Nurses' Perceived Effects of Visitor Restrictions in Hospital Maternity Units.

PURPOSE: To explore how perinatal nurses perceive the effects of visitor restrictions on patient care within a hospital setting. STUDY DESIGN AND METHODS: We distributed a cross-sectional survey online to perinatal nurses in May of 2022. Characteristics of respondents were analyzed using descriptive statistics. Responses to an open-ended question were analyzed via conventional content analysis. RESULTS: Among our sample of 101 nurses, we identified seven codes representing positive effects and seven codes representing negative effects. The most frequently reported positive effects were ability to provide person-centered care ( n = 36, 35.6%) and less patient stress and more rest ( n = 29, 28.7%). The most frequently reported negative effects were limited patient support ( n = 22, 21.8%) and emotional distress to the patient ( n = 15, 14.9%). Fourteen percent ( n = 14) of respondents cited both positive and negative effects. CLINICAL IMPLICATIONS: Nurses perceived that visitor restrictions resulted in both positive and negative patient experiences. Balancing clinical needs and safety considerations with emotional needs of the childbearing individual requires careful consideration by maternity care clinicians and health care systems. Subsequent research is needed to determine optimal visitation policies during intrapartum and postpartum with consideration to hospital context and patient preferences for optimal care.

Use of Behavioral Health Treatment Among Parenting Women With Opioid Use Disorder in the United States.

OBJECTIVE: To examine use of mental health treatment, substance use disorder treatment, and perceived barriers to treatment by whether a major depressive episode occurred during the past year among parenting women with opioid use disorder. DESIGN: Secondary analysis of survey data from the National Survey on Drug Use and Health, 2015-2019. SETTING: United States. PARTICIPANTS: Women aged 18 to 44 years with opioid use disorder and at least one child in the household. METHODS: We computed descriptive statistics for demographic characteristics, treatment by major depressive episode status, and barriers to treatment by major depressive episode status. We conducted multinomial logistic regression to examine associations among demographic characteristics, major depressive episode status, and type of treatment. RESULTS: Of the 36% of respondents in our weighted sample (N ≈ 254,300) who experienced major depressive episode, 35% received substance use disorder and mental health treatment, and 27% did not receive any form of treatment. We found that identification as a person of color was significantly associated with a lower relative risk of receiving any type of treatment. Frequently reported barriers to treatment included affordability, access, and stigma. CONCLUSION: Respondents with opioid use disorder and co-occurring major depressive episode did not obtain necessary treatment. Barriers to treatment, including affordability, access to treatment, and stigma, need to be addressed, particularly among women of color.

Survey of Postpartum People in the United States During the First Wave of the COVID-19 Pandemic to Explore Their Perspective on Support After Discharge.

INTRODUCTION: The purpose of this study was to capture the experiences of postpartum people during the first wave of COVID-19, specifically their access to contraception and lactation support. METHODS: This cross-sectional study surveyed individuals in the United States who used the Ovia Pregnancy and Parenting app. The survey was administered via an email Web link sent to postpartum people who gave birth between March 1, 2020, and June 11, 2020. Quantitative and qualitative analyses were conducted. RESULTS: A total of 388 postpartum people completed the survey. Most participants had just given birth to their first baby (68.5%; n = 261) at term gestation (37-41 weeks) (92.9%; n = 355). From the qualitative data, using content analysis, we derived 6 themes and 2 subthemes: quarantine, changes in postpartum care, loneliness and isolation, stress, resource changes, and positive impact. The theme loneliness and isolation had 2 subthemes: depression/sadness/hopelessness and anxiety. DISCUSSION: The experience of being postpartum during the COVID-19 pandemic brought unforeseen challenges. Providing care and support to postpartum people during a pandemic, specifically during a time of quarantine, should be reimagined. Increased use of virtual postpartum care services and expanded mental health support could serve to fill the gaps identified by participants.

Three Missed Critical Nursing Care Processes on Labor and Delivery Units During the COVID-19 Pandemic.

