African Immigrant Women's Experiences of Maternity Care in the United States.

OBJECTIVE: The purpose of this study was to explore maternity care experiences of African immigrant women during the perinatal period including factors affecting access to and use of care. METHODS: We used Sandelowski's (2010) qualitative descriptive approach to examine how African immigrant women from various countries of origin and with diverse ethnic backgrounds experienced and navigated the maternity care system in the United States during pregnancy and childbirth. We conducted semi-structured interviews with 15 African immigrant women living in the Columbus, Ohio area. Participants were recruited using purposive and snowball sampling between February 2021 and May 2021. Interviews were recorded, transcribed, and analyzed using a reflexive thematic analysis approach. FINDINGS: Four major themes defined the experiences of our study participants: access to information, patient-clinician relationships, experiences of discrimination, and costs of maternity care. CLINICAL IMPLICATIONS: Findings highlight key barriers to providing quality and acceptable maternity care to African immigrant women at multiple levels. This group's unique barriers underlie the importance of incorporating their diverse experiences into maternity care models and clinical practice. Further research is needed to evaluate and improve maternity care for African immigrant women.

Preventive Primary Care in the Postpartum Year: The Role of Medicaid Delivery System Reform.

INTRODUCTION: Preventive and primary care in the postpartum year is critical for future health and may be increased by primary care focused delivery system reform including implementation of Medicaid Accountable Care Organizations (ACO). This study examined associations of Massachusetts Medicaid ACO implementation with preventive visits in the postpartum year. METHODS: The Massachusetts All-Payer Claims Database was used to identify births to privately-insured or Medicaid ACO-eligible individuals from January 1, 2016 to February 28, 2019. Comparing these groups before and after implementation, a propensity score weighted difference-in-difference design was used to analyze associations of Medicaid ACO implementation with any preventive care visit and any primary care physician (PCP) preventive visit within one year postpartum, controlling for other characteristics. Analyses were performed in 2023 and 2024. RESULTS: Of the 110,601 births in the study population, 35.5% had any preventive care visit and 23.0% had any preventive PCP visit in the year postpartum, with higher rates of preventive visits among privately-insured individuals. In adjusted difference-in-difference analyses, relative to the pre-period, there was a 2.7 percentage point (pp) decrease (95% confidence interval [CI]: -4.3pp, -1.2pp) and 3.5 pp decrease (95% CI: -4.9pp, -2.0pp) in use of any preventive visits and any PCP preventive visits, respectively, for Medicaid-insured versus privately-insured individuals after ACO implementation. CONCLUSIONS: Implementation of Massachusetts Medicaid ACOs was associated with decreases in receipt of preventive visits and preventive PCP visits for Medicaid-insured individuals relative to privately-insured individuals. Medicaid ACOs should consider potential implications of primary care access in the postpartum year for health across the lifecourse.

Continuity of Clinician Type and Intrapartum Experiences During the Perinatal Period in California.

INTRODUCTION: Continuity of care with an individual clinician is associated with increased satisfaction and better outcomes. Continuity of clinician type (ie, obstetrician-gynecologist or midwife) may also impact care experiences; however, it is unknown how common it is to experience discontinuity of clinician type and what its implications are for the birth experience. We aimed to identify characteristics associated with having a different clinician type for prenatal care than for birth and to compare intrapartum experiences by continuity of clinician type. METHODS: For this cross-sectional study, data were from the 2017 Listening to Mothers in California survey. The analytic sample was limited to individuals with vaginal births who had midwifery or obstetrician-gynecologist prenatal care (N = 1384). Bivariate and multivariate analysis examined characteristics of individuals by continuity of clinician type. We then examined associations of clinician type continuity with intrapartum care experiences. RESULTS: Overall, 74.4% of individuals had the same type of clinician for prenatal care and birth. Of individuals with midwifery prenatal care, 45.1% had a different birth clinician type, whereas 23.5% of individuals who had obstetrician-gynecologist prenatal care had a different birth clinician type. Continuity of clinician type was positively associated with having had a choice of perinatal care clinician. There were no statistically significant associations between clinician type continuity and intrapartum care experiences. DISCUSSION: Findings suggest individuals with midwifery prenatal care frequently have a different type of clinician attend their birth, even among those with vaginal births. Further research should examine the impact of multiple dimensions of continuity of care on perinatal care quality.

Readiness to Implement a Doula-Hospital Partnership Program.

