The role of pandemic-related pregnancy stress in preference for community birth during the beginning of the COVID-19 pandemic in the United States.

BACKGROUND: The COVID-19 pandemic introduced unparalleled uncertainty into the lives of pregnant women, including concerns about where it is the safest to give birth, while preserving their rights and wishes. Reports on the increased interest in community births (at home or in birth centers) are emerging. The purpose of this project was to quantitatively investigate psychological factors related to this birth preference. METHODS: This study included 3896 pregnant women from the COVID-19 Pregnancy Experiences (COPE) Study who were anticipating a vaginal birth. COPE Study participants were recruited online between April 24 and May 15, 2020, and completed a questionnaire that included preference with respect to place of birth and psychological constructs: fear of childbirth, basic beliefs about birth, pandemic-related preparedness stress, and pandemic-related perinatal infection stress. RESULTS: Women who preferred a community birth, on average, had less childbirth fear, had stronger beliefs that birth is a natural process, were less likely to see birth as a medical process, and were less stressed about being unprepared for birth and being infected with COVID-19. In multivariate models, higher stress about perinatal COVID-19 infection was associated with greater likelihood of preferring a community birth. The effect of perinatal infection stress on preference was stronger when preparedness stress was high. DISCUSSION: Women's birth preferences during the COVID-19 pandemic are associated with psychological processes related to risk perception. Community births are more appealing to women who view being in a hospital as hazardous because of the pandemic. Policies and prenatal care aimed to increase access to safe in-hospital and out-of-hospital birth services should be encouraged.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era.

BACKGROUND: COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers. METHODS: A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers. RESULTS: If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births. CONCLUSIONS: Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

The "Cocoon," first alongside midwifery-led unit within a Belgian hospital: Comparison of the maternal and neonatal outcomes with the standard obstetric unit over 2 years.

OBJECTIVES: Our aim was to compare maternal and neonatal outcomes of women with a low-risk pregnancy attending the "Cocoon," an alongside midwifery-led birth center and care pathway, with women with a low-risk pregnancy attending the traditional care pathway in a tertiary care hospital in Belgium. METHODS: We performed a retrospective cohort study of maternal and neonatal outcomes of women with a low-risk pregnancy who chose to adhere to the Cocoon pathway of care (n = 590) and women with a low-risk pregnancy who chose the traditional pathway of care (n = 394) from March 1, 2014, to February 29, 2016. We performed all analyses using an intention-to-treat approach. RESULTS: In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25-0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30-0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09-0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17-0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively. CONCLUSIONS: Women planning their births in the midwifery-led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery-led care pathways in other hospitals in Belgium.

The Availability of Emergency Obstetric Care in Birthing Centres in Rural Nepal: A Cross-sectional Survey.

OBJECTIVE: The purpose of this health system's study is to assess the availability of Emergency Obstetric Care (EmOC) services in birthing centres in Taplejung District of eastern Nepal. METHODS: A cross-sectional survey was conducted in 2018 in all 16 public health facilities providing delivery services in the district. Data collection comprised: (1) quantitative data collected from health workers; (2) observation of key items; and (3) record data extracted from the health facility register. Descriptive statistics were used to calculate readiness scores using unweighted averages. RESULTS: Although key health personnel were available, EmOC services at the health facilities assessed were below the minimum coverage level recommended by the World Health Organisation. Only the district hospital provided the nine signal functions of Comprehensive EmOC. The other fifteen had only partially functioning Basic EmOC facilities, as they did not provide all of the seven signal functions. The essential equipment for performing certain EmOC functions was either missing or not functional in these health facilities. CONCLUSIONS FOR PRACTICE: The Ministry of Health and Population and the federal government need to ensure that the full range of signal functions are available for safe deliveries in partially functioning EmOC health facilities by addressing the issues related to training, equipment, medicine, commodities and policy.

Access and outcomes of general practitioner obstetrician (rural generalist)-supported birthing units in Queensland.

