Birth Experience Among Black Women in the United States: A Qualitative Meta-Synthesis.

INTRODUCTION: There are striking disparities in perinatal health outcomes for Black women in the United States. Although the causes are multifactorial, research findings have increasingly identified social and structural determinants of health as contributors to perinatal disparities. Maltreatment during perinatal care, which is disproportionately experienced by Black women, may be one such contributor. Qualitative researchers have explored Black women's perinatal care experiences, but childbirth experience data has yet to be analyzed in-depth across studies. The aim of this meta-synthesis was to explore the birthing experience of Black women in the United States. METHODS: PubMed, Embase, PsycINFO, and CINAHL databases were searched. Inclusion criteria were qualitative research studies that included birth experience data shared by self-identified Black or African American women who had given birth in the United States. Exclusion criteria were reports that did not include rich qualitative data or only included experience data that did not specify the race of the participant (eg, data pooled for women of color). The search began February 2022 and ended June 2022. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to appraise the research. Results were synthesized using content analysis. RESULTS: Fifteen studies met inclusion criteria. Main themes included (1) trust: being known and seen; (2) how race influences care; (3) preserving autonomy; and (4) birth as trauma. DISCUSSION: Fragmented care resulted in reports of poor birth experiences in several studies. Open communication and feeling known by perinatal care providers was influential in improving childbirth experiences among Black women; these themes are consistent with existing research. Further prospective research exploring relationships among these themes and perinatal outcomes is needed. Limitations of this report include the use of content analysis and meta-synthesis which may lose the granularity of the original reports; however, the aggregation of voices may provide valuable, transferable, actionable insight that can inform future supportive care interventions.

Predictors of maternal health services uptake in West African region: a multilevel multinomial regression analysis of demographic health survey reports.

BACKGROUND: Pursuant to studies, receiving the three key maternal health services (Antenatal Care, Skilled Delivery Service, and Postnatal Care) in a continuum could prevent 71% of global maternal deaths. Despite the Western African region being known for its high maternal death and poor access to maternal health services, there is a dearth of studies that delve into the spectrum of maternal health services uptake. Hence, this study aimed to assess the level and predictors of partial and adequate utilization of health services in a single analytical model using the most recent Demographic and Health Survey (DHS) data (2013-2021). METHODS: This study was based on the appended women's (IR) file of twelve West African countries. STATA software version 16 was used to analyze a weighted sample of 89,504 women aged 15-49 years. A composite index of maternal health service utilization has been created by combining three key health services and categorizing them into 'no', 'partial', or 'adequate' use. A multilevel multivariable multinomial logistic regression analysis was carried out to examine the effects of each predictor on the level of service utilization. The degree of association was reported using the adjusted relative risk ratio (aRRR) with a corresponding 95% confidence interval, and statistical significance was declared at p < 0.05. RESULTS: 66.4% (95% CI: 64.9, 67.7) and 23.8% (95% CI: 23.3, 24.2) of women used maternal health services partially and adequately, respectively. Togo has the highest proportion of women getting adequate health care in the region, at 56.7%, while Nigeria has the lowest proportion, at 11%. Maternal education, residence, wealth index, parity, media exposure (to radio and television), enrolment in health insurance schemes, attitude towards wife beating, and autonomy in decision-making were identified as significant predictors of partial and adequate maternal health service uptake. CONCLUSION: The uptake of adequate maternal health services in the region was found to be low. Stakeholders should plan for and implement interventions that increase women's autonomy. Program planners and healthcare providers should give due emphasis to those women with no formal education and from low-income families. The government and the private sectors need to collaborate to improve media access and increase public enrolment in health insurance schemes.

Validation of a measure of hospital maternal level of care for the United States.