OBJECTIVE: To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program. DESIGN: Survey of obstetric clinicians and leaders before implementation of the doula program. SETTING/LOCAL PROBLEM: Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality. PARTICIPANTS: Obstetric clinicians and leaders (N = 48). INTERVENTION/MEASUREMENTS: We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis. RESULTS: Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics. CONCLUSION: Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.

Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity.

Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.

Maternal Health Equity in Medicaid Accountable Care Organizations: Early Lessons from the Massachusetts Experience.

There are substantial inequities by race and ethnicity in maternal health care utilization and health outcomes across the perinatal period. As Medicaid covers 42% of births nationally and almost two-thirds of births to Black birthing people, state Medicaid financing and delivery system reforms have substantial scope to impact these inequities. Twenty-one states have implemented Medicaid Accountable Care Organizations (ACOs) at some point since 2015. Using public documents and interviews with ACO administrators, we examine the implications of Massachusetts Medicaid ACOs, implemented in March 2018, for maternal health equity. Although these Medicaid ACOs have the potential to impact maternal health equity, they face many challenges in doing so. We review future steps within Massachusetts Medicaid ACOs and Medicaid programs more generally to incorporate policies that may better address racial and ethnic inequities.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations.

BACKGROUND: Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid. PURPOSE: To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs. METHODOLOGY/APPROACH: Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment. RESULTS: Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included. CONCLUSION AND PRACTICE IMPLICATIONS: Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.

Timing of hospital admission at first childbirth: A prospective cohort study.

BACKGROUND AND AIMS: It is difficult for women in labor to determine when best to present for hospital admission, particularly at first childbirth. While it is often recommended that women labor at home until their contractions have become regular and ≤ 5-minutes apart, little research has investigated the utility of this recommendation. This study investigated the relationship between timing of hospital admission, in terms of whether women's labor contractions had become regular and ≤ 5-minutes apart before admission, and labor progress. METHODS: This was a cohort study of 1,656 primiparous women aged 18-35 years with singleton pregnancies who began labor spontaneously at home and delivered at 52 hospitals in Pennsylvania, USA. Women who were admitted before their contractions had become regular and ≤ 5-minutes apart (early admits) were compared to those who were admitted after (later admits). Multivariable logistic regression models were used to assess associations between timing of hospital admission and active labor status on admission (cervical dilation 6-10 cm), oxytocin augmentation, epidural analgesia and cesarean birth. RESULTS: Nearly two-thirds of the participants (65.3%) were later admits. These women had labored for a longer time period before admission (median, interquartile range [IQR] 5 hours (3-12 hours)) than the early admits (median, (IQR) 2 hours (1-8 hours), p < 0.001); were more likely to be in active labor on admission (adjusted OR [aOR] 3.78, 95% CI 2.47-5.81); and were less likely to experience labor augmentation with oxytocin (aOR 0.44, 95% CI 0.35-0.55); epidural analgesia (aOR 0.52, 95% CI 0.38-0.72); and cesarean birth (aOR 0.66, 95% CI 0.50-0.88). CONCLUSIONS: Among primiparous women, those who labor at home until their contractions have become regular and ≤ 5-minutes apart are more likely to be in active labor on hospital admission and less likely to experience oxytocin augmentation, epidural analgesia and cesarean birth.

Preventive care visits with OB/GYNs and generalist physicians among reproductive-age women with chronic conditions.

OBJECTIVE: To examine services delivered during preventive care visits among reproductive-age women with and without chronic conditions by physician specialty. DATA SOURCES: National Ambulatory Medical Care Surveys (2011-2018). STUDY DESIGN: We examined provision of specific services during preventive care visits by physician specialty among reproductive-age female patients, overall and among women with five common chronic conditions (diabetes, hypertension, depression, hyperlipidemia, and asthma). DATA COLLECTION/EXTRACTION METHODS: The sample included preventive visits to OB/GYNs or generalist physicians where the patient was female, age 18-44, and not pregnant. PRINCIPAL FINDINGS: In OB/GYN preventive visits, reproductive health services were more likely to be provided, while non-reproductive health services were less likely to be provided, both among reproductive-age female patients overall and among those with chronic conditions. For example, pap tests were provided in 44.5% of OB/GYN preventive visits (95% CI: 40.6-48.4) and in 21.4% of generalist preventive visits (95% CI: 17.2-26.6). Lipid testing was provided in 2.8% of OB/GYN preventive visits (95% CI: 1.7-3.9) and in 30.3% of generalist preventive visits (95% CI: 26.1-34.6). CONCLUSIONS: Understanding the full range of care received in preventive visits across settings could guide recommendations to optimize where reproductive-age women with chronic conditions seek care.

