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.

How to Foster Effective Midwife-Obstetrician Collaboration on Labor and Birth Units: Qualitative Analysis of Experiences of Clinicians in the United States.

INTRODUCTION: Effective collaboration between midwives and obstetricians on labor and birth units in hospitals has been shown to improve birth outcomes and quality of care. Guidelines for collaborative care in the United States exist; however, studies describing the actual lived experiences of midwives and obstetricians in collaborative practice are lacking. The goal of this study was to explore the experiences and perspectives of midwives and obstetricians working in collaborative practices on labor and birth units across the United States and to identify strategies that foster effective collaboration between them. METHODS: We performed qualitative analyses of open-ended comments obtained in an instrument validation survey assessing collaboration between midwives and obstetricians on labor and birth in the United States. Certified nurse-midwives, certified midwives, attending general obstetricians, maternal-fetal medicine attending physicians, and fellows across the United States were included in this study, herein called midwives and obstetricians. The final sample in the original validation survey included 232 midwives and 471 obstetricians (n = 703). Of these, 79 midwives and 132 obstetricians (n = 211) provided narrative comments on their perspectives and experiences with collaborative practice on labor and birth units in the United States. The narrative comments were analyzed using inductive techniques derived from grounded theory. RESULTS: Four themes around how to foster effective collaboration were identified: (1) developing trust and respect, (2) promoting effective communication, (3) individual variability and need for clear guidelines, and (4) balancing autonomy. The midwives and obstetricians shared lived experiences that they perceived affected their work satisfaction and clinical outcomes in collaborative practices. DISCUSSION: These findings hold potential to inform clinicians and health care leaders on ways to foster effective collaboration between midwives and obstetricians on labor and birth units. This in turn can improve quality of care for birthing persons, perinatal outcomes and clinician job satisfaction.

Reflections on obesity-related health behaviors over time and suggestions for health promotion programs from African American women.

African American (AA) women have the highest rate of obesity in the United States. To date, there are mixed findings on AA women's perception on obesity and their perceived changes in health behaviors over time that may have contributed to obesity. Therefore, the aims of this current qualitative descriptive study were to explore: 1) AA women's perception on obesity and perceived changes in health behaviors related to obesity through their reflection on life; 2) AA women's perceived facilitators and barriers to maintaining healthy behaviors; and 3) AA women's suggestions for future health promotion programs to manage obesity. Semi-structured interviews with ended questions were conducted with 21 AA women. Luborsky's method for thematic analysis was used to analyze data. Three main themes with subthemes were identified. First main theme was the AA culture that served as a facilitator and barrier to maintaining healthy lifestyle from childhood to young adulthood. Second main theme was gradual changes in their healthy lifestyle due to social and physical environment from young adulthood to middle adulthood. Third main theme was AA women's various suggestions for future health promotion programs. This study found obesity to be a multifactorial phenomenon that is a result of complex interaction of culture, environment, and social networks. Therefore, clinicians need to address the issue of obesity from a holistic perspective for AA women to actively engage with their primary health care. Future health promotion programs should incorporate culturally tailored lifestyle components and increase knowledge on healthy lifestyle against obesity through community-based programs.

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.

A qualitative study of midwives' perceptions on using video-calling in early labor.

BACKGROUND: Decisions made in early labor influence the outcomes of childbirth for women and infants. Telephone assessment during labor, the current norm in many settings, has been found to be a source of dissatisfaction for women and can present challenges for midwives. The aim of this qualitative study was to explore midwives' views on the potential of video-calling as a method for assessing women in early labor. METHODS: A series of 8 midwife focus groups (n = 45) and interviews (n = 4) in the Midlands region of England and the mid-South and Northeast regions of the United States were completed. Audio recordings were transcribed verbatim and coded using content analysis. Coding diagrams were used to help develop major themes in the data. RESULTS: Midwives were generally positive about the potential of video-calling in early labor and using visual cues to make more accurate assessments and to enhance trust. Some midwives expressed concerns about privacy, both for themselves and for women, and issues of accessibility. They suggested strategies for implementation and further research, such as the need for a private space in birth facilities and training for both staff and service users. CONCLUSIONS: Video-calling was seen as a viable option for assessment of women in early labor with some particular challenges related to implementation. This research focused on midwives' views; the views of women and their families should also be considered. There is a lack of evidence on the clinical and cost effectiveness of video-calling in maternity care and further research is warranted.

United States Model Midwifery Legislation and Regulation: Development of a Consensus Document.

INTRODUCTION: Midwifery is defined and regulated across all 50 United States. However, states' regulations vary markedly, creating confusion for policy makers and consumers, and can limit services to women. In 2011, the International Confederation of Midwives released Global Standards for Midwifery Education, Regulation, and Association, providing guidance for international midwifery for the first time. US organizations representing midwifery education, regulation, and professional associations (US MERA) agreed to work together on common goals. METHODS: The purpose of this modified Delphi study, conducted by US MERA, was to develop a consensus document on principles of model US midwifery legislation and regulation. Expert panelists (N = 51) across maternal and child health care professions and consumer groups participated over several iterative rounds. RESULTS: The final document establishes guiding principles for US midwifery regulation, including regulatory authority, education, qualifications, regulation, registration and licensure, standards of practice and conduct, complaints, and third-party payment for services. DISCUSSION: As more US states recognize and license midwives of all credentials and in every practice setting, we can envision a time when equity, informed choice, safety, and seamless access to quality midwifery care will be the right of every birthing family.

