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Separation at birth due to safeguarding concerns is a deeply distressing and impactful event, with numbers rising across the world, and has devastating outcomes for birth mothers and their children. It is one of the most challenging aspects of contemporary midwifery practice in high‐income countries, although rarely discussed and reflected on during pre‐ and post‐registration midwifery training. Ethnic and racial disparities are prevalent both in child protection and maternity services and can be explained through an intersectional lens, accounting for biases based on race, gender, class, and societal beliefs around motherhood. With this paper, we aim to contribute to the growing body of critical midwifery studies and re‐think the role of midwives in this context. Building on principles of reproductive justice theory, Intersectionality, and Standpoint Midwifery, we argue that midwives play a unique role when supporting women who go through child protection processes and should pursue a shift from passive bystander to active upstander to improve care for this group of mothers. [ABSTRACT FROM AUTHOR]

Background: Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten‐Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions. Methods: We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time. Results: The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period. Conclusions: The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct. [ABSTRACT FROM AUTHOR]

Background: Recent years have brought substantial declines in geographic access to abortion facilities and maternity care across the US. The purpose of this study was to identify the reproductive health consequences of living in a county without access to comprehensive reproductive health care services. Methods: We analyzed National Center for Health Statistics data on all live births occurring in the US in 2020. We used data on locations of abortion facilities and availability of maternity care in order to classify counties by level of access to comprehensive reproductive health care services and defined comprehensive reproductive health care deserts as counties that did not have an abortion facility in the county or in any neighboring county and did not have any maternity care practitioners. We fit modified Poisson regression models with generalized estimating equations to estimate the degree to which living in a comprehensive reproductive health care desert was associated with receipt of timely and adequate prenatal care and risk of preterm birth, controlling for individual‐level and county‐level characteristics. Results: In 2020, one third of counties in the US were comprehensive reproductive health care deserts (n = 1082), and 136,272 births occurred in these counties. In adjusted models, there was no difference in prenatal health care use (timeliness or adequacy of care) between persons in comprehensive reproductive health care deserts and those with full access to care, but the risk of preterm birth was significantly elevated (aRR =1.09, 95% CI = 1.06, 1.13). Conclusions: Lack of access to comprehensive reproductive health care services may increase the incidence of preterm birth. [ABSTRACT FROM AUTHOR]

Background: Woman‐centered maternity service delivery is endorsed by Australian federal health policy. Despite this, little evaluation of maternity care is conducted through the lens of women. We examined the responses of women birthing in Australia to the international Babies Born Better 2018 (Version 2) open‐response survey. Methods: An online international survey was distributed primarily by means of social media for women who had given birth in the last 5 years. In addition to closed‐ended questions to describe the sample, a series of open‐ended questions recorded women's experiences and satisfaction with their maternity care and place of birth. Results: Of 1249 women who reported birthing their most recent baby in Australia and speaking English, 84% responded to at least one open‐ended evaluation question. We thematically analyzed the data to identify three related themes of safety, choice, and respect for women. Women's experiences of these were closely tied to their model of care; those birthing at home with a private midwife more so reported positive experiences than those discussing obstetric care or, to a lesser extent, midwifery‐led care in a hospital. There was a strong preference and need for (1) access to affordable care with a known practitioner from early pregnancy to postpartum, and (2) individualized care with the removal of restrictive hospital policies not aligned with woman‐centered practice. Discussion: This is the first Australian national study of women's maternity experiences and evaluations. Consistent with previous state‐based research, women birthing in Australia continue to report maternity "care" that is physically and emotionally harmful. They also stated a need to address the psychosocial aspects of becoming a mother, in addition to the biological ones. Women and other birthing people must be at the center of defining quality maternity health service delivery, and services must be accountable for preventing and addressing harm, as defined by all birthing people. [ABSTRACT FROM AUTHOR]