Content Analysis of Patient-Facing Information Related to Preeclampsia.

BACKGROUND: Previous research has shown pregnant people are not knowledgeable about preeclampsia, a significant cause of maternal morbidity and mortality. This lack of knowledge may impact their ability to report symptoms, comply with recommendations, and receive appropriate follow-up care. Pregnant people commonly seek information from sources outside their treating clinician, including pregnancy-specific books and online sources. We examined commonly used preeclampsia information sources to evaluate whether pregnant people are receiving up-to-date, guideline-based information. METHODS: We conducted a content analysis of preeclampsia-related information in top-ranking websites and bestselling pregnancy books. We used American College of Obstetricians and Gynecologists preeclampsia guidelines to construct a codebook, which we used to examine source content completeness and accuracy. For each source, we analyzed information about preeclampsia diagnosis, patient-reported symptoms, risk factors, prevention, treatment, and complications. RESULTS: Across 19 included sources (13 websites and 6 books), we found substantial variation in completeness and accuracy of preeclampsia information. We found high rates of mentions for preeclampsia symptoms. Risk factors were more commonly included in online sources than book sources. Most sources mentioned treatment options, including blood pressure medication and giving birth; however, one-third of online sources positively mentioned the nonrecommended treatment of bed rest. Prevention methods, including prenatal aspirin for high-risk pregnancies, and long-term complications of preeclampsia were infrequently mentioned. CONCLUSIONS: Varying rates of accuracy in patient-facing preeclampsia information mean there is substantial room for improvement in these sources. Ensuring pregnant people receive current guideline-based information is critical for improving outcomes and implementing shared decision-making.

Transitions in Health Insurance During the Perinatal Period Among Patients With Continuous Insurance Coverage.

Importance: Although health insurance continuity is important during the perinatal period to improve birth outcomes and reduce maternal morbidity and mortality, insurance disruptions are common. However, little is known about insurance transitions among insurance types for individuals who remained insured during the perinatal period. Objective: To examine insurance transitions for birthing individuals with continuous insurance, including those with Medicaid and Medicaid managed care coverage, before, during, and after pregnancy. Design, Setting, and Participants: This cohort study used January 1, 2014 to December 31, 2018 data from the Massachusetts All-Payer Claims Database. The sample included deliveries from January 1, 2015, to December 31, 2017, to birthing individuals aged 18 to 44 years old with continuous insurance for 12 months before and after delivery. Data were analyzed from November 9, 2021, to September 2, 2022. Exposure: Insurance type at delivery. Main Outcomes and Measures: The primary outcome was a binary indicator of any transition in insurance type from 12 months before and/or after delivery. The secondary outcomes were measures of any predelivery transition (12 months before delivery month) and any transition during the postpartum period (delivery month to 12 months post partum). Multivariate logit regression models were used to analyze the association of an insurance transition in the perinatal period with insurance type in the delivery month, controlling for age and socioeconomic status based on a 5-digit zip code. Results: The analytic sample included 97 335 deliveries (mean [SD] maternal age at delivery, 30.4 [5.5] years). Of these deliveries, 23.4% (22 794) were insured by Medicaid and 28.1% (27 347) by Medicaid managed care in the delivery month. A total of 37.1% of the sample (36 127) had at least 1 insurance transition during the 12 months before and/or after delivery. In regression-adjusted analyses, those individuals covered by Medicaid and Medicaid managed care at delivery were 47.0 (95% CI, 46.3-47.7) percentage points and 50.1 (95% CI, 49.4-50.8) percentage points, respectively, more likely to have an insurance transition than those covered by private insurance. Those covered by Marketplace plans at delivery had a 33.1% (95% CI, 31.4%-34.8%) regression-adjusted predicted probability of having a postpartum insurance transition. Conclusions and Relevance: Results of this study showed that insurance transitions during the perinatal period occurred for more than 1 in 3 birthing individuals with continuous insurance and were more common among those with Medicaid or Medicaid managed care at delivery. Further research is needed to examine the role of insurance transitions in health care use and outcomes during the perinatal period.

Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum.

