Birth Behind Bars: The Need for Labor Support in the Incarcerated Population.

The population of women within carceral systems is growing rapidly. A portion of these individuals are pregnant and will deliver while incarcerated. Although shackling laws for pregnant persons have improved, incarcerated patients are forced to labor without the support of anyone but a carceral officer and their medical staff. We believe access to continuous labor support is critical for all pregnant persons. Carceral systems and their affiliated hospitals have the opportunity to change policies to reflect that continuous labor support is a basic human right and should be permitted for incarcerated pregnant persons in labor, either through a doula program or a selected person of choice.

Development and validation of the Midwife Profiling Questionnaire assessing women's preferred perinatal care professional and knowledge of midwives' legal competences.

OBJECTIVES: Currently maternity care organisation is developing worldwide. Therefore insight in the position of the midwife is important. The 'Midwife Profiling Questionnaire' (MidProQ) measures women's preferred perinatal care professional and their knowledge of midwives' legal competences. MidProQ is based on the European legal framework and was tested in a pilot study. This study aims to determine its content and face validity. STUDY DESIGN: A two-phase validation study with a Delphi method questioning content experts (n = 10) on items relevance and clarity as well as its scale and face validity. Further semi-structured interviews were performed with lay experts (n = 10) to evaluate the questionnaire's clarity, layout, phrasing and wording. RESULTS: After round one, most questions (42/47) were considered content valid for relevance and clarity (Item Content Validity Index 0.80-1.00). Scale (Scale Content Validity Index 0.92) and face validity (Face Validity Index 0.89) of the entire instrument was obtained. Five questions were revised until item content (0.83-1.00), scale content (0.92) and face validity (1.00) were appropriate. Lay experts' suggestions for improving the readability and usability were taken into account. CONCLUSIONS: We developed a valid instrument to elicit women's preferred health professional for uncomplicated pregnancy, labour and childbirth and to determine their knowledge about midwives' legal competences. Our instrument can be valuable in identifying knowledge gaps and improving the knowledge of the general population about the midwifery profession and maternity care. Finally, the MidProQ may improve research in the domain of maternity care culture, scale up midwifery and facilitate a more women-centred care.

How Should Trainees Respond in Situations of Obstetric Violence?

Argentina passed a law for humanized birth in 2004 and another law against obstetric violence in 2009, both of which stipulate the rights of women to achieve respectful maternity care. Clinicians and women might still be unaware of these laws, however. In this article, we discuss the case of a fourth-year medical student who, while visiting Argentina from the United States for his obstetric rotation, witnesses an act of obstetric violence. We show that the student's situation can be understood as one of moral distress and argue that, in this specific instance, it would be appropriate for the student to intervene by providing supportive care to the patient. However, we suggest that medical schools have an obligation to better prepare students for rotations conducted abroad.

Litigation in Perinatal Care: The Deposition Process.

Litigation in perinatal nursing represents a disproportionate share of indemnity payouts and results in excessive psychological stress. Testimony at deposition or trial can be challenging for clinicians; little is taught in training or postgraduate education regarding litigation. Nurses, midwives, and physicians can effectively navigate the deposition process and prepare for trial testimony by understanding the plaintiff's goals, recognizing the role of documentation, and becoming familiar with various plaintiff's strategies including reptile theory. Knowledge of psychological concepts such as confirmation bias and cognitive dissonance may assist clinicians in responding to plaintiff's lines of questioning. Deposition preparation is crucial to the defense and requires active participation on the part of clinicians; it may include mock deposition or use of simulation laboratories. Common mistakes in deposition may be avoided with foresight and anticipatory planning by clinicians working closely with risk managers and defense attorneys. This article provides an overview of the deposition process, including the plaintiff's goals and common approaches, as well as the role of documentation and common errors of deponents.

Time for a new zeitgeist in perinatal mental health.

Perinatal depression, and to a lesser extent anxiety, has been the focus of interest for perinatal psychiatrists for several decades. Policy and substantial funding has supported this. We argue that it is now time to change this focus and to invest greater funding to support clinical and research effort in 'high-risk' caregivers and their infants. We define high-risk caregivers as those who are likely to have attachment and relationship difficulties with their infant as a result of their own developmental experiences, personality difficulties and/or trauma-related mental disorders, often complicated by substance abuse, depression and anxiety. We propose that early intervention with such caregivers, focussing on both maternal mental health and on the needs of the infant for responsive and sensitive interaction and emotional care, would contribute to prevention of infant developmental disorders, with real gains to be made in breaking the transgenerational cycle of development of severe personality disorder.

