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Introduction: A positive childbirth experience promotes women's health, both during and beyond the perinatal period. Understanding what constitutes a positive childbirth experience is thus critical to providing high‐quality maternity care. Currently, there is no clear, inclusive, woman‐centered definition of a positive childbirth experience to guide practice, education, and research. Aim: To formulate an inclusive woman‐centered definition of a positive childbirth experience. Methods: A six‐step process was undertaken: (a) Key concepts associated with a positive childbirth were derived from a rapid literature review; (b) The key concepts were used by interdisciplinary experts in the author group to create a draft definition; (c) The draft definition was presented to clinicians and researchers during a European research meeting on perinatal mental health; (d) The authors integrated the expert feedback to refine the working definition; (e) A revised definition was shared with women from consumer groups in six countries to confirm its face validity; and (f) A final definition was formulated based on the women's feedback (n = 42). Results: The following definition was formulated: "A positive childbirth experience refers to a woman's experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women feel joy, confident, and/or accomplished and may have short and/or long‐term positive impacts on a woman's psychosocial well‐being." Conclusions: This inclusive, woman‐centered definition highlights the importance of provider interactions for facilitating a positive childbirth experience. Feeling supported and having a sense of control, safety, and respect are central tenets. This definition could help to identify and validate positive childbirth experience(s), and to inform practice, education, research, advocacy, and policy‐making. [ABSTRACT FROM AUTHOR]

How a woman experiences birth is influenced by how she is treated, and who has power and control in the birthing environment. Focus on 'delivery' of an infant disregards the transformative event for the woman, with poorer physical and psychological outcomes. New evidence is needed to understand how to prevent trauma and improve maternal wellbeing. This paper presents a feminist methodology to view the lived experience of caesarean birth. Feminist birthing theories integrated with a phenomenological perspective provide insight for those working in maternity care and create a novel framework for researchers considering the position of women in a medicalised healthcare system. Feminist phenomenology with a theoretical feminist overlay refreshes the methodological framework for a new understanding of how this perinatal event impacts women. [ABSTRACT FROM AUTHOR]

Social workers in Perinatal Palliative Care (PPC) play an essential role in caring for birthing people carrying a baby with a life-limiting condition and their families. Perinatal palliative care is consistent with social work values concerning fostering quality of life and promoting social justice and access to care. Social workers play a multidimensional role in providing a holistic approach to caring for the birthing person, baby, and family. Although social workers may be part of an interdisciplinary care team, their role is not defined solely by the goals of the greater team, nor has it been discussed in depth in the perinatal palliative care literature. The purpose of this paper is to describe the knowledge, values, and skills essential to the role of the social worker in a hospital-based perinatal palliative care team. A case study will be used to illustrate the relevant practices, and implications are outlined. [ABSTRACT FROM AUTHOR]

Background: Maternal healthcare service utilization is a pivotal indicator of a nation's progress in safeguarding the health and well-being of its women and children. In this context, women's empowerment emerges as a critical determinant influencing the utilization of maternal healthcare services. The study aims to assess the relationship between women's level of empowerment and utilization of maternal healthcare services among currently married women in India. Data and Methods: The study uses data from the fifth round of the National Family Health Survey conducted in 2019–2021 and analyzed 26,552 (15–49 aged) currently married women who had a live birth in the last 5 years preceding the survey. Additionally, univariate and bivariate analyses, multivariate logistic regression, and the SWPER index were used for the analysis. Results: Over the years, utilization of antenatal care, skilled birth attainment, and postnatal care has increased extensively in India. However, the study found that utilization of services was higher among empowered women, and it varies across the state with the extent of empowerment. State-level analysis shows that the extent of women empowerment was higher in Goa, followed by Tamil Nadu and Kerala, and lower in Jharkhand, followed by Tripura, so as the utilization of maternal and health care services. The extent of empowerment and utilization of services also varies by level of educational attainment, employment, and socio-economic status. Conclusion: There is a need for comprehensive strategies to enhance women's empowerment through education, employment, political participation, self-awareness, and reduction in gender-based violence and child marriages, which may improve awareness demand for better public health structure, and may ensure higher utilization of maternal healthcare services. Ultimately, these strategies may converse the higher maternal death and child mortality. Significance: What is already known about this subject? Existing literature in India mostly highlights a clear connection between women's autonomy and maternal healthcare services utilization. Women with higher autonomy, decision-making power, and mobility are more likely to use these services. However, in exploring the link between women's empowerment and maternal healthcare, some studies focus on education, employment, and media access among Indian mothers, sidelining broader empowerment dimensions. What this study adds? This study is likely the first to investigate the relationship between women's empowerment and the level of maternal healthcare service utilization in India. It covers key dimensions of women's empowerment, including Attitude to Violence, Social Independence, and Decision-making Power. Moreover, it is possibly the first Indian research paper to employ a survey-based women's empowerment index in this context. Notably, the assessment highlights Social Independence as a significant dimension. [ABSTRACT FROM AUTHOR]

Objective: To describe change in costs to different funders over time for women giving birth in Queensland between 2012 and 2018. Methods: A whole-of-population linked administrative dataset was used that contained all health service use in Queensland for women who gave birth between 1 July 2012 and 30 June 2018 and their babies. Aggregated costs for mother and baby from pregnancy to 12 months postpartum were used to compare the change in costs to funders over time. Results: There was an increase in mean total cost to all funders per birth in the public system and private system from 2012 to 2018. North West Hospital and Health Service (HHS) had the highest mean total cost (in Australian dollars) in 2018 (A$42 353), while home births had the lowest (A$6105). For the majority of HHSs the proportion of births with a positive birth outcome (as defined by a composite outcome measure) has remained largely static or declined during this time period. Cairns and Hinterland HHS and Townsville HHS had the largest declines of 15% and 16% respectively, while mean total cost to all funders rose 36.39% and 46.41%, respectively. Conclusions: There has been an increase over time across Queensland in the cost of childbirth in public hospitals and in the private system, while the cost of home birth has remained static. For most HHSs this increase in cost is also associated with little change or a decline in the percentage of births with a positive outcome. Increases in cost are therefore not being translated into better outcomes for women and their babies. Routine performance monitoring of cost, quality and safety should be adopted to ensure the provision of high value maternity care in Australia. What is known about the topic? Public maternity care costs vary in Australia dependent upon place of birth, even after adjusting for clinical and demographic factors. What does this paper add? This paper compares the change in costs for mother and baby from birth through to 12 months for births across Queensland over time. Costs for maternity care have increased over time and higher-cost treatment does not necessarily result in better health outcomes. What are the implications for practitioners? Reporting of cost alongside clinical outcomes should be included in performance monitoring of public hospital maternity care. [ABSTRACT FROM AUTHOR]

The views expressed here are based on my professional experience as a consultant obstetrician, and previous role as clinical head of service for a small (<1800 births/year) obstetric unit in Perth metro. The obstetric unit in which I work has no 24/7 on‐site staffed theatre capacity, no high dependency unit, and at night is staffed by a resident medical officer and junior obstetric registrar, with a consultant on‐call within 30 min travel time. Based on my review of the literature on obstetric services nationally and various state guidelines (see Sources section), other Australian metro‐located obstetric services appear to have similar challenges, but in this paper I focus on the health service models and patient safety systems that I am most familiar with (Perth metro) and ask why obstetric services in this, and by inference, other areas of the country which have similar high population density, would continue to have these staffing/service profiles. [ABSTRACT FROM AUTHOR]

