Prenatal care in US birth centers: Midwives' perceptions of contributors to birthing People's confidence in physiologic birth.

OBJECTIVE: The purpose of this study was to describe US freestanding birth center models of prenatal care and to examine how the components of this care contribute to birthing people's confidence in their ability to have a physiologic birth. DESIGN: This was a qualitative descriptive study utilizing semi-structured interviews with birth center midwives. Data were analyzed using thematic analysis, constant comparative method and consensus coding to ensure rigor. SETTING AND PARTICIPANTS: Midwives from six urban and rural freestanding birth centers in a Midwestern US state were interviewed. Twelve birth center midwives participated. FINDINGS: Six themes emerged: the birth center physical space and organization of care, dimensions of midwifery care within the birth center, continuity of care and seamless service, the empowered birthing person, physiologic birth as normative, and the hospital paradigm and US cultures of birth. KEY CONCLUSIONS: We identified significant components of birth center models of prenatal care that midwives believe enhance birthing people's confidence for physiologic childbirth. These components may be considered for application to other settings and may improve perinatal care and outcomes.

Randomized trial examining the effect of exercise and wellness interventions on preventing postpartum depression and perceived stress.

BACKGROUND: Approximately 13-19% of postpartum women experience postpartum depression and a majority report at least some stress during the postpartum phase. Traditional interventions such as psychotherapy and antidepressant medications are often not feasible or desirable. The purpose of this study was to examine two low cost, brief, accessible interventions designed to prevent postpartum depression and perceived stress among women at high risk. METHODS: Participants (n = 450) who were on average four weeks postpartum, had a history of depression before pregnancy, and exercised less than 60 min per week were randomly assigned to one of the following three conditions: (1) 6-month telephone-based exercise intervention; (2) 6-month telephone-based wellness/support intervention (e.g., healthy eating, sleep, and perceived stress); or (3) usual care. RESULTS: Overall, 2.4% of participants met criteria for depression at 6 months and 3.6% at 9 months with no differences between groups. At 6 months following randomization, median symptoms of depression were significantly lower among wellness participants compared to usual care participants (b = - 1.00, SE = 0.46, p = .03). Perceived stress at 6 months post-randomization was significantly lower among exercise vs. usual care participants (b = - 2.00, SE = .98, p = .04) and exercise vs. wellness participants (b = - 2.20, SE = 1.11, p = .04). CONCLUSIONS: The wellness intervention was efficacious for preventing symptoms of depression; however, postpartum depression that met the diagnostic criteria was surprisingly low in all conditions among this at risk sample of postpartum women. Exercise interventions may have a protective effect on perceived stress among women at risk for postpartum depression. Practitioners should consider integrating exercise and wellness interventions into postpartum care. TRIAL REGISTRATION: Clinical Trials Number: NCT01883479 (06/21/2013).

The Perinatal Birth Environment: Communication Strategies and Processes for Adherence to a Standardized Guideline in Women Undergoing Second-Stage Labor With Epidural Anesthesia.

Key to any perinatal safety initiative is buy-in and strong leadership from obstetric and pediatric providers, advanced practice nurses, and labor and delivery nurses in collaboration with ancillary staff. In the fall of 2007, executives of a large Midwestern hospital system created the Zero Birth Injury Initiative. This multidisciplinary group sought to eliminate birth injury using the Institute of Healthcare Improvement Perinatal Bundles. Concurrently, the team implemented a standardized second-stage labor guideline for women who choose epidural analgesia for pain management to continue the work of eliminating birth injuries in second-stage labor. The purpose of this article was to describe the process of the modification and adaptation of a standardized second-stage labor guideline, as well as adherence rates of these guidelines into clinical practice. Prior to implementation, a Web-based needs assessment survey of providers was conducted. Most (77% of 180 respondents) believed there was a need for an evidence-based guideline to manage the second stage of labor. The guideline was implemented at 5 community hospitals and 1 academic health center. Data were prospectively collected during a 3-month period for adherence assessment at 1 community hospital and 1 academic health center. Providers adhered to the guideline in about 57% of births. Of patients whose provider followed the guideline, 75% of women were encouraged to delay pushing compared with only 28% of patients delayed pushing when the provider did not follow the guideline.