OBJECTIVE: To examine the relationships of three missed critical nursing care processes on labor and delivery units with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic in the United States. DESIGN: A cross-sectional survey. SETTING: Online distribution from January 14 to February 26, 2021. PARTICIPANTS: A national convenience sample (N = 836) of registered nurses employed on labor and delivery units. METHODS: We conducted descriptive analyses on respondent characteristics and critical missed care items adapted from the Perinatal Missed Care Survey. We conducted robust logistic regression analyses to assess the relationships of three missed critical nursing care processes (surveillance of fetal well-being, excessive uterine activity, and development of new maternal complications) with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic. RESULTS: Less nursing time at the bedside was associated with greater odds of missing any of the critical aspects of care, adjusted odds ratio = 1.77, 95% confidence interval [1.12, 2.80]. Adequate staffing greater than or equal to 75% of the time was associated with lower odds of missing any of the critical aspects of care compared to adequate staffing less than or equal to 50% of the time, adjusted odds ratio = 0.54, 95% confidence interval [0.36, 0.79]. CONCLUSION: Perinatal outcomes are dependent on the timely recognition of and response to abnormal maternal and fetal conditions during childbirth. In times of unexpected complexity in care and resource constraints, a focus on three critical aspects of perinatal nursing care is needed to maintain patient safety. Strategies that enable bedside presence of nurses, including maintaining adequate unit staffing, may help to mitigate missed care.

Challenges, Job Satisfiers, and Self-Care among Perinatal Nurses in the United States during the COVID-19 Pandemic.

PURPOSE: To explore the perceived challenges, job satisfiers, and self-care of perinatal nurses in the United States during the COVID-19 pandemic. STUDY DESIGN AND METHODS: In May of 2021, a cross-sectional survey was distributed online to members of the Association of Women's Health, Obstetric, and Neonatal Nurses and the National Association of Neonatal Nurses. We calculated descriptive statistics on respondent characteristics and applied conventional content analysis to free-text comments. RESULTS: Perinatal nurses ( N = 297) responded to three open-ended questions on their perceived challenges, job satisfiers, and self-care. Frequently reported challenges included changing guidelines and policies ( n = 101, 34%), personal protective equipment as a barrier ( n = 73, 24.6%), and visitor restrictions ( n = 64, 21.5%). Frequently reported job satisfiers were provision of high-quality care ( n = 137, 46.1%) and visitor restrictions ( n = 77, 25.9%). Respondents reported using mental ( n = 152, 51.2%) and physical ( n = 145, 48.8%) self-care strategies and 12.8% ( n = 38) reported using no self-care strategies. CLINICAL IMPLICATIONS: The ability to provide high-quality care was reported as a leading job satisfier. Poor communication of consistent, evidence-based guidelines, lack of personal protective equipment, and inadequate unit staffing were leading challenges. Visitor restrictions were a challenge and a job satisfier, suggesting opportunities to better include visitors as support people. Most respondents reported engaging in one or more types of self-care outside of the hospital setting. Future research is needed to examine strategies for self-care among perinatal nurses when at work in the hospital setting.

Promoting Military Women's Health Through Research Design.

Although active duty women (ADW) represent over 17% of the total U.S. Armed Forces, there are few evidence-based guidelines to promote the health of women who serve in contemporary military roles. The existing body of evidence does not support guideline development because much of the evidence is not generalizable to ADW. The authors of this commentary recently conducted seven scoping reviews of the literature relevant to ADW's health and healthcare. While completing the literature reviews, it was noted that a substantial proportion of military studies either do not include ADW as research participants or fail to examine findings according to sex and/or active duty status. The authors of this commentary outline a rigorous, step-by-step approach to research design in which ADW are accounted for at every stage of the process. Furthermore, this team of authors identifies opportunities for key stakeholders to provide oversight of the research process to ensure rigorous methodology that includes ADW. Implementing these strategies is critical to building the evidence on which to support the health and healthcare of ADW, who represent a substantial and growing component of the U.S. Military. Optimizing the health of this population is critical to maintaining the strength and readiness of our U.S. Armed Forces.

Shared Decision-Making During Labor and Birth Among Low-Risk, Active Duty Women in the U.S. Military.