BACKGROUND: Lack of a validated assessment of maternal risk-appropriate care for use in population data has prevented the existing literature from quantifying the benefit of maternal risk-appropriate care. The objective of this study was to develop a measure of hospital maternal levels of care based on the resources available at the hospital, using existing data available to researchers. METHODS: This was a secondary data analysis. The sample was abstracted from the American Hospital Association Annual Survey Database for 2018. Eligibility was limited to short-term acute general hospitals that reported providing maternity services as measured by hospital reporting of an obstetric service level, obstetric services, or birthing rooms. We aligned variables in the database with the ACOG criteria for each maternal level of care, then built models that used the variables to measure the maternal level of care. In each iteration, the distribution of hospitals was compared to the distribution in the CDC Levels of Care Assessment Tool Validation Pilot, assessing agreement with the Wilson Score for proportions for each level of care. Results were compared to hospital self-report in the database and measurement reported with another published method. RESULTS: The sample included 2,351 hospitals. AHA variables were available to measure resources that align with ACOG Levels 1, 2, and 3. Overall, 1219 (51.9%) of hospitals reported resources aligned with Maternal Level One, 816 (34.7%) aligned with maternal level two, and 202 (8.6%) aligned with maternal level Three. This method overestimates the prevalence of hospitals with maternal level one compared to the CDC measurement of 36.1% (Mean 52.9%; 95% CI47.2%-58.7%), and likely includes hospitals that would not qualify as level one if all resources required by the ACOG guidelines could be assessed. This method underestimates the prevalence of hospitals with maternal critical care services (Level 3 or 4) compared to CDC measure of 12.1% (Mean 8.1%; 95%CI 6.2% - 10.0%) but is an improvement over hospital self-report (24.7%) and a prior published method (32.3%). CONCLUSIONS: This method of measuring maternal level of care allows researchers to investigate the value of perinatal regionalization, risk-appropriate care, and hospital differences among the three levels of care. This study identified potential changes to the American Hospital Association Annual Survey that would improve identification of maternal levels of care for research.

Improving maternal and neonatal outcomes for women with gestational diabetes through continuity of midwifery care: A cross-sectional study.

PROBLEM: Gestational Diabetes Mellitus (GDM) is a complication of pregnancy which may exclude women from midwife-led models of care. BACKGROUND: There is a paucity of research evaluating the safety and feasibility of continuity of midwifery care (CoMC) for women with GDM. AIM: To investigate the impact of CoMC on maternal and neonatal outcomes, for otherwise low-risk women with GDM. METHODS: This exploratory cross-sectional study observed maternal and neonatal outcomes including onset of labour, augmentation, labour analgesia, mode of birth, perineal trauma, gestation at birth, shoulder dystocia, infant birth weight, neonatal feeding at discharge. FINDINGS: Participants were 287 otherwise low-risk pregnant women, who developed GDM, and either received CoMC (n=36) or standard hospital maternity care (non-CoMC) (n=251). Women with GDM who received CoMC were significantly more likely to experience an spontaneous onset of labour (OR 6.3; 95% CI 2.7-14.5; p<.001), labour without an epidural (OR 4.2; 95% CI 2.0 - 9.2,<0.001) and exclusively breastfeed (OR 4.3; 95% CI 1.26 - 14.32; p=0.02). DISCUSSION: Receiving CoMC may be a public health initiative which not only improves maternal and neonatal outcomes, but also long-term morbidity associated with GDM. CONCLUSION: Findings provide preliminary evidence suggesting CoMC improves maternal and neonatal outcomes and is likely a safe and viable option for otherwise low-risk women with GDM. Larger studies are recommended to confirm findings and explore the full impact of CoMC for women with GDM.

Promoting maternal-child health by increasing breastfeeding rates: a National Canadian Baby-Friendly Initiative Quality Improvement Collaborative Project.

