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Objectives: The World Health Organization has adopted two main strategies to improve the quality of maternal health: increasing the number of deliveries by skilled birth attendants and increasing access to emergency obstetric care. Despite increased access to care, there continue to be high rates of maternal morbidity and mortality in part due to quality of care. This study aims to identify and summarize existing frameworks for measuring quality of maternal care at a facility-level. Methods: PubMed, Health Systems Evidence, Embase, Global Health, OVID Healthstar, OVID Medline, PsycINFO, and Web of Science were searched for frameworks, tools, theories, or components of frameworks relevant to maternal quality of care in facility-level settings. Title/abstract and full-text screening were completed by two independent reviewers and conflicts resolved through consensus or a third reviewer. Results: An initial search resulted in 3182 studies. Fifty-four studies were included in the qualitative analysis. A best fit framework analysis was done using the updated Hulton framework as the conceptual framework. A facility-based maternal quality of care framework is proposed including the following components, separated into provision and experience of care: (1) human resources; (2) infrastructure; (3) equipment, supplies and medicine; (4) evidence and information; (5) referral and networks of care; (6) cultural competence; (7) clinical practice; (8) financing; (9) leadership and governance; (10) cognition; and 11) respect, dignity, equity, and emotional support. Significance: Despite increased institutional access to care, there continue to be high rates of maternal morbidity and mortality in some low- and middle-income countries. This is in part due to the quality of maternal care once care has been accessed. Several frameworks have been proposed for understanding the complexities surrounding quality of care in maternal health but there has not been a single framework consistently used in the literature for facility-based quality of maternal care. This paper identifies and summarizes existing frameworks and tools, and uses a best fit framework analysis to propose a comprehensive framework for assessing facility-based maternal quality of care. [ABSTRACT FROM AUTHOR]

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women's reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges-life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes. [ABSTRACT FROM AUTHOR]

Despite high rates of early childbearing, maternal mortality, and under-five mortality, little is known about factors that affect access of teenage mothers to maternal and child health (MCH) services in Niger. This paper explores potential factors associated with the utilization of MCH care services by adolescent mothers. Using the third wave of the Niger demographic and health survey (NDHS) 2006, we estimate three multivariate logistic regression models to assess individual characteristics associated with the utilization of antenatal care (ANC) and safe delivery care services among adolescent women, as well as full immunization received by children born to adolescent mothers. The analytical sample includes 934 adolescent mothers out of 1,835 respondents aged 15-19, and within this group, 493 mother-child dyads for children aged 12-59 months. Possessing any level of education was found associated with the increased use of all three selected MCH services, while urban residence and higher income were associated with the increased use of two of three MCH services studied. Higher birth order plus a birth interval more than 2 years for the most recent birth appeared associated with the lower probability of antenatal care visits and safe delivery care. This study finds that women who attended at least four ANC visits were more likely to experience safe delivery care, and the children whose mothers had safe delivery care were more likely to receive full immunization. Therefore, an effective program should be designed to promote a continuum of MCH care with special attention to adolescent women who are uneducated, poor and residing in rural areas. [ABSTRACT FROM AUTHOR]

A significant reduction in maternal mortality was witnessed globally in the year 2010, yet, no significant reduction in the maternal mortality ratio (MMR) in Nigeria was recorded. The absence of accurate data on the numbers, causes and local factors influencing adverse maternal outcomes has been identified as a major obstacle hindering appropriate distribution of resources targeted towards improving maternal healthcare. This paper reports the first community based study that measures the incidence of maternal mortality in Ibadan, Nigeria using the indirect sisterhood method and explores the applicability of this method in a community where maternal mortality is not a rare event. A community-based study was conducted in Ibadan using the principles of the sisterhood method developed by Graham et al. for developing countries. Using a multi-stage sampling design with stratification and clustering, 3,028 households were selected. All persons approached agreed to take part in the study (a participation rate of 100%), with 2,877 respondents eligible for analysis. There was a high incidence of maternal mortality in the study setting: 1,324/6,519 (20.3%) sisters of the respondents had died, with 1,139 deaths reportedly related to pregnancy, childbirth or the puerperium. The MMR was 7,778 per 100,000 live births (95% CI 7,326-8,229). Adjusted for a published Total Fertility Rate of 6.0, the MMR was 6,525 per 100,000 live births (95% CI 6,144-6,909). Women in Ibadan were dying more from pregnancy related complications than from other causes. Findings of this study have implications for midwifery education, training and practice and for the first time provide policy makers and planners with information on maternal mortality in the community of Ibadan city and shed light on the causes of maternal mortality in the area. [ABSTRACT FROM AUTHOR]