INTRODUCTION: The cesarean birth rate of 24.7% in the Military Health System (MHS) is lower than the national rate of 31.7%. However, the MHS rate remains higher than the 15-19% threshold associated with optimal maternal and neonatal outcomes. For active duty servicewomen, increased morbidity associated with cesarean birth is likely to affect the ability to meet the demands of assigned missions. Several decision-points occur during pregnancy and after the onset of labor that can affect the likelihood of cesarean birth including choice of provider, choice of hospital, timing of admission, and type of fetal monitoring. Evidence suggests the overuse of labor interventions may be associated with cesarean birth. Shared decision-making (SDM) is a strategy that can be used to carefully consider the risks, benefits, and alternatives of each labor intervention and is shown to be associated with positive patient outcomes. Most existing evidence explores SDM as an interaction that occurs between women and their providers. Few studies have explored the role of stakeholders such as spouses, family members, friends, labor and delivery nurses, and doulas. Furthermore, little is known about the process of SDM during labor and childbirth in the hospital setting, particularly for active duty women in the U.S. military. The purpose of this study was to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. MATERIALS AND METHODS: A qualitatively driven mixed-methods approach was conducted to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. Servicewomen were recruited from September 2019 to April 2020. Semi-structured interviews were analyzed using a constructivist grounded theory approach. Participants also completed the SDM Questionnaire (SDM-Q-9). RESULTS: Interviews were conducted with 14 participants. The sample included servicewomen from the Air Force (n = 7), Army (n = 4), and Navy (n = 3). Two participants were enlisted and the remainder were officers. Ten births occurred at military treatment facilities (MTFs) and four births took place at civilian facilities. The mean score on the SDM Questionnaire was 86.7 (±11.6), indicating a high level of SDM. Various stakeholders (e.g., providers, labor and delivery nurses, doulas, spouses, family members, and friends) were involved in SDM at different points during labor and birth. The four stages of SDM included gathering information, identifying preferences, discussing options, and making decisions. Events that most often involved SDM were deciding when to travel to the hospital, deciding when to be admitted, and selecting a strategy for pain management. Military factors involved in SDM included sources of information, selecting and working with civilian providers, and delaying labor interventions to allow time for an active duty spouse to travel to the hospital. CONCLUSIONS: SDM during labor and birth in the hospital setting is a multi-stage process that involves a variety of stakeholders, including the woman, members of her social and support network, and healthcare professionals. Future research is needed to explore perspectives of other stakeholders involved in SDM.

Integrative Review of Racial Disparities in Perinatal Outcomes Among Beneficiaries of the Military Health System.

OBJECTIVE: To examine the extent to which racial disparities exist in the perinatal outcomes of beneficiaries of the Military Health System (MHS). DATA SOURCES: We searched the PubMed, CINAHL, and Embase databases. STUDY SELECTION: We selected articles published in English in peer-reviewed journals in which the authors examined race in relation to perinatal outcomes among beneficiaries of the MHS. Date of publication was unrestricted through March 2021. DATA EXTRACTION: Twenty-six articles met the inclusion criteria. We extracted data about study design, purpose, sample, setting, and results. We also assigned quality appraisal ratings to each article. DATA SYNTHESIS: In most of the included articles, researchers observed differences in perinatal outcomes between Black and White women. Compared to White women, Black women had greater rates of cesarean birth, preterm birth, low birth weight, and small for gestational age neonates. White women had greater rates of postpartum depression than Black women. CONCLUSION: Racial disparities in very low birth weight newborns and preterm birth may be smaller in the MHS than in the general population of the United States. The overall rates of preterm birth, cesarean birth, and neonatal mortality were lower for beneficiaries of the MHS than in the general population of the United States.

A Scoping Review of Unintended Pregnancy in Active Duty United States Military Women.

