Midwife-led continuity models versus other models of care for childbearing women

Cost minimisation analyses of birth care in low-risk women in Norway: a comparison between planned home birth and birth in a standard obstetric unit

BACKGROUND

Evidence exists that planned home births for low-risk women in settings in which they have access to hospital transfer if needed are safe. The costs of planned home births, compared to low-risk births in obstetric units, are not clear. The aim of this study was to compare costs associated with hospital births versus home births under different home birth organizations.

METHODS

We performed a cost minimisation analysis (CMA) based on decision-analytic modelling while assuming that health outcomes were not affected by place of birth. Estimations of resource use were mainly based on three existing Norwegian datasets: (1) women with planned home births (n = 354), (2) women with planned home births (n = 482) of which 63 were transferred to a hospital, and (3) women with planned births in a hospital (n = 1550).

RESULTS

Planned home birth costs 45.9% (credibility interval [CrI] 39.1-54.2) of a low-risk birth at a hospital. For planned home birth, the birth was the costliest activity (32.1%). The costs for planned home birth were estimated to be €1872 (CrI 1694-2071) and included hospitalisations for some. Costs for only those with actual home birth was €1353 (CrI 1244-1469). Costs of a birth, including possible birth-related complications, in low-risk women in a hospital was €4077 (CrI 3575-4615). When including the costs of being on call for one woman at a time, a planned home birth costs €5,531 (CrI 5,171-5,906), which is 135.7% (CrI 117.7-156.8) of low-risk births at a hospital. When organizing midwives in the on call teams for multiple women at a time, a planned home birth costs € 2,842 (CrI 2,647-3,053), which is 69.7% (CrI 60.3-80.9) of a low-risk birth in a hospital.

CONCLUSIONS

Home birth can be cost-effective if the midwives who facilitate home births are organised into larger groups, or they work for hospitals that also facilitate home births. A model in which midwives work separately or in pairs to assist with a home birth and are on call for one birth at a time may not be cost-effective.

Involving women with limited English proficiency in group antenatal care: Findings from the integrated process evaluation of the Pregnancy Circles pilot trial

Problem In the United Kingdom, poor experiences and outcomes of antenatal care among women with limited English proficiency (LEP) are widely documented.

BACKGROUND

Group antenatal care aims to address some limitations of traditional care by combining health assessment, information sharing and peer support, but the inclusion of women with LEP in mixed-language groups has not been explored.

AIM

This qualitative study used observations and interviews to explore whether linguistic diversity could be incorporated into group antenatal care (Pregnancy Circles). Women with LEP were invited to take part in mixed-language groups in a large urban NHS trust as part of the Pregnancy Circles pilot trial (ISRCTN66925258 Retrospectively registered 03 April 2017; North of Scotland Research Ethics Service 16/NS/0090).

FINDINGS

Three Pregnancy Circles including women with LEP were implemented. Linguistically integrated groups required additional resources (time, interpreters, midwifery skills). Four themes emerged: 'Interpreting as helping', 'Enhanced learning', 'Satisfaction and belonging' and 'Complex lives'.

DISCUSSION

Women with LEP accessing interpreting in Pregnancy Circles reported high levels of satisfaction, contrasting with reported experiences in traditional care. Three theories of effect emerged as relevant for women with LEP: social support.

Perinatal continuity of care for mothers with depressive symptoms: perspectives of mothers and clinicians

Background

Mothers with mild to moderate depression in pregnancy are at risk of developing postpartum depression. Midwife-led continuity of care may support maternal mental health throughout the perinatal period. Research is needed to better understand how continuity of care may support mothers experiencing depression in pregnancy. This study aimed to investigate the perspectives of mothers with mild to moderate depression and clinicians regarding continuity of care in the perinatal period.

Method

Fourteen mothers and clinicians participated in individual interviews or a focus group. Analysis was conducted using inductive reflexive thematic analysis with a constructivist orientation.

Results

From the perspectives of mothers and clinicians, continuity of care during the antenatal period benefitted mothers' mental health by providing connection and rapport, information about pregnancy and referral options, and reassurance about whether pregnancy symptoms were normal. The experience of seeing multiple clinicians was noted by mothers to increase distress while participants discussed the value of extending continuity of care into the postpartum period, including having someone familiar checking in on them. The importance of having a second opinion and not always relying on a single provider during pregnancy was highlighted by some mothers and clinicians. Mothers also described how multiple modes of communication with a midwife can be helpful, including the ease and accessibility of text or email.