Midwifery care and patient-provider communication in maternity decisions in the United States.

UNLABELLED: To characterize reasons women chose midwives as prenatal care providers and to measure the relationship between midwifery care and patient-provider communication in the U.S. CONTEXT: Retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 to a single newborn in a U.S. hospital (n = 2,400). We used multivariate logistic regression models to characterize women who received prenatal care from a midwife, to describe the reasons for this choice, and to examine the association between midwife-led prenatal care and women's reports about communication. Preference for a female clinician and having a particular clinician assigned was associated with higher odds of midwifery care (AOR = 2.65, 95 % CI 1.70, 4.14 and AOR = 1.63, 95 % CI 1.04, 2.58). A woman with midwifery care had lower odds of reporting that she held back questions because her preference for care was different from her provider's recommendation (AOR = 0.46, 95 % CI 0.23, 0.89) or because she did not want to be perceived as difficult (AOR = 0.48, 95 % CI 0.28, 0.81). Women receiving midwifery care also had lower odds of reporting that the provider used medical words were hard for them to understand (AOR = 0.58, 95 % CI 0.37, 0.91) and not feeling encouraged to discuss all their concerns (AOR = 0.54, 95 % CI 0.34, 0.89). Women whose prenatal care was provided by midwives report better communication compared with those cared for by other types of clinicians. Systems-level interventions, such as assigning a clinician, may improve access to midwifery care and the associated improvements in patient-provider communication in maternity care.

Improved Self-Assessed Collaboration Through Interprofessional Education: Midwifery Students and Obstetrics and Gynecology Residents Learning Together.

INTRODUCTION: Research suggests that interprofessional education, bringing learners together to learn about, with, and from each other, improves health professions education and can improve health outcomes. Little research has measured outcomes of interprofessional education between midwifery students and obstetrics and gynecology residents. The purpose of this study was to examine self-assessed interprofessional and collaborative competencies among midwifery students and obstetrics and gynecology residents. METHODS: Baseline self-assessed interprofessional and collaborative competencies were compared with follow-up measurements to evaluate learners' experiences over an 11-month study period. Participants were midwifery students and obstetrics and gynecology residents who experienced interprofessional learning activities. The Interprofessional Education Collaborative Competency Self-Assessment Survey (IPEC Survey) and Interprofessional Collaborative Competency Attainment Survey (ICCAS) were used. RESULTS: Of 256 learners at 4 demonstration sites, 223 (87%) completed the baseline, and 121 of 237 eligible learners (51%) completed the follow-up surveys. The IPEC Survey total score (t = 2.31, P = .02) and interaction subscale (t = 2.85, P = .005) and ICCAS score (t = 4.04, P = .001) increased for midwifery students but not obstetrics and gynecology residents on the IPEC Survey (t = 0.32, P = .75) and ICCAS (t = -0.05, P = .96) measures. Midwifery students (87%) and residents (57%) reported improved overall ability to collaborate. Learners responding to 3 open-ended questions valued team-based experiences, including learning how to communicate with each other; appreciated learning each other's education and scope of practice; and recommended skills development including uncommon clinical events, case discussions, and direct clinical care. DISCUSSION: This study advanced knowledge about interprofessional education between midwifery students and obstetrics and gynecology residents. Midwifery students improved in self-assessed interprofessional and collaborative competencies. Most learners reported better interprofessional collaboration skills and were positive about future interprofessional learning. This evaluation approach is available for other programs implementing or extending interprofessional education.

Health education priorities: perspectives from women's voices.