INTRODUCTION: The purpose of this scoping review was to apply the Social Ecological Model for Military Women's Health to literature on unintended pregnancy (UIP) to answer the question: In United States active duty military women (population) with the potential for UIP (context), what is known about risk factors, prevention, and pregnancy outcomes (concepts)? METHODS: We conducted this review based on a PRISMA-ScR protocol registered a priori in Open Science Framework. Following a literature search of six databases and the grey literature, we used DistillerSR to manage data screening and data charting. The Social Ecological Model for Military Women's Health served as the theoretical framework to chart findings regarding UIP at the individual, microsystem, mesosystem, exosystem, and macrosystem levels. RESULTS: A total of 74 research, review, and grey literature articles met the inclusion criteria. Risk factors included specific demographics, military service, and recent deployment. Prevention included contraceptive practices, access, and education that should take place early in servicewomen's careers and before deployment. Outcomes included early return from deployment, personal career challenges, and seeking alternative health services outside the military health system. CONCLUSIONS: Research and policy initiatives should focus on decreasing risk factors in the military working environment, with particular attention to the deployed environment. These initiatives should include input from military leaders, health care providers, servicewomen, and servicemen with the goal of decreasing the incidence of unintended pregnancies. Pregnancy intentionality among military women should be considered as a concept to shape intervention research to reduce unintended pregnancies.

A Scoping Review of Pregnancy, Childbirth, and the Postpartum Period in Active Duty U.S. Military Women.

PURPOSE: Women in the U.S. military encounter unique challenges during the perinatal period that are driven by military requirements for mission readiness. The purpose of this scoping review was to systematically examine the extent, range, and nature of the literature on pregnancy, childbirth, and the postpartum period of active duty military women. A secondary aim was to identify leverage points for changes to improve perinatal health of servicewomen. METHODS: We used a PRISMA-ScR protocol to guide this scoping review of research and non-research articles germane to the perinatal health of servicewomen. In the protocol, we identified the rationale, objectives, eligibility criteria, search strategy, sources of evidence, and data charting processes for the review. We used the social ecological model for military women's health framework to guide the synthesis of results. FINDINGS: Eighty-four articles on the topics of pregnancy, childbirth, and the postpartum period of servicewomen published from 2000 to 2018 were identified. The articles were mainly research studies (n = 76), of which 49 had observational designs. Leverage points to promote workplace safety and support of pregnant women, perinatal screening, recognition of pregnancy and postpartum depression, and maintaining physical fitness during pregnancy and the postpartum period were identified in multiple levels of the social ecological model for military women's health. CONCLUSIONS: Literature published from 2000 to 2018 is broad in scope, yet generally lacks a robust body of evidence on any one topic. Implementing strategies and military policies that are directed at the identified leverage points could enhance the health of childbearing servicewomen.

A Scoping Review of Breastfeeding in Active Duty U.S. Military Women.

PURPOSE: Active duty (AD) women in the U.S. military experience challenges during childbearing owing to unique occupational demands. The purpose of this article is to report the findings from a scoping review on pregnancy, childbirth, and the postpartum period that are specific to breastfeeding among servicewomen. A secondary aim is to identify leverage points that would promote breastfeeding in this population. METHODS: We developed a PRISMA-ScR protocol to identify publications from 2000 to 2018 regarding pregnancy, childbirth, and the postpartum period in AD women. Among articles pertaining to the postpartum period, we recognized those specific to breastfeeding for separate analysis. Using the social ecological model for military women's health (SEM-MWH) to synthesize our results, we identified actionable leverage points in the military setting for positive change. RESULTS: Research articles specific to breastfeeding (n = 8) included descriptive, cross-sectional, and qualitative studies. Non-research articles (n = 7) were either an integrative review, nonsystematic review, or commentary. Thirty-four leverage points were identified throughout the social ecological system of military women, including support for lactation in the workplace, employment of lactation consultants, occupational hazards assessment, personnel policies that delay the separation of women and their infants, and research to fill gaps in knowledge about breastfeeding while on AD. The greatest number of leverage points are in the SEM-MWH mesosystem and exosystem. CONCLUSIONS: There are multiple potential leverage points throughout the SEM-MWH to generate positive changes in the social ecological system of military women. These changes could serve to enhance the breastfeeding experiences of AD women.

The Gulf War Women's Health Cohort: Study Design and Protocol.

