Concerns of Women Choosing Community Birth During the COVID-19 Pandemic: A Qualitative Study.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, midwives have reported increased demand for community birth services. The purpose of this qualitative study was to understand childbearing persons' decision-making during the pandemic and to illuminate their experiences giving birth in community settings. METHODS: The study was framed by the interpretive phenomenological approach. Eligible participants were recruited from midwives providing out-of-hospital birth services. Of the 26 women who agreed to an interview, 17 were able to be reached and interviewed. Interviews followed a semistructured guide. Early paradigm cases were coded by all researchers, and then the first author coded the remaining transcripts. The final thematic structure was developed by the research team through an iterative process and validated through member checking. RESULTS: Four themes were identified: prior desire for a community birth, perceived susceptibility, barriers to choice, and isolation. DISCUSSION: Many participants had a preexisting desire for community birth and used the pandemic to justify their choice. However, birth options were often limited by finances and geography. Attitude toward COVID-19 varied by knowledge and experience. Many participants experienced stress and isolation.

A Public Health Ethics Analysis of the Criminalization of Direct Entry Midwifery.

Multiple types of midwives practice in the United States, but regulation of midwifery practice varies by state. In some states, direct entry midwifery practice is unregulated or criminalized. Because regulations are the most burdensome of the public health interventions, they require the most stringent ethical critique. This article uses the most recent Public Health Code of Ethics to analyze the ethics of regulations that criminalize direct entry midwifery practice. The Code establishes 8 criteria for ethical actions: (1) permissibility, (2) respect, (3) reciprocity, (4) effectiveness, (5) responsible use of scarce resources, (6) proportionality, (7) accountability and transparency, and (8) public participation. Laws that criminalize direct entry midwifery practice violate all of these criteria and therefore cannot be considered an ethical approach to the state's duty to safeguard public health. The remedy for this problem is for all states to license and regulate all types of midwives that meet international standards of education and training.

A Qualitative Study of the Maternity Care Experiences of Women with Obesity: "More than Just a Number on the Scale".

INTRODUCTION: The prevalence of obesity among pregnant women in the United States is high. Obesity can have long-term health consequences for both women and their offspring, so high-quality perinatal care for women with obesity is essential. However, stigmatizing encounters with health care professionals can decrease quality and promote avoidance of care. The purpose of this study was to explore the experiences of women with obesity in the maternity care system in the United States. METHODS: In-depth telephone interviews were conducted with 16 women with a body mass index of 30 or greater. The authors used an inductive analytical process to translate women's experiences into themes. RESULTS: Women with obesity reported diverse maternity care experiences, with some reporting appropriate and satisfactory care, while most reported at least one negative encounter over the course of perinatal care. Three major themes emerged from the analysis: personalized care, depersonalized care, and setting the tone. DISCUSSION: Interactions with providers during pregnancy had psychological and emotional effects on women with obesity and influenced the content and perceived quality of their care. Further research is required to explore this phenomenon and its implications for care of women during pregnancy and birth outcomes. In the meantime, providers may wish to consider greater sensitivity to the needs of women with obesity during the perinatal period.

Obesity stigma as a determinant of poor birth outcomes in women with high BMI: a conceptual framework.

Obesity stigma has been linked to poor health outcomes on an individual and population basis. However, little research has been conducted on the role of chronic or recent obesity stigma in the health disparities experienced by pregnant women with high body mass index. The purpose of this article is to discuss poor birth outcomes in this population from an integrated perinatal health framework perspective, incorporating obesity stigma as a social determinant. In studies of non-pregnant populations, obesity stigma has been associated with stress, unhealthy coping strategies, psychological disorders, and exacerbations of physical illness. This article examines the mechanisms by which obesity stigma influences health outcomes and suggests how they might apply to selected complications of pregnancy, including macrosomia, preterm birth and cesarean delivery. Given the rates of obesity and associated pregnancy complications in the United States, it is critical to examine the determinants of those problems from a life course and multiple determinants perspective. This paper offers a conceptual framework to guide exploratory research in this area, incorporating the construct of obesity stigma.

Paternal involvement and fetal morbidity outcomes in HIV/AIDS: a population-based study.

Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes. HIV is a recognized risk factor for adverse birth outcomes. However, the influence of paternal involvement on fetal morbidity outcomes in women with HIV remains poorly understood. Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), the authors assessed the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight [VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers (N=4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional logistic regression was employed to generate adjusted odds ratios (OR). Mothers of infants with absent fathers were more likely to be Black, younger (<35 years old), and unmarried with at least a high school education (p<.01). They were also more likely to have a history of drug (p<.01) and alcohol (p=.02) abuse. These differences disappeared after propensity score matching. Infants of HIV-positive mothers with absent paternal involvement during pregnancy had elevated risks for adverse fetal outcomes (LBW: OR=1.30, 95% confidence interval [CI]=1.05-1.60; VLBW: OR=1.72, 95% CI=1.05-2.82; PTB: OR=1.38, 95% CI=1.13-1.69; VPTB: OR=1.81, 95% CI=1.13-2.90). Absence of fathers increases the likelihood of adverse fetal morbidity outcomes in women with HIV infection. These findings underscore the importance of paternal involvement during pregnancy, especially as an important component of programs for prevention of mother-to-child transmission of HIV.