Spiritual Healing Practices Among Rural Postpartum Thai Women.

PURPOSE: Postpartum Thai women follow family instructions to recover health at home. This study explores first-time mothers' experiences with postpartum family practices. This article presents the experiences with spiritual healing, one of the three essences of Thai traditional medicine. DESIGN: An interpretive phenomenological study was conducted in rural Thailand. Participants were 16 pregnant women purposively recruited. Data were collected using in-depth interviews, participant observations, and a demographic record and were analyzed using thematic and exemplar analysis. RESULTS: The women adhered to practices and rituals related to beliefs about three essences (the body, mind-heart, and energy). Spiritual healing works on mind-heart essences. CONCLUSION: A new mother healed her spirit through traditional postpartum practices. The findings provide an understanding of the practices within the context of rural Thai women's families. This information can guide future implementation of postpartum care, with awareness of and respect for cultural practices in fulfilling spiritual needs.

The development of a consensus statement on normal physiologic birth: a modified Delphi study.

INTRODUCTION: This article describes the process of developing consensus on a definition of, and best practices for, normal physiologic birth in the United States. Evidence supports the use of physiologic birth practices, yet a working definition of this term has been elusive. METHODS: We began by convening a task force of 21 individuals from 3 midwifery organizations and various childbirth advocacy and consumer groups. A modified Delphi approach was utilized to achieve consensus around 2 research questions: 1) What is normal physiologic birth? and 2) What practices most effectively support its achievement? Answers to these questions were collected anonymously from task force members during multiple phases that included a preliminary briefing, an initial face-to-face roundtable, 9 iterative Delphi rounds, and reciprocal feedback from a wider audience of stakeholders at national and international conferences. Content analysis identified specific statements and concepts in the first Delphi round, which were subsequently ranked in following rounds. An initial draft was constructed based on the priorities that emerged and presented for feedback to peers and childbirth advocates whose comments were incorporated into the final document. RESULTS: Four key themes were identified from our initial questions; these provided the framework for the document: 1) definitions of normal physiologic birth, 2) mechanisms and outcomes of normal physiologic birth, 3) factors that influence normal physiologic birth, and 4) recommendations for increasing normal physiologic birth. These areas comprised the final sections in the multi-organizational consensus statement. DISCUSSION: The modified Delphi approach we employed allowed for the development of a consensus statement that will serve as a template for education, practice, and future research in maternity care. The completion of this statement marks the beginning of a project to promote systemic changes that support normal physiologic birth, and thus, have the potential to improve outcomes for mothers and infants.

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care.

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Improvement of maternal and newborn health through midwifery.

In the concluding paper of this Series about midwifery, we look at the policy implications from the framework for quality maternal and newborn care, the potential effect of life-saving interventions that fall within the scope of practice of midwives, and the historic sequence of health system changes that made a reduction in maternal mortality possible in countries that have expanded their midwifery workforce. Achievement of better health outcomes for women and newborn infants is possible, but needs improvements in the quality of reproductive, maternal, and newborn care, alongside necessary increases in universal coverage. In this report, we propose three priority research areas and outline how national investment in midwives and in their work environment, education, regulation, and management can improve quality of care. Midwifery and midwives are crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health; now and beyond 2015.

Responding to a crying infant - you do not learn it overnight: a phenomenological study.

OBJECTIVE: to examine the views and practices of first-time and experienced mothers in response to infant crying during the first 12 weeks post birth. DESIGN: longitudinal, qualitative study using an interpretive, phenomenological approach. SETTING: postnatal hospital and home settings in Switzerland. PARTICIPANTS: maximum variation sampling of 15 new mothers of diverse parity and educational background who had given birth to a full-term healthy neonate. METHODS: participant observations in the postnatal ward and two narrative interviews at participants' homes at 6-8 and 12-14 weeks post partum. Data analysis used interpretive approaches of case analysis, thematic analysis and exemplars. FINDINGS: first-time mothers showed some soothing skills from the beginning, but fine-tuned their practices of handling the crying infant and managing their own reactions. With growing experience mothers acquired a differentiated understanding of the crying's reason and urgency and used more successful soothing techniques. At the same time they learned to assess and mitigate their own stress reactions by self-soothing and adopting realistic expectations of normal infant behaviour. Experienced mothers knew the infant's frequent crying would diminish after a while whereas first-time mothers coped without this positive expectation. KEY CONCLUSIONS: with increasing child-care experience mothers' skills and attitudes towards crying changed, leading to a calmer and less escalating response to their crying infant. IMPLICATIONS FOR PRACTICE: inexperienced mothers need information on neonatal crying behaviour and on parents' stress response. They should be taught how to recognise and respond to the new-born's signals, and how to cope with their own stress. Postnatal care should provide novice mothers to learn from experienced role models.