The authors conducted a study to determine women's perceived health information needs in various geographic locations to plan health-related outreach in a Midwestern U.S. state. Eighty-seven women representing diverse communities in both urban and rural locations participated. Themes identified from transcripts of focus groups included confusion and information overload, concerns regarding lifestyle and specific health conditions, a lack of time for self care, factors influencing health-related behavior change, navigating the health system, and a need to ?make this system work for me.? The voices of these women contribute to the search for solutions to provide comprehensive, holistic women's health care in the U.S. and internationally.

Health History Skills for Interprofessional Learners in Transgender and Nonbinary Populations.

INTRODUCTION: Transgender and nonbinary peoplehave been identified as vulnerable and clinically underserved and experience health disparities. Lack of health care provider knowledge about transgender and gender diverse populations is a barrier to care, impacting health outcomes. The aim of this project was to develop, implement, and evaluate a simulation learning activity for midwifery and women's health nurse practitioner students and obstetrics and gynecology residents to interact with transgender and nonbinary individuals, with the goal of enhancing health history taking comfort and skills. METHODS: A partnership was formed among University faculty and simulation educators, a community clinic providing gender-affirming care, and members of transgender and gender diverse populations who served as patient-teachers. Two cases frequently encountered in clinics providing care to transgender individuals were developed for the simulation. Learners were divided into interprofessional groups of 3 and completed one of 2 case scenarios with a patient-teacher. Learners and patient-teachers debriefed after the simulation to discuss and reflect on the experience. RESULTS: Thirty-three learners participated in the simulation, 12 midwifery students, 16 women's health nurse practitioner students and 5 obstetrics and gynecology residents. Significant differences were observed for all comfort and skills questions, showing increased perceived comfort and skills from pre- to postsimulation. There were no significant differences in attitude responses. DISCUSSION: We successfully created and implemented a new sexual and reproductive history taking skills simulation in partnership with community clinic staff and transgender and nonbinary persons. The session was well received by learners and patient-teachers. Learners demonstrated significant improvements in comfort and skills in history taking in this setting and provided favorable feedback about the experience. This simulation can serve as a guide to others providing education to future midwives, women's health nurse practitioners, and obstetrician-gynecologists.

Development and Testing of the Preparation for Labor and Birth Instrument.

OBJECTIVE: To develop and assess the reliability and validity of a new instrument used during the third trimester of pregnancy to measure women's confidence in their ability to achieve physiologic birth, the Preparation for Labor and Birth (P-LAB) instrument. DESIGN: Two-phase instrument development study that consisted of item generation and a prospective field test. SETTING: Field testing occurred in five midwestern U.S. prenatal clinics. PARTICIPANTS: Participants in the field test were 203 nulliparous and parous pregnant women who intended to give birth vaginally. METHODS: Psychometric testing consisted of test-retest reliability testing and assessments of content validity, face validity, and construct validity. We measured construct validity using exploratory factor analysis and correlation with the Sense of Coherence Scale. RESULTS: The 22-item P-LAB showed good content validity, good internal consistency, and stability over time. All items had content validity index scores greater than or equal to 0.8, and the total instrument content validity index was 0.95. We identified four factors related to women's confidence in their ability to achieve physiologic birth: Planned Use of Pain Medication, Relationship With Care Provider and Supportive Birth Environment, Beliefs About Labor, and Labor Support (social and professional). Cronbach's alpha coefficient for the four extracted factors were .93, .76, .73 and .74, respectively. Intraclass correlation [95% confidence interval] for the total questionnaire was .92 [.88, .94]. We found no linear association between total P-LAB scores and sense of coherence. CONCLUSION: Our findings demonstrate acceptable initial psychometric properties for the P-LAB instrument. Additional testing is required to evaluate the instrument's construct, convergent, and divergent validity.

Interprofessional Education Between Midwifery Students and Obstetrics and Gynecology Residents: An American College of Nurse-Midwives and American College of Obstetricians and Gynecologists Collaboration.

