Between "a lot of room for it" and "it doesn't exist"-Advancing and limiting factors of autonomy in birth as perceived by perinatal care practitioners: An interview study in Switzerland.

BACKGROUND: Numerous studies show that negative birth experiences are often related to birthing people's loss of autonomy. We argue that a fetal-focused decision-making framework and a maternal-fetal conflict lens are often applied, creating a false dichotomy between autonomy and fetal beneficence. Given the high prevalence of autonomy-depriving decision-making, it is important to understand how autonomy can be enhanced. METHODS: We interviewed 15 Swiss perinatal care practitioners (eight midwives, five physicians, and two doulas) and employed reflexive thematic analysis. We offer a reflection on underlying assumptions and researcher positionality. RESULTS: We generated two descriptive themes: advancing and limiting factors of autonomy. Numerous subthemes, grouped at the levels of companion, birthing person, practitioners, birthing person-practitioner relationship, and structural determinants are also defined. The most salient advancing factors were practitioners' approaches to decision-making, antenatal contacts, and structural determinants. The most salient limiting factors were various barriers within birthing people (e.g., expertise, decisional capacity, and awareness of own rights), practitioners' attitudes and behavior, and structural determinants. DISCUSSION: The actualization of autonomy is multifactorially determined and must be understood against the background of power structures both underlying and inherent to decision-making in birth. Practitioners attributed a significant proportion of limited autonomy to birthing people themselves. This reinforces a "mother-blame" narrative that absolves obstetrics of primary responsibility. Practitioners' recognition of their contributions to upholding limits on autonomy should be leveraged to implement training towards rights-based practice standards. Most importantly, autonomy can only fully materialize if the underlying sociocultural, political, and medical contexts undergo a fundamental change.

Childbearing at the margins: A systematic metasynthesis of sexual and gender diverse childbearing experiences.

BACKGROUND: The reproductive and perinatal health of sexual and gender-diverse (SGD) individuals is a research priority area for the National Institutes of Health. Over the past decade, this childbearing population has been the focus of several qualitative studies providing the opportunity to evaluate and synthesize the qualitative literature on SGD childbearing experiences in a metasynthesis. METHODS: We conducted a literature search of four databases to identify original research published from January 2011 through June 2021. These results were augmented by forward and backward searching strategies. Two authors independently screened studies. All qualitative studies of the childbearing experience were eligible. Data were extracted and inductively coded using conventional content analysis, and studies underwent a quality appraisal by two authors. RESULTS: From 2396 articles, 127 full-text articles were screened, and 25 were included in this synthesis. Three overarching themes were identified: (a) Systematic Invisibility; (b) Creating Personhood Through Parenthood; and (c) Resilient Narratives of Childbearing. CONCLUSIONS: Relative to heterosexual and cisgender parents, SGD childbearing parents experience unique structural and interpersonal challenges and employ critically important resilience strategies and coping techniques to manage an overwhelming heterocisnormative experience. These findings provide an important target for health care organizations and professionals to improve SGD perinatal health. In addition, this metasynthesis identified persistent gaps in our understanding of this marginalized childbearing population, which have important implications for reducing health disparities that SGD parents experience.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration.

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Transdisciplinary Imagination: Addressing Equity and Mistreatment in Perinatal Care.

Inequities in birth outcomes are linked to experiential and environmental exposures. There have been expanding and intersecting wicked problems of inequity, racism, and quality gaps in childbearing care during the pandemic. We describe how an intentional transdisciplinary process led to development of a novel knowledge exchange vehicle that can improve health equity in perinatal services. We introduce the Quality Perinatal Services Hub, an open access digital platform to disseminate evidence based guidance, enhance health systems accountability, and provide a two-way flow of information between communities and health systems on rights-based perinatal services. The QPS-Hub responds to both community and decision-makers' needs for information on respectful maternity care. The QPS-Hub is well poised to facilitate collaboration between policy makers, healthcare providers and patients, with particular focus on the needs of childbearing families in underserved and historically excluded communities.

Kairos care in a Chronos world: Midwifery care as model of resistance and accountability in public health settings.