OBJECTIVE: To describe characteristics and outcomes of women birthing within GP-obstetrician (rural generalist) supported rural (level 3) obstetric units in Queensland. DESIGN: Retrospective descriptive study. SETTING: 21 GP-obstetrician supported birthing units in Queensland. PARTICIPANTS: Women (n = 3111) birthing from January 2017 to December 2017. MAIN OUTCOME MEASURES: Patient, pregnancy and labour characteristics and key maternal and neonatal outcomes routinely recorded in the Queensland Perinatal Data Collection and Queensland Hospital Admitted Patient Data Collection were compared to Queensland public hospital aggregate data. RESULTS: Women birthing in rural maternity units were significantly more likely to be Aboriginal or Torrs Strait Islander (16% v 9%), < 20 years old (7% v 4%), term deliveries (96% v 91%), achieve spontaneous onset of labour (67% v 51%), and birth (71% v 60%) (p<0.001) compared with all Queensland public hospitals. They were significantly less likely to be nulliparous (36% v 40%), use pharmacological analgesia (65% v 69%), or have continuous electronic fetal monitoring in labour (54% v 66%) (p<0.001). Neonatal outcomes were comparable; with no significant difference in stillbirth rate between rural units and all Queensland public hospitals (4.8 v 7.3 per 1000 births). Precipitate delivery was the most common labour complication (36% v 33%) (p<0.001). CONCLUSION: GP-obstetrician (rural generalist) supported rural birthing units in Queensland provide important access for low and medium risk women to deliver locally, with strong indicators of quality and safety.

The influence of the introduction of national guidelines on preterm birth prevention practice: UK experience.

OBJECTIVE: To identify the current status of specialist preterm labour (PTL) clinics and identify changes in management trends over the last 5 years following release of the NICE preterm birth (PTB) guidance. DESIGN: Postal Survey of Clinical Practice. SETTING: UK. POPULATION: All consultant-led obstetric units. METHODS: A questionnaire was sent by post to all 187 NHS consultant-led obstetric units. Units with a specialist PTL clinic were asked to answer a further six questions defining their protocol for risk stratification and management. MAIN OUTCOME MEASURES: Current practice in specialist PTL clinics. Changes in treatment trends over 5 years. RESULTS: Thirty-three PTL prevention clinics were identified, with 73% running weekly. NHS staff (84%) have replaced university staff as the lead clinicians (from 69% in 2012 to 21% in 2017), suggesting this clinic has become increasingly integrated with standard care for women at the highest risk of PTB. There has been a large shift from nearly half of clinics offering cerclage as primary treatment for short cervix to offering more choice (30%) between at least two of cerclage, vaginal progesterone or pessary and combinations of primary treatments (18%), demonstrating more equipoise among clinicians regarding therapies for short cervix. CONCLUSIONS: Over 5 years, there has been a 44% increase in the number of specialist PTL clinics in the UK. Although there is a better consensus over the target high-risk population, there is increasing heterogeneity among first-line treatments for short cervix. TWEETABLE ABSTRACT: UK PTB prevention clinics have increased by 44% over 5 years, with increasing clinical equipoise to best Rx for short cervix.

Using a Birth Center Model of Care to Improve Reproductive Outcomes in Informal Settlements-a Case Study.

The world is becoming increasingly urban. For the first time in history, more than 50% of human beings live in cities (United Nations, Department of Economic and Social Affairs, Population Division, ed. (2015)). Rapid urbanization is often chaotic and unstructured, leading to the formation of informal settlements or slums. Informal settlements are frequently located in environmentally hazardous areas and typically lack adequate sanitation and clean water, leading to poor health outcomes for residents. In these difficult circumstances women and children fair the worst, and reproductive outcomes for women living in informal settlements are grim. Insufficient uptake of antenatal care, lack of skilled birth attendants and poor-quality care contribute to maternal mortality rates in informal settlements that far outpace wealthier urban neighborhoods (Chant and McIlwaine (2016)). In response, a birth center model of maternity care is proposed for informal settlements. Birth centers have been shown to provide high quality, respectful, culturally appropriate care in high resource settings (Stapleton et al. J Midwifery Women's Health 58(1):3-14, 2013; Hodnett et al. Cochrane Database Syst Rev CD000012, 2012; Brocklehurst et al. BMJ 343:d7400, 2011). In this paper, three case studies are described that support the use of this model in low resource, urban settings.