Objectives: Person-centered care has been increasingly recognized as an important aspect of health care quality, including in maternity care. Little is known about correlates and outcomes of person-centered care in maternity care in the United States. Materials and Methods: Data were from a prospective cohort of more than 3000 individuals who gave birth to a first baby in a Pennsylvania hospital. Person-centered maternity care was measured via a 13-item rating scale administered 1-month postpartum. Content validity was established through exploratory factor analysis. The resulting scale had scores ranging from 13 to 54, with Cronbach's alpha of 0.86. Using linear and logistic regression models to control for covariates, we examined associations between participants' characteristics and person-centered maternity care and between person-centered maternity care and postpartum outcomes. Results: Participants had a mean total score of 47.80 on the person-centered maternity care scale. Patient factors independently associated with more person-centered maternity care included older age, more positive attitude toward vaginal birth during pregnancy, and spontaneous vaginal birth. In adjusted models, higher person-centered maternity scale scores were strongly associated with many positive physical and mental health outcomes at 1 and 6 months postpartum. Conclusions: Our findings underscore the importance of person-centered maternity not just due to its intrinsic value but also because it may be associated with both mental and physical health outcomes through the postpartum period. Results suggest that policy efforts are necessary to ensure person-centered maternity care, especially for delivery hospitalization experience.

Factors associated with labor after cesarean in a prospective cohort.

BACKGROUND: The goals of this study were (a) to determine how experiences in the first perinatal period shape birth mode preference among individuals with a first birth by cesarean; and (b) to examine the relationship between birth mode preference and other factors and subsequent labor after cesarean (LAC). METHODS: Data are from the First Baby Study, a prospective cohort of 3006 primiparous individuals. The analytic sample includes individuals with a first cesarean birth and a second birth during the 5-year follow-up period (n = 394). We used multivariable logistic regression to examine the relationship between experiences in the first perinatal period and subsequent preference for vaginal birth, and between preference for vaginal birth and LAC in the second birth. RESULTS: About a third of the sample preferred vaginal birth in a future birth, and 20% had LAC. Factors associated with higher odds of future vaginal birth preference were favorable prenatal attitude toward vaginal birth, lower perceived maternal-infant bonding at 1 month after the first birth, post-traumatic stress symptoms after the first birth, and desiring more than 1 additional child after the first birth. Odds of LAC were nearly 8 times higher among those who preferred vaginal birth (AOR = 7.69, P < .001). Fatigue after the first birth, post-traumatic stress symptoms after the first birth, and having higher predicted chances of vaginal birth after cesarean were also associated with higher odds of LAC. CONCLUSIONS: Our findings suggest that the formation of preferences around vaginal birth may present a modifiable target for future counseling and shared decision-making interventions.

Postpartum Visit Attendance in the United States: A Systematic Review.

INTRODUCTION: Adequate postpartum care, including the comprehensive postpartum visit, is critical for long-term maternal health and the reduction of maternal mortality, particularly for people who may lose insurance coverage postpartum. However, variation in previous estimates of postpartum visit attendance in the United States makes it difficult to assess rates of attendance and associated characteristics. METHODS: We conducted a systematic review of estimates of postpartum visit attendance. We searched PubMed, CINAHL, PsycInfo, and Web of Science for articles published in English from 1995 to 2020 using search terms to capture postpartum visit attendance and use in the United States. RESULTS: Eighty-eight studies were included in this analysis. Postpartum visit attendance rates varied substantially, from 24.9% to 96.5%, with a mean of 72.1%. Postpartum visit attendance rates were higher in studies using patient self-report than those using administrative data. The number of articles including an estimate of postpartum visit attendance increased considerably over the study period; the majority were published in 2015 or later. CONCLUSIONS: Our findings suggest that increased systematic data collection efforts aligned with postpartum care guidelines and attention to postpartum visit attendance rates may help to target policies to improve maternal wellbeing. Most estimates indicate that a substantial proportion of women do not attend at least one postpartum visit, potentially contributing to maternal morbidity as well as preventing a smooth transition to future well-woman care. Estimates of current postpartum visit attendance are important for informing efforts that seek to increase postpartum visit attendance rates and to improve the quality of care.

Recovery from Obstetric Anal Sphincter Injury in a Prospective Cohort of First Births.

