Association Between Mental Health Conditions at the Hospitalization for Birth and Postpartum Hospital Readmission.

Background: The relationship between physical comorbidities and postpartum hospital readmission is well studied, with less research regarding the impact of mental health conditions on postpartum readmission. Methods: Using hospital discharge data (2016-2019) from the Hospital Cost and Utilization Project Nationwide Readmissions Database (n = 12,222,654 weighted), we evaluated the impact of mental health conditions (0, 1, 2, and ≥3), as well as five individual conditions (anxiety, depressive, bipolar, schizophrenic, and traumatic/stress-related conditions) on readmission within 42 days, 1-7 days ("early"), and 8-42 days ("late") of hospitalization for birth. Results: In adjusted analyses, the rate of 42-day readmission was 2.2 times higher for individuals with ≥3 mental health conditions compared to those with none (3.38% vs. 1.56%; p < 0.001), 50% higher among individuals with 2 mental health conditions (2.33%; p < 0.001), and 40% higher among individuals with 1 mental health condition (2.17%; p < 0.001). We found increased adjusted risk of 42-day readmission for individuals with anxiety (1.98% vs. 1.59%; p < 0.001), bipolar (2.38% vs. 1.60%; p < 0.001), depressive (1.93% vs. 1.60%; p < 0.001), schizophrenic (4.00% vs. 1.61%; p < 0.001), and traumatic/stress-related conditions (2.21% vs. 1.61%; p < 0.001), relative to individuals without the respective condition. Mental health conditions had larger impacts on late (8-42 day) relative to early (1-7 day) readmission. Conclusions: This study found strong relationships between mental health conditions during the hospitalization for birth and readmission within 42 days. Efforts to reduce the high rates of adverse perinatal outcomes in the United States should continue to address the impact of mental health conditions during pregnancy and throughout the postpartum period.

Advancing health equity through partnerships of state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations.

Background: Reducing health inequities in marginalized populations, including people with Medicaid insurance, requires care transformation to address medical and social needs that is supported and incentivized by tailored payment methods. Collaboration across health care stakeholders is essential to overcome health system fragmentation and implement sustainable reform in the United States (U.S.). This paper explores how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model during early stages of their journey to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives. Methods: Advancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program in the U.S. funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consisted of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations in seven U.S. states. Between June and September 2021, semi-structured interviews were conducted with representatives (n = 23) from all seven teams about experiences implementing the Roadmap to Advance Health Equity model with technical assistance from Advancing Health Equity. Results: Facilitators of building cultures of equity included (1) build upon preexisting intra-organizational cultures of equity, (2) recruit and promote diverse staff and build an inclusive culture, and (3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included (1) use data to identify a health equity focus and (2) overcome stakeholder assumptions about inequities. Facilitators of implementing care transformation and payment reform included (1) partner with Medicaid members and individual providers and (2) support and incentivize equitable care and outcomes with payment. Facilitators of sustainability planning included (1) identify evidence of improved health equity focus and (2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency. Conclusions: Multi-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems.

Rates Of Preterm Birth And Low Birthweight: An Analysis Of Racial And Ethnic Populations.

Using National Center for Health Statistics data (2016-20), we evaluated variation in low birthweight and prematurity among racial and ethnic subcategories. Disparities as large as 2.3-fold among rates of low birthweight for "multiple race" subcategories underscore the need for granular data stratification and analysis by racial and ethnic subcategories to address the root causes of inequities in infant outcomes.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities.

The objective of this technical report is to provide clinicians with actionable evidence-based information upon which to make treatment decisions. In addition, this report will provide an evidence base on which to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are effective clinically based treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori Key Questions.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions.

The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are clinically based, effective treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori key questions.

Mental Health Conditions Increase Severe Maternal Morbidity By 50 Percent And Cost $102 Million Yearly In The United States.

Perinatal mental health disorders are increasingly acknowledged as contributors to adverse maternal outcomes. We analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample (2016 and 2017) to estimate hospitalization cost, length-of-stay, and severe maternal morbidity associated with perinatal mental health disorders overall, as well as stratified by payer and by specific mental health category. We found that people with mental health disorders had $458 higher costs per delivery hospitalization and 50 percent higher rates of severe maternal morbidity compared with people without mental health disorders. We estimated increased annual delivery hospitalization costs of $102 million in the US among people with perinatal mental health conditions compared with those without. Furthermore, people diagnosed with trauma- or stress-related mental health disorders had even higher rates of hospitalization costs-$825 higher per delivery-and 87 percent higher rates of severe maternal morbidity compared with people without those diagnoses. These findings provide important information for perinatal mental health program feasibility and cost-effectiveness analyses and suggest the need for increased focus on trauma- and stress-related disorders.