Introduction: In the United States, adverse birth outcomes are most prevalent among Black women and birthing people, who are known to experience increased mistreatment and disrespect in care. The purpose of this paper is to describe findings from a study that used two validated scales to examine factors associated with experiences of person‐centered care during pregnancy and birth among Black birthing people in California. Methods: We used data from 234 Black women and birthing people who were recruited between January and September 2020 as part of a validation study for the Person‐Centered Prenatal Care (PCPC) and the Person‐Centered Maternity Care (PCMC‐US) scales. Bivariate and multivariate analyses were conducted to examine the associations between PCPC and PCMC‐US scores and sociodemographic, health‐related, and care‐related factors. Results: The factors associated with lower PCPC scores were having foreign‐born parents, having public or no insurance, part‐time employment, unstable housing, late start of prenatal care (in the second or third trimester), poorer self‐rated health (less than very good), and lack of continuity of care with prenatal providers. Factors associated with lower PCMC‐US scores were having public insurance, late start of prenatal care, longer length of stay in facility following birth, poorer self‐rated health, lack of continuity of care between prenatal care and birth providers, and racial discordance with birth provider. Conclusions: Our analysis highlights the contributions of intersecting identities as well as health‐related and care‐related factors to Black birthing people's experiences of care in California. Continuity of care and provider racial concordance, in particular, were shown to improve pregnancy and birth experiences. [ABSTRACT FROM AUTHOR]

Introduction: Poor psychosocial support and lack of respectful care for women during childbirth are commonplace in health facilities in low- and middle-income countries. While WHO recommends providing supportive care to pregnant women, there is a scarcity of material for building the capacity of maternity staff to provide systematic and inclusive psychosocial support to women in the intrapartum phase, and prevent work stress and burnout in maternity teams. To address this need we adapted WHO's mhGAP for maternity staff to provide psychosocial support in labour room settings in Pakistan. Mental Health Gap Action Programme (mhGAP) is an evidence-based guidance which provides psychosocial support in resource-limited health care settings. This paper aims to describe the adaptation of mhGAP to develop psychosocial support capacity building materials for maternity staff to provide support to maternity patients, and also to staff, in the labour room context. Methods: Adaptation was conducted within the Human-Centered-Design framework in three phases: inspiration, ideation, and implementation feasibility. In inspiration, a review of national-level maternity service-delivery documents and in-depth interviews of maternity staff were conducted. Ideation involved a multidisciplinary team to develop capacity-building materials by adapting mhGAP. This phase was iterative and included cycles of pretesting, deliberations, and revision of materials. In implementation feasibility, materials were tested via the training of 98 maternity staff and exploring system feasibility via post-training visits to health facilities. Results: Inspiration phase identified gaps in policy directives and implementation and formative study identified limited understanding and skills of staff to assess patients' psychosocial needs and provide appropriate support. Also, it became evident that staff themselves needed psychosocial support. In ideation, team developed capacity-building materials comprising two modules: one dedicated to conceptual understanding, the other to implementing psychosocial support in collaboration with maternity staff. In implementation feasibility, staff found the materials relevant and feasible for the labour room setting. Finally, users and experts endorsed usefulness of the materials. Conclusion: Our work in developing psychosocial-support training materials for maternity staff extends the utility of mhGAP to maternity care settings. These materials can be used for capacity-building of maternity staff and their effectiveness can be assessed in diverse maternity care settings. [ABSTRACT FROM AUTHOR]

The purpose of the authors in this paper is to investigate the effects of negative experiences during delivery and postpartum period on the relationship between the mother. The quantitative part of this study was conducted with 289 mothers and the qualitative part with 40 mothers. It was found that experiencing upsetting problems during delivery (p = 0.006) and in the postpartum period (p = 0.002) had an effect on separation anxiety. Based on the examination of the feelings experienced during annoying or distressing situations in the postpartum period, it was determined that there was a significant correlation between guilt (p = 0.000), fear of not being a good mother (p = 0.035), and feeling weak (p = 0.001) and separation anxiety. Blues of birth is fear and anxiety that the baby will be harmed if the mother is separated from it, and it is attributed to negative experiences during delivery and the postpartum period. [ABSTRACT FROM AUTHOR]

This paper begins with the common phrase 'good girl' as a lens through which to explore the insidious nature of patronising and paternalistic language on women's agency in obstetric care. Here we see how misogynistic language is both violence against women in its own right, and serves to create a context in which more extreme obstetric violence can be precipitated. Based on thematic analysis of discussion on Mumsnet, and on contributions to a research-focused Facebook group, this paper illustrates the complexity of recognising and refuting misogyny as a female patient as well as the damage that can occur from a cultural context in which this language is normalised. Here, words both boast a materiality through the environments they reify, and become transient and slippery, with semiotic uncertainty. • Use of misogynistic language in obstetric and fertility care is widespread. • This language may be difficult to identify and address. • Language that positions women as incompetent creates a context in which violence may occur during childbirth. • Experiences of obstetric violence are common even in the UK, amongst well-educated women. [ABSTRACT FROM AUTHOR]

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study's programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants' motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase). Methods: In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness. Discussion: Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally. Trial registration: CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022). Plain language summary: The new WHO Labour Care Guide (LCG) is an innovative partograph that emphasises women-centred, evidence-based care during labour and childbirth. Together with clinicians working at four hospitals in India, we will develop and test a strategy to implement the LCG into routine care in labour wards of these hospitals. We will use a randomised trial design where this LCG strategy is introduced sequentially in each of the four hospitals, in a random order. We will collect data on all women giving birth and their newborns during this period and analyse whether the LCG strategy has any effects on the use of Caesarean section, women's and newborn's health outcomes, and women's experiences during labour and childbirth. While the trial is being conducted, we will also collect qualitative and quantitative data from doctors, nurses and midwives working in these hospitals, to understand their perspectives and experiences of using the LCG in their day-to-day work. In addition, we will collect economic data to understand how much the LCG strategy costs, and how much money it might save if it is effective. Through this study, our international collaboration will generate critical evidence and innovative tools to support implementation of the LCG in other countries. [ABSTRACT FROM AUTHOR]

Background: Woman-centred maternity care is respectful and responsive to women's needs, values, and preferences. Women's views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries. Methods: We undertook a qualitative meta-synthesis using a framework synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order and second-order constructs relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis. Results: Of the 7197 identified citations, 30 articles were included in this review. Women's needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for woman-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors. Conclusion: To improve care seeking and satisfaction with health services, woman-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for woman-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women's needs and preferences. [ABSTRACT FROM AUTHOR]

Objectives: Ethical dilemmas at both the individual and structural level are part of the daily work of midwives and gender inequality and injustice can affect women's sexual and reproductive health. Mainstream bioethical theory has been criticized for neglecting women's issues. To ensure women's experiences are addressed, a gender lens on ethics is crucial. Aim: This study develops a theory model by exploring ethical dilemmas related to gender in the context of maternity care from the perspective of midwifery science and feminist ethics. Methods: The research strategy followed a coherent stepwise approach: literature search, thematic analysis, elaboration of a gender ethics protocol, and the integration of various components into a preliminary gender ethics model for midwifery. Findings: A literature search was performed using Scopus and Web of Science to identify ethical dilemmas in maternity care linked to gender and power. The search of articles published between 1996 and 2019 returned 61 abstracts. These abstracts were screened and assigned one of the following themes: The Midwifery Profession, The Rights of the Woman, Fetal Rights Dominate, and Medicalization of Pregnancy and Childbirth. A tentative gender ethics frame was developed and tested on two articles on abortion, one from Denmark and one from Japan. The protocol facilitated the gender analysis of ethical dilemmas related to abortion, which were related to the imbalance of power relations in health care. In the final step, we synthesized the dimensions of gender and power in a gender ethics model for midwifery. Discussion: The gender ethics protocol developed revealed gendered dimensions of ethical dilemmas in midwifery. This gender analysis adds to the understanding of the "do no harm" principle by revealing assumptions and stereotypes that promote unequal power relations. The gender ethics model is an innovative approach that envisions and exposes power imbalance at the micro, meso, and macro levels. Conclusions: The protocol could improve gender competence among researchers, midwives/professionals, and midwifery students throughout the world. Plain Language summary: As gender inequity, gender inequality, and oppression infuse dimensions in all human cultures and societies, not the least in midwifery practice where the layers of injustice affect women during pregnancy and birth in high-, middle-, and low-income countries, the time has come to renew the perspectives of normative ethics. In this study, we explore gender ethical dilemmas unique to maternity care from the perspective of midwifery science and feminist ethics. A literature search uncovered ethical dilemmas in midwifery, and four broad themes were identified: Midwifery Profession, Rights of the Woman, Fetal Rights Dominate, and Medicalization of Pregnancy and Childbirth. Next, we developed a gender ethics protocol suitable for providing gender ethical interpretations of results. The protocol was tested and refined using two articles (one from the Denmark and one from Japan) that address ethical dilemmas of abortion care. The pilot analysis indicates that the autonomy of midwives and their scope of practice might be constrained and that the obstetric medicalized/authoritative knowledge still plays a dominate role in maternity practice. Here, we present an elaborate model, gender ethics model for midwifery (GEMM), developed for midwifery science that can be further refined. The model challenges the views of maternity care and contributes to a deeper understanding of how fluid concepts such as gender and power circulate and influence women's and birthing person's sexual and reproductive health. Statement of significance: Problem or issue Layers of injustice affect women during pregnancy and birth in both high-, middle-, and low-income countries. The time has come to renew the perspectives of normative ethics. What is already known? Globally, ethical dilemmas at both the individual and structural levels pervade the daily work of midwives, but ethical research that includes gender theory in midwifery science is limited. What this paper adds Here, we present a gender ethics protocol and develop an innovative gender theory ethics model for midwifery to improve gender competence among researchers, midwives/professionals, and midwifery students. [ABSTRACT FROM AUTHOR]