Background: A positive childbirth experience is an important outcome of maternity care. A significant component of a positive birth experience is the ability to exercise autonomy in decision‐making. In this study, we explore women's reports of their autonomy during conversations about their care with maternity care practitioners during pregnancy and childbirth. Method: Data were obtained from a cross‐sectional survey of women living in The Netherlands that asked about their experiences during pregnancy and childbirth, including their role in conversations concerning decisions about their care. Results: A total of 3494 women were included in this study. Most women scored high on autonomy in decision‐making conversations. During the latter stage of pregnancy (32+ weeks) and in childbirth, women reported significantly lower levels of autonomy in their care conversations with obstetricians as compared with midwives. Linear regression analyses showed that women's perception of personal treatment increased women's reported autonomy in their conversations with both midwives and obstetricians. Almost half (49.1%) of the women who had at least one intervention during birth reported pressure to accept or submit to that intervention. This was indicated by 48.3% of women with induced labor, 47.3% who had an instrumental vaginal birth, 45.2% whose labor was augmented, and 41.9% of women who had a cesarean birth. Conclusions: In general, women's sense of autonomy in decision‐making conversations during prenatal care and birth is high, but there is room for improvement, and this appeared most notably in conversations with obstetricians. Women's sense of autonomy can be enhanced with personal treatment, including shared decision‐making and the avoidance of pressuring women to accept interventions. [ABSTRACT FROM AUTHOR]

Background: The Baby‐Friendly Hospital Initiative suggests that in‐hospital supplementation should be avoided unless medically indicated. The supporting evidence is contradictory, as nonexperimental studies have shown an association between supplementation and decreased breastfeeding rates, whereas trials have failed to do so. The aim of this study was to investigate whether in‐hospital supplementation is associated with exclusive breastfeeding to the age of 5 months and any breastfeeding to the age of 12 months in full‐term, normal‐weight singleton infants. Methods: This is a secondary analysis of national‐level, cross‐sectional survey data. The data were collected in child health clinics in Finland. Families attending a regular health examination with a child aged 2 weeks to 12 months were eligible to participate. Full‐term, normal‐weight, singleton infants (n = 3025) were included in this study. Multivariate logistic regression was performed using in‐hospital supplementation and socioeconomic characteristics as covariates and exclusive and any breastfeeding as outcomes. Results: In total, 55.3% (n = 1631) of the infants received in‐hospital supplementation. After controlling for socioeconomic factors, in‐hospital supplementation was associated with decreased exclusive breastfeeding to the age of 5 months and with a decrease in any breastfeeding to the age of 7 months. Conclusions: Our findings suggest that noncontrolled supplementation, without a trial's rigorous procedures of care, is associated with decreased breastfeeding postdischarge. Both donor milk and infant formula use were associated with lower breastfeeding rates, although the association was stronger with formula use. In clinical settings, liberal, nonmedically indicated supplementation should be avoided. [ABSTRACT FROM AUTHOR]

Background: Patient‐centered care is the best practice in the care of pregnant and postpartum patients. The COVID‐19 pandemic prompted changes in perinatal care policies, which were often reactive, resulting in unintended consequences, many of which made the delivery of patient‐centered care more difficult. This study aimed to understand the impact of the COVID‐19 pandemic on perinatal health care delivery from the perspective of family physicians in the United States. Methods: From October 5 to November 4, 2020, we surveyed mid‐ to late‐career family physicians who provide perinatal care. We conducted descriptive analyses to measure the impact of COVID‐19 on prenatal care, labor and delivery, postpartum care, patient experience, and patient volume. An immersion‐crystallization approach was used to analyze qualitative data provided as open‐text comments. Results: Of the 1518 survey respondents, 1062 (69.8%) stated that they currently attend births; 595 of those elaborated about the impact of COVID‐19 on perinatal care in free‐text comments. Eight themes emerged related to the impact of COVID‐19 on perinatal care: visitation, patient decisions, testing, personal protective equipment, care continuity, changes in care delivery, reassignment, and volume. The greatest perceived impact of COVID‐19 was on patient experience. Conclusions: Family physicians who provided perinatal care during the COVID‐19 pandemic noted a considerable impact on patient experience, which particularly affected the ability to deliver patient‐centered and family‐centered care. Continued research is needed to understand the long‐term impact of policies affecting the delivery of patient‐centered perinatal care and to inform more evidence‐based, proactive policies to be implemented in future pandemic or disaster situations. [ABSTRACT FROM AUTHOR]