Is the place of birth related to the mother's satisfaction with childbirth? A cross-sectional study in a rural district of the Lao People's Democratic Republic (Lao PDR).

BACKGROUND: The place of birth has been rapidly changing from home to health facility in Lao People's Democratic Republic (Lao PDR) following the strategy to improve the maternal and neonatal mortality. This change in the place of birth might affect the mother's satisfaction with childbirth. The objective of this study was to assess whether the place of birth is related to the mother's satisfaction with childbirth in a rural district of the Lao PDR. METHODS: A community-based survey was implemented in 21 randomly selected hamlets in Xepon district, Savannakhet province, between February and March, 2016. Questionnaire-based interviews were conducted with mothers who experienced a normal vaginal birth in the past 2 years. Satisfaction with childbirth was measured by the Satisfaction with Childbirth Experience Questionnaire. Using the median, the outcome variable was dichotomized into "high satisfaction group" and "low satisfaction group". Logistic regression was performed to assess the association between place of birth and satisfaction with childbirth. Three models were examined: In Model 1, only the predictor of interest (i.e., place of birth) was included. In Model 2, the predictor of interest and the obstetrical predictors were included. In Model 3, in addition to these predictors, socio-demographic and economic predictors were included. A mixed-effects model was used to account for the hierarchical structure. RESULTS: Among the 226 mothers who were included in data analysis, 60.2% gave birth at the health facility and the remaining 39.8% gave birth at home. Logistic regression analysis showed that the mothers who gave birth at the health facility were significantly more likely to have a higher level of satisfaction compared to the mothers who gave birth at home (crude odds ratio: 5.44, 95% confidence interval: 3.03 to 9.75). This association remained even after adjusting for other predictors (adjusted odds ratio: 6.05, 95% confidence interval: 2.81 to 13.03). CONCLUSION: Facility-based birth was significantly associated with a higher level of satisfaction with childbirth among the mothers in the study district where maternal and neonatal mortalities are relatively high. The findings of the present study support the promotion of facility-based birth in a rural district of the Lao PDR.

Short- and Long-Term Outcomes of Extremely Preterm Infants in Japan According to Outborn/Inborn Birth Status.

OBJECTIVES: Outborn (born outside tertiary centers) infants, especially extremely preterm infants, are at an increased risk of mortality and morbidity in comparison to inborn (born in tertiary centers) infants. Extremely preterm infants require not only skilled neonatal healthcare providers but also highly specialized equipment and environment surroundings. Maternal transport at an appropriate timing must be done to avoid the delivery of extremely preterm infants in a facility without the necessary capabilities. Cases of unexpected deliveries at birth centers or level I maternity hospitals need to be attended emergently. We compared the differences in short- and long-term outcomes between outborn and inborn infants to improve our regional perinatal system. DESIGN: Retrospective cohort study. SETTING: Neonatal Research Network of Japan database. PATIENTS: Extremely preterm infants (gestational age between 22 + 0 and 27 + 6 wk) in the Neonatal Research Network of Japan database between 2003 and 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 12,164 extremely preterm infants, who were divided into outborn (n = 785, 6.5%) and inborn (n = 11,379, 93.5%) groups, were analyzed. Significant differences were observed in demographic and clinical factors between the two groups. Outborn infants had higher short-term odds of severe intraventricular hemorrhage (adjusted odds ratio, 1.49; 95% CI, 1.11-2.00; p < 0.01), necrotizing enterocolitis (adjusted odds ratio, 1.49; 95% CI, 1.11-2.00; p < 0.01), and focal intestinal perforation (adjusted odds ratio, 1.58; 95% CI, 1.09-2.30; p = 0.02). There were no significant differences in long-term outcomes between the two groups, except in the rate of cognitive impairment (adjusted odds ratio, 1.49; 95% CI, 1.01-2.20; p = 0.04). CONCLUSIONS: The frequency of severe intraventricular hemorrhage, necrotizing enterocolitis or focal intestinal perforation, and cognitive impairment was significantly higher in outborn infants. Thus, outborn/inborn birth status may play a role in short- and long-term outcomes of extremely preterm infants. However, more data and evaluation of improvement in the current perinatal environment are needed.