In Brazil, Black women are disproportionately denied access to timely care and are made vulnerable to death by avoidable obstetric causes. However, they have not been at the center of recent initiatives to improve maternal health. This paper contends that the effectiveness of Brazilian maternal and infant health policy is limited by failures to robustly address racial health inequities. Multi-sited ethnographic research on the implementation of the Rede Cegonha program in Bahia, Brazil between 2012 and 2017 reveals how anti-Blackness structures iatrogenic harms for Black women as well as their kin in maternal healthcare. Building on the work of Black Brazilian feminists, the paper shows how Afro-Brazilian women experience anti-Black racism in obstetric care, which the paper argues can be better understood through Dána-Ain Davis' concept of obstetric racism. The paper suggests that such forms of violence reveal the necropolitical facets of reproductive governance and that the framing of obstetric violence broadens the scales and temporalities of iatrogenesis. [ABSTRACT FROM AUTHOR]

Background: Women's childbirth experiences in health facilities is at the core of quality of care. Their perceptions of poor-quality care, including disrespectful care at health facilities during childbirth, is recognized as a significant barrier to seeking care for subsequent births. Research that explores women's perspectives of the dimensions of disrespect and mistreatment during childbirth in Arab countries is scarce, and there is none pertaining to refugee groups who carry the burden of multiple vulnerabilities and who suffer from discontinued care, especially in fragile health systems. This paper aims at presenting Palestinian, Iraqi and Syrian refugee women's experiences, understanding and interpretation of disrespect and mistreatment during childbirth in hospitals in Lebanon.Methods: This study employed phenomenology, a qualitative research design to generate data through in-depth interviews. Women who were 3 to 6 months postpartum were recruited through the non-governmental organizations (NGOs) that are actively engaged in providing welfare and healthcare services to different populations of refugee women in Lebanon. In total, 24 women were interviewed. All interviews were audio recorded, transcribed verbatim and subjected to thematic analysis.Results: Of the 24 women who participated in this study, 9 were Palestinian, 12 were Syrian and 3 were Iraqi. The participants spoke of restricted choices to hospitals, care providers and to types of birth, while revealing adverse experiences during childbirth in healthcare facilities, including verbal and physical abuse, disrespectful verbal and non-verbal communication by healthcare providers. They also reported sub-standard care, denial of birth companions and breaches to their privacy. Our findings exemplify how the coverage of the cost of facility-based births by UN agencies and NGOs increase refugee women's vulnerability to disrespect and mistreatment during childbirth.Conclusion: This study shows how disrespect and mistreatment are intertwined in a complex system which is devised to ensure access to facility-based birth for displaced populations. Implications for programs and policies point to the need for strengthening capacity and for providing resources for the adaptation of global guidelines into context-specific strategies for the provision of quality maternity care during humanitarian crises and beyond. [ABSTRACT FROM AUTHOR]

Background: For pregnant and birthing women, maintaining a relationship with the same health care practitioner is critical to establishing a sense of safety. In postsocialist Serbia, where care is fragmented and depersonalized, this continuity is often missing. Patients are frequently handed over to new practitioners, sometimes without even knowing the name of the person overseeing their care. In response, many women turn to the private sector to keep the same practitioner across their prenatal period and their birth by establishing a personal "connection" within the hospital that they believe will shield them from mistreatment during childbirth. Methods: Data presented in this paper were collected through participant observation in one public maternity hospital and one public primary care center in Serbia; semistructured interviews with 14 physicians; and semistructured interviews with 80 women who had given birth in one public maternity hospital in Serbia. Results: Public maternity hospital physicians who supplement their income working in the private sector have the power to blur the distinctions between favors and services. They offer continuity of personalized care to their private clients/patients once they enter the public system, and they themselves obtain social and economic security unavailable to those working in only one sector. At the same time, there is evidence that personalized continuity of care does not actually shield women from mistreatment in hospitals. Conclusions: The private sector is reshaping existing informal strategies and blurring the lines between formal and informal payments. In the postsocialist context, consumer practices are not separate from, but entangled with, informality. Neoliberalism has not brought about empowerment and eliminated informality, but has instead further exacerbated existing inequalities in maternity care in Eastern Europe. [ABSTRACT FROM AUTHOR]

Background: Abusive and disrespectful treatment of women during childbirth is a critical global issue that threatens women's sexual rights and reproductive rights and access to quality maternal care. This phenomenon has been documented in Colombia. However, little emphasis has been placed on identifying the drivers of and potential interventions against disrespect and abuse against particularly vulnerable populations in the country, including internally displaced indigenous women.Methods: This report is a sub-analysis of a larger project. Semi-structured interviews were conducted with indigenous (Embera) women with childbirth experience (n = 10), maternal healthcare workers (n = 6), and community stakeholders (n = 5) in Medellín, Colombia. Qualitative analysis techniques, consisting of inductive and deductive approaches, were used to identify and characterize the drivers of disrespect and abuse against indigenous women during childbirth and points for intervention. Existing frameworks were adapted to thematically organize drivers and potential solutions into four interrelated subsystems: individual and community factors, clinician factors, facility factors, and national health system factors.Results: Participants highlighted disrespect and abuse as stemming from (within the individual and community level) its normalization, lack of autonomy and empowerment among indigenous women, lacking antenatal care, (within the clinician level) prejudice, linguistic or cultural barriers to communication, lack of understanding of indigenous culture, medical culture and training, burnout and demoralization, (within the facility level) inadequate infrastructure, space, and human resources, and (within the national systems level) lack of clear policies and the devaluing of respectful maternity care. They called for interventions specific to these drivers, grounded in dignity and respect for indigenous culture.Conclusion: This paper expands upon the growing literature on global mistreatment during childbirth by highlighting drivers of mistreatment and identifying points for intervention in a previously unstudied population. Our data show that indigenous women are especially vulnerable to mistreatment due to cultural and linguistic barriers and prejudice. Broad and meaningful action is urgently needed to realize these women's rights to respectful maternity care. Interventions must be multifaceted and locally specific, taking into account the needs and wants of the women they serve. [ABSTRACT FROM AUTHOR]

Dr. Akira Ikegawa opened a maternity clinic in Japan and has been helping parents handle childbirth for 40 years. His interest in ensuring the healthy growth of children and a happy family life was stimulated while interacting with the people who visited his clinic. His research on prenatal memory resulted in a new parenting method designed to increase the happiness of parents and children. He discovered that parents must be conscious of receiving love from their children. In this paper, Ikegawa compares his experience with standard obstetrical practices in Japan and his experience after introducing the Prenatal Memory method in his clinic. He also provides thoughts on Prenatal Memory Education, which evolved from prenatal memory research from Japan. [ABSTRACT FROM AUTHOR]