Background: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. Methods: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. Results: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round‐trip to access care if those FPs were to stop delivering. Conclusions: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has led to multiple changes in maternity services worldwide. Systems rapidly adapted to meet public health requirements aimed at preventing transmission of SARS‐CoV‐2, including quarantine procedures, travel restrictions, border closures, physical distancing and "stay‐at‐home" orders. Although these changes have impacted all stakeholders in maternity services, arguably the women at the center of this care have been most affected. This study aimed to explore women's experiences of receiving maternity care during the COVID‐19 pandemic in Australia. Methods: A national cross‐sectional online survey, including fixed choice and open‐ended questions, was conducted during the first wave of the COVID‐19 pandemic in Australia; pregnant and postnatal women were recruited through social media networks. Results: The survey was completed by 3364 women. Women felt distressed and alone due to rapid changes to their maternity care. Limited face‐to‐face contact with health practitioners and altered models of care often required women to accommodate significant changes and to coordinate their own care. Women felt that they were often "doing it alone," due to public health restrictions on support people and visitors, both within and outside health services. Women described some benefits of visitor restrictions, such as, more time for rest, breastfeeding establishment, and bonding with their baby. Conclusions: This large nationwide Australian study provides unique data on women's experiences of receiving maternity care during the COVID‐19 pandemic. Lessons learned provide an opportunity to rebuild and reshape the maternity sector to best meet the needs of women and their families during current and future public health crises. [ABSTRACT FROM AUTHOR]

Background: The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. Methods: Descriptive, cross‐sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High‐risk geographic areas were defined as those where women needed to travel >30 miles for maternity‐related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%‐60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. Results: In Michigan's 57 rural counties, only 29 hospitals provide maternity care. Geographic high‐risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. Conclusions: Maternity care services are limited for many rural Michigan women. Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities. [ABSTRACT FROM AUTHOR]

Background: Over a two‐year period between 2015 and 2016, unprecedented numbers of people arrived in Greece fleeing conflict, persecution, and poverty. With new arrivals every day, there is a significant unmet need for health care provision, posing a challenge to the Greek Healthcare System. For pregnant refugees, a known vulnerable group, this has resulted in a complex partnership of shared maternity care between humanitarian organizations, the Greek national health care system, and European multi‐state initiatives. Our aim was to understand the challenges to providing maternity care services in Greek refugee camps as perceived by health care providers. Methods: A qualitative study comprising observation and semi‐structured interviews with health care providers working with pregnant refugees was conducted in five refugee camps in May 2017. Interviews were transcribed and analyzed with thematic coding. Results: Twenty‐one health care providers were interviewed and field notes taken from observational study of services in five refugee camps. Health care providers describe difficult cross‐cultural communication to be their biggest challenge to caring for pregnant refugee women. The limited availability of female only safe spaces is also identified as a barrier. Lastly, the overburdened Greek public health system limits their ability to provide care. Conclusions: Our research supports other literature describing difficult communication and the overburdened Greek health system as significant health care barriers for pregnant refugees in Greece. There is limited literature examining the role of "safe space," and further research is needed. Stakeholders providing maternity care to refugees should look to tackle these key issues as they seek to provide care to this population. [ABSTRACT FROM AUTHOR]

Background: Public patient involvement (PPI) generates knowledge about the health‐illness process through the incorporation of people's experiences and priorities. The Babies Born Better (BBB) survey is a pan‐European online questionnaire that can be used as a PPI tool for preliminary and consultative forms of citizens' involvement. The purpose of this research was to identify which practices support positive birth experiences and which ones women want changed. Methods: The BBB survey was distributed in virtual communities of practice and through social networks. The version launched in Spain was used to collect data in 2014 and 2015 from women who had given birth in the previous 5 years. A descriptive, quantitative analysis was applied to the sociodemographic data. Two open‐ended questions were analyzed by qualitative content analysis using a deductive and inductive codification process. Results: A total of 2841 women participated. 41.1% of the responses concerned the category "Care received and experienced," followed by "Specific interventions and procedures" (26.6%), "Involved members of care team" (14.2%), and "Environmental conditions" (9%). Best practices were related to how care is provided and received, and the main areas for improvement referred to specific interventions and procedures. Conclusions: This survey proved a useful tool to map the best and poorest practices reported. The results suggest a need for improvement in some areas of childbirth care. Women's reports on negative experiences included a wide range of routine clinical interventions, avoidable procedures, and the influence exerted by professionals on their decision‐making. [ABSTRACT FROM AUTHOR]

