Migration and maternity: insights of context, health policy, and research evidence on experiences and outcomes from a three country preliminary study across Germany, Canada, and the United kingdom.

A group from Germany, Canada, and the United Kingdom undertook country-specific scoping reviews and stakeholder consultations before joining to holistically compare migration and maternity in all three countries. We examined four interlinking dimensions to understand how international migrant/minority maternal health might be improved upon using transnational research: (a) wider sociopolitical context, (b) health policy arena, (c) constellation, outcomes, and experiences of maternity services, and (d) existing research contexts. There was clear evidence that the constellation and delivery of services may undermine good experiences and outcomes. Interventions to improve access and quality of care remain small scale, short term, and lacking in rigorous evaluation.

Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion.

BACKGROUND: Pakistan is one of the six countries estimated to contribute to over half of all maternal deaths worldwide. To address its high maternal mortality rate, in particular the inequities in access to maternal health care services, the government of Pakistan created a new cadre of community-based midwives (CMW). A key expectation is that the CMWs will improve access to skilled antenatal and intra-partum care for the poor and disadvantaged women. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay. METHODS/DESIGN: Data will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW's in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan. DISCUSSION: The findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women's marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.

The experience of pregnancy and birth with midwives: results from the Canadian maternity experiences survey.

BACKGROUND: In Canada maternity care is publicly funded, and although women may choose their care providers, choices may be limited. The purpose of this study was to compare perceptions of maternity outcomes and experiences of those who received care from midwives with those who received care from other providers. METHODS: Based on the 2006 Canadian census, a random sample of women (n = 6,421) who had recently given birth in Canada completed a computer-assisted telephone interview for the Maternity Experiences Survey. The sample was stratified according to province or territory where birth occurred, age, rural or urban residence, and presence of other children in the home. Those who were 15 years of age and older, gave birth to a singleton baby, and were living with their infant were eligible for inclusion. RESULTS: Women whose primary prenatal providers were midwives had fewer ultrasounds and were more likely to attend prenatal classes and have at least five or more prenatal visits. They were also more likely to rate satisfaction with their maternity experience as "very positive" and be satisfied with information provided on a variety of pregnancy and birth topics if their primary prenatal provider was a midwife. They were almost half as likely to experience induction and 7.33 times more likely to experience a medication-free delivery. They were more likely to initiate and maintain breastfeeding at 3 and 6 months. CONCLUSIONS: Evidence shows that midwifery outcomes and levels of satisfaction meet or exceed Canadian maternity care standards. Facilitation of the continuing integration of midwives as autonomous practitioners throughout Canada is recommended. (BIRTH 38:3 September 2011).

Contributions and challenges of cross-national comparative research in migration, ethnicity and health: insights from a preliminary study of maternal health in Germany, Canada and the UK.

BACKGROUND: Public health researchers are increasingly encouraged to establish international collaborations and to undertake cross-national comparative studies. To-date relatively few such studies have addressed migration, ethnicity and health, but their number is growing. While it is clear that divergent approaches to such comparative research are emerging, public health researchers have not so far given considered attention to the opportunities and challenges presented by such work. This paper contributes to this debate by drawing on the experience of a recent study focused on maternal health in Canada, Germany and the UK. DISCUSSION: The paper highlights various ways in which cross-national comparative research can potentially enhance the rigour and utility of research into migration, ethnicity and health, including by: forcing researchers to engage in both ideological and methodological critical reflexivity; raising awareness of the socially and historically embedded nature of concepts, methods and generated 'knowledge'; increasing appreciation of the need to situate analyses of health within the wider socio-political setting; helping researchers (and research users) to see familiar issues from new perspectives and find innovative solutions; encouraging researchers to move beyond fixed 'groups' and 'categories' to look at processes of identification, inclusion and exclusion; promoting a multi-level analysis of local, national and global influences on migrant/minority health; and enabling conceptual and methodological development through the exchange of ideas and experience between diverse research teams. At the same time, the paper alerts researchers to potential downsides, including: significant challenges to developing conceptual frameworks that are meaningful across contexts; a tendency to reify concepts and essentialise migrant/minority 'groups' in an effort to harmonize across countries; a danger that analyses are superficial, being restricted to independent country descriptions rather than generating integrated insights; difficulties of balancing the need for meaningful findings at country level and more holistic products; and increased logistical complexity and costs. SUMMARY: In view of these pros and cons, the paper encourages researchers to reflect more on the rationale for, feasibility and likely contribution of proposed cross-national comparative research that engages with migration, ethnicity and health and suggests some principles that could support such reflection.

Women's feelings about early contact with their infants on the labour ward.