With its independence secured on 9th July 2011, the Republic of South Sudan faces a daunting task to improve public health and primary care in one of the poorest countries in the world. Very high maternal and child mortality rates must be a major concern for the new national government and for the many international agencies working in the country. Poor maternal health outcomes are primarily due to poor prenatal, delivery and post natal care services in health facilities, coupled with low literacy, widespread poverty, and poor nutrition among the general population. Child mortality is the result of widespread malnutrition, pneumonia, malaria, vaccine preventable diseases and diarrheal diseases. National responses to HIV and AIDS with international assistance have been encouraging with relatively low rates of infection. This paper explores barriers and identifies opportunities available to work toward achieving the targets for Millennium Development Goals (MDGs) 5 and 4 to reduce maternal mortality from its current rate of 2,054 deaths per 100,000 live births, and child mortality (currently 135 deaths per 1,000 live births) respectively in the new nation. National and international organizations have a social responsibility to mobilize efforts to focus on maternal, child health and nutrition issues targeting the worst affected regions for improving access to primary care and obstetrical services. Initiatives are needed to build up community access to primary care with a well supervised community health workers program, as well as training mid level management capacity with higher levels of funding from national and international sources to promote public health than current in the new republic. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form. Description: In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality. Assessment: Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs. Conclusion: The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form. [ABSTRACT FROM AUTHOR]

The coronavirus 2019 (COVID-19) pandemic and related policies have led to an unequal distribution of morbidity and mortality in the U.S. For Black women and birthing people, endemic vulnerabilities and disparities may exacerbate deleterious COVID-19 impacts. Historical and ongoing macro-level policies and forces over time have induced disproportionately higher rates of maternal morbidity and mortality among Black women and birthing people, and contemporary macroeconomic and healthcare policies and factors continue to hold particular consequence. These factors induce detrimental psychological, health, and behavioral responses that contribute to maternal health disparities. The COVID-19 pandemic is likely to disproportionately impact Black women and birthing people, as policy responses have failed to account for the their unique socioeconomic and healthcare contexts. The resulting consequences may form a 'vicious cycle', with upstream impacts that exacerbate upstream macro-level policies and forces that can further perpetuate the clustering of maternal morbidity and mortality in this population. Understanding the impacts of COVID-19 among Black women and birthing people requires theoretical frameworks that can sufficiently conceptualize their multi-level, interacting, and dynamic nature. Thus, we advocate for the proliferation of syndemic perspectives to guide maternal disparities research and prevention during the COVID-19 pandemic. These perspectives can enable a holistic and nuanced understanding of the intersection of endemic and COVID-19-specific vulnerabilities and disparities experienced by Black women and birthing people. Syndemic-informed research can then lead to impactful multi-level prevention strategies that simultaneously tackle both endemic and COVID-19-specific factors and outcomes that lead to the clustering of vulnerabilities and disparities over time. [ABSTRACT FROM AUTHOR]