Introduction: Approximately 21% of Germany's inhabitants or their parents have been born abroad. There is evidence that immigrant women are starting antenatal care later than nonimmigrants. In Berlin, equality in health care access had improved until 2011‐2012, leaving only women with Low German language proficiency and an insecure residence status particularly at risk. With the recent influx of refugees, we analyzed whether access to antenatal and postpartum care differs depending on immigration, residence status, income, and education. Methods: At our Berlin tertiary care center, a modified version of the Migrant Friendly Maternity Care Questionnaire was administered to women who delivered in the first half of 2017. Multivariate modeling compared nonimmigrant women, immigrants, and women who are direct descendants of immigrants. Results: The study included 184 nonimmigrant women, 214 immigrant women, and 62 direct descendants of immigrants. Germany is relatively good in prenatal care for immigrant women, as most are getting adequate prenatal care. However, 21% of immigrants compared with 11% of nonimmigrant women started pregnancy care after the first trimester (P =.03). Low income was a more powerful predictor than immigration status for starting prenatal care after the first trimester. Immigrant women (23%) were less informed on postpartum care availability than nonimmigrants (3%) and used less postpartum midwifery care. Conclusions: When designing health care interventions for immigrant women, not only migration‐specific factors should be considered but also low income as a barrier to access to maternity care. [ABSTRACT FROM AUTHOR]

Objective: Low‐risk pregnant women cared for by midwives have similar birth outcomes to women cared for by physicians, although experiencing fewer medical procedures. However, limited research has assessed cost implications in the United States. Using national data, we assessed costs and resource use of midwife‐led care vs obstetrician‐led care for low‐risk pregnancies using a decision‐analytic approach. Methods: We developed a decision‐analytic model of costs (health plan payments to clinicians) and use of medical procedures during childbirth (epidural analgesia, labor induction, cesarean birth, episiotomy) and outcomes of care (birth at preterm gestation) that may differ with midwife‐led vs obstetrician‐led care. Model parameters for obstetric procedures were generated using Listening to Mothers III data, a national survey of women who gave birth in US hospitals in 2011‐2012 and other published estimates. Cost estimates came from published or publicly available information on health insurance claims payments. Results: The costs of childbirth for low‐risk women with midwife‐led care were, on average, $2262 less than births to low‐risk women cared for by obstetricians. These cost differences derive from lower rates of preterm birth and episiotomy among women with midwife‐led care, compared with obstetrician‐led care. Across the population of US women with low‐risk births each year (approximately 2.6 million), the model predicted substantially fewer preterm births (167 259 vs 219 427 for midwife‐led vs obstetrician‐led care) and fewer episiotomies (170 504 vs 415 686, for midwife‐led vs obstetrician‐led care). Conclusions: A shift from obstetrician‐led care to midwife‐led care for low‐risk pregnancies could be cost saving. [ABSTRACT FROM AUTHOR]

Background: Increasing numbers of childbearing women with a history of female genital mutilation (FGM) are accessing maternity services in high‐income countries across the world. For many of these women, their first contact with the health services in their host country is when they are pregnant. While the clinical consequences of certain categories of FGM are well documented, how high‐risk maternity services — designed to mitigate the obstetric consequences of FGM — impact upon women's experience of childbearing is less clear. Methods: Using a meta‐synthesis approach, this paper synthesizes 12 qualitative research papers, conducted in 5 high‐income countries, to explore how migrant women with a history of FGM experience maternity care in their host countries. Results: One over‐arching theme and four discrete subthemes of migrant women's experience of the maternity services in their host country were identified: feelings of alienation; fatalism and divine providence, positive and negative feelings about maternity care, different understandings of the birthing process, and feelings about FGM. Conclusions: The findings illustrate that migrant women with a history of FGM frequently encounter negative attitudes when accessing the maternity services in their host countries. Women's experiences suggest a concerning absence of sensitive and empathetic care; a more woman‐centered approach is recommended. [ABSTRACT FROM AUTHOR]

Background: Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high‐income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM. Methods: We undertook a systematic review and meta‐synthesis of peer‐reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers. Results: Sixteen peer‐reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care. Conclusions: The findings suggest that future actions for improving maternity care quality should be focused on woman‐centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high‐income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman‐focused policy is developed and implemented. [ABSTRACT FROM AUTHOR]