OBJECTIVE: To identify risk factors for obstetric anal sphincter injuries (OASIS) for primiparous women who gave birth vaginally and to compare recovery by OASIS status in three domains as follows: (1) physical health and functioning, (2) mental health, and (3) healthcare utilization. STUDY DESIGN: This secondary analysis used data from 2,013 vaginal births in the First Baby Study, a prospective cohort study of women with first births between 2009 and 2011. Interview data at multiple time points were linked to birth certificate and hospital discharge data. The key exposure of interest was OASIS (3rd or 4th degree perineal laceration, identified in the hospital discharge data; n = 174) versus no OASIS (n = 1,839). We used multivariable logistic regression models to examine the association between OASIS and a range of outcomes including physical health and functioning, depression, and health care utilization, assessed at 1 month and 6 months postpartum. RESULTS: Eight percent of women had OASIS. In adjusted models, there were no differences in general physical health and functioning measures by OASIS (such as fatigue and overall self-rated health), but women with OASIS had higher rates of reporting perineal pain (p < 0.001), accidental stool loss (p = 0.001), and bowel problems (p < 0.001) at 1-month postpartum. By 6-month postpartum, there were no differences in reported physical health and functioning. There were no differences in probable depression at 1- or 6-month postpartum. Women with OASIS were more likely to attend a comprehensive postpartum visit, but there were no other differences in health care utilization by OASIS. CONCLUSION: Women with OASIS were at increased risk of accidental stool loss, bowel problems, and perineal pain in the immediate postpartum period. Women who had OASIS had similar physical functioning across a range of general health outcomes to women who gave birth vaginally without OASIS. KEY POINTS: · Higher risk of bowel problems and accidental stool loss 1-month postpartum with OASIS.. · Higher risk of perineal pain 1-month postpartum with OASIS.. · No differences in health outcomes at 6-months postpartum by OASIS..

Community Perspectives on the Creation of a Hospital-Based Doula Program.

Objective: Racial and ethnic inequities in perinatal health outcomes are pervasive. Doula support is an evidence-based practice for improving maternal outcomes. However, women in lower-income populations often do not have access to doulas. This study explored community perspectives on doula care to inform the development of a hospital-based doula program to serve primarily low-income women of color. Methods: Four focus groups and four individual interviews were conducted with: (1) women who were pregnant or parenting a child under age 2 (n=20); (2) people who had provided support during a birth in the previous 2 years (n=5); and (3) women who had received doula training (n=4). Results: Participants had generally positive perceptions of doula services. Many aspects of doula support desired by participants are core to birth doula services. Participants identified ways that doulas could potentially address critical gaps in health care services known to impact outcomes (e.g., continuity of care and advocacy), and provide much-needed support in the postpartum period. Responses also suggested that doula training and hospital-based doula programs may need to be adapted to address population-specific needs (e.g., women with substance use disorder and younger mothers). Novel program suggestions included "on call" informational doulas. Conclusions: Findings suggested that women in racial/ethnic minority and lower income groups may be likely to utilize a hospital-based doula program and identified adaptations to traditional doula care that may be required to best meet the needs of women in groups with higher risk of poor maternal health and birth outcomes.

Physician Referrals During Prenatal Care.

OBJECTIVE: Referrals are an important component of patient care, and have been increasing over time. During pregnancy, people have intensive contact with the healthcare system, but little is known about the involvement of different physicians for pregnant patients during this period. This study examines referral patterns during prenatal care visits. METHODS: Using the 2006-2015 National Ambulatory Medical Care Survey and national birth certificate data, we estimate the number of referrals per pregnancy from prenatal care visits with OB/GYN and family medicine physicians. We use multivariable regression analysis to compare the probability of receiving a referral during a prenatal visit for visits with family medicine and OB/GYN physicians, controlling for visit, patient, and physician characteristics. Analyses are weighted to make results nationally representative. RESULTS: 224,335,436 prenatal visits over 19,893,015 pregnancies were included; 60% of these visits were covered by private insurance. On average, 0.3 referrals are made per pregnancy (95% confidence interval [CI] 0.22, 0.38). A prenatal visit with an OB was 5.5% points less likely to result in a referral than a visit with a family medicine physician, controlling for other characteristics. CONCLUSIONS: Referrals are relatively common in prenatal care, and are more commonly initiated by family medicine physicians than by OB/GYNs. Understanding the contribution of multiple clinicians to a pregnant person's health during the prenatal period and how coordination among clinicians impacts care receipt is an important next step. As healthcare becomes more specialized, better understanding care teams of individuals during the perinatal period is important for improving prenatal care.

Perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content: Evidence from the Listening to Mothers in California survey.