Trends and state variations in out-of-hospital births in the United States, 2004-2017.

BACKGROUND: Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women's access to these births. METHODS: National birth certificate data from 2004 to 2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options. RESULTS: After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35 578 in 2004 to 62 228 in 2017. In 2017, 1 of every 62 births in the United States was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004 to 2017, whereas birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared with 1/3 of birth center and just 3% of hospital births, with large variations by state. CONCLUSIONS: Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlight the strong motivation of some women to choose out-of-hospital birth.

Severity and frequency of moral distress among midwives working in birth centers.

BACKGROUND: When individuals are aware of the appropriate ethical practice, but lack the ability to do it, they will suffer from moral distress. Moral distress is a frequent phenomenon in clinical practice which can have different effects on the performance of physicians, nurses, and midwives, and therefore patients and health care systems. RESEARCH OBJECTIVE: The present study aimed to determine the severity and frequency of moral distress in midwives working in birth centers. RESEARCH DESIGN: This study is a descriptive cross-sectional research. Researcher-made questionnaire was used to gather data. PARTICIPANTS AND RESEARCH CONTEXT: A total of 180 midwives working in the labor ward of the public birth centers affiliated to Shahid Beheshti University of Medical Sciences were included to the study by census. ETHICAL CONSIDERATIONS: Official permission for data collecting was obtained from the directors of the birth centers affiliated to Shahid Beheshti University of Medical Sciences. Then, after explaining the objectives of the study and assuring the confidentially of information, verbal consent of the participants was obtained. FINDINGS: The total mean ± standard deviation of the severity and frequency of moral distress were 3.85 ± 0.75 and 3.03 ± 0.48, respectively. The highest severity and the lowest frequency of moral distress were obtained for the assistance for abortion and the lowest severity of moral distress was related to the organizational domain. However, the highest frequency of moral distress was related to futile care field. The mean of moral distress severity in the midwives with associate degree was significantly lower than other levels of education. Also, there was a significant relationship between age and moral distress frequency (p = 0.010). DISCUSSION: The midwives' moral distress was relatively high as expected. This finding is consistent with the results of similar studies in intensive care unit nurses. CONCLUSION: After identifying the level and most important factors of moral distress among midwives, the next step is empower them to prevent moral distress, in particular efforts to change structures.

Predictors of breast milk substitute feeding among newborns in delivery facilities in urban Cambodia and Nepal.

Introducing breast milk substitutes (BMS) in the first days after birth can increase infant morbidity and reduce duration and exclusivity of breastfeeding. This study assessed determinants of BMS feeding among newborns in delivery facilities in Phnom Penh, Cambodia, and Kathmandu Valley, Nepal. Cross-sectional surveys were conducted among mothers upon discharge from health facilities after delivery: 304 mothers in Kathmandu Valley and 306 mothers in Phnom Penh participated. On the basis of a conceptual framework for prelacteal feeding, multivariable logistic regression was used to identify factors associated with BMS feeding prior to facility discharge. In both Phnom Penh and Kathmandu Valley, feeds of BMS were reported by over half of mothers (56.9% and 55.9%, respectively). Receiving a health professional's recommendation to use BMS increased the odds of BMS feeding in both Kathmandu Valley and Phnom Penh (odds ratio: 24.87; confidence interval [6.05, 102.29]; odds ratio: 2.42; CI [1.20, 4.91], respectively). In Kathmandu Valley, recommendations from friends/family and caesarean delivery were also associated with BMS use among mothers. Early initiation of breastfeeding and higher parity were protective against the use of BMS in Kathmandu Valley. Breastfeeding support from a health professional lowered the odds of BMS feeding among newborns. Exposure to BMS promotions outside the health system was prevalent in Phnom Penh (84.6%) and Kathmandu Valley (27.0%) but was not associated with BMS feeds among newborns. Establishment of successful breastfeeding should be prioritized before discharging mothers from delivery facilities, and health professionals should be equipped to support and encourage breastfeeding among all new mothers.