Abstract: Background: Shared decision‐making (SDM) is a critical but challenging component of high quality maternity care. In co‐creation with parents and professionals, we are developing an intervention to improve SDM. As a first step we aimed to explore the experiences and needs of parents and professionals regarding shared decision‐making in interprofessional antenatal, natal, and postnatal care. Methods: We organized 11 focus groups in the Netherlands in November and December 2016. Parents, primary care midwives, hospital‐based midwives, obstetricians, obstetric nurses, and maternity care assistants participated. Results: Parents and professionals recognized the SDM steps of introducing a decision (choice talk) and discussing options (option talk), but most parents did not seem to discuss preferences and weigh options with professionals before making their final decision (decision talk). Barriers to SDM were often related to interprofessional collaboration, while good communication skills of parents and professionals facilitated SDM. An intervention to improve SDM would need to: (a) increase awareness and offer insight into the SDM process and roles and responsibilities of parents and professionals, (b) develop good communication skills, and (c) encourage interprofessional collaboration. The preferred design of the intervention was online, interactive, and practical. Conclusions: Parents and professionals will benefit from an intervention designed to improve SDM. A practical e‐learning for all maternity care providers and e‐health information for parents seems most appropriate. Key elements for the e‐learning are raising awareness of the roles and responsibilities of parents and professionals, developing good communication skills and encouraging interprofessional collaboration. This requires a variety of educational strategies. [ABSTRACT FROM AUTHOR]

Abstract: Background: Most research on women experiencing stillbirth relies on online user group surveys or qualitative interviews. The objective of this study was to investigate the experience of women who are at a higher risk of stillbirth, living in areas of greatest deprivation, and are commonly not well represented. Methods: This study used birth and death registrations in 2012‐2013 to identify a sample of mothers whose babies had died as a result of stillbirth. These women were sent a survey 6‐9 months after the stillbirth. We undertook descriptive analysis of quantitative data and used binary logistic regression with the Index of Multiple Deprivation as a measure of disadvantage. We used thematic analysis to describe free text responses. Results: The survey response rate was 30% (N = 473). Ethnic minority, younger age, and single parenthood were associated with disadvantage. Women residents in the most deprived areas perceived care more negatively: during labor they were significantly less likely to be spoken to by medical staff so they could understand (73% compared with 90%, adjusted odds ratio [aOR] 0.33 [95% confidence interval {CI} 0.18‐0.65]), or treated with respect by midwives (79% compared with 90%, aOR 0.41 [95% CI 0.22‐0.77]). The qualitative themes identified were: “Difficulty in accessing care,” “More could have been done,” “Ineffective communication,” and “Cared for and not cared for” which support the quantitative findings. Conclusion: Women living in the most deprived areas reported poorer experiences of care compared with more advantaged women. All women need compassionate and sensitive care around the time of a stillbirth. [ABSTRACT FROM AUTHOR]

Objectives Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status. Methods Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms. Results Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery ( AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured. Conclusions There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth. [ABSTRACT FROM AUTHOR]

Background Breastfeeding rates are disproportionately low among young mothers in the United States. Although the use of hospital practices to promote breastfeeding is widely supported, the extent to which these practices help explain breastfeeding disparities by maternal age is unclear. Accordingly, we aimed to explore how maternal age may affect (1) receipt of hospital practices and (2) associations between these practices and exclusive breastfeeding. Methods Data were derived from participants (n = 1598) of Listening to Mothers III, a national survey administered to mothers of singleton births in United States hospitals from July 2011 to June 2012. We used multivariable logistic regression models and interaction terms to examine maternal age as an effect modifier. Results Compared with mothers aged 30 and older, mothers aged 18-19 had lower odds of reporting that nurses helped them initiate breastfeeding when ready ( OR 0.59 [95% CI 0.35-0.99]), they roomed-in with their baby (OR 0.32 [95% CI 0.19-54]) and they did not receive a pacifier ( OR 0.53 [95% CI 0.32-0.90]). Many associations with breastfeeding were stronger among mothers aged 18-19 and 20-24 than mothers aged 25-29 and 30 and older. Additionally, compared with receiving a pacifier, not receiving a pacifier was associated with greater odds of exclusive breastfeeding at 1 week among mothers aged 30 and older (OR 1.47 [95% CI 1.02-2.11]) but lower odds among mothers aged 18-19 (OR 0.26 [95% CI 0.10-0.70]). Conclusions Hospital practices to promote breastfeeding may be differentially implemented by maternal age. Encouraging teenage mothers to room-in with their babies may be particularly important for reducing breastfeeding disparities. Pacifier use among babies of teenage mothers requires further exploration. [ABSTRACT FROM AUTHOR]