The Coronavirus pandemic raises significant concerns about pervasive social inequities and disparate gender relations, particularly between mothers/fathers. Indeed, the pandemic engendered a general retreat into traditional parenting roles across myriad, everyday, institutional, spaces, including workplaces, homes, and welfare/healthcare services. These effects have been especially marked for couples expecting a child. Visitor-restriction policies, implemented to curb viral-spread within healthcare settings, effectively 'barred' many expectant fathers in the UK (and elsewhere) from attending antenatal appointments, and even the birth of their child; milestone moments widely regarded as significant socio-cultural 'rites-of-passage' in fathers' transition to parenthood. Many pregnant women had to face these moments alone, sparking campaigns including #ButNotMaternity. This paper critically examines how such institutional responses exhibit a complex 'welfare trade-off' effectively (re)positioning fathers as spectators, rather than participants, in pregnancy/parenthood and risk embodying a potential U-turn to recent decades' emphasis on involved, equitable fatherhood. Drawing upon the accounts of expectant mothers/fathers in the UK reported in the popular press since March 2020 and the #ButNotMaternity campaign, it employs thematic social-media analysis to explore the emotional impacts of visitor-restrictions and the gendered, emotional governance of parenting amidst the pandemic through the exclusion of particular (fathers') bodies within maternity care spaces. [ABSTRACT FROM AUTHOR]

Objective: to map the current knowledge on recommendations for labor, childbirth, and newborn (NB) care in the context of the novel coronavirus. Method: scoping review of papers identified in databases, repositories, and reference lists of papers included in the study. Two researchers independently read the papers' full texts, extracted and analyzed data, and synthesized content. Results: 19 papers were included, the content of which was synthesized and organized into two conceptual categories: 1) Recommendations concerning childbirth with three subcategories -- Indications to anticipate delivery, Route of delivery, and Preparation of the staff and birth room, and 2) Recommendations concerning postpartum care with four categories -- Breastfeeding, NB care, Hospital discharge, and Care provided to NB at home. Conclusion: prevent the transmission of the virus in the pregnancy-postpartum cycle, assess whether there is a need to interrupt pregnancies, decrease the circulation of people, avoid skin-to-skin contact and water births, prefer epidural over general anesthesia, keep mothers who tested positive or are symptomatic isolated from NB, and encourage breastfeeding. Future studies are needed to address directed pushing, instrumental delivery, delayed umbilical cord clamping, and bathing NB immediately after birth. [ABSTRACT FROM AUTHOR]

Objective: This study sought to compare costs for women giving birth in different public hospital services across Queensland and their babies. Methods: A whole-of-population linked administrative dataset was used containing all health service use in a public hospital in Queensland for women who gave birth between 1 July 2012 and 30 June 2015 and their babies. Generalised linear models were used to compare costs over the first 1000 days between hospital and health services. Results: The mean unadjusted cost for each woman and her baby (n = 134 910) was A$17406 in the first 1000 days. After adjusting for clinical and demographic factors and birth type, women and their babies who birthed in the Cairns Hospital and Health Service (HHS) had costs 19% lower than those who birthed in Gold Coast HHS (95% confidence interval (CI) –32%, –4%); women and their babies who birthed at the Mater public hospitals had costs 28% higher than those who birthed at Gold Coast HHS (95% CI 8, 51). Conclusions: There was considerable variation in costs between hospital and health services in Queensland for the costs of delivering maternity care. Cost needs to be considered as an important additional element of monitoring programs. What is known about the topic?: The Australian maternal care system delivers high-quality, safe care to Australian mothers. However, this comes at a considerable financial cost to the Australian public health system. It is known that there are variations in the cost of care depending upon the model of care a woman receives, and the type of delivery she has, with higher-cost treatment not necessarily being safer or producing better outcomes. What does this paper add?: This paper compares the cost of delivering a full cycle of maternity care to a woman at different HHSs across Queensland. It demonstrates that there is considerable variation in cost across HHSs, even after adjusting for clinical and demographic factors. What are the implications for practitioners?: Reporting of cost should be an ongoing part of performance monitoring in public hospital maternity care alongside clinical outcomes to ensure the sustainability of the high-quality maternal health care Australian public hospitals deliver. [ABSTRACT FROM AUTHOR]

Background: The birth of a child entails major changes in a woman's life. In the perinatal period, the woman is particularly susceptible to emotional problems. The objective of the present paper was to investigate the relationship between global orientation to life and its components on the one hand, and socio-demographic factors on the other, with regard to early postpartum emotional disorders.Methods: The study included 643 patients hospitalized in obstetric departments in Lublin, Poland, who had had a spontaneous vaginal delivery. Research instruments included: the Edinburgh Postnatal Depression Scale (EPDS), the Orientation to Life Questionnaire (SOC-29), and the authors' own survey questionnaire to record participants' characteristics.Results: The study findings indicate an association between lower levels of postpartum blues and higher levels of global sense of coherence, as well as a stronger sense of meaningfulness, manageability, and comprehensibility. More severe emotional disorders were found in patients who were single. Postpartum blues symptoms were more intense in less educated respondents.Conclusions: Postpartum emotional disorders are associated with a global sense of coherence and its components. Higher levels of SOC reduce the risk of postpartum blues. [ABSTRACT FROM AUTHOR]

Background: In Madagascar, maternal mortality remains stable and high (426 deaths per 100,000 live births). This situation is mainly due to a delay or lack of use of maternal healthcare services. Problems related to maternal healthcare services are well documented in Madagascar, but little information related to maternal healthcare seeking is known. Thus, this paper aims to identify and analyze the factors that influence the utilization of maternal services, specifically, the use of antenatal care (ANC) during pregnancy and the use of skilled birth attendants (SBAs) at delivery.Method: We used quantitative and qualitative approaches in the study. Two communes of the Vakinankaratra region, which are located in the highlands, were the settings. Data collection occurred from October 2016 to July 2017. A total of 245 pregnant women were included and followed up in the quantitative survey, and among them, 35 participated in in-depth interviews(IDIs). Logistic regressions were applied to explore the influencing factors of antenatal and delivery healthcare seeking practices through thematic qualitative analysis.Results: Among the 245 women surveyed, 13.9% did not attend any ANC visits. School level, occupation and gravidity positively influenced the likelihood of attending one or more ANC visits. The additional use of traditional caregivers remained predominant and was perceived as potentially complementary to medical care. Nine in ten (91%) women expressed a preference for delivery at healthcare facilities (HFs), but 61% of births were assisted by a skilled birth attendant (SBA).The school level; the frequency of ANCs; the origin region; and the preference between modern or traditional care influenced the use of SBAs at delivery. A lack of preparation (financial and logistics problems) and women's low involvement in decision making at delivery were the main barriers to giving birth at HFs.Conclusion: The use of maternal healthcare services is starting to gain ground, although many women and their relatives still use traditional caregivers at the same time. Relatives play a crucial role in maternal healthcare seeking. It would be necessary to target women's relatives for awareness-raising messages about ANC and childbirth in healthcare facilities and to support and formalize collaborations between traditional healers and biomedical caregivers. [ABSTRACT FROM AUTHOR]

Background: Maternal near miss (MNM) is one of the important criteria for checking the quality of care in maternal health. This systematic review and meta analysis study was conducted in 2017 to evaluate the incidence ratio of MNM using the World Health Organization approach in Iran. Materials and Methods: This study was designed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for systematic reviews, and Web of Science and PubMed databases were searched systematically, which, respectively, yielded 171 and 137 papers published before June 9, 2017. To include papers written in Persian by Iranian scholars, Google Scholar database was searched and 542 papers were retrieved. Finally, 12 papers which had covered the topic more appropriately were included in the study. Random-effects meta- analysis was used to pool the incidence ratio. Heterogeneity was explored using formal tests and subgroup analyses, then the study quality was also explored. Results: The pooling of overall potentially life-threatening conditions ratio was I2 (97.60%, p < 0.001, ratio = 2.50/1000 live births [LBs] [95% CI: 2.00 3.00]), which is divided into two indicators: severe complication ratio (2.40/1000 LBs) and critical intervention ratio (2.54/1000 LBs). The pooling of overall life threatening conditions ratio was I2 (95.10%, p < 0.001, ratio = 0.86/1000 LBs [95% CI: 0.64 1.07]). Conclusions: The incidence ratio of MNM needs more attention in Iran. Therefore, it is necessary to identify the factors related to MNM and then implement suitable strategies to reduce the risk factors of the maternal morbidity and improve the quality of maternal care in facilities. [ABSTRACT FROM AUTHOR]