BACKGROUND: In the United States (US), pregnancy-related mortality is 2-4 times higher for Black and Indigenous women irrespective of income and education. The integration of midwifery as a fundamental component of standard maternity services has been shown to improve health outcomes and service user satisfaction, including among underserved and minoritized groups. Nonetheless, there remains limited uptake of this model in the United States. In this study, we examine a series of interdependent factors that shape how midwifery care operates in historically disenfranchised communities within the Unites States. METHODS: Using data collected from in-depth, semi-structured interviews, the purpose of this study was to examine the ways midwives recount, describe, and understand the relationships that drive their work in a publicly funded urban health care setting serving minoritized communities. Using a qualitative exploratory research design, guided by critical feminist theory, twenty full-scope midwives working in a large public health care network participated. Data were thematically analyzed using Braun & Clarke's inductive thematic analysis to interpret data and inductively identify patterns in participants' experiences. FINDINGS: The overarching theme "Kairos care in a Chronos World" captures the process of providing health-promoting, individualized care in a system that centers measurement, efficiency, and pathology. Five subthemes support the central theme: (1) the politics of progress, (2) normalizing pathologies, (3) cherished connections, (4) protecting the experience, and (5) caring for the social body. Midwives used relationships to sustain their unique care model, despite the conflicting demands of dominant (and dominating) medical models. CONCLUSION: This study offers important insight into how midwives use a Kairos approach to maternity care to enhance quality and safety. In order to realize equitable access to optimal outcomes, health systems seeking to provide robust services to historically disenfranchised communities should consider integration of relationship-based strategies, including midwifery care.

I felt so much conflict instead of joy: an analysis of open-ended comments from people in British Columbia who declined care recommendations during pregnancy and childbirth.

BACKGROUND: No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended. METHODS: In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations. RESULTS: More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences. CONCLUSIONS: Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

How Practice Facilitation Strategies Differ by Practice Context.

BACKGROUND: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

A case study on building capacity to improve clinical mentoring and maternal child health in rural Tanzania: the path to implementation.

BACKGROUND: Tanzania is a low income, East African country with a severe shortage of human resources for health or health workers. This shortage threatens any gains the country is making in improving maternal health outcomes. This paper describes a partnership between Touch Foundation and NYU Rory Meyers College of Nursing - Global, aimed at improving clinical mentorship and capacity among nurses and midwives at two rural hospitals in the Tanzanian Lake Zone Region. Clinical mentoring capacity building and supportive supervision of staff has been shown to be a facilitator of retaining nurses and would be possible to acquire and implement quickly, even in a context of low resources and limited technology. METHODS: A case study approach structures this program implementation analysis. The NYU Meyers team conducted a 6-day needs assessment at the two selected hospitals. A SWOT analysis was performed to identify needs and potential areas for improvement. After the assessment, a weeklong training, tailored to each hospitals' specific needs, was designed and facilitated by two NYU Meyers nursing and midwifery education specialists. The program was created to build on the clinical skills of expert nurse and midwife clinicians and suggested strategies for incorporating mentoring and preceptorship as a means to enhance clinical safety and promote professional communication, problem solving and crisis management. RESULTS: Nineteen participants from both hospitals attended the training. Fourteen of 19 participants completed a post training, open ended questionnaire for a 74% response rate. Fifty-seven percent of participants were able to demonstrate and provide examples of the concepts of mentorship and supervision 4 and 11 months' post training. Participants indicated that while confidence in skills was not lacking, barriers to quality care lay mostly in understaffing. Implementation also offered multiple insights into contextual factors affecting sustainable program implementation. CONCLUSIONS: Three recommendations from this training include: 1) A pre-program assessment should be conducted to ascertain contextual relevance to curriculum development; 2) flexibility and creativity in teaching methods are essential to engage students; and 3) access to participants a priori to program implementation may facilitate a more tailored approach and lead to greater participant engagement.

Notes from the Field: Residents' Perceptions of Simulation-Based Skills Assessment in Obstetrics and Gynecology.

Simulation in obstetrics and gynecology (OBGYN) training captures a range of interpersonal, cognitive, and technical skills. However, trainee perspectives on simulation-based assessment remain unexplored. After an observed structured clinical examination (OSCE) simulation hybrid exam, two focus groups of residents were conducted. Analysis grounded in a thematic coding guided the qualitative research process. Responses suggest a valuation of cognitive and technical skills over interpersonal skills. Realism was seen as critical and residents perceived the assessment as more valuable for the educator than the learner. Feedback was highly valued. Resident perspectives on this exam give insight into their perceptions of simulation-based assessment as well as their conceptions of their own learning through simulations.