Confronting safety gaps across labor and delivery teams.

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.

Elective caesarean delivery: a mixed method qualitative investigation.

BACKGROUND: the rates of primary, repeat, and elective caesarean deliveries have risen dramatically over the past several decades. The reasons for the rise are complex and likely reflect a cultural shift to a greater acceptance of surgical birth as a reasonable option, which may favour infant over maternal outcomes. The purpose of this interpretive qualitative study was to explore the complexities of women's and clinicians' choices around elective caesarean delivery. METHOD: this analysis was part of an institutional ethnography to understand the complex issues of childbearing care. Two English National Health Service Maternity Service Providers in an inner city setting were chosen for their reputation for commitment to normalising birth and decreasing caesarean birth rate. A sample of 27 women and 34 clinicians (midwifery, obstetric, anaesthesia) were interviewed and/or observed in practice settings. We also conducted a documentary analysis of local policy guidelines on elective caesarean delivery. Narrative analysis was conducted on interview, field observation, and document review data. Coding was conducted by three independent analysts and checked for consistency using Atlas.ti qualitative software. RESULTS: variations on elective caesarean choice and outcomes seemed to reflect how the team worked together and their underlying philosophies and commitments about caesarean birth. Four themes reflected the issues around elective caesarean birth: (1) the culture of caesarean, (2) caesarean counseling, (3) perceptions of choice and (4) negotiating the rules. CONCLUSIONS: counselling about elective caesarean and vaginal birth after a prior caesarean is complex and reflects an intersection of culture and science. Women and clinicians enter the discussion with different backgrounds and concerns, but ultimately want the best outcome possible. Future exploration should address shared decision-making, evidence-based clinical guidelines, and the social context of care.

In a hard spot: providing group prenatal care in two urban clinics.

OBJECTIVES: CenteringPregnancy (Centering) group prenatal care has been demonstrated to improve perinatal outcomes and provide a positive experience of care for women, but it can be difficult to implement and sustain in some clinical settings. The purpose of this study was to examine the challenges encountered when Centering group prenatal care was provided, and the responses of Centering group leaders to these challenges. DESIGN: this was a longitudinal, qualitative study using interpretive description. Data collection included participant-observation and interviews with group leaders and women receiving group prenatal care. SETTING: two urban clinics providing care to low income women in the northeastern United States. PARTICIPANTS: interview participants were 23 pregnant women (primarily African-American and Hispanic) receiving group prenatal care; other participants were 24 significant others and support staff participating in groups, and two nurse-midwife group leaders. FINDINGS: the clinics did not always provide full resources for implementing Centering as designed, creating numerous challenges for the group leaders, who were committed to providing group prenatal care. In an attempt to sustain the model in the face of these limitations, the group leaders made a number of compromises and modifications to the Centering model. KEY CONCLUSIONS: the limited clinic resources and resulting modifications of the model had a number of downstream effects, some of which affected relationships within groups, participation, and group cohesion. IMPLICATIONS: modifications of the Centering model should be undertaken with caution. Strategies are needed to enhance the success and sustainability of Centering in varied clinical settings so that the benefits of the model, which have been demonstrated under more controlled circumstances, can be conferred to women receiving routine care during pregnancy.

Collaboration in maternity care: possibilities and challenges.

The United States is about to face a maternity workforce crisis in the next decade because the number of medical students choosing obstetrics and gynecology is stagnant, the number of patients requiring care is increasing and many in the current workforce of obstetricians/gynecologists and midwives are ready to retire. There are not enough maternity providers to meet the future needs of women. Creative strategies must be explored to address these concerns. Collaborative practice among different types of maternity providers requires commitment, interpersonal skills, and teamwork. This article explores these issues and provides practical tips and a case study of the process in action between the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives.

"The midwifery two-step": a study on evidence-based midwifery practice.

INTRODUCTION: To date, there has been little documentation of how practice-based midwifery networks in the United States might influence the transfer and development of knowledge in childbearing and women's health care. The first phase of this participatory action research project was to conduct a qualitative study with a community of midwifery practices to understand their perspectives on evidence-based practice and how an organized network could facilitate their work. METHODS: Midwives within the community of interest were invited by letter or e-mail to participate in individual or small group interviews about knowledge transfer, primary concerns of evidence-based practice, and potential for a midwifery practice-based research network. Participatory action research strategies and organizational ethnographic approaches to data collection were used to guide qualitative interviews. RESULTS: Eight midwifery practices enrolled in the study with 23 midwives participating in interviews. They attended births at 2 hospitals in the community. Two broad areas of discourse about evidence-based practice were identified: 1) challenges from influential persons, finances and resources, and the cultural perception of midwifery, and 2) strategies to foster best practice in the face of those challenges. The midwives believed a research network could be useful in learning collectively about their practices and in the support of their work. DISCUSSION: Evidence-based practice is a goal but also has many challenges in everyday implementation. Practice-based research networks hold promise to support clinicians to examine the evidence and form strong coalitions to foster best clinical practice. The second phase of this study will work with this community of midwives to explore collective strategies to examine and improve practice.