Brazil is a middle-income country with universal maternity care, mostly by doctors. The experience of normal birth often includes rigid routines, aggressive interventions, and abusive, disrespectful treatment. In Brazil, this has been referred to as dehumanised care and, more recently, as obstetric violence. Since the early 1990s, social movements (SM) have struggled to change practices, public policies and provider training. The aim of this paper is to describe and analyse the role of SM in promoting change in maternity care, and in provider training. In this integrative review using a gender-oriented approach, we searched the Scielo database and the Ministry of Health’s (MofH) publications and edicts for institutional and research papers on SM initiatives addressing disrespect and abuse in the last 25 years (1993-2018) in Brazil, and their impact on public policies and training programmes. We analyse these groups of interrelated initiatives: (1) political actions of SM resulting in changes in public policies and legislation; (2) events organised by SM for diffusion of information to the public; (3) MofH policies to humanise childbirth with participation of SM; and (4) initiatives to change providers’ training, including legal actions based on obstetric violence reports. To promote real change in maternity care, the progression of policies and enabling environment of laws, regulations, and broad dissemination of information, need to go hand in hand with changes in all health providers’ training - including a solid base in ethics, gender and human rights. [ABSTRACT FROM AUTHOR]

Background: In Ghana, studies documenting the effectiveness of evidence-based specialized training programs to promote respectful maternity care (RMC) practices in healthcare facilities are few. Thus, we designed a four-day RMC training workshop and piloted it with selected midwives of a tertiary healthcare facility in Kumasi, Ghana. The present paper evaluated the impact of the training by exploring midwives' experiences of implementing RMC knowledge in their daily maternity care practices 4 months after the training workshop. Methods: Through a descriptive qualitative research design, we followed-up and conducted 14 in-depth interviews with participants of the RMC training, exploring their experiences of applying the acquired RMC knowledge in their daily maternity care practices. Data were managed and analysed using NVivo 12. Codes were collapsed into subthemes and assigned to three major predetermined themes. Results: The findings have been broadly categorized into three themes: experiences of practising RMC in daily maternity care, health facility barriers to practising RMC, and recommendations for improving RMC practices. The midwives mentioned that applying the newly acquired RMC knowledge has positively improved their relationship with childbearing women, assisted them to effectively communicate with the women, and position them to recognize the autonomy of childbearing women. Despite the positive influence of the training on clinical practice, the midwives said the policy and the built environment in the hospital does not support the exploration of alternative birthing positions. Also, the hospital lacked the required logistics to ensure privacy for multiple childbearing women in the open labour ward. The midwives recommended that logistics for alternative birthing positions and privacy in the ward should be provided. Also, all midwives and staff of the hospital should be taken through the RMC training program to encourage good practice. Conclusion: Despite the report of some RMC implementation challenges, the midwives noted that the 4-day RMC training has had a positive impact on their maternity caregiving practice in the hospital. Policies and programs aimed at addressing the issue of disrespect and abusive practices during maternity care should advocate and include the building of facilities that support alternative birthing positions and privacy of childbearing women during childbirth. [ABSTRACT FROM AUTHOR]

Background: Maternal deaths among young women (15-24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India.Methods: The study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992-93, 1998-99, 2005-06 and 2015-16. Young married women aged 15-24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05.Results: The use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992-2016. SBA utilization was 88 and 83% during 2015-16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time.Conclusions: In India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states. [ABSTRACT FROM AUTHOR]

This paper is about the clinical principle of informed choice-the hallmark feature of the midwifery model of care in Ontario, Canada. Drawing on ethnographic history interviews with midwives, I trace the origins of the idea of informed choice to its roots in the social movement of midwifery in North America in the late 1960s and 1970s. At that time informed choice was not the distinctive feature of midwifery but was deeply embedded what I call midwifery's feminist experiment in care. But as midwifery in Ontario transitioned from a social movement to a full profession within the formal health care system, informed choice was strategically foregrounded in order to make the midwifery model of care legible and acceptable to a skeptical medical profession, conservative law makers, and a mainstream clientele. As mainstream biomedicine now takes up the rhetoric of patient empowerment and informed choice, this paper is at once a nuanced history of the making of the concept and also a critique of the ascendant 'regime of choice' in contemporary health care, inspired by the reflections of the midwives in my study for whom choice is impossible without care. [ABSTRACT FROM AUTHOR]

This paper focuses on the topic of childbirth, exploring the history of its marginalization within the humanities. This history becomes particularly salient when we compare academic research on birth to that on death. This paper demonstrates that ignoring birth on an intellectual level contributes to diminishing the topic more broadly on the cultural level, and this has real-world implications for how our societies treat children, women, and families. [ABSTRACT FROM AUTHOR]

Background: Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. Methodology: In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. Findings: The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care. Conclusion: By listening to women's experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers' wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor. [ABSTRACT FROM AUTHOR]

Background: A physiological breech birth is one in which the woman is encouraged to remain active throughout her labor and able to assume the position of her choice for the birth. Use of this strategy within the United Kingdom National Health Service has led to the use of innovative maneuvers to relieve obstruction when women give birth in upright positions, for example, kneeling or standing. This includes use of the face‐to‐pubes rotational maneuver to relieve extended nuchal arm(s). In this paper, we report a case where the face‐to‐pubes rotational maneuver was used to relieve bilateral nuchal arm entrapment in a breech birth. Methods: Single‐case study. We aimed to generate an in‐depth understanding of how this maneuver works and how professionals decide to use it by exploring its use in a real‐life context. Results: The face‐to‐pubes rotational maneuver appears to be an effective method of relieving nuchal arm entrapment when used by experienced hands. In cases of bilateral nuchal arm entrapment, elevation to a higher station may be necessary to dis‐impact the arms above the pelvic inlet before the fetus can be rotated. After face‐to‐pubes rotation and release of arms, the head should be realigned in an occiput anterior position for delivery. Conclusion: The face‐to‐pubes rotational maneuver can be taught for resolution of nuchal arms in an upright position. Parents should be informed of the availability or not of a specialist midwife trained in physiological breech birth, as this may be important to their decision‐making. [ABSTRACT FROM AUTHOR]

The 3-Delays Model has helped in the identification of access barriers to obstetric care in low and middle-income countries by highlighting the responsibilities at household, community and health system levels. Critiques of the Model include its one-dimensionality and its limited utility in triggering preventative interventions. Such limitations have prompted a review of the evidence to establish the usefulness of the Model in optimising timely access to intrapartum care. To determine the current utility of the 3-Delays Model and its potential for supporting a solution-based approach to accessing intrapartum care. We conducted a qualitative evidence synthesis across several databases and included qualitative findings from stand-alone studies, mixed-methods research and literature reviews using the Model to present their findings. Papers published between 1994 and 2019 were included with no language restrictions. Twenty-seven studies were quality appraised. Qualitative accounts were analysed using the 'best-fit framework approach'. This synthesis included twenty-five studies conducted in Africa, Asia, Latin America and the Caribbean. Five studies adhered to the original 3-Delays Model's structure by identifying the same factors responsible for the delays. The remaining studies proposed modifications to the Model including alterations of the delay's definition, adding of new factors explaining the delays, and inclusion of a fourth delay. Only two studies reported women's individual contributions to the delays. All studies applied the Model retrospectively, thus adopting a problem-identification approach. This synthesis unveils the need for an individual perspective, for prospective identification of potential issues. This has resulted in the development of a new framework, the Women's Health Empowerment Model, incorporating the 3 delays. As a basis for discussion at every pregnancy, this framework promotes a solution-based approach to childbirth, which could prevent delays and support women's empowerment during pregnancy and childbirth. [ABSTRACT FROM AUTHOR]