Policy Opportunities To Improve Prevention, Diagnosis, And Treatment Of Perinatal Mental Health Conditions.

One in five pregnant or postpartum people has a diagnosed mood or anxiety disorder, which are the most common mental health illnesses that occur during the perinatal period. Untreated perinatal mental health conditions, encompassing pregnancy and the first five years of a child's life, carry a societal burden of $14 billion per year in the US. This overview article describes the prevalence of perinatal mental health conditions; the implications of those conditions; and associated barriers to screening, treatment, and bias associated with mental health conditions. We offer six policy opportunities designed to overcome the barriers and support overall sexual and reproductive health: extending Medicaid coverage through twelve months postpartum; redesigning care and reimbursement through co-location of services; establishing coverage for home visiting and peer support programs; enhancing telehealth policies that support access and coverage beyond the COVID-19 pandemic; enhancing data, research, and accountability; and enacting social and economic policies that support families.

Race, Medicaid Coverage, and Equity in Maternal Morbidity.

BACKGROUND: Severe maternal morbidity (SMM) affects 50,000 deliveries in the United States annually, with around 1.5 times the rates among Medicaid-covered relative to privately covered deliveries. Furthermore, large racial inequities exist in SMM for non-Hispanic Black women and Hispanic women with rates being 2.1 and 1.4 times higher than White women, respectively. This study aimed to compare the differences in SMM among women of different races/ethnicities and delivery insurance types. Quantifying the rates of SMM based on the intersection of race/ethnicity and insurance status can help to elucidate how multiple forms of oppression and racism may contribute to the substantial inequities in SMM among Black women. METHODS: Using hospital discharge data from the Healthcare Cost and Utilization Project National Inpatient Sample (years 2016 and 2017), we conducted multivariate logistic models to evaluate equity in maternal outcomes among women with different primary payers, overall and stratified by race/ethnicity. RESULTS: We found a rate of SMM equal to 138.3 per 10,000 deliveries. Differences in the rate of SMM among non-Hispanic Black, non-Hispanic Asian, and Hispanic women relative to White women were lower among Medicaid-covered deliveries relative to deliveries of all payer types. For example, among all payers, Black women had 2.17 (221.3 vs. 102.1 per 10,000) times the rate of SMM compared with White women; however, among Medicaid-covered deliveries, Black women had 1.84 (227.3 vs. 123.2) times the rate. Despite increased risk associated with Medicaid coverage (adjusted odds ratio, 1.12; 95% confidence interval, 1.07-1.16), the risk was no longer significant in the stratified regression including Black women (adjusted odds ratio, 1.06; 95% confidence interval, 0.98-1.15). CONCLUSIONS: Our findings suggest that Black women with Medicaid do not have higher rates of SMM relative to Black women with private insurance. National and state policy efforts should continue to focus on addressing structural racism and other socioeconomic drivers of adverse maternal outcomes, including barriers to high-quality care among women with Medicaid coverage.

Geographic Hotspots for Low Birthweight: An Analysis of Counties With Persistently High Rates.

This study evaluated persistency in county-level rates of low birthweight outcomes to identify "hotspot counties" and their associated area-level characteristics. Administrative data from the National Center for Health Statistics Birth Data Files, years 2011 to 2016 were used to calculate annual county-level rates of low birthweight. Counties ranking in the worst quintile (Q5) for ≥3 years with a neighboring county in the worst quintile were identified as hotspot counties. Multivariate logistic regression was used to associate county-level characteristics with hotspot designation. Adverse birth outcomes were persistent in poor performing counties, with 52% of counties in Q5 for low birthweight in 2011 remaining in Q5 in 2016. The rate of low birthweight among low birthweight hotspot counties (n = 495) was 1.6 times the rate of low birthweight among non-hotspot counties (9.3% vs 5.8%). The rate of very low birthweight among very low birthweight hotspot counties (n = 387) was twice as high compared to non-hotspot counties (1.8% vs 0.9%). A one standard deviation (6.5%) increase in the percentage of adults with at least a high school degree decreased the probability of low birthweight hotspot designation by 1.7 percentage points (P = .006). A one standard deviation (20%) increase in the percentage of the population that was of minority race/ethnicity increased hotspot designation for low birthweight by 5.7 percentage points (P < .001). Given the association between low birthweight and chronic conditions, hotspot counties should be a focus for policy makers in order to improve health equity across the life course.