OBJECTIVE: Postpartum visits are an important opportunity to address ongoing maternal health. Experiences of discrimination in healthcare can impact healthcare use, including postpartum visits. However, it is unknown whether discrimination is associated with postpartum visit content. This study aimed to examine the relationship between perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content. RESEARCH DESIGN: Data were from Listening to Mothers in California, a population-based survey of people with a singleton hospital birth in California in 2016. Adjusted logistic regression models estimated the association between perceived discrimination during the childbirth hospitalization and 1) postpartum visit attendance, and 2) topics addressed at the postpartum visit (birth control, depression and breastfeeding) for those who attended. RESULTS: 90.6% of women attended a postpartum visit, and 8.6% reported discrimination during the childbirth hospitalization. In adjusted models, any discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit, respectively. There was a 7pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%), a 15pp lower predicted probability of being asked about depression (64% vs. 79%), and a 9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%). CONCLUSIONS: Amid heightened attention to the importance of postpartum care, there is a need to better understand determinants of postpartum care quality. Our findings highlight the potential consequences of healthcare discrimination in the perinatal period, including lower quality of postpartum care.

A prospective cohort study of post-traumatic stress disorder and maternal-infant bonding after first childbirth.

OBJECTIVE: To investigate risk factors for childbirth-related post-traumatic stress disorder (CR-PTSD) measured 1-month after first childbirth, and the association between CR-PTSD and maternal-infant bonding. METHODS: In this prospective cohort study 3006 nulliparous women living in Pennsylvania, USA, were asked about CR-PTSD at 1-month postpartum, and maternal-infant bonding at 1, 6 and 12-months postpartum. Multivariable logistic regression models identified risk factors for CR-PTSD and associations between CR-PTSD and maternal-infant bonding at 1, 6 and 12-months postpartum, controlling for confounding variables - including postpartum depression, stress and social support. RESULTS: Nearly half (47.5%) of the women reported that during labor and delivery they were afraid that they or their baby might be hurt or die, and 225 women (7.5%) reported experiencing one or more CR-PTSD symptoms at 1-month postpartum. Depression, stress and low social support during pregnancy were associated with CR-PTSD, as well as labor induction, delivery complications, poor pain control, and unplanned cesarean delivery. Women with CR-PTSD reported a less positive childbirth experience, less shared decision-making, and were more likely to score in the bottom third on maternal-infant bonding at 1-month postpartum (adjusted odds ratio [aOR] 2.5, 95% CI 1.8-3.3, p < 0.001); at 6-months postpartum (aOR 2.1, 95% CI 1.5-2.8, p < 0.001); and at 12-months postpartum (aOR 2.2, 95% CI 1.6-3.0, p < 0.001). CONCLUSION: In this large-scale prospective cohort study we found that CR-PTSD was consistently associated with lower levels of maternal-infant bonding over the course of the first year after first childbirth.

Racial/Ethnic Differences in Socioeconomic Status and Medical Correlates of Trial of Labor After Cesarean and Vaginal Birth After Cesarean.

Objectives: Black and Latinx women have higher rates of trial of labor after cesarean (TOLAC) compared with White women, but lower rates of vaginal birth after cesarean (VBAC). This study examined potential racial/ethnic differences in correlates of TOLAC and VBAC. Materials and Methods: The analytic sample includes term, singleton hospital births to women with one prior cesarean in birth certificate data for 2016. We estimated associations between medical factors (diabetes, hypertension, and prepregnancy obesity) and socioeconomic status (education level and insurance type) and TOLAC and VBAC using logistic regression, stratifying by race/ethnicity and testing whether coefficients differed across models. Results: Hypertension and obesity were more strongly related to reduced chances of TOLAC among White women than among women of color. For example, having a body mass index (BMI) between 30 and 39 (vs. normal BMI) was associated with a 6.3 percentage-point (pp) lower probability of TOLAC for White women, a 5.9 pp lower probability for Black women, and 2.9 pp lower probability for Latinx women. Paying out-of-pocket for birth was associated with a 5.5 pp increase in the probability of TOLAC among White women, versus a 3.2 pp decrease among Black women. Overweight and obesity were associated with lower probability of VBAC, but the magnitude of this association was smaller for Black and Latinx women than for White women. Conclusions: More research is needed to elucidate the underlying decision-making processes that lead to these associations. Future work should focus on ensuring equity in access to VBAC-supportive providers and hospitals and fostering informed decision-making after a prior cesarean.