Outcomes in Continuing Pregnancies Diagnosed with a Severe Fetal Abnormality and Implication of Antenatal Neonatology Consultation: A 10-Year Retrospective Study.

PURPOSE: To describe a population choosing to continue their pregnancy despite a severe fetal abnormality and to evaluate the role of antenatal neonatology consultation in perinatal decision-making. METHODS: A 10-year (2005-2015) retrospective descriptive study in a single Multidisciplinary Prenatal Diagnosis Center in South France. A series of pregnancies with severe fetal abnormalities were collected by a person outside the decision making process and/or the child's care. RESULTS: Thirty-nine pregnancies were included, among which 12 couples chose the perinatal palliative care. In total, there were 25 live births (10 later died, with median of survival of 52.5 h [16-943.5]); only five infants received a palliative care plan at birth. CONCLUSION: The choice to continue a pregnancy diagnosed with severe fetal pathology is on the rise in France. Treatment options point to standardize perinatal palliative care provided by trained perinatal professionals using standardized practices.

Can we assess risk of psychiatric sequelae from perinatal injuries?

Medical malpractice litigation involving seven to nine figure settlements has been on the rise over the past decade. Given the life-altering scope of these incidents, forensic child psychiatrists may be asked to opine on the effects of a permanent perinatal injury on normal human development. Whether forensic child psychiatrists can assess risk of future psychiatric effects from such incidents is an important question. This paper is spurred by two separate cases, each involving a male infant having a portion of their genitals accidentally amputated by an obstetrician-gynecologist (OB/GYN) during a routine circumcision. In each case, the genitals were repaired, but permanent defects remained. The question arises how such injuries would affect these children as they matured. An analysis of the literature supported that there are risks of psychiatric effects of such birth-related injuries. Such predictions are made with reference to what is already known about human development, and by an exploration of the literature on the psychiatric effects of comparable injuries to children.

US and territory telemedicine policies: identifying gaps in perinatal care.

BACKGROUND: Perinatal regionalization is a system of maternal and neonatal risk-appropriate health care delivery in which resources are ideally allocated for mothers and newborns during pregnancy, labor and delivery, and postpartum, in order to deliver appropriate care. Typically, perinatal risk-appropriate care is provided in-person, but with the advancement of technologies, the opportunity to provide care remotely has emerged. Telemedicine provides distance-based care to patients by consultation, diagnosis, and treatment in rural or remote US jurisdictions (states and territories). OBJECTIVE: We sought to summarize the telemedicine policies of states and territories and assess if maternal and neonatal risk-appropriate care is specified. STUDY DESIGN: We conducted a 2014 systematic World Wide Web-based review of publicly available rules, statutes, regulations, laws, planning documents, and program descriptions among US jurisdictions (N = 59) on telemedicine care. Policies including language on the topics of consultation, diagnosis, or treatment, and those specific to maternal and neonatal risk-appropriate care were categorized for analysis. RESULTS: Overall, 36 jurisdictions (32 states; 3 territories; and District of Columbia) (61%) had telemedicine policies with language referencing consultation, diagnosis, or treatment; 29 (49%) referenced consultation, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment. In all, 26 jurisdictions (22 states; 3 territories; and District of Columbia) (44%), referenced all topics. Only 3 jurisdictions (3 states; 0 territories) (5%), had policy language specifically addressing perinatal care. CONCLUSION: The majority of states have published telemedicine policies, but few specify policy language for perinatal risk-appropriate care. By ensuring that language specific to the perinatal population is included in telemedicine policies, access to maternal and neonatal care can be increased in rural, remote, and resource-challenged jurisdictions.

Examining Privacy Regulatory Frameworks in Canada in the Context of HIV.

In the process of receiving perinatal care, women living with HIV (WLWH) in Canada have experienced disclosure of their HIV status without their express consent. This disclosure often occurs by well-intentioned healthcare providers; however, from the perspective of WLWH, it is a breach of confidentiality and leaves WLWH to manage the consequences. This paper is a critical review of the regulatory and legislative infrastructure that exists to protect the personal health information of WLWH in Ontario and Canada; the recourse that WLWH have in the event that their confidentiality is breached; and potential approaches that could be applied to organize the system differently to decrease the chance of a privacy breach and to facilitate appropriate collection, use and disclosure of personal health information.

United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement.