Introduction The Islamic Republic of Pakistan’s maternal mortality ratio is particularly high, and the nation ranks 126 out of 149 countries on the Human Development Report-Gender Inequality Index. This is because Pakistani women have low levels of empowerment, make limited economic contributions, and underutilization of maternal health care. The aim of this study is to create a multidimensional index of women’s empowerment and assess the association between this index and maternal health care utilization in Pakistan, controlling for individual characteristics and community-level traits. Methods Data from the 2012-2013 Pakistan Demographic and Health Surveys were employed to investigate the relationship between this index and the latent construct of maternal health care utilization. Results Using exploratory factor analysis, four indicators of maternal health care utilization were loaded onto a single latent factor. Multivariate analyses found support for the association between empowerment and health care utilization, despite adjustments for individual and area level factors. Positive associations between education, wealth, and maternal health care utilization were found. Conclusions Although we find support for the association of educational attainment with maternal health care utilization, the multidimensional women’s empowerment index was independently a consistent associate of maternal health care utilization. This illustrates a complex mechanism with both—education and empowerment, being necessary for improved maternal health care utilization. Policy makers seeking to improve outcomes should expand their focus beyond simply improving rates of education to examining effects of cultural norms which constrain the independence of women in making decisions about their own health care. [ABSTRACT FROM AUTHOR]

Introduction Nigeria contributes more obstetric, postpartum and neonatal deaths and stillbirths globally than any other country. The Clinton Health Access Initiative in partnership with the Nigerian Federal Ministry of Health and the state Governments of Kano, Katsina, and Kaduna implemented an integrated Maternal and Neonatal Health program from July 2014. Up to 90% women deliver at home in Northern Nigeria, where maternal mortality ratio and neonatal mortality rates (MMR and NMR) are high and severe challenges to improving survival exist. Methods Community-based leaders (“key informants”) reported monthly vital events. Pre-post comparisons of later (months 16-18) with conservative baseline (months 7-9) rates were used to assess change in MMR, NMR, perinatal mortality (PMR) and stillbirth. Two-tailed cross-tabulations and unadjusted and adjusted logistic regression analyses were conducted. Results Data on 147,455 births (144,641 livebirths and 4275 stillbirths) were analyzed. At endline (months 16-18), MMR declined 37% (OR 0.629, 95% CI 0.490-0.806, p ≤ 0.0003) vs. baseline 440/100,000 births (months 7-9). NMR declined 43% (OR 0.574, 95% CI 0.503-0.655, p < 0.0001 vs. baseline 15.2/1000 livebirths. Stillbirth rates declined 15% (OR 0.850, 95% CI 0.768-0.941, p = 0.0018) vs. baseline 21.1/1000 births. PMR declined 27% (OR 0.733, 95% CI 0.676-0.795, p < 0.0001) vs. baseline 36.0/1000 births. Adjusted results were similar. Discussion The findings are similar to the Cochrane Review effects of community-based interventions and indicate large survival improvements compared to much slower global and flat national trends. Key informant data have limitations, however, their limitations would have little effect on the results magnitude or significance. [ABSTRACT FROM AUTHOR]