Background Surveys have shown that women are highly satisfied with their maternity care. Their satisfaction has been associated with various demographic, personal, and care factors. Isolating the factors that most matter to women about their care can guide quality improvement efforts. This study aimed to identify the most significant factors associated with high ratings of care by women in the three maternity periods (antenatal, birth, and postnatal). Methods A survey was sent to 2,048 women who gave birth at seven public hospitals in New South Wales, Australia, exploring their expectations of, and experiences with maternity care. Women's overall ratings of care for the antenatal, birth, and postnatal periods were analyzed, and a number of maternal characteristics and care factors examined as potential predictors of 'Very good' ratings of care. Results Among 886 women with a completed survey, 65 percent assigned a 'Very good' rating for antenatal care, 74 percent for birth care, 58 percent for postnatal care, and 44 percent for all three periods. One factor was strongly associated with care ratings in all three maternity periods: women who were 'always or almost always' treated with kindness and understanding were 1.8-2.8 times more likely to rate their antenatal, birth, and postnatal care as 'Very good.' A limited number of other factors were significantly associated with high care ratings for one or two of the maternity periods. Conclusions Women's perceptions about the quality of their interpersonal interactions with health caregivers have a significant bearing on women's views about their maternity care journey. [ABSTRACT FROM AUTHOR]

Background Access to information on the features and outcomes associated with the various models of maternity care available in Australia is vital for women's informed decision-making. This study sought to identify women's preferences for information access and decision-making involvement, as well as their priority information needs, for model of care decision-making. Methods A convenience sample of adult women of childbearing age in Queensland, Australia were recruited to complete an online survey assessing their model of care decision support needs. Knowledge on models of care and socio-demographic characteristics were also assessed. Results Altogether, 641 women provided usable survey data. Of these women, 26.7 percent had heard of all available models of care before starting the survey. Most women wanted access to information on models of care (90.4%) and an active role in decision-making (99.0%). Nine priority information needs were identified: cost, access to choice of mode of birth and care provider, after hours provider contact, continuity of carer in labor/birth, mobility during labor, discussion of the pros/cons of medical procedures, rates of skin-to-skin contact after birth, and availability at a preferred birth location. This information encompassed the priority needs of women across age, birth history, and insurance status subgroups. Conclusions This study demonstrates Australian women's unmet needs for information that supports them to effectively compare available options for model of maternity care. Findings provide clear direction on what information should be prioritized and ideal channels for information access to support quality decision-making in practice. [ABSTRACT FROM AUTHOR]

Objective This observational study examined the proportion of family physicians continuing to perform deliveries from 2003-2010. Methods Data were collected annually from the same census questionnaire completed by family physicians who passed their recertification examination. Aggregated responses began in 2003 when data first became available electronically and ended in 2009 before recertification changes. Using cross-sectional design and logistic regression analysis, we examined associations between physician demographic or geographic factors and performance of deliveries. Results The sample consisted of 49,267 family physicians between 2003 and 2009, including 7,456 in 2009. The proportion performing any deliveries declined by 40.6 percent, from 17.0 percent in 2003 to 10.1 percent in 2009. Most recently, 5.5 percent of all family physicians delivered 1-25 babies per year, whereas 2.8 percent delivered 26-50, and 1.9 percent delivered ≥ 51. Those who performed deliveries were most likely to be junior members of a partnership or group practice, and provided prenatal and newborn care. Deliveries were more common in nonmetropolitan areas, where other obstetric practitioners were unavailable. Conclusions The proportion of family physicians performing deliveries continues to decline with most delivering 25 or fewer babies per year. This change will require more effort by obstetrician-gynecologists and midwives in being primary birth attendants. [ABSTRACT FROM AUTHOR]

Background Maternity care in Serbia is an integrated part of the centralized health care system inherited from the former Yugoslavia. Childbirth is often perceived as a medical event instead of a physiological process. This paper examines quality and access indicators, and patient payments for maternity care in Serbia. Methods We apply a method of triangulation using data collected through three sources: online questionnaires filled in by mothers who delivered in one of the maternity wards in Serbia in the period 2000-2008, research publications, and official guidelines. To compare the qualitative data from all three sources, we apply framework analysis. Results The results show a good network of maternity wards in Serbia. On the other hand, many women who gave birth in maternity wards in Serbia indicate problems with the treatment they received. The existence of informal patient payments and so-called 'special connections' make the position of Serbian women in maternity wards vulnerable, especially when they have neither connections nor the ability to pay. Poor communication and bedside manner of medical staff (obstetricians, other physicians, midwives, and nurses) during the birth process are also frequently reported. Discussion Actions should be taken to improve bedside manners of medical staff. In addition, the government should consider the involvement of private practitioners paid by the national insurance fund to create competition and decrease the need for informal payments and 'connections.' [ABSTRACT FROM AUTHOR]

