Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

Home and Birth Center Birth in the United States: Time for Greater Collaboration Across Models of Care

There has been a small, but significant, increase in community births (home and birth-center births) in the United States in recent years. The rate increased by 20% from 2004 to 2008, and another 59% from 2008 to 2012, though the overall rate is still low at less than 2%. Although the United States is not the only country with a large majority of births occurring in the hospital, there are other high-resource countries where home and birth-center birth are far more common and where community midwives (those attending births at home and in birth centers) are far more central to the provision of care. In many such countries, the differences in perinatal outcomes between hospital and community births are small, and there are lower rates of maternal morbidity in the community setting. In the United States, perinatal mortality appears to be higher for community births, though there has yet to be a national study comparing outcomes across settings that controls for planned place of birth. Rates of intervention, including cesarean delivery, are significantly higher in hospital births in the United States. Compared with the United States, countries that have higher rates of community births have better integrated systems with clearer national guidelines governing risk criteria and planned birth location, as well as transfer to higher levels of care. Differences in outcomes, systems, approaches, and client motivations are important to understand, because they are critical to the processes of person-centered care and to risk reduction across all birth settings.

A Survey of University Students' Preferences for Midwifery Care and Community Birth Options in 8 High-Income Countries

INTRODUCTION

Midwifery care is associated with positive birth outcomes, access to community birth options, and judicious use of interventions. The aim of this study was to characterize and compare maternity care preferences of university students across a range of maternity care systems and to explore whether preferences align with evidence-based recommendations and options available.

METHODS

A cross-sectional, web-based survey was completed in 2014 and 2015 by a convenience sample of university students in 8 high-income countries across 4 continents (N = 4569). In addition to describing preferences for midwifery care and community birth options across countries, this study examined sociodemographic characteristics, psychological factors, knowledge about pregnancy and birth, and sources of information that shaped students' attitudes toward birth in relation to preferences for midwifery care and community birth options.

RESULTS

Approximately half of the student respondents (48.2%) preferred midwifery-led care for a healthy pregnancy; 9.5% would choose to give birth in a birthing center, and 4.5% preferred a home birth. Preference for midwifery care varied from 10.3% among women in the United States to 78.6% among women in the United Kingdom. Preferences for home birth varied from 0.3% among US women to 18.3% among Canadian women. Women, health science students, those with low childbirth fear, those who learned about pregnancy and birth from friends (compared with other sources, eg, the media), and those who responded from Europe were significantly more likely to prefer midwifery care and community birth. High confidence in knowledge of pregnancy and birth was linked to significantly higher odds of community birth preferences and midwifery care preferences.

DISCUSSION

It would be beneficial to integrate childbirth education into high school curricula to promote knowledge of midwifery care, pregnancy, and childbirth and to reduce fear among prospective parents. Community birth options need to be expanded to meet demand among the next generation of maternity service users.

Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans

Background: Maternal morbidity and mortality are key indicators of women's health status and quality of care. Maternal morbidity and mortality are high and rising in the United States. There has been no evaluation of severe maternal morbidity and mortality among veteran women, although population characteristics suggest that they may be at risk. This study aimed to evaluate a surveillance methodology at the U.S. Department of Veterans Affairs (VA) and describe the characteristics of women veterans who experienced severe maternal morbidity events. Materials and Methods: The study sample derived from a national sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who were enrolled for care at the VA. The surveillance methodology followed a recommended process of case identification and chart review following a standardized guide. Centers for Disease Control and Prevention (CDC) International Classification of Diseases codes for maternal morbidity were applied to billing, inpatient, and outpatient data for 9,829 pregnancies among 91,061 veteran women between January 1, 2014 and December 31, 2016. Descriptive statistics is reported. Results: One hundred twenty-seven pregnancies with severe maternal morbidity events were identified, 66 of which were confirmed after chart review. The positive predictive value of CDC indicators to identify cases was 0.52. High rates of mental health problems, obesity, rurality, maternal conditions, and racial discrepancies were noted among veterans who experienced severe maternal morbidity events. Conclusions: Severe maternal morbidity affects a significant number of veteran women. Systematic reporting of pregnancy outcomes and a multidisciplinary review committee would improve surveillance and case management at the VA. The VA is uniquely positioned to develop innovative comanagement strategies, especially in the area of perinatal mental health.

Using the Robson 10-Group Classification System to Compare Cesarean Birth Utilization Between US Centers With and Without Midwives

INTRODUCTION

The Robson 10-group classification system stratifies cesarean birth rates using maternal characteristics. Our aim was to compare cesarean birth utilization in US centers with and without midwifery care using the Robson classification.