Background: Caesarean section is recommended in situations in which vaginal birth presents a greater likelihood of adverse maternal or perinatal outcomes than normal. However, it is associated with a higher risk of complications, especially when performed without a clear medical indication. Since labour attendants have no standardised clinical method to assist in this decision, statistical tools developed based on multiple labour variables may be an alternative. The objective of this paper was to develop and evaluate the accuracy of models for caesarean section prediction using maternal and foetal characteristics collected at admission and through labour. Method: This is a secondary analysis of the World Health Organization's Better Outcomes in Labour Difficulty prospective cohort study in two sub-Saharan African countries. Data were collected from women admitted for labour and childbirth in 13 hospitals in Nigeria as well as Uganda between 2014 and 2015. We applied logistic regression to develop different models to predict caesarean section, based on the time when intrapartum assessment was made. To evaluate discriminatory capacity of the various models, we calculated: area under the curve, diagnostic accuracy, positive predictive value, negative predictive value, sensitivity and specificity. Results: A total of 8957 pregnant women with 12.67% of caesarean births were used for model development. The model based on labour admission characteristics showed an area under the curve of 78.70%, sensitivity of 63.20%, specificity of 78.68% and accuracy of 76.62%. On the other hand, the models that applied intrapartum assessments performed better, with an area under the curve of 93.66%, sensitivity of 80.12%, specificity of 89.26% and accuracy of 88.03%. Conclusion: It is possible to predict the likelihood of intrapartum caesarean section with high accuracy based on labour characteristics and events. However, the accuracy of this prediction is considerably higher when based on information obtained throughout the course of labour. [ABSTRACT FROM AUTHOR]

Episiotomy is an enlargement of the vaginal orifice made by a surgical incision of the perineum. This review aimed to provide a socio-historical retrospective on the practice or episiotomy. Using the criteria from the PRISMA guidelines, the authors conducted a literature review, browsing twenty databases and several papers available in the gray literature. Sixty-four articles, seven reports, and fifteen books were selected. Through this study, four eras with different approaches to episiotomy practice could be identified: 1792–1920, 1920–1980, 1980–1996, and 1996–2018. This review shows that institutionalization and medicalization of birth lead to a systematic practice of episiotomy in many westernized countries until 1996. Lay questioning and evidence-based medicine may have reversed this trend into a restrictive practice. After making an inventory of the factors associated with the evolution of change in the rate of episiotomies, the review finally revealed that evolution of the practice of episiotomy has also been influenced by ideological, political, and social factors. [ABSTRACT FROM AUTHOR]

Access to maternal health services has increased in Ethiopia during the past decades. However, increasing the demand for government birthing facility use remains challenging. In Ethiopia's Afar Region, these challenges are amplified given the poorly developed infrastructure, pastoral nature of communities, distinct cultural traditions, and the more nascent health system. This paper features semi-structured interviews with 22 women who were purposively sampled to explore their experiences giving birth in government health facilities in Afar. We used thematic analysis informed by a cultural safety framework to interpret findings. Our findings highlight how women understand, wield, and relinquish power and agency in the delivery room in government health facilities in Afar, Ethiopia. We found that Afari women are treated as 'others', that they manipulate their care as they negotiate 'cultural safety' in the health system, and that they use trust as a pathway towards more cultural safety. As the cultural safety framework calls for recognizing and navigating the diverse and fluid power dynamics of healthcare settings, the onus of negotiating power dynamics cannot be placed on Afari women, who are already multiply marginalized due to their ethnicity and gender. Health systems must adopt cultural safety in order to ensure health quality. Providers, particularly in regions with rich cultural diversity, must be trained in the cultural safety framework in order to be aware of and challenge the multidimensional power dynamics present in health encounters. • Cultural safety is a powerful framework to interpret and contextualize minority women's experiences in birth. • Afari women are treated as 'others' in their health system. • Afari women manipulate their care to enhance their own safety during childbirth. • Health systems, and their providers, must adopt cultural safety to ensure health quality. [ABSTRACT FROM AUTHOR]

Background: Disrespect and abuse or mistreatment of women by health care providers in maternity settings has been identified as a key deterrent to women seeking delivery care. Mistreatment includes physical and verbal abuse, stigma and discrimination, a poor relationship between women and providers and policy and health systems challenges. This paper uses qualitative data to describe mistreatment of women in Kenya.Methods: Data are drawn from implementation research conducted in 13 facilities and communities. Researchers conducted a range of in-depth interviews with women (n-50) who had given birth in a facility policy makers health managers and providers (n-63); and focus group discussions (19) with women and men living around study facilities. Data were captured on paper and audio tapes, transcribed and translated and exported into Nvivo for analysis. Subsequently we applied a typology of mistreatment which includes first order descriptive themes, second and third-order analytical themes. Final analysis was organized around description of the nature, manifestations and experiences, and factors contributing to mistreatment.Results: Women describe: their negative experiences of childbirth; frustration with lack of confidentiality and autonomy; abandonment by the providers, and dirty maternity units. Providers admit to challenges but describe reasons for apparent abuse (slapped on thighs to encourage women to focus on birthing process) and 'detention' is because relatives have abandoned them. Men try to overcome challenges by paying providers to ensure they look after their wives. Drivers of mistreatment are perpetuated by social and gender norms at family and community levels. At facility level, poor managerial oversight, provider demotivation, and lack of equipment and supplies, contribute to a poor experience of care. Weak or non-existent legal redress perpetuate the problem.Conclusion: This paper builds on the expanding literature on mistreatment during labour and childbirth -outlining drivers from an individual, family, community, facility and policy level. New frameworks to group the manifestations into themes or components makes it increasingly more focused on specific interventions to promote respectful maternity care. The Kenya findings resonate with budding literature - demonstrating that this is indeed a global issue that needs a global solution. [ABSTRACT FROM AUTHOR]

Background: For countries to contribute to Sustainable Development Goal 3.1 of reducing the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030, identifying the drivers of maternal mortality is critically important. The ability of countries to identify the key drivers is however hampered by the lack of data sources with sufficient observations of maternal death to allow a rigorous analysis of its determinants. This paper overcomes this problem by utilising census data. In the context of Indonesia, we merge individual-level data on pregnancy-related deaths and households’ socio-economic status from the 2010 Indonesian population census with detailed data on the availability and quality of local health services from the Village Census. We use these data to test the hypothesis that health service access and quality are important determinants of maternal death and explain the differences between high maternal mortality and low maternal mortality provinces. Methods: The 2010 Indonesian Population Census identifies 8075 pregnancy-related deaths and 5,866,791 live births. Multilevel logistic regression is used to analyse the impacts of demographic characteristics and the existence of, distance to and quality of health services on the likelihood of maternal death. Decomposition analysis quantifies the extent to which the difference in maternal mortality ratios between high and low performing provinces can be explained by demographic and health service characteristics. Findings: Health service access and characteristics account for 23% (CI: 17.2% to 28.5%) of the difference in maternal mortality ratios between high and low-performing provinces. The most important contributors are the number of doctors working at the community health centre (8.6%), the number of doctors in the village (6.9%) and distance to the nearest hospital (5.9%). Distance to health clinics and the number of midwives at community health centres and village health posts are not significant contributors, nor is socio-economic status. If the same level of access to doctors and hospitals in lower maternal mortality Java-Bali was provided to the higher maternal mortality Outer Islands of Indonesia, our model predicts 44 deaths would be averted per 100,000 pregnancies. Conclusion: Indonesia has employed a strategy over the past several decades of increasing the supply of midwives as a way of decreasing maternal mortality. While there is evidence of reductions in maternal mortality continuing to accrue from the provision of midwife services at village health posts, our findings suggest that further reductions in maternal mortality in Indonesia may require a change of focus to increasing the supply of doctors and access to hospitals. If data on maternal death is collected in a subsequent census, future research using two waves of census data would prove a useful validation of the results found here. Similar research using census data from other countries is also likely to be fruitful. [ABSTRACT FROM AUTHOR]