While breastfeeding has long been an important, globally recognized aspect of population health, disparities exist across Canada. The Baby-Friendly Initiative (BFI) is a WHO/UNICEF best-practice program that helps ensure families receive evidence-based perinatal care and is associated with improved breastfeeding rates. However, <10% of hospitals in Canada are designated as 'Baby-Friendly'.The Breastfeeding Committee for Canada (BCC) aimed to increase the number of hospitals that moved towards BFI designation by implementing a National BFI Quality Improvement Collaborative Project. Key activities included (1) implementing and evaluating the BFI Project with 25 hospital teams across Canada and (2) making recommendations for scaling up BFI in Canada.As of December 2023, three hospitals in the BFI Project have attained designation and six have started the official process towards designation with the BCC. Breastfeeding initiation rates remained high and stable (>80%); however, breastfeeding exclusivity rates did not meet targets. All BFI care indicators improved across participating facilities. All skin-to-skin indicators improved, with rates of immediate and sustained skin-to-skin meeting targets of >80% for vaginal births. BFI care indicators of documented assistance and support with breastfeeding within 6 hours of birth, rooming-in and education about community supports also met target levels. Leadership buy-in, parent partner engagement and collaborative activities of workshops, webinars and mentoring with BFI Project leadership were viewed as valuable.This BFI Project demonstrated that hospitals could successfully implement Baby-Friendly practices in various Canadian settings despite challenges introduced by the COVID-19 pandemic. Indicators collected as part of this work demonstrate that delivery of Baby-Friendly care improved in participating facilities. Sustainability and scaling up BFI implementation in both hospitals and community health services across Canada through implementation of a BFI Coach Mentor Program is ongoing to enable continued progress and impact on breastfeeding and maternal-child health.

Health-related quality of life of postpartum women and associated factors in Dendi district, West Shoa Zone, Oromia Region, Ethiopia: a community-based cross-sectional study.

BACKGROUND: Promoting a favorable experience of postpartum care has become increasingly emphasized over recent years. Despite the fact that maternal health care services have improved over the years, postnatal care service utilization is generally low and the health-related quality of life of postpartum women remains overlooked. Furthermore, the health-related quality of life of postpartum women is not well studied. Therefore, this study aimed to assess the health-related quality of life of postpartum women and associated factors in Dendi district, West Shoa Zone, Oromia, Region, Ethiopia. METHODS: A community-based cross-sectional study was conducted among 429 participants. A multistage stratified sampling procedure was used to select the sampling unit and simple random sampling technique was employed to select the study participants from 23 August 2022 to 16 November 2022. A pre-tested standard structured questionnaire was used to collect the data. Data were entered using Epi-Data 3.1 and then exported to Statistical package for social science version 26. Binary logistic regression analysis was computed at p-value < 0.25 were considered candidates for multivariable logistic regression. Adjusted Odds Ratios (AOR) with 95% confidence interval and statistical significance was declared at a p-value < 0.05. RESULTS: The study revealed that 73.7% (95% CI: 69.4-77.7) had a low level of health-related quality-of-life with a mean of 44.02 (SD ± 10.4). Urban residing [AOR = 0.27, 95% CI: (0.10-0.74)], no education [AOR = 3.44, 95% CI (1.35-8.74)], received at least four antenatal contact [AOR = 0.56, 95% CI (0.33-0.95)], received at least one postnatal care [AOR = 0.30, 95% CI (0.14-0.62)], poor social support [AOR = 2.23, 95% CI: (1.025-4.893)], having postpartum depression [AOR = 2.99, 95% CI: (1.52-5.56)], cesarean delivery [AOR = 3.18, 95% CI: (1.09-9.26)], and lowest household assets [AOR = 5.68, 95% CI: (2.74-11.76)] were significant associations with low health-related quality of life of postpartum women. CONCLUSIONS: The health-related quality of life among postpartum women was very low. Postpartum women with low socio-economic status and inadequate maternal health service utilization had a low health-related quality of life. Promoting women's education and postnatal care services is needed to improve the health-related quality of life of postpartum women.

Pregnant women's satisfaction with the quality of antenatal care and the continued willingness to use health facility care in Lusaka district, Zambia.

