Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action.

BACKGROUND: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Knowledge and use of the ICM global standards for midwifery education.

OBJECTIVE: To explore how the International Confederation of Midwives Global Standards for Midwifery Education are currently used and their influence, if any, on the development of education programs globally. Secondarily, to identify current challenges to midwifery education. DESIGN: Cross-sectional exploratory descriptive qualitative study using focus groups and one-on-one interviews to collect data about knowledge of and use of the Education Standards and participants perceived current challenges to midwifery education. Interviews conducted in English, Spanish, and French. SETTING AND PARTICIPANTS: Midwife educators, education directors, or regulators attending one of four national/international conferences or one-on-one interviews in person or via internet. Thematic analysis was employed using the Framework approach for data analysis. FINDINGS: There were 11 focus groups and 19 individual interviews involving 145 midwives from 61 countries. There was a general awareness of the Education Standards amongst the participants although knowledge about the specifics of the document was lacking. The Standards were mainly used as a reference and greater use was made when developing new educational programs. The Standards identified as most difficult to meet included: organization and administration of the program, ensuring that teachers were formally prepared as teachers, meeting targets for teacher to student ratios and that 50% of educational time took place in the clinical setting. Universally endorsed challenges to midwifery education were: 1) inability to accommodate the increase in curricular content without compromising prior content or lengthening programs; 2) insufficient resources including lack of classroom and clinical teachers; 3) medicalization of childbirth and health system changes limiting student exposure to the midwifery care model; 4) role conflict and competition for clinical experience with other health professionals. KEY CONCLUSIONS: The Education Standards need to be more widely disseminated and implemented. Stronger collaborations with clinical settings and government systems are required to solve the current challenges to midwifery education. IMPLICATION OF PRACTICE: Well-educated midwives can provide the majority of maternal and neonatal care, however it will require an investment in strengthening midwifery programs globally for this goal to be achieved.

Implementation of a programme to develop research projects in a school of midwifery in Santiago, Chile.

BACKGROUND: The acquisition of research skills by midwifery students is increasingly important especially for midwifery programmes in universities. Recently, universities in Chile have included the development of research skills in the majority of professional curricula for basic and post-basic degree programmes. The lack of research training is a limitation recognised and shared with other Latin American countries which prevents scientific and technological development. OBJECTIVES: To describe the process of implementation of a programme of research projects by midwifery students in a school in Chile and the results obtained, and the perceptions of students and teachers. RESULTS: 31 work groups were formed (92 students), who developed and implemented research projects in gynecology, public health and neonatology. Research was conducted at six public hospitals serving high risk populations, a private clinic, and nine family health centres. The average scores earned for the projects was a 5.7 (scale of 1-7). The students and teachers positively rated the experience of undertaking research. CONCLUSION: The development of research projects allows students to acquire competencies and confidence in their research skills. It is an experience that can be replicated in other countries supported by the commitment of the midwifery and university faculty and the training and motivation of a group of midwifery educators.

Exploring global recognition of quality midwifery education: Vision or fiction?

BACKGROUND: Midwifery education is the foundation for preparing competent midwives to provide a high standard of safe, evidence-based care for women and their newborns. Global competencies and standards for midwifery education have been defined as benchmarks for establishing quality midwifery education and practice worldwide. However, wide variations in type and nature of midwifery education programs exist. AIM: To explore and discuss the opportunities and challenges of a global quality assurance process as a strategy to promote quality midwifery education. DISCUSSION: Accreditation and recognition as two examples of quality assurance processes in education are discussed. A global recognition process, with its opportunities and challenges, is explored from the perspective of four illustrative case studies from Ireland, Kosovo, Latin America and Bangladesh. The discussion highlights that the establishment of a global recognition process may assist in promoting quality of midwifery education programs world-wide, but cannot take the place of formal national accreditation. In addition, a recognition process will not be feasible for many institutions without additional resources, such as financial support or competent evaluators. In order to achieve quality midwifery education through a global recognition process the authors present 5 Essential Challenges for Quality Midwifery Education. CONCLUSION: Quality midwifery education is vital for establishing a competent workforce, and improving maternal and newborn health. Defining a global recognition process could be instrumental in moving toward this goal, but dealing with the identified challenges will be essential.

Mantram Repetition With Homeless Women: A Pilot Study.

Women and families are the fastest growing segment of the homeless population. Negative attitudes of nurses toward homeless women are a major barrier to homeless women seeking health care. This cross-sectional, mixed-methods pilot study, conducted primarily by nurses, tested the Mantram Repetition Program for the first time with 29 homeless women. The Mantram Repetition Program is a spiritually based skills training that teaches mantram (sacred word) repetition as a cost-effective, personalized, portable, and focused strategy for reducing stress and improving well-being. For the cross-sectional, pretest-posttest design portion of the study, the hypothesis that at least half of the homeless women would repeat their mantram at least once a day was supported with 88% of the women repeating their mantram 1 week later. The qualitative portion of this study using phenomenology explored the women's thoughts on mantram week 2. Themes of mantram repetition, mantram benefits, and being cared for emerged. This groundbreaking, interventional, mixed-methods pilot study fills a gap in interventional homeless research.