Pilot Test of a Preconception and Midwifery Care Promotion Program for College Women.

INTRODUCTION: College campuses remain an underused setting for implementing the 10 strategies for promoting preconception health proposed by the US Centers for Disease Control and Prevention. This setting can also be used to educate young women about their options for care in future pregnancies, including midwifery care. To address these needs, the author and 2 peer educators developed and pilot-tested a multiweek health education program for college women. METHODS: Women from a small public liberal arts college in the mid-Atlantic region of the United States were recruited to participate in the pilot program, which offered 6 hours of education over 4 weeks in an interactive, participant-led format. Of 26 women who participated, 20 completed at least 3 of the 4 sessions, as well as the pre- and posttests. RESULTS: The program group reported greater awareness of the importance of preconception health and an increased preference for midwifery care in future pregnancies. Program participants experienced an increase in knowledge about preconception health, midwifery care, and risks associated with cesarean birth, labor induction, and preterm birth, but did not report a statistically significant change in behavior related to preconception health, including lifestyle changes and immunizations. DISCUSSION: Further research should be conducted with a larger sample, longer follow-up, and a more rigorous evaluation design to assess the potential contributions of this promising pilot program.

HIV infection and its impact on fetal outcomes among women of advanced maternal age: a propensity score weighted matching approach.

Advanced maternal age (AMA) and HIV status have been investigated separately for their influence on infant outcomes. Both are associated with adverse fetal growth outcomes, including low birth weight (LBW) and preterm birth (PTB). However, the impact of the cooccurrence of these factors in relation to birth outcomes remains relatively understudied. We analyzed Florida hospital discharge data linked to vital records. The study population consisted of women who had a singleton live birth between 1998 and 2007 (N=1,687,176). The exposure variables were HIV infection and maternal age, while the outcomes of interest were LBW, PTB, and small for gestational age (SGA). We matched HIV-positive women to HIV-negative women on selected variables using propensity scores. To approximate relative risks, we computed adjusted odds ratios (AOR) and 95% confidence intervals (CI) generated from logistic regression models and accounted for the matched design using the generalized estimating equations framework. After adjusting for demographic variables, clinical conditions, and route of birth, the risks of LBW, PTB, and SGA remained significant for HIV-positive women, regardless of age. HIV-positive women of AMA (≥35 years) were more likely to have infants of LBW (AOR=1.73, 95% CI=1.37-2.18), PTB (AOR=1.35, 95% CI: 1.06-1.71), and SGA (AOR=1.52, 95% CI=1.22-1.89), compared to uninfected mothers of younger age (<35 years). For women of advanced age, HIV positivity elevates their risk for LBW and PTB. The interplay of HIV status and age should be considered by healthcare providers when determining appropriate interconception strategies for women and their families.

"Midwives are nice, but . . .": perceptions of midwifery and childbirth in an undergraduate class.

INTRODUCTION: The purpose of this study was to explore college students' beliefs about childbirth and midwifery. METHODS: A critical qualitative analysis was used to identify common themes that occurred in an online class discussion about midwifery. RESULTS: This population of 459 college students drew on the larger social discourse of the medical model of childbirth to frame their discussion of childbirth and midwives. Common beliefs that emerged from class discussions included the perceived dangerous nature of childbirth, the necessity for technologic interventions in childbirth, and doubts about the quality of midwifery training and practice. DISCUSSION: To promote midwifery among this population, advocates should continue public education efforts through a variety of media and communication strategies, with an emphasis on the safety of midwifery care.

The shifting sands for applicants to maternal and child health training programs.

OBJECTIVE: Anecdotal evidence suggests that fewer students today than in decades past are applying to maternal and child health (MCH) graduate training programs with previous clinical degrees. The purpose of this study was to determine the extent to which applicants accepted to an MCH training program demonstrated a shift away from the tradition of having a prior health professional degree and discuss options needed to provide responsive training. METHODS: Twenty years of demographic face sheet data (1983 through 2002) for admitted applicants to the MCH training program at the University of South Florida College of Public Health were examined. RESULTS: Quantitative analysis of admission records confirmed the anecdotal data. Today's applicants are more likely to possess undergraduate nonclinical backgrounds rather than clinical health professional training. Statistically significant differences were found between the students with clinical and without clinical degrees for ethnicity, GRE score, GPA, and the length of time needed to complete the MPH degree. CONCLUSION: Adjustments in MCH curricula may be necessary to be responsive to the "shifting sands" of clinical and public health work experience among program applicants. However, curriculum modifications need to be ones that maintain the zeal of the new generation of MCH students without diluting the rigor of traditional professional preparation. Some possible responses of training programs are suggested.

Abstinence-only education: how we got here and where we're going.

This paper examines the history of abstinence education in the United States and the empirical evidence of its effectiveness in preventing teenage pregnancy. It concludes that abstinence education has not yet been proven effective, and therefore recommends that federal policy and funding should be directed towards teen pregnancy prevention programs that have demonstrated success.