Conclusion

Mothers and clinicians perceived benefits of continuity of care for maternal mental health. Offering midwife-led continuity of care to mothers with mild to moderate depression during the perinatal period is recommended.

Improving birth experiences and provider interactions: Expert opinion on critical links in Maternity care

This article explores the Quality of Provider Interaction (QPI) within maternity care, spotlighting its crucial role in positive childbirth experiences. It emphasizes the need for trust-based relationships between women and their care providers, a necessity amplified by the profound neurohormonal sensitivities experienced during labor. Drawing from the 'Optimizing the birth environment' COST DEVOTION CA18211 Working Group, this article aims to provide insights and stimulate discussion on how to mitigate birth trauma and improve childbirth experiences. The study evolved through discussions on QPI, engagement with the group, a review of COST Action research, and conference contributions, leading to essential recommendations. From our dialogue and evaluation of existing literature, we identified four pivotal aspects critical to enhancing QPI: 1) Empathy and emotional availability, 2) Trauma-informed maternity care, 3) Integrating woman-centered individual and institutional attitudes, and 4) Empowering language use. We examine how these elements influence women's emotional and psychological well-being throughout childbirth and beyond, underscoring their critical contribution. This article proposes a framework to improve maternity care by enhancing the Quality of Provider Interaction (QPI). It offers practical recommendations for refining care protocols and language guidelines, emphasizing the importance of respectful, secure birthing environments. Adopting care models that prioritize high-quality provider interactions is crucial for the well-being of women and their families.

Postpartum care for parent-infant dyads: A community midwifery model

INTRODUCTION

Postpartum health is in crisis in the United States, with rising pregnancy-related mortality and worsening racial inequities. The World Health Organization recommends four postpartum visits during the 6 weeks after childbirth, yet standard postpartum care in the United States is generally one visit 6 weeks after birth. We present community midwifery postpartum care in the United States as a model concordant with World Health Organization guidelines, describing this model of care and its potential to improve postpartum health for birthing people and babies.

METHODS

We conducted semi-structured interviews with 34 community midwives providing care in birth centers and home settings in Oregon and California. A multidisciplinary team analyzed data using reflexive thematic analysis.

RESULTS

A total of 24 participants were Certified Professional Midwives; 10 were certified nurse-midwives. A total of 14 midwives identified as people of color. Most spoke multiple languages. We describe six key elements of the community midwifery model of postpartum care: (1) multiple visits, including home visits; typically five to eight over six weeks postpartum; (2) care for the parent-infant dyad; (3) continuity of personalized care; (4) relationship-centered care; (5) planning and preparation for postpartum; and (6) focus on postpartum rest.

CONCLUSION

The community midwifery model of postpartum care is a guideline-concordant approach to caring for the parent-infant dyad and may address rising pregnancy-related morbidity and mortality in the United States.

Continuous Support from the Same Public Health Nurse and Parental Perception and Use of Health Care Services: A Retrospective Observational Study

OBJECTIVE

Continuity is considered essential for high-quality maternal and child health care services, but studies to show this effect on parental well-being are still rare. We studied whether receiving support from the same public health nurse has a beneficial effect on parental perceptions of health care professionals and the use of childcare support services.

METHODS

Maternal and child health care services were provided by different nurses in a Japanese municipality until March 2019. From April 2019, all families with infants received continuous support from the same assigned nurse. A questionnaire covering parental perception and the use of services was sent by postal mail to 1,341 families with infants. The data were analyzed using χ2-test, t-test and logistic regression producing odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Parental perceptions of the availability of professionals to discuss children's issues, the degree of understanding about available other childcare support services, the degree of utilizing other services, and satisfaction with health care services were higher in parents who received continuous support from the same assigned nurse compared to those who did not receive continuous support. Continuous support was associated with parental perceptions of the availability of professionals to discuss children's issues (OR = 1.97, 95% CI 1.34-2.91) and the degree of understanding about available other child-care support services (OR = 1.65, 95% CI 1.11-2.44) after adjusting the results for socioeconomic factors.

