eligible, including 4,972,061 deliveries. A subcohort of individuals with a documented history of OUD in the 3 months before delivery was identified. We estimated the cumulative incidence of death as occurring between delivery and 1 year postpartum among all individuals and individuals with OUD. Risk factors for opioid overdose death were assessed using odds ratios (ORs) and descriptive statistics, including demographics, health care utilization, obstetric conditions, comorbidities, and medications. RESULTS: The incidence of postpartum opioid overdose death per 100,000 deliveries was 5.4 (95% CI 4.5-6.4) among all individuals and 118 (95% CI 84-163) among individuals with OUD. Individuals with OUD had a sixfold higher incidence of all-cause postpartum death than all individuals. Common causes of death in individuals with OUD were other drug- and alcohol-related deaths (47/100,000), suicide (26/100,000), and other injuries, including accidents and falls (33/100,000). Risk factors strongly associated with postpartum opioid overdose death included mental health and other substance use disorders. Among patients with OUD, postpartum use of medication to treat OUD was associated with 60% lower odds of opioid overdose death (OR 0.4, 95% CI 0.1-0.9). CONCLUSION: Postpartum individuals with OUD have a high incidence of postpartum opioid overdose death and other preventable deaths, including nonopioid substance-related injuries, accidents, and suicide. Use of medications for OUD is strongly associated with lower opioid-related mortality.

Maternal health policy environment and the relationship with service utilization in low- and middle-income countries.

Background: The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods: We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using χ2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results: The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions: Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Changes in the health systems and policy environment for maternal and newborn health, 2008-2018: An analysis of data from 78 low-income and middle-income countries.

BACKGROUND: Political, social, economic, and health system determinants play an important role in creating an enabling environment for maternal and newborn health. This study assesses changes in health systems and policy indicators for maternal and newborn health across 78 low- and middle-income countries (LMICs) during 2008-2018, and examines contextual factors associated with policy adoption and systems changes. METHODS: We compiled historical data from WHO, ILO, and UNICEF surveys and databases to track changes in ten maternal and newborn health systems and policy indicators prioritized for tracking by global partnerships. Logistic regression was used to examine the odds of systems and policy change based on indicators of economic growth, gender equality, and country governance with available data from 2008 to 2018. RESULTS: From 2008 to 2018, many LMICs (44/76; 57·9%) substantially strengthened systems and policies for maternal and newborn health. The most frequently adopted policies were national guidelines for kangaroo mother care, national guidelines for use of antenatal corticosteroids, national policies for maternal death notification and review, and the introduction of priority medicines in Essential Medicines Lists. The odds of policy adoption and systems investments were significantly greater in countries that experienced economic growth, had strong female labor participation, and had strong country governance (all p < 0·05). CONCLUSIONS: The widespread adoption of priority policies over the past decade is a notable step in creating an environment supportive for maternal and newborn health, but continued leadership and resources are needed to ensure robust implementation that translates into improved health outcomes.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare.

BACKGROUND: Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE: This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. STUDY DESIGN: We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). RESULTS: Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals. CONCLUSION: We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia.

BACKGROUND: Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women. OBJECTIVE: This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia. STUDY DESIGN: The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities. RESULTS: Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ2=58.3) was nearly 3 times greater than variation between communities (σ2=21.2). CONCLUSION: Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

Perinatal telemedicine at lower-level birthing hospitals in Maryland: lessons learned from a landscape analysis.

BACKGROUND: The aim of this study was to assess the current perinatal telemedicine (PTM) landscape and inform the design and implementation of a PTM network linking level I/II birthing hospitals with the two-level IV hospitals in Maryland, to improve access to maternal-fetal medicine (MFM) specialist care. METHODS: Qualitative in-depth interviews were conducted with 24 clinicians and telemedicine experts during July-September 2020. We obtained data on 12 level I/II and both level IV hospitals. RESULTS: Less than half of level I/II hospitals currently offer obstetric services through telemedicine, and both level IV hospitals have interest and technical capacity to support implementation of a PTM network in Maryland. The COVID-19 related shift to telehealth and telemedicine was identified as a facilitator for such PTM programs. Perceived barriers to provider adoption of PTM services and network in Maryland included hospital leadership buy-in, information technology (IT) literacy, and patient triage complexities. Perceived barriers to patient adoption of PTM were access to technology, IT literacy, and language. Key benefits of PTM services included overall improved patient access, convenience, cost-savings, and safety during the COVID-19 pandemic. Influential factors for implementing a PTM network in Maryland included buy-in and approval from hospital and health system administration, a streamlined telehealth platform allowing for electronic medical record integration and interoperability, program funding, and sustainability. CONCLUSIONS: Gaps in availability of MFM care at level I/II birth hospitals call for expanded telemedicine programming to improve high-risk patients' access to specialty obstetric care and support the development of a PTM network in Maryland.

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland.

Importance: In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities. Objective: To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program. Design, Setting, and Participants: This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records. Exposures: Hospitalization during pregnancy or within 42 days post partum. Main Outcomes and Measures: The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care. Results: A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such. Conclusions and Relevance: The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.