[Survey on follow-up of new born babies after the discharge from the birth centres of the Ligurian public hospitals]. / Studio descrittivo sul follow-up post-dimissione dei nati sani a termine nei centri nascita degli ospedali pubblici liguri.

INTRODUCTION: Continuity of care in the postpartum period is strongly recommended by international guidelines. Several studies demonstrate how an individualized follow-up program may decrease newborn's mortality and morbidity and prevent or early identify chronic diseases or diseases with long-term effects for mother, newborn and family. In Italy the lastest recommendations on postnatal care of mothers and newborns have been relea- sed in 2000. AIM: To describe the organization of healthy term newborns post-discharge follow-up in the 10 birth centers of Ligurian public hospitals. METHODS: Descriptive study, conducted in 2015 through telephonic interview with head nurses (or their delegates) of the centers. RESULTS: All 10 birth centers participated in the study recommend a follow-up visit, but only half have a formalized procedure for follow-up. Most of them recommend the first follow-up visit within 2-3 days from discharge. Half of centers provide the first follow-up visit at the birth center's clinic, three don't recommend follow-up visits after the first one. None of them links the follow-up visit of the newborn with the mother's one; usually the needs of mother and newborn are identified and met by pediatric nurses, nurses and neonatologist. All the centers provide a telephone number for post-discharge needs. Two centers make calls to mothers considered to be at risk of postpartum depression. DISCUSSION: The study describes different newborn care pathways related to follow-up after discharge in the Ligurian birth centers. At the moment there is no homogeneous implementation of the interventions recommended at national level.

Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births.

BACKGROUND: Research on outcomes of out-of-hospital breech birth is scarce. This study evaluates the outcomes of singleton term breech and cephalic births in a home or birth center setting. METHODS: This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity. RESULTS: 50 breech and 102 cephalic presentations were still in the obstetrician's care at the onset of labor; of those, 10 breech and 11 cephalic mothers required transport during labor. 76% of breech and 92.2% of cephalic births were planned to occur at home, with the remainder at a freestanding birth center. When compared to the cephalic group, the breech group had a higher rate of antepartum and in-labor transfer of care and cesarean section. Among completed out-of-hospital births, the breech group had a significantly higher rate of 1-min Apgar scores < 7 but no significant difference at 5 min. Rates of vaginal birth for both groups were high, with 84% of breech and 97.1% of cephalic mothers giving birth vaginally in this series. Compared to primiparas, multiparas in both groups had less perineal trauma and higher rates of out-of-hospital birth, vaginal birth, and spontaneous vaginal birth. No breech infant or mother required postpartum hospital transport, while one cephalic infant and one cephalic mother required postpartum transport. Of the babies born out-of-hospital, there was one short-term and one longer-term birth injury among the breech group and one short-term brachial plexus injury in the cephalic group. CONCLUSIONS: A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section-especially when there is no option of a hospital breech birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.

The perceptions and experiences of women who achieved and did not achieve a waterbirth.

BACKGROUND: There is a gap in knowledge and understanding relating to the experiences of women exposed to the opportunity of waterbirth. Our aim was to explore the perceptions and experiences of women who achieved or did not achieve their planned waterbirth. METHODS: An exploratory design using critical incident techniques was conducted between December 2015 and July 2016, in the birth centre of the tertiary public maternity hospital in Western Australia. Women were telephoned 6 weeks post birth. Demographic data included: age; education; parity; and previous birth mode. Women were also asked the following: what made you choose to plan a waterbirth?; what do you think contributed to you having (or not having) a waterbirth?; and which three words would you use to describe your birth experience? Frequency distributions and univariate comparisons were employed for quantitative data. Thematic analysis was undertaken to extract common themes from the interviews. RESULTS: A total of 31% (93 of 296) of women achieved a waterbirth and 69% (203 of 296) did not. Multiparous women were more likely to achieve a waterbirth (57% vs 32%; p < 0.001). Women who achieved a waterbirth were less likely to have planned a waterbirth for pain relief (38% vs 52%; p = 0.24). The primary reasons women gave for planning a waterbirth were: pain relief; they liked the idea; it was associated with a natural birth; it provided a relaxing environment; and it was recommended. Two fifths (40%) of women who achieved a waterbirth suggested support was the primary reason they achieved their waterbirth, with the midwife named as the primary support person by 34 of 37 women. Most (66%) women who did not achieve a waterbirth perceived this was because they experienced an obstetric complication. The words women used to describe their birth were coded as: affirming; distressing; enduring; natural; quick; empowering; and long. CONCLUSIONS: Immersion in water for birth facilitates a shift of focus from high risk obstetric-led care to low risk midwifery-led care. It also facilitates evidence based, respectful midwifery care which in turn optimises the potential for women to view their birthing experience through a positive lens.