Background There are concerns about the Dutch maternity care system, characterized by a strict role division between primary and secondary care. The objective of this study was to describe trends in referrals and in perinatal outcomes among labors that started in primary midwife-led care. Methods We performed a descriptive study of all 789,795 labors that started in primary midwife-led care during 2000 to 2008 in The Netherlands. Referrals to obstetrician-led care or pediatrician were classified as urgent or nonurgent. Perinatal safety was described by perinatal mortality (intrapartum or neonatal 0-7 days), admission to neonatal intensive care unit 0-7 days, and Apgar score < 7 at 5 minutes. Results The proportion of referrals during labor or after birth declined from 52.6 to 42.6 percent for nulliparous women and from 83.2 to 76.7 percent for multiparous women. Especially nonurgent referrals during the first stage increased, for nulliparous women from 28.7 to 40.7 percent and for multiparous women from 10.5 to 16.5 percent. Referrals were less frequent in planned home births. Perinatal mortality was 0.9 per thousand births for nulliparous women, and 0.6 per thousand for multiparous women. A low Apgar score was registered in 8.6 per thousand births for nulliparous women, and 4.1 per thousand for multiparous women. Conclusions There was a considerable rise in nonurgent referrals to obstetrician-led care in primary midwife-led care during labor. Perinatal safety did not improve significantly over time. The persisting rise in referrals challenges the sustainability of the current strict role division between primary and secondary maternity care in The Netherlands. [ABSTRACT FROM AUTHOR]

Background Exclusive breastfeeding for 6 months and continued breastfeeding for at least 1 year is recommended by all major health organizations. Whereas 74.6 percent of mothers initiate breastfeeding at birth, exclusivity and duration remain significantly lower than national goals. Empirical evidence suggests that exposure to infant formula marketing contributes to supplementation and premature cessation. The objective of this study was to explore how women interpret infant formula advertising to aid in an understanding of this association. Methods Four focus groups were structured to include women with similar childbearing experience divided according to reproductive status: preconceptional, pregnant, exclusive breastfeeders, and formula feeders. Facilitators used a prepared protocol to guide discussion of infant formula advertisements. Authors conducted a thematic content analysis with special attention to women's statements about what they believed the advertisements said about how the products related to human milk (superior, inferior, similar) and how they reported reacting to these interpretations. Results Participants reported that the advertisements conveyed an expectation of failure with breastfeeding, and that formula is a solution to fussiness, spitting up, and other normal infant behaviors. Participants reported that the advertisements were confusing in terms of how formula-feeding is superior, inferior or the same as breastfeeding. This confusion was exacerbated by an awareness of distribution by health care practitioners and institutions, suggesting provider endorsement of infant formula. Conclusions Formula marketing appears to decrease mothers' confidence in their ability to breastfeed, especially when provided by health care practitioners and institutions. Therefore, to be supportive of breastfeeding, perinatal educators and practitioners could be more effective if they did not offer infant formula advertising to mothers. ( BIRTH 40:2 June 2013) [ABSTRACT FROM AUTHOR]

Background The Inuulitsivik midwifery service is a community-based, Inuit-led initiative serving the Hudson coast of the Nunavik region of northern Québec. This study of outcomes for the Inuulitsivik birth centers, aims to improve understanding of maternity services in remote communities. Methods We used a retrospective review of perinatal outcome data collected at each birth at the Inuulitsivik birth centers to examine outcomes for 1,372 labors and 1,382 babies from 2000 to 2007. Data were incomplete for some indicators, particularly for transfers to Montreal. Results Findings revealed low rates of intervention with safe outcomes in this young, largely multiparous 'all risk' Inuit population. Ninety-seven percent of births were documented as spontaneous vaginal deliveries, and 85 percent of births were attended by midwives. Eighty-six percent of the labors occurred in Nunavik, whereas 13.7 percent occurred outside Nunavik. The preterm birth rate was found to be 10.6 percent. Postpartum hemorrhage was documented in 15.4 percent of women; of these cases, 6.9 percent had blood loss greater than 1,000 mL. Four fetal deaths (2.9 per 1,000) and five neonatal deaths (< 3.6 per 1,000) were documented. Nine percent (9%) of births involved urgent transfers of mother or baby. The most common reasons for medical evacuation were preterm labor and preeclampsia, and preterm birth was the most common reason for urgent neonatal transfer. Conclusions The success of the Innulitsivik midwifery service rests on the knowledge and skills of the Inuit midwives, and support of an interprofessional health team. Our study points to the potential for safe, culturally competent local care in remote communities without cesarean section capacity. Our findings support recommendations for integration of midwifery services and Aboriginal midwifery education programs in remote communities. ( BIRTH 39:3 September 2012) [ABSTRACT FROM AUTHOR]