METHODS

We used National Institute of Child and Human Development Consortium on Safe Labor data from 2002 to 2008. Births to women in centers with interprofessional care that included midwives (n = 48,857) were compared with births in non-interprofessional centers (n = 47,935). To compare cesarean utilization, births were classified into the Robson categories. Cesarean birth rates within each category and the contribution to the overall rate were calculated. Maternal demographics, labor and birth outcomes, and neonatal outcomes were described. Logistic regression was used to adjust for maternal comorbidities.

RESULTS

Women were less likely to have a cesarean birth (26.1% vs 33.5%, P < .001) in centers with interprofessional care. Nulliparous women with singleton, cephalic, term fetuses (category 2) were less likely to have labor induced (11.1% vs 23.4%, P < .001), and women with a prior uterine scar (category 5) had lower cesarean birth rates (73.8% vs 85.1%, P < .001) in centers with midwives. In centers without midwives, nulliparous women with singleton, cephalic, term fetuses with induction of labor (category 2a) were less likely to have a cesarean birth compared with those in interprofessional care centers in unadjusted comparison (30.3% vs 35.8%, P < .001), but this was reversed after adjustment for maternal comorbidities (adjusted odds ratio, 1.21; 95% CI, 1.12-1.32; P < .001). Cesarean birth rates among women at risk for complications (eg, breech) were similar between groups.

DISCUSSION

Interprofessional care teams were associated with lower rates of labor induction and overall cesarean utilization as well as higher rates of vaginal birth after cesarean. There was consistency in cesarean rates among women with higher risk for complications.

Preventing Cesarean Birth in Women with Obesity: Influence of Unit-Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set

INTRODUCTION

Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work.

METHODS

A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors.

RESULTS

The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m2 .

DISCUSSION

Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.

Preference, knowledge and utilization of midwives, childbirth education classes and doulas among U.S. black and white women: implications for pregnancy and childbirth outcomes

This secondary analysis explored preference, knowledge and utilization of midwifery care, childbirth education and doula care among 627 black and white women at three Midwestern U.S. health clinics. Women who were white, more educated, not living in a high crime neighborhood, and privately insured were more likely to attend childbirth classes. Sociodemographic factors that predicted having heard about doula care included being more educated and having a partner. None of the sociodemographic variables predicted midwifery care. Education about existing childbearing resources and availability of low-cost options should be expanded, particularly for black women and those with low resources.

Barriers to equitable maternal health in Aotearoa New Zealand: an integrative review

BACKGROUND

The purpose of this review was to examine the literature for themes of underlying social contributors to inequity in maternal health outcomes and experiences in the high resource setting of Aotearoa New Zealand. These 'causes of the causes' were explored and compared with the international context to identify similarities and New Zealand-specific differences.

METHOD

A structured integrative review methodology was employed to enable a complex cross disciplinary analysis of data from a variety of published sources. This method enabled incorporation of diverse research methodologies and theoretical approaches found in the literature to form a unified overall of the topic.

RESULTS

Six integrated factors - Physical Access, Political Context, Maternity Care System, Acceptability, Colonialism, and Cultural factors - were identified as barriers to equitable maternal health in Aotearoa New Zealand. The structure of the maternal health system in New Zealand, which includes free maternity care and a woman centred continuity of care structure, should help to ameliorate inequity in maternal health and yet does not appear to. A complex set of underlying structural and systemic factors, such as institutionalised racism, serve to act as barriers to equitable maternity outcomes and experiences. Initiatives that appear to be working are adapted to the local context and involve self-determination in research, clinical outreach and community programmes.

CONCLUSIONS

The combination of six social determinants identified in this review that contribute to maternal health inequity is specific to New Zealand, although individually these factors can be identified elsewhere; this creates a unique set of challenges in addressing inequity. Due to the specific social determinants in Aotearoa New Zealand, localised solutions have potential to further maternal health equity.

Lactation Education for Resident Obstetricians: Promoting Breastfeeding Advocates for the Future

Obstetrics and gynecology residency training programs are historically lacking in breastfeeding education and advocacy. Healthy People 2020 supports interventions that promote breastfeeding as a primary care strategy with significant health benefits to the newborn and woman. Midwives are well poised to engage obstetrics and gynecology residents in lactation education. A few educational interventions have been described in the literature to increase knowledge, confidence, and behavior related to lactation among residents. This article describes a breastfeeding education curriculum developed by midwifery faculty at Boston University School of Medicine. The project included 3 lectures and a simulation center workshop covering topics including lactogenesis, prenatal, intrapartum, and postpartum interventions that promote or limit lactation, hands-on latch assistance, hand expression, use of breast pumps and storage of human milk, and common disorders of lactation. Postintervention evaluations demonstrated improvements in knowledge and confidence. Providing breastfeeding education to resident physicians may be an intervention to promote patient breastfeeding education and support and close the gap of disparities in breastfeeding rates.