BACKGROUND: Antenatal healthcare (ANC) reduces maternal and neonatal deaths in low-middle-income countries. Satisfaction with ANC services and perception of quality of care are critical determinants of service utilization. The study aimed to assess pregnant women's satisfaction with ANC and identify sociodemographic factors associated with satisfaction and their continued willingness to use or recommend the facility to relatives or friends, in Lusaka district, Zambia. METHODS: This was a cross-sectional study involving 499 pregnant women in Lusaka district. A combination of stratified, multistage, and systematic sampling procedures was used in selecting health facilities and pregnant women. This allowed the researcher to assess exposure and status simultaneously among individuals of interest in a population. Structured survey instruments and face-face-interview techniques were used in collecting data among pregnant women who were receiving ANC in selected health facilities. RESULTS: Overall, the proportion of pregnant women who were fully satisfied with ANC was 58.9% (n = 292). Pregnant women's satisfaction score ranged from physical aspects (40.9 - 58.3%), interpersonal aspects (54.3 - 57.9%) to technical aspects of care (46.9 - 58.7%). Husbands' employment status (OR = 0.611, 95%CI = 0.413 - 0.903, p = 0.013), monthly household income level of > 3000 - ≤6000 Kwacha (OR = 0.480, 95%CI = 0.243 - 0.948, p = 0.035 were significantly associated with the interpersonal aspects and the physical aspects of care, respectively. Besides, pregnant women who were in their third trimester (above 33 weeks), significantly predicted satisfaction with the physical environment of antenatal care (OR = 3.932, 95%CI = 1.349 - 11.466, p = 0.012). In terms of the type of health facility, women who utilized ANC from Mtendere (OR = 0.236, 95% CI = 0.093 - 0.595, p = 0.002) and N'gombe (OR = 0.179, 95% CI = 0.064 - 0.504, p = 0.001) clinics were less satisfied with the physical environment of care. Place of residence and educational attainment showed significant association with 'willingness to return'. N'gombe clinic (n = 48, 77.4%) received the lowest consideration for 'future care'. CONCLUSION: Drawing on Donabedian framework on assessing quality of healthcare, we posit that pregnant women's satisfaction with the quality of antenatal care was low due to concerns about the physical environment of health facilities, the interpersonal relationships between providers and pregnant women as well as the technical aspects of care. All these accounted for pregnant women's dissatisfaction with the quality of care, and the indication of unwillingness to return or recommend the health facilities to colleagues. Consistent with Donabedian framework, we suggest that the codes and ethics of healthcare must be upheld. We also call for policy initiatives to reshape the physical condition of ANC clinics and to reinforce healthcare providers' focus on the 'structures' and the 'processes' relevant to care in addition to the 'outcomes'.

Assessment of Family Medicine Obstetrics Fellowship Websites in the United States: Content and Usability.

INTRODUCTION: The United States is experiencing maternity care shortages. Family physicians can play a role in addressing these shortages. Family medicine obstetrics fellowships train family physicians in obstetrics care. Fellowship websites are important for promoting programs and attracting applicants. However, whether websites provide sufficient program information is unknown. This study aimed to assess completeness and utility of family medicine obstetrics fellowship websites across the United States. METHOD: The study analyzed 46 family medicine obstetrics fellowship websites. The component analysis evaluated the presence of 17 components related to orientation, curriculum, program, personnel, and additional content. The qualitative analysis included ratings for navigation and application, information quality, and esthetics. Analysis included percentages for websites and components and average qualitative ratings. RESULTS: Common components included overviews, training requirements, and contact information. Description of the patient population was the least common component. Usability ratings varied across programs, with higher ratings observed for navigation and application, and information quality. Esthetics and visual appeal received lower ratings. Regional analysis indicated that websites from fellowships in the West and Southwest tended to include more components compared to those in the Southeast. DISCUSSION: Family medicine obstetrics fellowship websites serve as valuable sources of program information for prospective applicants. However, not all websites include essential program details. Some information is rarely provided. Given the shortage of maternity care providers, it is crucial to develop informative and functional websites to attract applicants. Improving website content and design could prove to be a cost-effective strategy to increase the number of applicants.

Retaining the perinatal care workforce: Lessons learned from experienced physicians who no longer attend deliveries.

OBJECTIVE: To inform policy supporting the retention of family physicians (FPs) in the perinatal care workforce by identifying physician characteristics that are associated with retention. DATA SOURCES AND STUDY SETTING: We surveyed FPs who had been in practice for at least 11 years and reported attending deliveries as part of their practice. STUDY DESIGN: We compared the characteristics of FPs who continue to provide perinatal care to those who have ceased and explored their reasons for no longer attending deliveries. DATA COLLECTION/EXTRACTION METHODS: We estimated a probit regression with the dependent variable: whether the physician currently delivers babies. Open-ended survey responses were analyzed and close-coded using a conceptual content analysis approach. PRINCIPLE FINDINGS: Of the FPs who received a survey, 1505 (37%) responded. Those who continue attending deliveries were more likely to receive a stipend or be paid per hour/shift in addition to their salary versus those paid a salary (percentage point difference = 13), and less likely to work part-time versus full-time (percentage point difference = -20). Those who ceased attending deliveries cite lifestyle (n = 208), call structure (n = 113), and delivery volume (n = 89) among the reasons for doing so. CONCLUSIONS: Evidence-based policies aimed at preventing attrition from the perinatal care workforce, which might include targeting compensation models and work-life balance.