Mantram Repetition Program Decreases Insomnia Among Homeless Women: A Pilot Study.

The current pre-/posttest pilot study recruited homeless women from "safe" car parks and transitional housing to evaluate the use of mantram in regard to insomnia. At baseline, study participants completed measures of cognitive function, depression, and the Insomnia Severity Index (ISI). In 40 minutes, women were taught three skills of the Mantram Repetition Program (MRP) in the natural environment: (a) silently repeating a mantram several times, several times per day; (b) repeating the mantram slowly every night before sleep; and (c) focusing full attention on the mantram during repetitions. One week later, participants completed a second ISI. Of the 29 women recruited, 83% completed 1-week follow up. After 1 week, 88% were using their mantram daily and one half were using it prior to sleep. Insomnia severity significantly decreased (p = 0.03), with a mean difference of 2.36 (SD = 4.75). The practice of MRP, an intervention that is portable and easy to teach, shows significant promise in decreasing insomnia in this unique population.

Midwives as primary care providers for women.

Midwives certified by the American Midwifery Certification Board (AMCB) are prepared to provide primary care to women from menarche across the lifespan and to well newborns to 28 days using consultation, collaboration, and referral to other providers as needed. The scope of midwifery in the United States did not always include primary care for women, although imprecise definitions of primary care make this difficult to study. The expansion of the scope of practice occurred in response to population needs and research on nurse-midwifery practice patterns. The scope of practice of midwifery is tied to educational standards through the regulation and licensure at the state level. Although the current scope of practice includes primary care for women, many certified nurse-midwives and certified midwives are unable to practice to the full extent of their education due to state-level licensure restrictions. We discuss the addition of primary care to midwifery and the current state of AMCB-certified midwives as primary care providers for women.

A midwifery-led in-hospital birth center within an academic medical center: successes and challenges.

The University of California San Diego Community Women's Health Program (CWHP) has emerged as a successful and sustainable coexistence model of women's healthcare. The cornerstone of this midwifery practice is California's only in-hospital birth center. Located within the medical center, this unique and physically separate birth center has been the site for more than 4000 births. With 10% cesarean delivery and 98% breast-feeding rates, it is an exceptional example of low-intervention care. Integrating this previously freestanding birth center into an academic center has brought trials of mistrust and ineffectual communication. Education, consistent leadership, and development of multidisciplinary guidelines aided in overcoming these challenges. This collaborative model provides a structure in which residents learn to be respectful consultants and appreciate differences in medical practice. The CWHP and its Birth Center illustrates that through persistence and flexibility a collaborative model of maternity services can flourish and not only positively influence new families but also future generations of providers.

Maternal nutrition and perinatal outcomes.

Diet and patterns of eating during pregnancy can affect perinatal outcomes through direct physiologic effects or by stressing the fetus in ways that permanently affect phenotype. Supplements are not a magic nutritional remedy, and evidence of profound benefit for most supplements remains inconclusive. However, research supports calcium supplements to decrease preeclampsia. Following a low glycemic, Mediterranean-type diet appears to improve ovulatory infertility, decrease preterm birth, and decrease the risk of gestational diabetes. Although women in the United States have adequate levels of most nutrients, subpopulations are low in vitamin D, folate, and iodine. Vitamin D has increasingly been shown to be important not only for bone health, but also for glucose regulation, immune function, and good uterine contractility in labor. To ensure adequate vitamin and micronutrient intake, especially of folate before conception, all reproductive age women should take a multivitamin daily. In pregnancy, health care providers need to assess women's diets, give them weight gain recommendations based on their body mass index measurement, and advise them to eat a Mediterranean diet rich in omega-3 fatty acids (ingested as low-mercury risk fatty fish or supplements), ingest adequate calcium, and achieve adequate vitamin D levels through sun exposure or supplements. Health care providers should continue to spend time on nutrition assessment and counseling.

Specialized care for women pregnant after bariatric surgery.

Growing numbers of women today will seek bariatric surgery before pregnancy. Protein-calorie malnutrition; hyperemesis; intestinal hernias; dumping syndrome; anemia; and deficiencies in calcium, folic acid, and vitamins B12, D, and K are all possible complications that can impact pregnancy. This article reviews the nutritional and pregnancy-related consequences of current surgical procedures and summarizes existing research showing positive and negative effects of weight-loss surgery on pregnancy outcomes. Practice-based clinical recommendations will help guide clinicians caring for the increasing number of women who become pregnant after having bariatric surgery.