Factors associated with intended use of a maternity waiting home in Southern Ethiopia: a community-based cross-sectional study.

BACKGROUND: Although Ethiopia is scaling up Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, women's use of MWHs varies markedly between facilities. To maximize MWH utilization, it is essential that policymakers are aware of supportive and inhibitory factors. This study had the objective to describe factors and perceived barriers associated with potential utilization of an MWH among recently delivered and pregnant women in Southern Ethiopia. METHODS: A community-based cross-sectional study was conducted between March and November 2014 among 428 recently delivered and pregnant women in the Eastern Gurage Zone, Southern Ethiopia, where an MWH was established for high-risk pregnant women to await onset of labour. The structured questionnaire contained questions regarding possible determinants and barriers. Logistic regression with 95% Confidence Intervals (CI) was used to examine association of selected variables with potential MWH use. RESULTS: While only thirty women (7.0%) had heard of MWHs prior to the study, 236 (55.1%), after being explained the concept, indicated that they intended to stay at such a structure in the future. The most important factors associated with intended MWH use in the bivariate analysis were a woman's education (secondary school or higher vs. no schooling: odds ratio [OR] 6.3 [95% CI 3.46 to 11.37]), her husband's education (secondary school or higher vs. no schooling: OR 5.4 [95% CI 3.21 to 9.06]) and envisioning relatively few barriers to MWH use (OR 0.32 [95% CI 0.25 to 0.39]). After adjusting for possible confounders, potential users had more frequently suffered complications in previous childbirths (adjusted odds ratio [aOR] 4.0 [95% CI 1.13 to 13.99]) and envisioned fewer barriers to MWH use (aOR 0.3 [95% CI 0.23 to 0.38]). Barriers to utilization included being away from the household (aOR 18.1 [95% CI 5.62 to 58.46]) and having children in the household cared for by the community during a woman's absence (aOR 9.3 [95% CI 2.67 to 32.65]). CONCLUSIONS: Most respondents had no knowledge about MWHs. Having had complications during past births and envisioning few barriers were factors found to be positively associated with intended MWH use. Unless community awareness of preventive maternity care increases and barriers for women to stay at MWHs are overcome, these facilities will continue to be underutilized, especially among marginalized women.

Experiences with and expectations of maternity waiting homes in Luapula Province, Zambia: a mixed-methods, cross-sectional study with women, community groups and stakeholders.

BACKGROUND: Luapula Province has the highest maternal mortality and one of the lowest facility-based births in Zambia. The distance to facilities limits facility-based births for women in rural areas. In 2013, the government incorporated maternity homes into the health system at the community level to increase facility-based births and reduce maternal mortality. To examine the experiences with maternity homes, formative research was undertaken in four districts of Luapula Province to assess women's and community's needs, use patterns, collaboration between maternity homes, facilities and communities, and promising practices and models in Central and Lusaka Provinces. METHODS: A cross-sectional, mixed-methods design was used. In Luapula Province, qualitative data were collected through 21 focus group discussions with 210 pregnant women, mothers, elderly women, and Safe Motherhood Action Groups (SMAGs) and 79 interviews with health workers, traditional leaders, couples and partner agency staff. Health facility assessment tools, service abstraction forms and registers from 17 facilities supplied quantitative data. Additional qualitative data were collected from 26 SMAGs and 10 health workers in Central and Lusaka Provinces to contextualise findings. Qualitative transcripts were analysed thematically using Atlas-ti. Quantitative data were analysed descriptively using Stata. RESULTS: Women who used maternity homes recognized the advantages of facility-based births. However, women and community groups requested better infrastructure, services, food, security, privacy, and transportation. SMAGs led the construction of maternity homes and advocated the benefits to women and communities in collaboration with health workers, but management responsibilities of the homes remained unassigned to SMAGs or staff. Community norms often influenced women's decisions to use maternity homes. Successful maternity homes in Central Province also relied on SMAGs for financial support, but the sustainability of these models was not certain. CONCLUSIONS: Women and communities in the selected facilities accept and value maternity homes. However, interventions are needed to address women's needs for better infrastructure, services, food, security, privacy and transportation. Strengthening relationships between the managers of the homes and their communities can serve as the foundation to meet the needs and expectations of pregnant women. Particular attention should be paid to ensuring that maternity homes meet quality standards and remain sustainable.