Associations Between Comorbidities and Severe Maternal Morbidity.

OBJECTIVE: To evaluate the associations between the number of chronic conditions and maternal race and ethnicity (race) with the risk of severe maternal morbidity. METHODS: Using the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, years 2016-2017, we examined risk of severe maternal morbidity among 1,480,925 delivery hospitalizations among women of different races and with different numbers of comorbid conditions using multivariable logistic regression. RESULTS: The rate of severe maternal morbidity was 139.7 per 10,000 deliveries. Compared with women with no comorbidities (rate 48.5/10,000), there was increased risk of severe maternal morbidity among women with one comorbidity (rate 238.6; odds ratio [OR] 5.0, 95% CI 4.8-5.2), two comorbidities (rate 379.9; OR 8.1, 95% CI 7.8-8.5), or three or more comorbidities (rate 560; OR 12.1, 95% CI 11.5-12.7). In multivariable regressions, similar associations were noted for women with one (adjusted odds ratio [aOR] 4.4, 95% CI 4.2-4.6), two (aOR 6.6, 95% CI 6.3-6.9), or three or more comorbidities (aOR 9.1, 95% CI 8.7-9.6). Black women had higher rates of comorbid conditions than all other racial and ethnic groups, with 55% (95% CI 54-56%) of Black women having no comorbidities, compared with 67% (95% CI 67-68%) of White women, 68% (95% CI 67-69%) of Hispanic women, and 72% (95% CI 71-73%) of Asian women. CONCLUSION: We found a dose-response relationship between number of comorbidities and risk of severe maternal morbidity, with the highest rates of severe maternal morbidity among women with three or more comorbidities. Focusing on the prevention and treatment of chronic conditions among women of childbearing age may have the potential to improve maternal outcomes across races and ethnicities.

County-level Variation in Low Birthweight and Preterm Birth: An Evaluation of State Medicaid Expansion Under the Affordable Care Act.

BACKGROUND: Rates of low birthweight and prematurity vary 2-fold across states in the United States, with increased rates among states with higher concentrations of racial minorities. Medicaid expansion may serve as a mechanism to reduce geographic variation within states that expanded, by improving health and access to care for vulnerable populations. OBJECTIVE: The objective of this study was to identify the association of Medicaid expansion with changes in county-level geographic variation in rates of low birthweight and preterm births, overall and stratified by race/ethnicity. RESEARCH DESIGN: We compared changes in the coefficient of variation and the ratio of the 80th-to-20th percentiles using bootstrap samples (n=1000) of counties drawn separately for all births and for white, black, and Hispanic births, separately. MEASURES: County-level rates of low birthweight and preterm birth. RESULTS: Before Medicaid expansion, counties in expansion states were concentrated among quintiles with lower rates of adverse birth outcomes and counties in nonexpansion states were concentrated among quintiles with higher rates. In expansion states, county-level variation, measured by the coefficient of variation, declined for both outcomes among all racial/ethnic categories. In nonexpansion states, geographic variation reduced for both outcomes among Hispanic births and for low birthweight among white births, but increased for both outcomes among black births. CONCLUSIONS: The decrease in county-level variation in adverse birth outcomes among expansion states suggests improved equity in these states. Further reduction in geographic variation will depend largely on policies or interventions that reduce racial disparities in states that did and did not expand Medicaid.

Association of State Medicaid Expansion Status With Low Birth Weight and Preterm Birth.