Background: Cesarean section is an increasingly common mode of birth, and although clinical care has improved and the risks reduced, less attention has been paid to the effect of the procedure and the care received. The aim of this study was to gain a better understanding by investigating individual women’s recent experiences and reflections on their care. Methods: Views of women who had recently undergone cesarean birth were obtained in a study in which a random sample of women was selected by means of birth registrations in England and invited to complete a questionnaire 3 months after the birth. Text responses to open-ended questions about care during labor and birth, the postnatal period in hospital, and anything else women wished to say about their maternity care were analyzed using qualitative methods. Results: A response rate of 63 percent was achieved; 23 percent of women (n = 682) had a cesarean section birth, 53 percent of which were because of unforeseen problems in labor. A total of 66 percent of women who had a cesarean section responded to one or more open questions. Anticipated themes that were confirmed related to expectations, uncertainty, emotional reactions, pain and discomfort, explanations, support, and adjustment. Emerging themes included “being heard,”“how it might have been different,”“wasted effort,”“just another mother,”“wounds and hurt feelings,” and “needing to talk.” Conclusions: Women responded as individuals and despite different clinical circumstances, the role of the staff and the institutions in which care was provided were key factors in the way most women constructed their cesarean section experience. The themes described present a powerful argument and reminder about why health professionals working in maternity care need to continue to listen to women. (BIRTH 37:2 June 2010) [ABSTRACT FROM AUTHOR]

Background: Since the 1970s, the movement to “humanize” birth in North America has evolved into “family-centered maternity care,” which has focused on providing evidence-based maternity care that is responsive to the needs of women and their families. The objective of this research was to explore women’s birth experiences within the context of the numerous changes that have occurred in perinatal care and to determine how information and knowledge acquired about pregnancy and birth influenced women’s birth experiences. Methods: Semi-structured interviews were conducted in prenatal health clinics in Montreal and Vancouver with 36 women before and after birth. Results: Most study participants were unaware of the range of available providers and birth settings. Of the women who were more aware of their options, those selecting a birth center or home birth and midwives had different notions of risk than those who planned a hospital birth. Study participants felt generally well informed, but thought that information sharing, collaborative decision making, or both were inadequate during labor and birth within the hospital setting. Conclusions: Despite positive changes in recent years, family-centered maternity care in Canada still needs to be improved. Women’s ability to use their acquired prenatal knowledge to feel satisfied by their birth experience continues to be undermined by a system of care that does not prioritize women’s informed choice. Further systemic change is required to align maternity care with the needs of Canadian birthing women and their families. (BIRTH 37:2 June 2010) [ABSTRACT FROM AUTHOR]

Background: The use of complementary and alternative medicine has attracted much attention and debate in recent years. The objective of this critical review is to examine the evidence base on use of complementary products and therapies during pregnancy. It examines an important but neglected issue in maternity care. Methods: A database search was conducted in MEDLINE, CINAHL, AMED, and Maternity and Infant Care. A total of 24 papers published between 1999 and 2008 met the selection criteria and were included in the review. Results: Findings of these 24 papers were extracted and reported under four themes: “user prevalence and profile,”“motivation and condition of use,”“perception and self-reported evaluation,” and “referral and information sources.” Conclusions: This review highlights four research gaps in the literature, a lack of: large representative samples; in-depth understanding of user experiences and risk perceptions; research comparing consumption patterns across cultures and over time; and work exploring the nature of the therapeutic encounter with complementary practitioners in this area of women's health care. [ABSTRACT FROM AUTHOR]

Background: Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries, pregnant women often prepare written birth plans, outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low–socioeconomic status Mexicans and to document women’s and health practitioners’ perspectives on the advantages and barriers in implementing a birth plan program. Methods: We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in-depth interviews with 4 women who had given birth in the past year, and with 2 nurses, 2 social workers, and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. Results: All 9 women who completed a birth plan found the experience highly satisfying, despite the fact that in some cases, their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners, but facilities often lacked space and financial incentives for birth plan programs. Conclusions: Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation. (BIRTH 34:1 March 2007) [ABSTRACT FROM AUTHOR]