Purpose To showcase several current national initiatives that focus on reducing maternal mortality and severe maternal morbidity and promote postpartum health and wellness for all women. Description Maternal injuries and deaths are a serious public health concern with tremendous impact on families, communities, and healthcare providers. Over the past two decades, it has become apparent that the timing of serious maternal complications has shifted, with more than half of deaths occurring in the immediate postpartum period up to 1 year following birth. Many of these reported deaths could have been prevented, and the number of 'near misses' of maternal morbidity cases continues to grow exponentially. In addition, postpartum women experience substantial unmet health needs, compromising their wellbeing. Assessment The American College of Obstetricians and Gynecologists and the Association of Women's Health, Obstetric, and Neonatal Nurses have thoroughly assessed the significance of the rising trends in maternal morbidity/mortality and are leading efforts to reduce these rates and improve overall health and wellbeing for all women during the postpartum period. Conclusion Developing national initiatives to improve postpartum health are vital to increasing the effectiveness of postpartum discharge education, and improving the participation in and the quality of postpartum care. Hopefully, evidence-based practice and widespread dissemination of these efforts will lead to a reduction in preventable post-birth maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objectives Obstetric hemorrhage is one of the leading causes of maternal mortality. The Florida Perinatal Quality Collaborative coordinates a state-wide Obstetric Hemorrhage Initiative (OHI) to assist hospitals in implementing best practices related to this preventable condition. This study examined intervention characteristics that influenced the OHI implementation experiences among Florida hospitals. Methods Purposive sampling was employed to recruit diverse hospitals and multidisciplinary staff members. A semi-structured interview guide was developed based on the following constructs from the intervention characteristics domain of the Consolidated Framework for Implementation Research: evidence strength; complexity; adaptability; and packaging. Interviews were audio-recorded, transcribed and analyzed using Atlas.ti. Results Participants (n = 50) across 12 hospitals agreed that OHI is evidence-based and supported by various information sources (scientific literature, experience, and other epidemiologic or quality improvement data). Participants believed the OHI was 'average' in complexity, with variation depending on participant's role and intervention component. Participants discussed how the OHI is flexible and can be easily adapted and integrated into different hospital settings, policies and resources. The packaging was also found to be valuable in providing materials and supports (e.g., toolkit; webinars; forms; technical assistance) that assisted implementation across activities. Conclusions for Practice Participants reflected positively with regards to the evidence strength, adaptability, and packaging of the OHI. However, the complexity of the initiative adversely affected implementation experiences and required additional efforts to maximize the initiative effectiveness. Findings will inform future efforts to facilitate implementation experiences of evidence-based practices for hemorrhage prevention, ultimately decreasing maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objectives: To compare the results of two maternal death review processes conducted from 2002 to 2012 by Illinois regionalized perinatal centers with those conducted by the Illinois Department of Public Health's (IDPH's) statewide multidisciplinary external Maternal Mortality Review Committee (MMRC). Methods: This is a retrospective record review linking MMRC case assessment forms to the IDPH's Maternal Mortality Review Form database to compare causes of death and potential preventability as determined by both review processes. Results: MMRC records for 76 maternal death reviews were linked to the IDPH maternal mortality review form database. Most deaths reviewed by the statewide MMRC were due to pregnancy-related causes. The statewide MMRC differed from the regional perinatal centers on cause of death in 55.3 % (n = 42) of cases and on the disposition of potential preventability in 48.7 % (n = 37) of cases. The statewide MMRC judged 69.7 % (n = 53) of cases potentially preventable, compared with 40.8 % (n = 31) for the regional perinatal centers. The MMRC identified more preventable provider and systems factors for potentially preventable deaths compared with regional perinatal centers which identified more preventable patient factors. Conclusions for practice: The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews. [ABSTRACT FROM AUTHOR]

Although most developing countries monitor the proportion of births attended by skilled birth attendants (SBA), they lack information on the availability and performance of emergency obstetric care (EmOC) signal functions by different cadres of health care providers (HCPs). The World Health Organisation signal functions are set of key interventions that targets direct obstetric causes of maternal deaths. Seven signal functions are required for health facilities providing basic EmOC and nine for facilities providing comprehensive EmOC. Our objectives were to describe cadres of HCPs who are considered SBAs in Tanzania, the EmOC signal functions they perform and challenges associated with performance of EmOC signal functions. We conducted a cross-sectional study of HCPs offering maternity care services at eight health facilities in Moshi Urban District in northern Tanzania. A questionnaire and health facility assessment forms were used to collect information from participants and health facilities. A total of 199 HCPs working at eight health facilities in Moshi Urban District met the inclusion criteria. Out of 199, 158 participated, giving a response rate of 79.4 %. Ten cadres of HCPs were identified as conducting deliveries regardless of the level of health facilities. Most of the participants (81 %) considered themselves SBAs, although some were not considered SBAs by the Ministry of Health and Social Welfare (MOHSW). Only two out of the eight facilities provided all of the required EmOC signal functions. While Assistant Medical Officers are expected to perform all the signal functions, only 38 % and 13 % had performed vacuum extraction or caesarean sections respectively. Very few registered and enrolled nurse-midwives had performed removal of retained products (22 %) or assisted vaginal delivery (24 and 11 %). Inadequate equipment and supplies, and lack of knowledge and skills in performing EmOC were two main challenges identified by health care providers in all the level of care. In the district, gaps existed between performance of EmOC signal functions by SBAs as expected by the MOHSW and the actual performance at health facilities. All basic EmOC facilities were not fully functional. Few health care providers performed all the basic EmOC signal functions. Competency-based in-service training of providers in EmOC and provision of enabling environment could improve performance of EmOC signal functions in the district. [ABSTRACT FROM AUTHOR]