Knowledge of US Midwifery Credentials Among Members of the American College of Nurse-Midwives

INTRODUCTION

Three midwifery credentials are granted in the United States: certified nurse-midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Confusion about US midwifery credentials may restrict growth of the midwifery profession. This survey assessed American College of Nurse-Midwives (ACNM) members' knowledge of US midwifery credentials.

METHODS

ACNM members (N = 7551) were surveyed via email in 2017. The survey asked respondents to report demographic information and to identify correct statements about the education, certification, and scope of practice of CNMs, CMs, and CPMs. Responses to 17 items about all midwives certified in the United States, a 5-item subset specific to CNMs/CMs, and one item related to location of midwifery practice by credential were analyzed.

RESULTS

Nearly a quarter of the membership (22.1%) responded to the survey. Higher scores on the survey indicated greater identification of correct statements about the education, certification, scope, and location of practice of CNMs, CMs, and CPMs. Significant differences in scores were found among ACNM members based on their level of education, degree of professional involvement in midwifery, and prior practice as a nurse. ACNM members with higher scores on the survey held a doctorate, worked in Region I, and had greater professional leadership involvement in midwifery organizations. Participants with less nursing experience prior to their midwifery education also scored significantly higher on the survey.

DISCUSSION

Although two-thirds of respondents correctly answered items on the preparation, credentialing, and scope of practice of CNMs, CMs, and CPMs, a significant minority had gaps in knowledge. Results of this survey suggest the need for outreach about US midwifery credentials. Future research to replicate and expand upon this survey may benefit the profession of midwifery in the United States.

Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study

BACKGROUND

Sixty percent of United States births are to multiparous women. Hospital-level policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women.

METHODS

We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes.

RESULTS

There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes.

CONCLUSIONS

Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Call Us Midwives: Critical Comparison of What Is a Midwife and What Is Midwifery

Research has identified midwifery as key to improving maternal and child health globally. Consequently, increasing the numbers, access, and quality of midwives is paramount as attention, funding, education, and support increases. Yet what a midwife and midwifery are is often misunderstood. The terms midwife and midwifery are often used interchangeably. Other cadres such as nurses, doulas, Skilled Birth Attendant, traditional birth attendant, and nurses with obstetric/perinatal experience are often referred to as midwives or providers of midwifery care. As health systems work to integrate midwives and midwifery, global clarity and understanding must exist on what midwives are and what they are not, and what midwifery is and is not. As the first step to establishing clarity; we undertook a critical comparison of existing different countries, ‘not for profit and professional organizations’ definitions and interpretation of a midwife and midwifery philosophy. The International Confederation of Midwives' definition of a midwife and midwifery philosophy, and their Global Standards for Midwifery Education acted as the baseline. A global consensus and commitment to educational systems and culture that teaches the midwifery model and the philosophy behind that care can positively impact and improve outcomes for women and babies.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey

Introduction

Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians.

Methods

This study was a secondary analysis of data from the population‐based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife‐attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates.

Results

Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making.

Discussion

Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

BACKGROUND

Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study.

METHODS

Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables.

RESULTS

Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment.

CONCLUSION

This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

BACKGROUND

Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study.

METHODS

Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables.

RESULTS

Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment.

CONCLUSION

This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

Trends and state variations in out-of-hospital births in the United States, 2004-2017

BACKGROUND

Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women's access to these births.

METHODS

National birth certificate data from 2004 to 2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options.

RESULTS

After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35 578 in 2004 to 62 228 in 2017. In 2017, 1 of every 62 births in the United States was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004 to 2017, whereas birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared with 1/3 of birth center and just 3% of hospital births, with large variations by state.

CONCLUSIONS

Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlight the strong motivation of some women to choose out-of-hospital birth.

A Literature Review of Midwifery-Led Care in Reducing Labor and Birth Interventions

Certified nurse-midwives are usually recognized as independently practicing advanced practice registered nurses because they provide maternity care to pregnant women in various states. In the United States, certified nurse-midwives are historically underused. Culture favors physician-led care, with 90% of all births attended by physicians. Midwifery-led care is considered high-touch/low-intervention and is guided by a philosophy of care that regards pregnancy and childbirth as normal life events for most women. Evidence from the literature supports midwifery-led care as being safe, effective, and associated with fewer interventions.

Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth

BACKGROUND

Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada.

METHODS

Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care.

RESULTS

Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43).

CONCLUSIONS

Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Transforming Maternity Care in the United States

In this column, the associate editor of The Journal of Perinatal Education provides a snapshot of the current state of maternity care in the United States and highlights the efforts of researchers, childbirth educators, and professional organizations to transform maternity care practices and, in doing so, to improve outcomes for mothers and babies. The associate editor also describes the contents of this issue, which offer a broad range of resources, research, and inspiration for childbirth educators in their efforts to promote, support, and protect natural, safe, and healthy birth.