Giving birth on the way to the clinic: undocumented migrant women's perceptions and experiences of maternal healthcare accessibility along the Thailand-Myanmar border.

BACKGROUND: Millions of women give birth annually without the support of a trained birth attendant. Generally and globally, countries provide maternal health services for their citizens but there is a coverage gap for undocumented migrant women who often can't access the same care due to their legal status. The objective of this investigation is to explore undocumented migrants' experiences and perceptions of maternal healthcare accessibility. METHODS: We held focus groups discussions with 64 pregnant women at 3 migrant health clinics on the Thailand-Myanmar border and asked how they learned about the clinic, their health care options, travel and past experiences with birth services. In this context undocumented women could sign up for migrant health insurance at the clinic that would allow them to be referred for tertiary care at government hospitals if needed. RESULTS: Women learned about care options through a network approach often relying on information from community members and trusted care providers. For many, choice of alternate care was limited by lack of antenatal care services close to their homes, limited knowledge of other services and inability to pay fees associated with hospital care. Women travelled up to 4 h to get to the clinic by foot, bicycle, tractor, motorcycle or car, sometimes using multiple modes of transport. Journeys from the Myanmar side of the border were sometimes complicated by nighttime border crossing closures, limited transport and heavy rain. CONCLUSIONS: Undocumented migrant women in our study experienced a type of conditional or variable accessibility where time of day, transport and weather needed to align with the onset of labour to ensure that they could get to the migrant clinic on time to give birth. We anticipate that undocumented migrants in other countries may also experience conditional accessibility to birth care, especially where travel is necessary due to limited local services. Care providers may improve opportunities for undocumented pregnant women to access maternal care by disseminating information on available services through informal networks and addressing travel barriers through mobile services and other travel supports. Trial registration The research project was approved by Research Ethics Committee at the Faculty of Medicine, Chiang Mai University (FAM-2560-05204), and the Department of Community Medicine and Global Health at the University of Oslo-Norwegian Centre for Research Data (58542).

Undocumented pregnant migrants have difficulties and limitations in accessing maternal health care services. Although the governments have tried to provide maternal health care services to all, there is still a gap in coverage among this population. This study explores how undocumented pregnant migrants perceive their ability to access maternal health care and share their experiences when utilizing it. We used focus groups to interview 64 pregnant women at three migrant health clinics on the Thailand­Myanmar border. We asked how they learned about the clinic, their health care options, travel, and past experiences with birth services. The results showed that they usually knew about care options from community members and trusted care providers. The limitations for the choice of alternate care were due to a lack of services close to their homes, limited knowledge of other services, inability to pay hospital fees, and difficulty traveling from their residence to the clinic. Therefore, we anticipate that undocumented migrants in other countries may also experience difficulties in accessibility to birth care, especially where travel is necessary due to limited local services. Care providers may improve opportunities for these migrants to access maternal care by disseminating information on available services through informal networks and addressing travel barriers through mobile services and other travel supports.

User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study.

Background: Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors. Methods: A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching. Results: The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13). Conclusion: User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.

Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis.

BACKGROUND: Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS: We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants' perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS: Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS: In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER: NCT03112018.

International and national frameworks, guidelines, recommendations, and strategies for maternal tobacco prevention and cessation: A scoping review protocol.

