Perinatal Mood and Anxiety Disorder and Reproductive Justice: Examining Unmet Needs for Mental Health and Social Services in a National Cohort.

Introduction: Perinatal Mood and Anxiety Disorders (PMADs) are the most common complications during the perinatal period. There is limited understanding of the gaps between need and provision of comprehensive health services for childbearing people, especially among racialized populations. Methods: The Giving Voice to Mothers Study (GVtM; n=2700), led by a multistakeholder, Steering Council, captured experiences of engaging with perinatal services, including access, respectful care, and health systems' responsiveness across the United States. A patient-designed survey included variables to assess relationships between race, care provider type (midwife or doctor), and needs for psychosocial health services. We calculated summary statistics and tested for significant differences across racialized groups, subsequently reporting odds ratios (ORs) for each group. Results: Among all respondents, 11% (n=274) reported unmet needs for social and mental health services. Indigenous women were three times as likely to have unmet needs for treatment for depression (OR [95% confidence interval, CI]: 3.1 [1.5-6.5]) or mental health counseling (OR [95% CI]: 2.8 [1.5-5.4]), followed by Black women (OR [95% CI]: 1.8 [1.2-2.8] and 2.4 [1.7-3.4]). Odds of postpartum screening for PMAD were significantly lower for Latina women (OR [95% CI]=0.6 [0.4-0.8]). Those with midwife providers were significantly more likely to report screening for anxiety or depression (OR [95% CI]=1.81 [1.45-2.23]) than those with physician providers. Discussion: We found significant unmet need for mental health screening and treatment in the United States. Our results confirm racial disparities in referrals to social services and highlight differences across provider types. We discuss barriers to the integration of assessments and interventions for PMAD into routine perinatal services. Implications: We propose incentivizing reimbursement schema for screening and treatment programs; for community-based organizations that provide mental health and social services; and for culture-centered midwife-led perinatal and birth centers. Addressing these gaps is essential to reproductive justice.

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator.

OBJECTIVE: To describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors. METHODS: We invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts. RESULTS: Among the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC. CONCLUSION: Our findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

"I was able to take it back": Seeking VBAC after experiencing dehumanizing maternity care in a primary cesarean.

In this article, we present findings from a qualitative narrative analysis that examined the pregnancy, primary cesarean, and subsequent birth experiences of women in the United States. Using a maximal variation sampling strategy, we recruited participants via social media and networking to participate in semistructured interviews. Twenty-five women from diverse backgrounds and geographic locations across the U.S. participated, eight self-identified as racialized and seventeen as non-Hispanic, White. Data were analyzed iteratively using Clandinin and Connelly's approach to Narrative Inquiry. Across their narratives, participants described their experiences of maternity care that were either generally negative (dehumanizing care) or positive (humanized care). They further described how their experiences of dehumanizing or humanized care impacted their decision-making for subsequent births, mental health, relationships with the healthcare system, early parenting birth satisfaction, and family planning. Findings suggest that regardless of ultimate mode of birth, what was most important to women was how they are treated by their maternity care team. We suggest practice changes that may improve the experience of maternity care for primary cesarean and subsequent births, especially among those made marginal by systems of oppression.

Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean.

OBJECTIVE: High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S. METHODS: Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother's Autonomy in Decision Making Scale; MADM). RESULTS: Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician. CONCLUSION: Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration.

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Transdisciplinary Imagination: Addressing Equity and Mistreatment in Perinatal Care.

Inequities in birth outcomes are linked to experiential and environmental exposures. There have been expanding and intersecting wicked problems of inequity, racism, and quality gaps in childbearing care during the pandemic. We describe how an intentional transdisciplinary process led to development of a novel knowledge exchange vehicle that can improve health equity in perinatal services. We introduce the Quality Perinatal Services Hub, an open access digital platform to disseminate evidence based guidance, enhance health systems accountability, and provide a two-way flow of information between communities and health systems on rights-based perinatal services. The QPS-Hub responds to both community and decision-makers' needs for information on respectful maternity care. The QPS-Hub is well poised to facilitate collaboration between policy makers, healthcare providers and patients, with particular focus on the needs of childbearing families in underserved and historically excluded communities.