Objective: Review primary research regarding PTSD Post-Childbirth (PTSD-PC) that focussed on Quality of Provider Interaction (QPI) from the perspective of women who developed PTSD-PC, or midwives. Background: Up to 45% of women find childbirth traumatic. PTSD-PC develops in 4% of women (18% in high-risk groups). Women's subjective experiences of childbirth are the most important risk factor in the development of PTSD-PC, with perceived QPI being key. Methods: A systematic search was performed for PTSD-PC literature. Reviewed papers focussed on either women's subjective childbirth experiences, particularly QPI, or midwives' perspectives on QPI. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tools, and a narrative synthesis of findings produced. Results: Fourteen studies were included. Three features of QPI contribute towards developing PTSD-PC: interpersonal factors; midwifery care factors; and lack of support. Conclusion: QPI is a significant factor in the development of PTSD-PC and the identified key features of QPI have potential to be modified by midwives. The development of guidelines for midwives should be grounded on evidence highlighted in this review, along with further high-quality qualitative research exploring QPI from the perspective of women with PTSD-PC, but also midwives' knowledge and needs regarding their role within QPI. [ABSTRACT FROM AUTHOR]

Background: Community participation can provide increased understanding and more effective implementation of strategies that seek to improve outcomes for women and newborns. There is limited knowledge on how participatory processes take place and how this affects the results of an intervention. Objective: This paper presents the results of two years of implementing (2013–2015) community groups for maternal health care in Magu District, Tanzania. Method: A total of 102 community groups were established, and 77 completed the four phases of the participatory learning and action cycle. The four phases included identification of problems during pregnancy and childbirth (phase 1), deciding on solutions and planning strategies (phase 2), implementation of strategies (phase 3) and evaluation of impact (phase 4). Community group meetings were facilitated by 15 trained facilitators and groups met monthly in their respective villages. Data was collected as an ongoing process from facilitator and meeting reports, through interviews with facilitators and local leaders and from focus group discussions with community group participants. Results: The majority of groups prioritized problems related to the availability of and accessibility to health services. The most commonly actioned solution was the provision of health education to the community. Almost all groups (95%) experienced a positive impact on the community as results of their actions, including increased maternal health knowledge and positive behaviour changes among health care workers. Facilitators were positive about the community groups, stating that they were grateful for the gained knowledge on maternal health, and positively regarded the involvement of men in community groups, which are traditionally women-only. Conclusion: The process of establishing and undertaking community groups in itself appeared to have a positive perceived impact on the community. However, sustained behaviour change, power dynamics and financial incentives need to be carefully considered during implementation and sustaining the community groups. [ABSTRACT FROM AUTHOR]

In this paper, we examine the perceptions and experiences of childbirth among a group of wealthier women in Dhaka through in-depth interviews. We find that a number of factors including preference for Caesarean Section (CS), socio-economic position, family structure, and perceptions of modern childbirth contributed to the women's overuse of medical childbirth services. Furthermore, women's capacity to purchase modern maternal health care in the private sector did not necessarily ensure high quality care in a health system which approaches maternal healthcare as a profit-making enterprise rather than as an essential human right. [ABSTRACT FROM AUTHOR]

This paper examines the contrasting perspectives of doctors and midwives in Portugal regarding their roles in childbirth, the institutional contexts in which these divergent perspectives are enacted and sustained, and the inter-related experiences of birthing women. The ethnographic research presented found obstetricians' rhetoric to focus on potential risk; interventions were often explicated through a perception of childbirth as a risk-laden, and potential emergency, situation. Within this discourse, hospital-based birth was presented as a triumph of progress. Technical measures were justified using institutional rationales, such as the use of anaesthetic pain relief during labour ensuring tranquillity within maternity units, and labour induction guaranteeing "throughput" and freeing up hospital beds. Midwives, contrastingly, described a philosophy of care focused on offering women presence, guidance, and informed choices during birthing, professing their commitment to minimal intervention, except in cases of clinical necessity. Both professional groups expressed mutual respect for each other's skills and respective roles. Yet the co-existence of different professional rationales within the same hospital setting resulted in tensions which were exacerbated by historical power dynamics and the present spatial and organisational separation of the two groups. The ramifications of the current situation for the provision of effective maternity care are discussed, and the conceptualisation of women as autonomous consumers of services is challenged. Extracts from Portuguese women's birth narratives from the same study are utilised to elucidate the highly variegated experiences of women. [ABSTRACT FROM AUTHOR]

Mistreatment of women during childbirth at health facilities violates their human rights and autonomy and may be associated with preventable maternal and newborn mortality and morbidity. In this paper, we explore women’s perspectives on mistreatment during facility-based childbirth as part of a bigger World Health Organization (WHO) multi-country study for developing consensus definitions, and validating indicators and tools for measuring the burden of the phenomenon. Focus group discussions (FGDs) and in-depth interviews (IDIs) were used to explore experiences of mistreatment from women who have ever given birth in a health facility in Koforidua and Nsawam, Ghana. Interviews were audio-recorded, transcribed and thematic analysis conducted. A total of 39 IDIs and 10 FGDs involving 110 women in total were conducted. The major types of mistreatment identified were: verbal abuse (shouting, insults, and derogatory remarks), physical abuse (pinching, slapping) and abandonment and lack of support. Mistreatment was commonly experienced during the second stage of labour, especially amongst adolescents. Inability to push well during the second stage, disobedience to instructions from birth attendants, and not bringing prescribed items for childbirth (mama kit) often preceded mistreatment. Most women indicated that slapping and pinching were acceptable means to “correct” disobedient behaviours and encourage pushing. Women may avoid giving birth in health facilities in the future because of their own experiences of mistreatment, or hearing about another woman’s experience of mistreatment. Consensus definitions, validated indicators and tools for measuring mistreatment are needed to measure prevalence and identify drivers and potential entry points to minimise the phenomenon and improve respectful care during childbirth. [ABSTRACT FROM AUTHOR]

Background: Pregnancy and childbirth are socio-cultural events that carry varying meanings across different societies and cultures. These are often translated into social expectations of what a particular society expects women to do (or not to do) during pregnancy, birth and/or the postnatal period. This paper reports a study exploring beliefs around childbirth in Nepal, a low-income country with a largely Hindu population. The paper then sets these findings in the context of the wider global literature around issues such as periods where women are viewed as polluted (or dirty even) after childbirth.Methods: A qualitative study comprising five in-depth face-to-face interviews and 14 focus group discussions with mainly women, but also men and health service providers. The qualitative findings in Nepal were compared and contrasted with the literature on practices and cultural beliefs related to the pregnancy and childbirth period across the globe and at different times in history.Results: The themes that emerged from the analysis included: (a) cord cutting & placenta rituals; (b) rest & seclusion; (c) purification, naming & weaning ceremonies and (d) nutrition and breastfeeding. Physiological changes in mother and baby may underpin the various beliefs, ritual and practices in the postnatal period. These practices often mean women do not access postnatal health services.Conclusions: The cultural practices, taboos and beliefs during pregnancy and around childbirth found in Nepal largely resonate with those reported across the globe. This paper stresses that local people's beliefs and practices offer both opportunities and barriers to health service providers. Maternity care providers need to be aware of local values, beliefs and traditions to anticipate and meet the needs of women, gain their trust and work with them. [ABSTRACT FROM AUTHOR]