Tobacco use during and around pregnancy can significantly increase the risk of stillbirth, congenital disabilities, premature birth, and low-weight birth. To establish maternal tobacco prevention and cessation frameworks for primary care and dental providers and to facilitate cross-national learning, this scoping review aims: 1) to analyze the body of literature on maternal tobacco prevention and cessation frameworks, guidelines, recommendations, and strategies at the international and national level; 2) to identify common core elements; and 3) to identify gaps in the literature, and propose future initiatives and policy development directions. A systematic database search based on the JBI methodology and corresponding PRISMA-ScR guidelines will be conducted from January 2015 to August 2023. Searches in different databases will be combined with an expert survey among the members of the World Federation of Public Health Associations (WFPHA) - Oral Health, Tobacco Control, and the Women, Adolescent, and Children's Working Groups to evaluate the search outcomes and add maternal tobacco prevention and cessation frameworks, guidelines, recommendations, or strategies. Using a systematic review tool to support the screening, two independent reviewers will screen the titles and abstracts of all articles, in order to include the relevant ones for full-text screening, and an independent third author will resolve conflicts, if there is any discrepancy between the two independent reviewers' search. After a full-text review, data extraction will be conducted for analysis. Descriptive analyses include the publication year, country, legal quality, and target group addressed. A narrative synthesis will describe the scope and content of the frameworks, guidelines, recommendations, and strategies. The scoping review will serve as a stepping-stone to creating a WFPHA policy resolution on tobacco prevention and cessation framework for women of childbearing age led by the WFPHA Oral Health, Tobacco Control and the Women, Adolescent, and Children's Working Group members. This WFPHA policy resolution 'Maternal Tobacco Cessation and Prevention Recommendations for Primary Care Providers and Dental Providers' will be forwarded to the WFPHA General Council and the General Assembly for approval and will be disseminated to the WFPHA public health association members. Ultimately, this recommendation will be used by each national public health association to consider integrating it into their maternal health strategy.

Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012-2021.

To evaluate associations between depression and/or anxiety disorders during pregnancy (DAP), delivery-related outcomes, and healthcare utilization among individuals with Michigan Medicaid-funded deliveries. We conducted a retrospective delivery-level analysis comparing delivery-related outcomes and healthcare utilization among individuals with and without DAP between January 2012 and September 2021. We used generalized estimating equation models assessing cesarean and preterm delivery; 30-day readmission after delivery; severe maternal morbidity within 42 days of delivery; and ambulatory, inpatient, emergency department or observation (ED), psychotherapy, or substance use disorders (SUD) visits during pregnancy. We adjusted models for age, race/ethnicity, urbanicity, federal poverty level, and obstetric comorbidities. Among 170,002 Michigan Medicaid enrollees with 218,890 deliveries, 29,665 (13.6%) had diagnoses of DAP. Compared to those without DAP, individuals with DAP were more often White, rural dwelling, had lower income, and had more comorbidities. In adjusted models, deliveries with DAP had higher odds of cesarean and preterm delivery OR = 1.02, 95% CI: [1.00, 1.05] and OR = 1.15, 95% CI: [1.11, 1.19] respectively), readmission within 30 days postpartum (OR = 1.14, 95% CI: [1.07, 1.22]), SMM within 42 days (OR = 1.27, 95% CI: [1.18, 1.38]), and utilization compared to those without DAP diagnoses (ambulatory: OR = 7.75, 95% CI: [6.75, 8.88], inpatient: OR = 1.13, 95% CI: [1.11, 1.15], ED: OR = 1.86, 95% CI: [1.80, 1.92], psychotherapy: OR = 172.8, 95% CI: [160.10, 186.58], and SUD: OR = 5.6, 95% CI: [5.37, 5.85]). Among delivering individuals in Michigan Medicaid, DAP had significant associations with adverse delivery-related outcomes and greater healthcare use. Early detection and intervention to address mental illness during pregnancy may help mitigate burdens of these complex yet treatable disorders.

Impact of quality improvement interventions on facility readiness, quality and uptake of maternal and child health services in developing regions of Ethiopia: a secondary analysis of programme data.