International guidelines and recommendations for availability and spatial distribution of emergency obstetric care services do not adequately address the challenges of providing emergency health services in island communities. The isolation and small population sizes that are typical of islands and remote populations limit the applicability of international guidelines in such communities. Universal access to emergency obstetric care services, when pregnant women encounter complications, is one of the three key strategies for reducing maternal and newborn mortality; the other two being family planning and skilled care during labor. The performance of selected lifesaving clinical interventions (signal functions) over a 3-month period is commonly used to assess and assign performance categories to health facilities but island communities might not have a large enough population to generate demand for all the signal functions over a 3-month period. Similarly, availability and spatial distribution recommendations are typically based on the size of catchment populations, but the populations of island communities tend to be sparsely distributed. With illustrations from six South Pacific Island states, we argue that the recommendation for availability of health facilities, that there should be at least five emergency obstetric care facilities (including at least one comprehensive facility) for every 500,000 population, and the recommendation for equitable distribution of health facilities, that all subnational areas meet the availability recommendation, can be substituted with a focus on access to blood transfusion and obstetric surgical care within 2 hours for all pregnant residents of islands. Island communities could replace the performance of signal functions over a 3-month period with a demonstrated capacity to perform signal functions if the need arises. [ABSTRACT FROM AUTHOR]

Hypertension is a major global public health risk and significant precursor to cardiovascular disease, stroke, diabetes and maternal mortality. A possible strategy to reduce chronic disease in resource-poor areas is social intervention. Research into the possible relationship of social determinants and disease is needed to determine appropriate social interventions. This study aims to determine the association between social capital and hypertension in rural Haitian women. From June to August 2005, 306 women, ages 18-49, who attended one of Hôpital Albert Schweitzer's five rural dispensaries as patients or accompanying patients, were interviewed. Individual interviews on social capital, demographics and anthropometrics were conducted. SAS statistical package was used to analyze the data. Groups/networks, personal empowerment, collective action/cooperation and trust components significantly decreased the likelihood of hypertension in multivariate analysis. In an additive model, the ranked index of social capital indicated that each social capital component score above the conceptual midpoint showed a 41 % reduction in the likelihood of hypertension. The findings suggest that interventions aimed to increase components of social capital may significantly lower hypertension. [ABSTRACT FROM AUTHOR]

The Maternal Mortality Ratio is an important public health indicator that reflects both the quality of a health care system and the role of women within that society. In September 2000 the United Nations Millennium Declaration outlined the eight Millennium Development Goals (MDGs) that set targets to be achieved by 2015. MDG 5 focused on improving maternal health. It had two clear subgoals: to reduce maternal mortality globally by three quarters between 1990 and 2015 and to obtain universal access to reproductive health for women. Despite a global trend of declining maternal mortality only a handful of nations are currently 'on track' to achieve their MDG targets by 2015. The Islamic Republic of Iran is one of these nations. In just over three decades, Iran has undergone demographic transition with significant reductions in total fertility and population growth rates. In concert with this transition, Iran has achieved a dramatic decline in the maternal mortality ratio that has fallen to a rate comparable with developed nations. Significantly Iran has also experienced a paradigm shift in its major causes of maternal mortality from those characteristic of developing nations (postpartum haemorrhage, infection) to causes more commonly seen in developed nations (pulmonary embolus, stroke). There is no single explanation that may account for this transition, rather it is the product of a number of different initiatives that have incorporated family planning, grass roots focus and wider improvements within the health care system of Iran over the past three decades. However the experience of this nation may provide a useful example to other developing countries looking to reduce maternal mortality. [ABSTRACT FROM AUTHOR]