Military service and deployment affect women differently than men, underscoring the need for studies of the health of women veterans and their receipt of health care services. Despite the large numbers of women who served during the 1990-1991 Gulf War, few studies have evaluated Gulf War illness (GWI) and other medical conditions specifically as they affect women veterans of the 1991 Gulf War. The objectives of the Gulf War Women's Health Cohort study are: (1) to establish the Gulf War women's cohort (GWWC), a large sample of women veterans who served in the 1990-1991 Gulf War and a comparison group of women who served in other locations during that period; and (2) to provide current, comprehensive data on the health status of women who served during the 1990-1991 Gulf War, and identify any specific conditions that affect Gulf War women veterans at excess rates. The study will utilize both existing datasets and newly collected data to examine the prevalence and patterns of Gulf War Illness symptoms, diagnosed medical conditions, reproductive health, birth outcomes and other health issues among women who served during the Gulf War. The Gulf War Women's Health Cohort study will address the need for information about the comprehensive health of women veterans who were deployed to the Gulf War, and other wars during the Gulf War era.

Prevalence and Patterns of Symptoms Among Female Veterans of the 1991 Gulf War Era: 25 Years Later.

Background: A new national cohort of Gulf War (GW) veterans of 1,318 participants was created from the Veterans Affairs Cooperative Studies Program 585 Gulf War Era Cohort and Biorepository (GWECB) pilot study. However, female veteran health outcomes have not been reported separately for those deployed versus nondeployed to the 1990-1991 GW. Methods: Using data from the cooperative studies program (CSP) #585 GWECB, this study examined whether excess prevalence and patterns of Gulf War Illness (GWI) symptoms were present among female veterans who served during the GW compared with female veterans who did not deploy to the GW (GW-Era). Results: A total of 301 women veterans participated in the survey (203 GW, 98 GW-era). Mean ages in 2016 were 53 years among GW women veterans and 54 years among GW-era women. Participant groups did not differ by age, race, ethnicity, or education, but GW women were more likely to have served in the army or navy and less likely to have served in the air force. Compared with GW-era women, GW-deployed women were significantly more likely to report 7 out of 34 symptoms related to cognitive, neurological, and mood problems and respiratory complaints when controlling for age, race, GW deployment, branch of service, and smoking status in logistic regression analyses. Ordered logistic regression was also used to estimate the association between the total number of self-reported symptoms and deployment status, age, race, branch of service, and smoking status. Results showed deployed GW veterans to have a nearly twofold risk of reporting more symptoms than GW-era women, with younger, nonwhite, army-enlisted GW women significantly more likely to report more total symptoms. Discussion: Twenty-five years after the war, GWECB women GW veterans continued to report a wide variety of symptoms at a significantly higher excess frequency prevalence than GW-era women. Our results showed at least a 14% excess frequency prevalence in all seven significantly different symptoms encompassing two out of the six Kansas GWI criteria, including neurological/mood/cognition, and respiratory domains. These results suggest that further study of these symptom domains is warranted in GW women veterans.

Systematic Review and Meta-Analysis of the Effect of Nutrients on Blood Lead Levels in Pregnancy.

OBJECTIVE: To synthesize experimental and nonexperimental research on the relationship between nutrients and blood lead levels in pregnant women. We also performed a meta-analysis on a subgroup of studies on calcium and blood lead levels. DATA SOURCES: PubMed, Embase, and CINAHL databases were searched in July 2019. STUDY SELECTION: We included articles published in English in any year that reported the results of experimental or observational studies on the effect of nutrients on blood lead levels in pregnancy. DATA EXTRACTION: Three nurse reviewers extracted data and appraised the studies using tools from the Joanna Briggs Institute. DATA SYNTHESIS AND META-ANALYSIS: We included 28 studies from 16 countries. Study authors examined 14 distinct nutrients, with calcium being the most frequent. The metaregression included nine analyses of the effect of calcium on blood lead levels and showed a small but significant inverse relationship. The quality of evidence for the effect of calcium on lead levels was high. Eleven analyses were related to the effect of iron on blood lead levels. The quality of evidence was high, and we found mostly negative associations between iron intake and blood lead levels. The quality of evidence for the remaining nutrients was moderate, with few significant findings. CONCLUSION: Targeted nutritional interventions may be beneficial for pregnant women with current lead exposure or a history of elevated lead levels, particularly those with calcium- or iron-deficient diets. More rigorously designed studies are needed in this area.

Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women.