BACKGROUND: Quality improvement intervention (QI) was implemented from 2018 to 2021 in health facilities of developing regional states of Ethiopia. The main objective of this study was to examine the impact of QI interventions on facility readiness, service availability, quality and usage of health services in these regions. METHODS: We used district health information system data of 56 health facilities (HFs). We also used baseline and endline QI monitoring data from 28 HFs. Data were summarised using descriptive statistics and various tests. Regression analysis was employed to examine the impact of QI interventions on various outcomes. RESULT: The QI intervention improved readiness of HFs, service availability and quality of maternal and child health service delivery. The mean availability of basic amenities increased from 1.89 to 2.89; HF cleanliness score increased from 4.43 to 5.96; family planning method availability increased from 4 to 5.75; score for emergency drugs at labour ward increased from 5.32 to 7.00; and the mean score for basic emergency obstetric and newborn care service availability increased from 5.68 to 6.75; intrauterine contraceptive devices removal service increased from 39.3% to 82.1%; and partograph use increased from 53.6% to 92.9%. HFs that use partograph for labour management increased by 39.3%. The QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7% and correct active third-stage labour management, a 19.6% improvement from the baseline. The interventions also increased the service uptake of maternal health services, but not significantly associated with improvement in contraceptive service uptake. CONCLUSION: The integrated QI interventions in HFs could have an impact on facility readiness for service delivery, service accessibility and quality of service delivery. The effectiveness of the QI intervention should be evaluated using robust methods, and efforts to enhance contraceptive services through a QI approach requires further study.

Impact of the COVID-19 Pandemic on Births, Vaginal Deliveries, Cesarian Sections, and Maternal Mortality in a Brazilian Metropolitan Area: A Time-Series Cohort Study.

Purpose: The COVID-19 pandemic posed a worldwide challenge, leading to radical changes in healthcare. The primary objective of the study was to assess the impact of the COVID-19 pandemic on birth, vaginal delivery, and cesarian section (c-section) rates. The secondary objective was to compare the maternal mortality before and after the pandemic. Patients and Methods: Time-series cohort study including data of all women admitted for childbirth (vaginal delivery or c-section) at the maternities in the Public Health System of Federal District, Brazil, between March 2018 and February 2022, using data extracted from the Hospital Information System of Brazilian Ministry of Health (SIH/DATASUS) on September 30, 2022. Causal impact analysis was used to evaluate the impact of COVID-19 on birth, vaginal delivery, and c-section using the CausalImpact R package, and a propensity score matching was used to evaluate the effect on maternal mortality rate using the Easy R (EZR) software. Results: There were 150,617 births, and considering total births, the effect of the COVID-19 pandemic was not statistically significant (absolute effect per week: 5.5, 95% CI: -24.0-33.4). However, there was an increase in c-sections after COVID-19 (absolute effect per week: 18.1; 95% CI: 11.9-23.9). After propensity score matching, the COVID-19 period was associated with increased maternal mortality (OR: 3.22, 95% CI: 1.53-6.81). The e-value of the adjusted OR for the association between the post-COVID-19 period and maternal mortality was 5.89, with a 95% CI: 2.43, suggesting that unmeasured confounders were unlikely to explain the entirety of the effect. Conclusion: Our study revealed a rise in c-sections and maternal mortality during the COVID-19 pandemic, possibly due to disruptions in maternal care. These findings highlight that implementing effective strategies to protect maternal health in times of crisis and improve outcomes for mothers and newborns is crucial.

Implementing a new birthing room design: a qualitative study with a care provider perspective.

BACKGROUND: Research shows that interventions to protect the sensitive physiological process of birth by improving the birthing room design may positively affect perinatal outcomes. It is, however, crucial to understand the mechanisms and contextual elements that influence the outcomes of such complex interventions. Hence, we aimed to explore care providers' experiences of the implementation of a new hospital birthing room designed to be more supportive of women's birth physiology. METHODS: This qualitative study reports on the implementation of the new birthing room, which was evaluated in the Room4Birth randomised controlled trial in Sweden. Individual interviews were undertaken with care providers, including assistant nurses, midwives, obstetricians, and managers (n = 21). A content analysis of interview data was conducted and mapped into the three domains of the Normalisation Process Theory coding manual: implementation context, mechanism, and outcome. RESULTS: The implementation of the new room challenged the prevailing biomedical paradigm within the labour ward context and raised the care providers' awareness about the complex interplay between birth physiology and the environment. This awareness had the potential to encourage care providers to be more emotionally present, rather than to focus on monitoring practices. The new room also evoked a sense of insecurity due to its unfamiliar design, which acted as a barrier to integrating the room as a well-functioning part of everyday care practice. CONCLUSION: Our findings highlight the disparity that existed between what care providers considered valuable for women during childbirth and their own requirements from the built environment based on their professional responsibilities. This identified disparity emphasises the importance of hospital birthing rooms (i) supporting women's emotions and birth physiology and (ii) being standardised to meet care providers' requirements for a functional work environment. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03948815, 14/05/2019.