OBJECTIVES: to identify women's feelings after early contact with their newborn infants in the delivery room, and to identify how health professionals involved in mother and infant care behave in the intrapartum setting. DESIGN: a qualitative approach using semi-structured interviews and observation. Content analysis was used to derive the three themes that emerged from the interviews. SETTING AND PARTICIPANTS: 23 postpartum women and their caregivers in a public maternity hospital in Ribeirão Preto, Brazil. FINDINGS: three thematic categories emerged from the interviews: heightened fear, severe pain and intense conflict. The professionals' actions revealed that they have theoretical and practical abilities for humanisation of care, but their actions are fragmented. FINAL CONSIDERATIONS: women can feel lonely, fearful and conflicted in the delivery room, and they also experience pain. Giving birth is a major event in a woman's life, so it is important to facilitate a positive experience. Health professionals were found to display interventionist and impersonal attitudes; these influenced the potential choices of women at their first contact with their infant. IMPLICATIONS FOR PRACTICE: the focus of health care needs to extend beyond the institution. This means fewer normative actions performed by health professionals, enabling women to enjoy their early contact with their newborn infants.

Comparison of costs and associated outcomes between women choosing newly integrated autonomous midwifery care and matched controls: a pilot study.

OBJECTIVE: In response to consumer demand and a critical shortage of Canadian maternity care providers, provinces have integrated or are in the process of integrating midwives into their health care systems. We compared the costs and outcomes of newly integrated, autonomous midwifery care with existing health care services in the province of Alberta. METHODS: Alberta Health and Wellness cost data from (1) physician fee-for-service, (2) outpatient, and (3) inpatient records, as well as outcome data from vital statistics records, were compared between participants in a midwifery integration project and individually matched women who received standard perinatal care during the same time period. Records of births occurring within the same time frame were matched according to risk score, maternal age, parity, and postal code. RESULTS: For women who chose midwifery care, an average saving of $1172 per course of care was realized without adversely affecting maternal or neonatal outcomes. Cost reductions are partially realized through provision of out-of-hospital health services. Women who chose midwifery care had more prenatal visits (P < 0.01) and fewer inductions of labour (P < 0.01); their babies had greater gestational ages (P < 0.05) and higher birth weights (P < 0.05) than controls. The sample size was insufficient to compare events associated with extremely high costs, or rare or catastrophic outcomes. CONCLUSION: Regulated and publicly funded midwifery care appears to be an effective intervention for low-risk women who make this choice. When compared with existing care, autonomous care by newly integrated midwives does not increase health care costs.

Meeting the needs of Nunavut families: a community-based midwifery education program.

CONTEXT: Pregnant Nunavut women are usually expected to relocate to distant and larger urban centres, often for several weeks, to give birth. A national study revealed that these women are less likely to have necessary information on pregnancy related topics and less satisfied with their maternity experiences. While prenatal and postpartum care can be accessed through nursing stations, opportunities for intrapartum care within Nunavut are limited to the hospital in Iqaluit or the birthing centre in Rankin Inlet. ISSUES: One strategy that may be help ameliorate these regional differences is increasing the integration of midwifery services. Many historical and political factors have contributed to the loss of traditional maternity care among the Inuit of Nunavut. A unique, multi-layered midwifery education program, with a range of exit points from maternity care worker to baccalaureate degree, was implemented by a partnership between the Government of Nunavut and Nunavut Arctic College (NAC). Creative approaches were invoked to develop a program that is both culturally safe and ensures that graduates at midwifery diploma level are eligible to write the Canadian Midwifery Regulatory Exam (CMRE). The loss of traditional midwifery and the very dispersed population created challenges with respect to development of appropriate clinical learning sites where students can learn midwifery from midwives. Because NAC does not grant degrees, a collaborative partnership with Laurentian University is underway to meet the needs of those midwifery students who wish to complete a degree. LESSONS LEARNED: Midwifery has a bright future in Nunavut. Two students have already passed CMREs on their first attempt. Plans are in place to enroll a class in Cambridge Bay in the fall of 2010. One NAC student is enrolled in courses at Laurentian University and should complete the third year of that program in 2010.

Use of routine interventions in vaginal labor and birth: findings from the Maternity Experiences Survey.

BACKGROUND: Intervention rates in maternity practices vary considerably across Canadian provinces and territories. The objective of this study was to describe the use of routine interventions and practices in labor and birth as reported by women in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Rates of interventions and practices are considered in the light of current evidence and both Canadian and international recommendations. METHODS: A sample of 8,244 estimated eligible women was identified from a randomly selected sample of recently born infants drawn from the May 2006 Canadian Census and stratified primarily by province and territory. Birth mothers living with their infants at the time of interview were invited to participate in a computer-assisted telephone interview conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews averaged 45 minutes long and were completed when infants were between 5 and 10 months old (9-14 mo in the territories). Completed responses were obtained from 6,421 women (78%). RESULTS: Women frequently reported electronic fetal monitoring, a health care practitioner starting or speeding up their labor (or trying to do so), epidural anesthesia, episiotomy, and a supine position for birth. Some women also reported pubic or perineal shaves, enemas, and pushing on the top of their abdomen. CONCLUSIONS: Several practices and interventions were commonly reported in labor and birth in Canada, although evidence and Canadian and international guidelines recommend against their routine use. Practices not recommended for use at all, such as shaving, were also reported.