The Impact of Culturally-Centered Care on Peripartum Experiences of Autonomy and Respect in Community Birth Centers: A Comparative Study.

OBJECTIVE: National studies report that birth center care is associated with reduced racial and ethnic disparities and reduced experiences of mistreatment. In the US, there are very few BIPOC-owned birth centers. This study examines the impact of culturally-centered care delivered at Roots, a Black-owned birth center, on the experience of client autonomy and respect. METHODS: To investigate if there was an association between experiences of autonomy and respect for Roots versus the national Giving Voice to Mothers (GVtM) participants, we applied Wilcoxon rank-sum tests for the overall sample and stratified by race. RESULTS: Among BIPOC clients in the national GVtM sample and the Roots sample, MADM and MORi scores were statistically higher for clients receiving culturally-centered care at Roots (MADM p < 0.001, MORi p = 0.011). No statistical significance was found in scores between BIPOC and white clients at Roots Birth Center, however there was a tighter range among BIPOC individuals receiving care at Roots showing less variance in their experience of care. CONCLUSIONS FOR PRACTICE: Our study confirms previous findings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturally-centered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners offering culturally-centered care.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries.

BACKGROUND: The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States. METHOD: We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system. RESULTS: The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems. CONCLUSIONS: The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

Reflecting on Equity in Perinatal Care During a Pandemic.

Growing discourse around maternity care during the pandemic offers an opportunity to reflect on how this crisis has amplified inequities in health care. We argue that policies upholding the rights of birthing people, and policies decreasing the risk of COVID-19 transmission are not mutually exclusive. The explicit lack of standardization of evidence-based maternity care, whether expressed in clinical protocols or institutional policy, has disproportionately impacted marginalized communities. If these factors remain unexamined, then it would seem that equity is not the priority, but retaining power and control is. We advocate for a comprehensive understanding of how this pandemic has revealed our deepest failures.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

BACKGROUND: Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study. METHODS: Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables. RESULTS: Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment. CONCLUSION: This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

Patient-led decision making: Measuring autonomy and respect in Canadian maternity care.

OBJECTIVE: The Changing Childbirth in British Columbia study explored women's preferences and experiences of maternity care, including women's role in decision-making. METHODS: Following content validation by community members, we administered a cross-sectional online survey exploring novel topics, including drivers for interventions, and experiences of autonomy, respect, or mistreatment during maternity care. Using the Mothers Autonomy in Decision-Making (MADM) scale as an outcome measure in a mixed-effects analysis, we examined differential experiences by socio-demographic and prenatal risk profile, type of care provider, interventions received, and nature of communication with care providers. RESULTS: A geographically representative sample of Canadian women (n = 2051) reported on 3400 pregnancies. Most women (95.2%) preferred to be the lead decision-maker during care. Patients of physicians had significantly lower autonomy (MADM) scores than midwifery clients as did women who felt pressured to accept interventions. Women who had a difference in opinion with their provider, and those who felt their provider seemed rushed reported the lowest MADM scores. CONCLUSION: Women's autonomy is significantly altered by model of maternity care, the nature of interactions with care providers, and women's ability for self-determination. PRACTICE IMPLICATIONS: If health professionals acquire skills in person-centred decision-making experience of autonomy among pregnant women may improve.

Reduced prevalence of small-for-gestational-age and preterm birth for women of low socioeconomic position: a population-based cohort study comparing antenatal midwifery and physician models of care.