What are the risk factors associated with hospital birth among women planning to give birth in a birth center in Washington State?

BACKGROUND: Few studies have evaluated risk factors associated with hospital birth among women planning to give birth in a birth center in the United States. This study describes the obstetrical risk factors for hospital birth among women intending to deliver in a birth center in Washington State. METHODS: We performed a retrospective cohort study of Washington State birth certificate data for women with singleton, term pregnancies planning to give birth at a birth center from 2004 to 2011. We assessed risk factors for hospital birth including demographic, obstetrical, and medical characteristics. We used multivariable logistic regression to estimate the odds ratio (OR) and 95% confidence interval (CI) of the association between risk factors and hospital birth. RESULTS: Among the 7118 women planning to give birth at a birth center during the study period, 7% (N = 501) had a hospital birth, and 93% delivered at a birth center (N = 6617). The strongest risk factors for hospital transfer included nulliparity (OR 7.2 [95% CI 5.3-9.8]), maternal age >40 years (OR 3.7 [95% CI 2.1-6.7]), inadequate prenatal care (OR 3.7 [95% CI 2.7-5.0]), body mass index ≥30 (OR 2.1 [95% CI 1.6-3.0]), government health insurance (OR 9.3 [95% CI 5.0-17.1]), and hypertension (10.1 [95% CI 5.7-18.1]). Among nulliparous women, all of these demographic and obstetrical factors remained strongly associated with hospital birth. CONCLUSIONS: This information may be useful for counseling women who plan a birth center birth about the risk of hospital birth.

Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009.

BACKGROUND: Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women. METHODS: Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors. RESULTS: Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies. CONCLUSION: Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.

Infants born with critical CHD in Arizona and capacities of birth centres for screening and management.

OBJECTIVES: The aims of this study were to identify locations of births in Arizona with critical CHD, as well as to assess the current use of pulse-oximetry screening and capacities of birth centres to manage a positive screen. Study design Infants (n=487) with a potentially critical CHD were identified from the Arizona Department of Health Services from 2012 and 2013; charts were retrospectively reviewed. Diagnosis was confirmed using echocardiographies. ArcGIS was used to generate maps to visualise the location of treating facility and mother's residence. Birth centres were surveyed to assess screening practices and capacities to manage critical CHD in 2015. RESULTS: Of the 272 patients identified with critical CHD, 52% had been diagnosed prenatally. Patients travelled an average distance of 55.1 miles to their treating facility. Mortality was not related to prenatal diagnosis (p=0.30), living at a high elevation (p=0.82), or to distance travelled to the treating facility (p=0.68). Of 50 birth centres, 33 responded to the survey and all centres practiced critical CHD screening. A total of 25 centres could perform paediatric echocardiographies; 64% of these centres could digitally transmit echocardiograms. In all, 24 birth centres maintained access to prostaglandins. CONCLUSIONS: Pulse-oximetry screening in newborns is currently implemented in the majority of Arizona hospitals. Although most centres could perform initial management steps following a positive screen, access to paediatric cardiology services was limited. Patients with critical CHD sometimes travelled a great distance to treating facilities. Digital transmission of echocardiograms or tele-echocardiography would reduce the distance travelled for the management of a positive screen, decrease the financial burden of transportation, and expedite care for critically ill neonates.