OBJECTIVE: Summarize policies that support maternal and neonatal transport among states and territories. STUDY DESIGN: Systematic review of publicly available, web-based information on maternal and neonatal transport for each state and territory in 2014. Information was abstracted from published rules, statutes, regulations, planning documents and program descriptions. Abstracted information was summarized within two categories: transport and reimbursement. RESULTS: Sixty-eight percent of states and 25% of territories had a policy for neonatal transport; 60% of states and one territory had a policy for maternal transport. Sixty-two percent of states had a reimbursement policy for neonatal transport, whereas 20% reimbursed for maternal transport. Thirty-two percent of states had an infant back-transport policy while 16% included back-transport for both. No territories had reimbursement or back-transport policies. CONCLUSION: The lack of development of maternal transport reimbursement and neonatal back-transport policies negatively impacts the achievements of risk-appropriate care, a strategy focused on improving perinatal outcomes.

Linking Medicaid Expansion and Cuts to Disproportionate-Share Hospitals: Will Safety Nets Survive?

The predominant mechanism by which the health care reforms of the Patient Protection and Affordable Care Act of 2010 are to be financed is through the government's simultaneous defunding of major portions of Medicare and Medicaid, including the reduction of up to 75% of federal payments to disproportionate-share hospitals. The justification for curtailment of other public programs is that after Medicaid expansion under the Affordable Care Act, the decrease in the proportion of uninsured among the U.S. population will render disproportionate-share hospital payments extraneous and unnecessary. Such justification was reiterated in the recent American College of Obstetricians and Gynecologists Committee Opinion No. 627, entitled Health Care for Unauthorized Immigrants. Herein, the soundness of the Committee Opinion's proposed policy is evaluated by reviewing available literature on the potential effect of Medicaid disproportionate-share hospital cuts with and without concomitant Medicaid expansion. Limitations of Medicaid expansion efforts before and under the Affordable Care Act, the disproportionate-share hospital payment program, and other legislation providing safety net hospitals with (some) relief of financial burdens related to uncompensated care are explicated. Findings raise concern that acceptance of cuts of up to 75% of federal disproportionate-share hospital funds on the premise that nationwide state expansion of Medicaid will offset the difference may be overly optimistic. Indeed, foregoing disproportionate-share hospital payments undercuts the otherwise laudable intent of Committee Opinion No. 627, namely to advocate for universal health care for all women, including undocumented immigrants.

Improving Medicaid: three decades of change to better serve women of childbearing age.

Over the past 3 decades, major changes enhanced Medicaid's role in improving the health of women and perinatal outcomes. Reforms in the 1980s and 1990s had impact not only on coverage but also on current policy debates. Whether or not states expand eligibility under the Affordable Care Act, Medicaid is important. Increased coverage for well-woman visits, preconception care, and contraceptive methods are opportunities in gynecology. As a critical source of maternity coverage, Medicaid can improve prenatal care, reduce preterm births, limit early elective deliveries, and increase postpartum visits. Obstetrician-gynecologists play a role in translating coverage into access to quality services.

From home deliveries to health care facilities: establishing a traditional birth attendant referral program in Kenya.

OBJECTIVE: To assess the effectiveness of a traditional birth attendant (TBA) referral program on increasing the number of deliveries overseen by skilled birth attendants (SBA) in rural Kenyan health facilities before and after the implementation of a free maternity care policy. METHODS: In a rural region of Kenya, TBAs were recruited to educate pregnant women about the importance of delivering in healthcare facilities and were offered a stipend for every pregnant woman whom they brought to the healthcare facility. We evaluated the percentage of prenatal care (PNC) patients who delivered at the intervention site compared with the percentage of PNC patients who delivered at rural control facilities, before and after the referral program was implemented, and before and after the Kenya government implemented a policy of free maternity care. The window period of the study was from July of 2011 through September 2013, with a TBA referral intervention conducted from March to September 2013. RESULTS: The absolute increases from the pre-intervention period to the TBA referral intervention period in SBA deliveries were 5.7 and 24.0% in the control and intervention groups, respectively (p < 0.001). The absolute increases in SBA delivery rates from the pre-intervention period to the intervention period before the implementation of the free maternity care policy were 4.7 and 17.2% in the control and intervention groups, respectively (p < 0.001). After the policy implementation the absolute increases from pre-intervention to post-intervention were 1.8 and 11.6% in the control and intervention groups, respectively (p < 0.001). CONCLUSION: The percentage of SBA deliveries at the intervention health facility significantly increased compared to control health facilities when TBAs educated women about the need to deliver with a SBA and when TBAs received a stipend for bringing women to local health facilities to deliver. Furthermore, this TBA referral program proved to be far more effective in the target region of Kenya than a policy change to provide free obstetric care.