OBJECTIVE: Our aim was to investigate if antenatal midwifery care was associated with lower odds of small-for-gestational-age (SGA) birth, preterm birth (PTB) or low birth weight (LBW) compared with general practitioner (GP) or obstetrician (OB) models of care for women of low socioeconomic position. SETTING: This population-level, retrospective cohort study used province-wide maternity, medical billing and demographic data from British Columbia, Canada. PARTICIPANTS: Our study included 57 872 pregnant women, with low socioeconomic position, who: were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, delivered between 2005 and 2012 and received medical insurance premium assistance. PRIMARY AND SECONDARY OUTCOME MEASURES: We report rates, adjusted ORs (aOR), and 95% CIs for the primary outcome, SGA birth (

Asking different questions: A call to action for research to improve the quality of care for every woman, every child.

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.

METHODS: Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race. RESULTS: MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state. CONCLUSION: The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Assessing quality of maternity care in Hungary: expert validation and testing of the mother-centered prenatal care (MCPC) survey instrument.

BACKGROUND: Instruments to assess quality of maternity care in Central and Eastern European (CEE) region are scarce, despite reports of poor doctor-patient communication, non-evidence-based care, and informal cash payments. We validated and tested an online questionnaire to study maternity care experiences among Hungarian women. METHODS: Following literature review, we collated validated items and scales from two previous English-language surveys and adapted them to the Hungarian context. An expert panel assessed items for clarity and relevance on a 4-point ordinal scale. We calculated item-level Content Validation Index (CVI) scores. We designed 9 new items concerning informal cash payments, as well as 7 new "model of care" categories based on mode of payment. The final questionnaire (N = 111 items) was tested in two samples of Hungarian women, representative (N = 600) and convenience (N = 657). We conducted bivariate analysis and thematic analysis of open-ended responses. RESULTS: Experts rated pre-existing English-language items as clear and relevant to Hungarian women's maternity care experiences with an average CVI for included questions of 0.97. Significant differences emerged across the model of care categories in terms of informal payments, informed consent practices, and women's perceptions of autonomy. Thematic analysis (N = 1015) of women's responses identified 13 priority areas of the maternity care experience, 9 of which were addressed by the questionnaire. CONCLUSIONS: We developed and validated a comprehensive questionnaire that can be used to evaluate respectful maternity care, evidence-based practice, and informal cash payments in CEE region and beyond.

Informal cash payments for birth in Hungary: Are women paying to secure a known provider, respect, or quality of care?

BACKGROUND: In Central and Eastern Europe, many women make informal cash payments to ensure continuity of provider, i.e., to have a "chosen" doctor who provided their prenatal care, be present for birth. High rates of obstetric interventions and disrespectful maternity care are also common to the region. No previous study has examined the associations among informal payments, intervention rates, and quality of maternity care. METHODS: We distributed an online cross-sectional survey in 2014 to a nationally representative sample of Hungarian internet-using women (N = 600) who had given birth in the last 5 years. The survey included items related to socio-demographics, type of provider, obstetric interventions, and experiences of care. Women reported if they paid informally, and how much. We built a two-part model, where a bivariate probit model was used to estimate conditional probabilities of women paying informally, and a GLM model to explore the amount of payments. We calculated marginal effects of the covariates (provider choice, interventions, respectful care). RESULTS: Many more women (79%) with a chosen doctor paid informally (191 euros on average) compared to 17% of women without a chosen doctor (86 euros). Based on regression analysis, the chosen doctor's presence at birth was the principal determinant of payment. Intervention and procedure rates were significantly higher for women with a chosen doctor versus without (cesareans 45% vs. 33%; inductions 32% vs. 19%; episiotomy 75% vs. 62%; epidural 13% vs. 5%), but had no direct effect on payments. Half of the sample (42% with a chosen doctor, 62% without) reported some form of disrespectful care, but this did not reduce payments. CONCLUSION: Despite reporting disrespect and higher rates of interventions, women rewarded the presence of a chosen doctor with informal payments. They may be unaware of evidence-based standards, and trust that their chosen doctor provided high quality maternity care.