Importance: Low birth weight and preterm birth are associated with adverse consequences including increased risk of infant mortality and chronic health conditions. Black infants are more likely than white infants to be born prematurely, which has been associated with disparities in infant mortality and other chronic conditions. Objective: To evaluate whether Medicaid expansion was associated with changes in rates of low birth weight and preterm birth outcomes, both overall and by race/ethnicity. Design, Setting, and Participants: Using US population-based data from the National Center for Health Statistics Birth Data Files (2011-2016), difference-in-differences (DID) and difference-in-difference-in-differences (DDD) models were estimated using multivariable linear probability regressions to compare birth outcomes among infants in Medicaid expansion states relative to non-Medicaid expansion states and changes in relative disparities among racial/ethnic minorities for singleton live births to women aged 19 years and older. Exposures: State Medicaid expansion status and racial/ethnic category. Main Outcomes and Measures: Preterm birth (<37 weeks' gestation), very preterm birth (<32 weeks' gestation), low birth weight (<2500 g), and very low birth weight (<1500 g). Results: The final sample of 15 631 174 births (white infants: 8 244 924, black infants: 2 201 658, and Hispanic infants: 3 944 665) came from the District of Columbia and 18 states that expanded Medicaid (n = 8 530 751) and 17 states that did not (n = 7 100 423). In the DID analyses, there were no significant changes in preterm birth in expansion relative to nonexpansion states (preexpansion to postexpansion period, 6.80% to 6.67% [difference: -0.12] vs 7.86% to 7.78% [difference: -0.08]; adjusted DID: 0.00 percentage points [95% CI, -0.14 to 0.15], P = .98), very preterm birth (0.87% to 0.83% [difference: -0.04] vs 1.02% to 1.03% [difference: 0.01]; adjusted DID: -0.02 percentage points [95% CI, -0.05 to 0.02], P = .37), low birth weight (5.41% to 5.36% [difference: -0.05] vs 6.06% to 6.18% [difference: 0.11]; adjusted DID: -0.08 percentage points [95% CI, -0.20 to 0.04], P = .20), or very low birth weight (0.76% to 0.72% [difference: -0.03] vs 0.88% to 0.90% [difference: 0.02]; adjusted DID: -0.03 percentage points [95% CI, -0.06 to 0.01], P = .14). Disparities for black infants relative to white infants in Medicaid expansion states compared with nonexpansion states declined for all 4 outcomes, indicated by a negative DDD coefficient for preterm birth (-0.43 percentage points [95% CI, -0.84 to -0.02], P = .05), very preterm birth (-0.14 percentage points [95% CI, -0.26 to -0.02], P = .03), low birth weight (-0.53 percentage points [95% CI, -0.96 to -0.10], P = .02), and very low birth weight (-0.13 percentage points [95% CI, -0.25 to -0.01], P = .04). There were no changes in relative disparities for Hispanic infants. Conclusions and Relevance: Based on data from 2011-2016, state Medicaid expansion was not significantly associated with differences in rates of low birth weight or preterm birth outcomes overall, although there were significant improvements in relative disparities for black infants compared with white infants in states that expanded Medicaid vs those that did not.

Disparities by Sex Tracked in the 2015 National Healthcare Quality and Disparities Report: Trends across National Quality Strategy Priorities, Health Conditions, and Access Measures.

INTRODUCTION: Established by the Affordable Care Act, the National Quality Strategy (NQS) is the national policy goals aimed at improving the quality of health care for all Americans. The NQS established six priorities to provide better, more affordable care for individuals and communities. This is the first analysis of data on the NQS and access measures that focus on sex differences, health conditions, trends, and disparities. METHODS: Measures from the 2015 National Healthcare Quality and Disparities Report (QDR) for the four National Quality Strategy priorities (Patient Safety, Person Centered Care, Effective Treatment, and Healthy Living), access to care, and health conditions for women were compared to measures for men. Trends were analyzed for women by health condition and the four NQS priorities and access to care. Baseline year (2000-2002) and most current year (2012-2013) were compared to assess disparity trends. All non-institutionalized women and men in the U.S. over the age of 18 were included in the sample. RESULTS: Disparities between males and females for the four NQS priority and access measures did not change for 83 percent of measures (n=81); disparities remained constant. The greatest improvement over time for females from the baseline year was in the patient safety measures (3.66 percent increase per year). Access of care measures showed the least amount of improvement with a median change of -1.20 percent per year. The greatest improvement in quality of care by health condition was amongst chronic kidney disease (11.95 median percent change) and HIV/AIDS (6.63 median percent change) measures. Behavioral health measures showed the least amount of improvement with a median change of -0.33 percent per year. CONCLUSIONS: This analysis highlights cardiovascular disease, behavioral health, and access to care as problem areas for women that require immediate attention. It is of concern that 83% of the measures showed a persistent disparity over time between men and women. These results indicate that there is room for improving the quality of healthcare received by women and reducing sex-based disparities experienced by women in the healthcare delivery system.

Variation in Coverage for Progesterone to Prevent Preterm Birth: A Survey of Medicaid Managed Care Organizations.