Background: Patient reported outcomes and experience measures (PROM and PREM) provide an opportunity to prioritize patients' health goals in care decisions and quality improvement. In perinatal care, the use of PROM and PREM is scarce and limited to research and quality purposes. The International Consortium of Health Outcomes Measurement (ICHOM) published an outcome set for pregnancy and childbirth (PCB set), including PROM and PREM. In the Netherlands, the PCB set was implemented in a pilot project with the primary goal to integrate its PROM and PREM in clinical practice over the full course of pregnancy and postpartum care. To ensure continuity of care, the project was explicitly organized within integrated obstetric care networks (OCN): collaborating with all care professionals and organizations involved. Objectives: This study aimed to report first outcomes, experiences, and practice insights of implementing the PCB set in clinical practice of perinatal care. We assessed compliance to the PROM and PREM questionnaires, outcomes per domain, and clinical use of threshold values. Methods: Seven OCN across the Netherlands, each consisting of one or two hospitals and multiple community midwifery practices (2 - 18), implemented the PROM and PREM of the PCB set as part of clinical routine. This observational study included all women participating in the clinical project who gave informed consent for research purposes. The PROM and PREM were assessed with questionnaires at five timepoints: two during pregnancy and three postnatally until six months postpartum. Clinical threshold values (alerts) supported physicians interpretating the answers, indicating worrisome outcomes per domain. Data collection took place from February 2020 till September 2021. Questionnaires were assessed mostly digital - in one site on paper. Data analysis included missing (pattern) analysis, sum scores, alert rates, and sensitivity analysis. Results: In total 1923 questionnaires were collected across the five timepoints: 816 at T1 (first trimester), 793 at T2 (third trimester), 125 at T3 (maternity week), 170 at T4 (6 weeks postpartum) and 19 at T5 (6 months postpartum). Of these, 84% were filled out completely. Missing items per domain ranged from 0 to 13%, with highest missing rates for depression, pain with intercourse and experience with pain relief at birth. No notable missing patterns were found. Relatively high alert rates were found for urine incontinence (27%), pain with intercourse (25%), breastfeeding selfefficacy (23%) and mother-child binding (45%). Regarding PREM domains, most alerts were found for birth experience (23%), shared decision making (11%) and discussing pain relief antepartum (41%). Some domains showed very little clinical variation: mother role and satisfaction with care. Conclusions: The PCB set is a useful and acceptable tool to assess patient reported outcomes that need to be addressed over the whole course of pregnancy and childbirth. Our findings reveal a window of opportunity to improve and personalize perinatal care. Furthermore, based on our findings we could propose several recommendations about the methods and timeline of PROM and PREM measurement based. This study supports further implementation of the PCB set in clinical practice and the transformation towards patient centred value driven care. [ABSTRACT FROM AUTHOR]

This paper shores up the overdetermined web of fear-desire-helplessness-aspiration that impinges on the birthing experiences of women at the economic periphery of urbanity, i.e. the urban poor, positioned at the borders of the urban and its outside, affluence and its lack. The urban poor (pregnant) woman, by dint of being physically located in the city remains unable to be part of the state healthcare network in rural areas; at the same time she is marked by an inability to purchase healthcare from high-end urban private providers. Consequently, she is positioned in an in-between space of access and care, aspirations and resistance, occasionally getting (even physically) trapped in a limbo between the hospital/institution and its outside. For this woman, the materiality of the hospital symbolises development-modernity; in accessing the hospital, the urban poor woman accesses an ontology that is “like the well-off people,” the “legitimate” claimants of the city. Between her dreams of approximating the space of urbanity and development, and an experience of being pushed back to the city's periphery—locationally and metaphorically, the urban poor woman gets inscribed by conflicting and counterpoised experiences of birthing, which is what this paper maps. [ABSTRACT FROM PUBLISHER]

This paper presents the findings of a research project which has involved the establishment of a maternal health phone line in Milne Bay Province of Papua New Guinea (PNG). Mobile phones and landline phones are key information and communication technologies (ICTs). This research study uses the "ICTs for healthcare development" model to ascertain benefits and barriers to the successful implementation of the Childbirth Emergency Phone. PNG has a very high maternal mortality rate. The "three stages of delay" typology was developed by Thaddeus and Maine to determine factors that might delay provision of appropriate medical treatment and hence increase risk of maternal death. The "three stages of delay" typology has been utilised in various developing countries and also in the present study. Research undertaken has involved semi-structured interviews with health workers, both in rural settings and in the labour ward in Alotau. Additional data has been gathered through focus groups with health workers, analysis of notes made during phone calls, interviews with women and community leaders, observations and field visits. One hundred percent of interviewees (n = 42) said the project helped to solve communication barriers between rural health workers and Alotau Provincial Hospital. Specific examples in which the phone line has helped to create positive health outcomes will be outlined in the paper, drawn from research interviews. The Childbirth Emergency Phone project has shown itself to play a critical role in enabling healthcare workers to address life-threatening childbirth complications. The project shows potential for rollout across PNG; potentially reducing maternal morbidity and maternal mortality rates by overcoming communication challenges. [ABSTRACT FROM AUTHOR]

Mother and baby units (MBUs) provide inpatient psychiatric care for mothers and their infants up to a year after childbirth. They are commissioned to support the mother-infant relationship as well as stabilize maternal mental health. As their efficacy at meeting these aims had not previously been systematically assessed, this paper reviewed the international literature relating to psychological outcomes following MBU admission. A systematic search of five databases identified 23 papers eligible for inclusion, reporting on a range of outcomes indicating positive effects on maternal mental health and the mother-infant relationship and an absence of adverse effects on child development. The review also highlighted specific groups responding less favorably to MBU admission, eg, mothers with a diagnosis of schizophrenia. Although the included studies were of variable methodological quality, the research findings consistently indicated positive effects. Implications for research and clinical practice are outlined in the discussion. [ABSTRACT FROM AUTHOR]

Background: Poor quality of care including fear of disrespect and abuse (D&A) perpetuated by health workers influences women’s decisions to seek maternity care. Key manifestations of D&A include: physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination, abandonment, and detention in facilities. This paper describes manifestations of D&A experienced in Kenya and measures their prevalence. Methods: This paper is based on baseline data collected during a before-and-after study designed to measure the effect of a package of interventions to reduce the prevalence of D&A experienced by women during labor and delivery in thirteen Kenyan health facilities. Data were collected through an exit survey of 641 women discharged from postnatal wards. We present percentages of D&A manifestations and odds ratios of its relationship with demographic characteristics using a multivariate fixed effects logistic regression model. Results: Twenty percent of women reported any form of D&A. Manifestations of D&A includes: non-confidential care (8.5%), non-dignified care (18%), neglect or abandonment (14.3%), Non-consensual care (4.3%) physical abuse (4.2%) and, detainment for non-payment of fees (8.1). Women aged 20-29 years were less likely to experience non-confidential care compared to those under 19; OR: [0.6 95% CI (0.36, 0.90); p=0.017]. Clients with no companion during delivery were less likely to experience inappropriate demands for payment; OR: [0.49 (0.26, 0.95); p=0.037]; while women with higher parities were three times more likely to be detained for lack of payment and five times more likely to be bribed compared to those experiencing there first birth. Conclusion: One out of five women experienced feeling humiliated during labor and delivery. Six categories of D&A during childbirth in Kenya were reported. Understanding the prevalence of D&A is critical in developing interventions at national, health facility and community levels to address the factors and drivers that influence D&A in facilities and to encourage clients’ future facility utilization. [ABSTRACT FROM AUTHOR]

Abstract: Background: Due to civil war, Somalis immigrants have settled in Norway and the United States. Large families are valued among Somalis and Somali women continue to give birth in their new countries. Research studies have been conducted with Somali immigrant new mothers in Norway and Minnesota, United States to understand perceptions of their childbirth experience. Purpose: The purpose of this qualitative study was to compare the childbirth experiences of Somali immigrant mothers in the United States and Norway to make recommendations to improve health care practice. Design: This paper presents a comparison of two research studies in order to identify and explain similarities and differences between cross‐cultural immigrant populations. Results: Both studies identified themes related to the importance of family support in the postpartum period, fear of Cesarean delivery, and relationships with nurses. These studies give recommendations for nurses on how to provide culturally sensitive care for Somali new mothers. Conclusions: Implications for practice are that nurses should develop trusting relationships with Somali mothers and facilitate cultural and religious practices. Information regarding support resources in the community should be provided to Somali mothers throughout the perinatal period. [ABSTRACT FROM AUTHOR]