Despite areas of excellence, US perinatal care outcomes lag behind most developed countries. In addition, a shortage and maldistribution of health care providers exists. The American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists (ACOG) partnered to obtain funding to develop interprofessional education modules and other learning activities for midwifery students and obstetrics and gynecology residents in 4 demonstration sites. The multidisciplinary 2016 ACOG document Collaboration in Practice: Implementing Team-Based Care was adopted as a framework. Core competencies of values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork developed by the Interprofessional Education Collaborative were used to guide the work. Seven modules have been developed including guiding principles, patient-centered care, role clarification, collaborative practice, history and culture, care transition, and difficult conversations. Learners participate in laboratory and simulation activities and work together in clinical care settings. Stakeholder experiences as well as barriers to implementation are discussed. Learning materials and activity descriptions are open resourced and shared on a project website for use by programs interested in implementing an interprofessional curriculum. Ongoing formal evaluation including pilot testing of a program evaluation method is described.

Design and Implementation of a Group Prenatal Care Model for Somali Women at a Low-Resource Health Clinic.

OBJECTIVE: To design and implement group prenatal care (GPC) for Somali women and to evaluate participants' satisfaction, knowledge, and care engagement. DESIGN: Quality improvement project. SETTING/LOCAL PROBLEM: A federally qualified health center in an urban Midwestern setting, which serves a largely East African immigrant and refugee population. PARTICIPANTS: Pregnant Somali women at more than 20 weeks gestation receiving prenatal care at the project site. Many participants were non-English speaking. INTERVENTION/MEASUREMENTS: While honoring the 13 essential elements of CenteringPregnancy, the model was adapted to the East African population at the project site and offered to all eligible women receiving individual prenatal care at the clinic. Women attended biweekly sessions, including individual assessment and education, exposure to integrative health therapies, and group discussion. Pre- and postintervention data were collected in surveys and in-depth interviews from March through August 2017. RESULTS: Seventeen Somali women attended a median of two sessions (range = 1-7). Self-reported results for knowledge of safe exercise in pregnancy (p = .02), exclusive breastfeeding (p = .04), what happens in the hospital (p = .02), and stress management (p = .03) increased after GPC participation. Ninety-three percent of women preferred GPC to individual care. CONCLUSION: When adapted to meet the needs of Somali women, GPC has the potential to improve care satisfaction, increase knowledge, and reduce stress during pregnancy and the postpartum period. This model may interest women and care providers in similar community health care settings.

Women's Perceptions of Prenatal Influences on Maternal Confidence for Physiologic Birth.

INTRODUCTION: A physiologic approach to labor and birth is preferred for most women. The United States spends more on birth than any other country. Cesarean rates are currently 32%, and approximately 23% of women with a singleton pregnancy experience induction or augmentation of labor. Most physiologic birth research has focused on care during labor and birth. The purpose of this study was to describe women's perceptions of the care processes, support, and information received during pregnancy that helped them feel confident for physiologic labor and birth. METHODS: Using a qualitative descriptive design with 2 phases, women were recruited from an urban area and a smaller city in Minnesota. Phase 1 included focus groups with women who had given birth within the previous 6 months. They participated in a discussion about experiences that helped them feel confident for labor and birth. In Phase 2, women who had a physiologic birth, which was defined as term pregnancy, spontaneous labor, no epidural analgesia, and vaginal birth, participated in individual interviews. Focus group and individual interview recordings were transcribed and analyzed using Glaser's constant comparative approach. RESULTS: Thirty-eight women participated in 9 focus groups. Seventeen women had a physiologic birth; 14 participated in individual interviews. Themes derived from the analysis included confidence in the face of uncertainty, belief in the normalcy of birth and the body's ability to birth, research on my own, supportive care partnership, on the same page, and sources of information and support. DISCUSSION: Women who experienced physiologic birth believed that this was possible and expected. They sought information, including searching on their own, from maternity care providers and a broader support system. Relationships with their maternity care providers were important. Prenatal care focused on women's strengths and abilities, while also monitoring pregnancy health and safety, may help reduce unnecessary interventions, improve outcomes, and reduce costs.