Millennium Development Goals (MDGs) 4 and 5 set ambitious targets to reduce maternal, newborn and child mortality by 2015. With 2015 fast approaching, there has been a concerted effort in the global health community to 'close the gap' on the MDG targets. Recent consensus initiatives and frameworks have refocused attention on evidence-based, low-cost interventions that can reduce mortality and morbidity, and have argued for additional funding to increase access to and coverage of these life-saving interventions. However, funding alone will not close the gap on MDGs 4 and 5. Even when high-quality, affordable products and services are readily available, uptake is often low. Progress will therefore require not just money, but also advances in health-related behavior change and decision-making. Behavioral economics offers one way to achieve real progress by improving our understanding of how individuals make choices under information and time constraints, and by offering new approaches to make it easier for individuals to do what is in their best interest and harder to do what is not. We introduce five behavioral economic principles and demonstrate how they could boost efforts to improve maternal, newborn, and child health in pursuit of MDGs 4 and 5. [ABSTRACT FROM AUTHOR]

Objectives : Maternal mortality ratios in the United States are higher than those of many other industrialized nations. Moreover, these ratios have not changed in the past 20 years, and large racial disparities persist in measures of both maternal mortality and morbidity. In an affluent developed country, maternal deaths should serve as rare sentinel events, highlighting opportunities for prevention and reduction of morbidities. However, existing surveillance efforts are poorly developed, and pregnancy-related deaths and illnesses tend to be underreported. To formulate recommendations for improved surveillance, the authors reviewed existing data on maternal health. Methods : This review examines the scope and quality of existing information and the strengths and limitations of definitions of maternal mortality and morbidity used in data collection and reporting. Results : This review suggests numerous gaps in surveillance of U.S. maternal health. Psychological as well as physical morbidity, and the presence and adequacy of appropriate treatment, should be ascertained. Quality of pregnancy-related care at the clinical and community levels, and the impact on mortality and morbidity, must be assessed. Collection of morbidity data outside of health care delivery sites is also essential. Trade-offs between nationally representative and other less comprehensive data sources, such as sentinel clinics, large healthcare organizations, and public healthcare financing systems, should be considered. Conclusion : Maternal health remains an important frontier for U.S. public health surveillance efforts. Improved surveillance offers opportunities for reducing pregnancy-related mortality and gaining a better understanding of the relationship between maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objectives: When perinatal medicine emerged as a new medical discipline in the 1960s, Berlin was as one of the world's leading centers. During that time, the city was separated into two parts, each fostering its own health care system. After the destruction of the Berlin Wall, it was possible to speak with the citizens of East Berlin and to access their database systems. This created the singular opportunity to objectively compare the development of perinatal care in both parts of Berlin. Methods: Rates of maternal, perinatal, and infant mortality as well as the rate of preterm deliveries were evaluated over time and between East and West Berlin. The timing of introduction of 20 specific perinatal interventions was evaluated across 18 hospitals with more than 500 deliveries (11 in West Berlin and 7 in East Berlin). Interviews were conducted with 100 gynecologists, 100 midwives, and 100 women who had recently delivered their first child from each side of the city regarding their opinions of the importance of these interventions for the quality of perinatal medicine and how they would distribute a budget to improve maternity care. Results: Maternal, perinatal, and infant mortality decreased in both parts of Berlin until 1990 (p <0.0001), without significant differences between East and West Berlin, though the preterm delivery rate was slightly lower in East Berlin compared with West Berlin (p <0.06). Some new clinical techniques and treatments—such as cardiotocography, ultrasound, tocolytic therapy, and peridural anesthesia—were introduced earlier in West Berlin. In contrast, certain public health measures—such as maternal transport, screening programs for diabetes, and support of breastfeeding—were introduced much earlier in East Berlin. There were significant differences between the beliefs of gynecologists, midwives, and mothers in East and West Berlin. In general, citizens of East Berlin were more enthusiastic about technological medical advances, whereas citizens of West Berlin were more supportive of public health and alternative methods. In addition, there were significant differences between female and male physicians in their beliefs about how to improve health care, regardless of whether they resided in East or West Berlin. Conclusions: The results of this study may serve as a basis for reflection on how different social circumstances and health care policies can influence the improvement of maternal and child health care. [ABSTRACT FROM AUTHOR]