BACKGROUND: Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor. METHODS: A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes. RESULTS: The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]). CONCLUSIONS: Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

Associations Among Intrapartum Interventions and Cesarean Birth in Low-Risk Nulliparous Women with Spontaneous Onset of Labor.

INTRODUCTION: Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth. METHODS: This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth. RESULTS: More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21). DISCUSSION: Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women.

Clinicians' Perspectives on Admission of Pregnant Women: A Triad.

PURPOSE: Reducing primary cesarean births is a national priority in the United States. Recommendations include delaying admission of low-risk pregnant women to the hospital until they are in active labor, considered to be 6 cm cervical dilatation. How this recommendation affects decision-making during triage requires further exploration. The purpose of this study was to explore the clinician's perspective on the triage process and deferral of hospital admission for low-risk pregnant women who were not yet in active labor. METHODS: A qualitative descriptive approach was used via semistructured interviews with physicians, midwives, and nurses. Data analysis used an inductive approach and identified codes, a theme and subthemes. RESULTS: Twenty-five clinicians participated. A triad of decision-making occurred between three main stakeholders: the low-risk pregnant woman, the triage nurse, and the physician or midwife. One theme and four subthemes related to this triad were identified. The theme Admission of Low-Risk Pregnant Women Depends on Many Factors provides context to the maternity care triage process. There are many factors clinicians consider prior to admitting women, including situational and clinical factors. Subthemes related to the woman are her expectation and knowledge about birth and her ability to cope with labor. Subthemes associated with the provider and triage nurse are care variation and concern for maternal and fetal safety. CLINICAL IMPLICATIONS: From the clinician's perspective, triage is a complex, dynamic process, even for low-risk pregnant women. There is an interplay of different factors affecting clinical decision-making, thus the decision-making triad provides a possible framework for shared decision-making.

Clinicians' Perspectives on Admission of Pregnant Women: A Triad.

PURPOSE: Reducing primary cesarean births is a national priority in the United States. Recommendations include delaying admission of low-risk pregnant women to the hospital until they are in active labor, considered to be 6 cm cervical dilatation. How this recommendation affects decision-making during triage requires further exploration. The purpose of this study was to explore the clinician's perspective on the triage process and deferral of hospital admission for low-risk pregnant women who were not yet in active labor. METHODS: A qualitative descriptive approach was used via semistructured interviews with physicians, midwives, and nurses. Data analysis used an inductive approach and identified codes, a theme and subthemes. RESULTS: Twenty-five clinicians participated. A triad of decision-making occurred between three main stakeholders: the low-risk pregnant woman, the triage nurse, and the physician or midwife. One theme and four subthemes related to this triad were identified. The theme Admission of Low-Risk Pregnant Women Depends on Many Factors provides context to the maternity care triage process. There are many factors clinicians consider prior to admitting women, including situational and clinical factors. Subthemes related to the woman are her expectation and knowledge about birth and her ability to cope with labor. Subthemes associated with the provider and triage nurse are care variation and concern for maternal and fetal safety. CLINICAL IMPLICATIONS: From the clinician's perspective, triage is a complex, dynamic process, even for low-risk pregnant women. There is an interplay of different factors affecting clinical decision-making, thus the decision-making triad provides a possible framework for shared decision-making.

Sex Differences in Gulf War Illness: A Reanalysis of Data From the CDC Air Force Study Using CDC and Modified Kansas Case Definitions.

OBJECTIVE: Estimate and compare the prevalence of Gulf War Illness (GWI) in male and female Gulf War veterans using Centers for Disease Control and Prevention (CDC) and modified Kansas case definitions. METHODS: Data from the landmark CDC Air Force Study of GW Air Force veterans is used. RESULTS: Nearly half of the deployed veterans met the GWI CDC case definition compared with 14% of non-deployed veterans. Only 29% met the definition using the modified Kansas criteria compared with 8% of non-deployed veterans. Deployed veterans and female veterans exhibited significantly higher GWI risk. Female GW veterans had higher rates of severe and mild-to-moderate cases of GWI. CONCLUSION: Results suggest increased GWI rates based on CDC and modified Kansas criteria among deployed and female veterans. Further research is needed to examine the chronic health outcomes of female GW veterans independently.