Maternal confidence for physiologic birth: Associated prenatal characteristics and outcomes.

OBJECTIVES: Pregnancy, labor, and birth are normal, physiologic processes. Women often seek information during pregnancy to enhance their confidence for physiologic birth. Little is known about confidence for physiologic birth and associated prenatal characteristics and birth outcomes such as provider type, source of labor and birth information, mode of birth, and use of pain medication in labor. The purpose of this study was to examine prenatal confidence for physiologic birth and associated prenatal characteristics and birth outcomes. DESIGN: This study was completed as part of a multi-phased instrument development study, the Preparation for Labor and Birth (P-LAB) instrument. P-LAB confidence scores were examined for their relationship with variables including labor type, provider type, source of labor support, pain medication use, and birth mode. SETTING AND PARTICIPANTS: Women (N = 192) from five prenatal clinics in the Midwestern United States who had completed the P-LAB instrument participated in postpartum telephone interviews. FINDINGS: Women with previous birth experience had higher confidence than nulliparous women. Prenatal care providers were reported as main source of labor and birth information. Confidence for birth was associated with intention to not use pain medication in labor. Women's overall intention to use or not use pain medication was consistent with use. Prenatal confidence was not associated with mode of birth. IMPLICATIONS FOR FUTURE RESEARCH: Special emphasis should be paid to nulliparous women when developing interventions to enhance confidence for physiologic birth. Women rely on their care providers for information regarding labor and birth, therefore one area to strengthen confidence for physiologic birth is within the provider-patient relationship.

Maternal and newborn care during disasters: thinking outside the hospital paradigm.

Emergencies that challenge the infrastructure of the current health care system require a shift in the standard of usual practice. Pregnant women and their newborns are intimately linked special populations that require continued care despite the community circumstances. Pre-event planning with community partners can generate a safer alternative for providing care during a public health emergency. Lessons learned from international and United States public health emergencies have resulted in a better understanding of the essentials of care and the development of resources to guide planning for these populations.

Faculty teaching time: a comparison of web-based and face-to-face graduate nursing courses.

Web-based education brings a new dimension to the issue of measuring faculty workload. Current literature reflects instructor concerns related to the time required to teach web-based courses (McAlpine, Lockerbie, Ramsay & Beaman 2002; Sellani & Harrington, 2002; Smith, Ferguson & Caris, 2001). This descriptive, comparative study seeks to determine the time required to teach web-based graduate nursing courses and compare that to teaching similar courses in the face-to-face setting. Utilizing time records previously collected as part of a federally funded grant, data from 11 web-based and five face-to-face graduate level nursing courses were analyzed. Although a statistically significant difference in teaching time requirements was not demonstrated, several interesting trends did appear. Examples include differences related to preparation time and the division of teacher time while teaching web-based as opposed to face-to-face courses. Future research and continued data collection related to faculty workload and time usage will be needed as web-based courses become a growing part of graduate nursing education.

Evaluation of an online graduate nursing curriculum: examining standards of quality.

Recent offerings of online courses have outpaced the evaluation of the quality of those offerings, particularly at the program level. The purpose of this project was to evaluate the quality of a set of 16 graduate nursing courses developed for three master's specialty programs. An interdisciplinary group of nursing faculty and instructional technologists collaborated in the development of a quality assessment tool and evaluated 16 online graduate nursing courses. Faculty members for each of the courses were interviewed as part of the process. The collaborative design and development process is discussed, as well as evaluation techniques and the data collection instrument. Examples of best practices and areas for improvement in online courses are presented. The findings will help others as they develop and evaluate online curricula. This project provides a model for interdisciplinary collaboration on the evaluation of online programs that can be reviewed, modified, and implemented at other institutions. Instruments are included as supplementary material.