INTRODUCTION: Preterm birth is the leading cause of U.S. infant morbidity and mortality; Medicaid enrollees disproportionately experience preterm deliveries. Data suggest that progesterone-an evidence-based therapy for preventing preterm birth-is not accessible to all eligible Medicaid beneficiaries. This study aimed to identify variation in progesterone coverage guidelines in a sample of state Medicaid managed care organizations (MMCOs). MATERIAL AND METHODS: Using a cross-sectional design, participation in a web-based survey was offered to 20 MMCO members of the Medicaid Health Plans of America. The survey assessed coverage guidelines for progesterone and associated interventions to prevent preterm birth. MMCOs identified key barriers in providing progesterone. Descriptive analyses were performed. RESULTS: Analyses included data from 18 plans providing coverage in 31 of the 39 states with MMCOs (response rate, 90.0%). Responding MMCOs were diverse: 55.6% were multistate, 33.3% were nonprofit, and 31.2% covered more than 1,000,000 lives. Most respondents (87.5%) covered branded progesterone, and 81.3% covered compounded progesterone. Prior authorization was required by most plans for branded progesterone (86.7%) or compounded progesterone (75.0%). The MMCO gestational age restrictions for initiating progesterone varied from 22 to 37 weeks of gestation, even within the same state. MMCO-identified barriers to providing progesterone included cost, lack of clinician knowledge of indications and coverage, and variation in billing procedures. DISCUSSION: Marked variation in MMCO coverage policies and procedures for progesterone and related interventions to prevent preterm birth was noted. IMPLICATIONS FOR PRACTICE AND POLICY: Standardizing MMCO coverage policies may be one way to improve access to evidence-based interventions that prevent preterm birth.

Women's Voices in Maternity Care: The Triad of Shared Decision Making, Informed Consent, and Evidence-Based Practices.

The United States is the only industrialized nation that has experienced dramatic increases in the use of maternity interventions resulting in poor birth outcomes. It is speculated that the increased rates of maternal mortality and other outcomes are attributed to the current maternity model of care focused on the overuse of interventions, such as induction of labor, in otherwise healthy pregnant women. The overuse of induction of labor to artificially speed up the birth process has been linked to an increase in preterm and cesarean births. The cost of these interventions and poor outcomes has been substantial. The purpose of this article is to present concepts that demonstrate the challenges and value of informed, shared decision making, informed consent, and women's use of evidence within the context of maternity care. To highlight these important concepts, this article presents original findings from a secondary analysis of data on induction of labor. Findings from this analysis further highlight the importance of including women as part of informed, shared decision making in models of maternity care.

A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients.

Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dual-minority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender ("LGBT") racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.

Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model.

BACKGROUND: In response to the passage of the Affordable Care Act in the United States, clinicians and researchers are critically evaluating methods to engage patients in implementing evidence-based care to improve health outcomes. However, most models on implementation only target clinicians or health systems as the adopters of evidence. Patients are largely ignored in these models. A new implementation model that captures the complex but important role of patients in the uptake of evidence may be a critical missing link. DISCUSSION: Through a process of theory evaluation and development, we explore patient-centered concepts (patient activation and shared decision making) within an implementation model by mapping qualitative data from an elective induction of labor study to assess the model's ability to capture these key concepts. The process demonstrated that a new, patient-centered model for implementation is needed. In response, the Evidence Informed Decision Making through Engagement Model is presented. We conclude that, by fully integrating women into an implementation model, outcomes that are important to both the clinician and patient will improve. CONCLUSIONS: In the interest of providing evidence-based care to women during pregnancy and childbirth, it is essential that care is patient centered. The inclusion of concepts discussed in this article has the potential to extend beyond maternity care and influence other clinical areas. Utilizing the newly developed Evidence Informed Decision Making through Engagement Model provides a framework for utilizing evidence and translating it into practice while acknowledging the important role that women have in the process.

Moving toward patient-centered care: Women's decisions, perceptions, and experiences of the induction of labor process.

BACKGROUND: Patient preferences and clinician practices are possible causative factors to explain the increase in induction of labor, but scientific studies that demonstrate this link are limited. The purpose of this study is to identify factors that influence inductions from the perspective of women. METHODS: A qualitative investigation using grounded theory methodology was conducted. Women were interviewed preinduction and postinduction. Analysis of the interviews was conducted using constant comparison to identify codes, categories, and themes. Through this process the complex intersection between women, their clinician, and the application of evidence-based care in clinical practice was explored. RESULTS: Five major themes from the preinduction interview were identified; safety of baby, women's trust in their clinician, relief of discomfort and/or anxiety, diminish potential or actual risk, and lack of informed decision making. Five major themes were identified from the postinduction interview; lack of informed decision making, induction as part of a checklist, women's trust in their clinician, happy with induction, and opportunities to improve the experience. CONCLUSIONS: Lack of informed decision making was cited as a barrier to optimal care. This study has important implications for patient-centered research and clinical care, requiring the inclusion of women and the salient concepts of care that they identify.