What do mothers think about their antenatal classes? A mixed-method study in Switzerland.

PROBLEM: Research so far has evaluated the effect of antenatal classes, but few studies have investigated its usefulness from the perspective of mothers after birth. BACKGROUND: Antenatal classes evolved from pain management to a mother-centred approach, including birth plans and parenting education. Evaluating the perception of the usefulness of these classes is important to meet mother's needs. However, so far, research on the mothers' perception of the usefulness of these classes is sparse, particularly when measured after childbirth. Given that antenatal classes are considered as adult education, it is necessary to carry out this evaluation after mothers have had an opportunity to apply some of the competences they acquired during the antenatal classes during their childbirth. AIM: This study investigated mothers' satisfaction and perceived usefulness of antenatal classes provided within a university hospital in Switzerland, as assessed in the postpartum period. METHODS: Primiparous mothers who gave birth at a Swiss university hospital from January 2018 to September 2020 were contacted. Those who had attended the hospital's antenatal classes were invited to complete a questionnaire consisting of a quantitative and qualitative part about usefulness and satisfaction about antenatal classes. Quantitative data were analysed using both descriptive and inferential statistics. Qualitative data were analysed using thematic analysis. FINDINGS: Among the 259 mothers who answered, 61% (n = 158) were globally satisfied with the antenatal classes and 56.2% (n = 145) found the sessions useful in general. However, looking at the utility score of each theme, none of them achieved a score of usefulness above 44%. The timing of some of these sessions was questioned. Some mothers regretted the lack of accurate information, especially on labour complications and postnatal care. DISCUSSION: Antenatal classes were valued for their peer support. However, in their salutogenic vision of empowerment, they did not address the complications of childbirth, even though this was what some mothers needed. Furthermore, these classes could also be more oriented towards the postpartum period, as requested by some mothers. CONCLUSION: Revising antenatal classes to fit mothers' needs could lead to greater satisfaction and thus a better impact on the well-being of mothers and their families.

Differences in postpartum mental healthcare among women with identified needs: The role of migration status.

AIMS: The aim of this study was to examine the association between women's migrant status (majority, immigrant, descendant) and use of postpartum mental healthcare and investigate whether migration characteristics are associated with mental healthcare use. METHODS: Retrospective cohort study. We included all mothers of children born between 2002 and 2018 in 34 municipalities of Denmark who had an identified mental health need as clinically assessed by a child health visitor (CHV) or by a score of 11 or more on the Edinburgh Postpartum Depression Scale (EPDS). Women were followed until the first mental healthcare received 2 years' postpartum, death or emigration. Using Cox regression models, we estimated the time to mental healthcare by migrant status and explored the role of migration characteristics. RESULTS: A total of 29% of women (n = 45,573) had a mental health need identified by the CHV, and 7% (n = 4968) had an EPDS ⩾ 11. Immigrants accounted for 19.5%, and descendants for 4.7% of the sample. Immigrants were at lower risk of using mental healthcare than the majority group (CHV: hazard ratio adjusted (HRa) 0.75 (0.70-0.79), EPDS: HRa 0.67 (0.58-0.78)), as were descendants (CHV: HRa 0.77 (0.70-0.86), EPDS: HRa 0.69 (0.55-0.88)). Among migrants, those not refugees, newly arrived, whose partners were immigrants or descendants, and those originally from Africa showed a lower risk of using postpartum mental healthcare. CONCLUSIONS: Our findings emphasize the need to strengthen access to mental healthcare for immigrants and descendants experiencing postpartum mental health concerns and consider migration characteristics as indicators of potential inequalities in access to maternal mental healthcare.

The impact of funding models on the integration of Ontario midwives: a qualitative study.

BACKGROUND: Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. METHODS: Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. RESULTS: We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. CONCLUSIONS: Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.