CONCLUSIONS

Continuous support from the same assigned nurse has benefits for parents. This offers a cost-effective way to improve parental well-being.

A scoping review of costing methodologies used to assess interventions for underserved pregnant people and new parents

BACKGROUND

Lack of evidence about the long-term economic benefits of interventions targeting underserved perinatal populations can hamper decision making regarding funding. To optimize the quality of future research, we examined what methods and costs have been used to assess the value of interventions targeting pregnant people and/or new parents who have poor access to healthcare.

METHODS

We conducted a scoping review using methods described by Arksey and O'Malley. We conducted systematic searches in eight databases and web-searches for grey literature. Two researchers independently screened results to determine eligibility for inclusion. We included economic evaluations and cost analyses of interventions targeting pregnant people and/or new parents from underserved populations in twenty high income countries. We extracted and tabulated data from included publications regarding the study setting, population, intervention, study methods, types of costs included, and data sources for costs.

RESULTS

Final searches were completed in May 2024. We identified 103 eligible publications describing a range of interventions, most commonly home visiting programs (n = 19), smoking cessation interventions (n = 19), prenatal care (n = 11), perinatal mental health interventions (n = 11), and substance use treatment (n = 10), serving 36 distinct underserved populations. A quarter of the publications (n = 25) reported cost analyses only, while 77 were economic evaluations. Most publications (n = 82) considered health care costs, 45 considered other societal costs, and 14 considered only program costs. Only a third (n = 36) of the 103 included studies considered long-term costs that occurred more than one year after the birth (for interventions occurring only in pregnancy) or after the end of the intervention.

CONCLUSIONS

A broad range of interventions targeting pregnant people and/or new parents from underserved populations have the potential to reduce health inequities in their offspring. Economic evaluations of such interventions are often at risk of underestimating the long-term benefits of these interventions because they do not consider downstream societal costs. Our consolidated list of downstream and long-term costs from existing research can inform future economic analyses of interventions targeting poorly served pregnant people and new parents. Comprehensively quantifying the downstream and long-term benefits of such interventions is needed to inform decision making that will improve health equity.

Barriers and facilitators when implementing midwifery continuity of carer: a narrative analysis of the international literature

BACKGROUND

Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging.

METHODS

In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence.

RESULTS

Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced.

CONCLUSIONS

By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.

Barriers and enablers to accessing perinatal health services for rural Australian women: A qualitative exploration of rural health care providers perspectives

OBJECTIVE

To identify perceived barriers and enablers for rural women in accessing perinatal care within their own community from the perspective of perinatal health care providers.

DESIGN

A qualitative descriptive study design utilising reflexive thematic analysis, using the socioecological framework to organise and articulate findings.

SETTING

Victoria, Australia.

PARTICIPANTS

Semi-structured interviews were conducted with nine perinatal health care providers who provide care to pregnant women or new mothers in rural communities. Participants were recruited across Victoria in 2023.

RESULTS

Providers reported multi-level barriers and enablers that exist for rural women in accessing perinatal care within their communities. Barriers included women's personal circumstances, challenging professional relationships, inequitable service provision, ineffective collaboration between services and clinicians and government funding models and policies. Enablers included strength and resilience of rural women, social capital within rural communities, flexible care delivery and innovative practice, rural culture and continuity of care models.

CONCLUSION

Rural perinatal health care providers perceived that rural women face multiple barriers that are created or sustained by complex interpersonal, organisational, community and policy factors that are intrinsic to rural health care delivery. Several addressable factors were identified that create unnecessary barriers for rural women in engaging with perinatal care. These included education regarding health systems, rights and expectations, equitable distribution of perinatal services, improved interprofessional relationships and collaborative approaches to care and equity-based funding models for perinatal services regardless of geographical location.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries

BACKGROUND

Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration.

METHODS

Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality.

RESULTS

In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country.

CONCLUSIONS

A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

Preferences of Recent Mums in Remote and Rural Areas for Type of Intrapartum Care: A Discrete Choice Experiment

BACKGROUND AND OBJECTIVES

Pregnant women living in rural areas considering their preferred place of birth may have to 'trade-off' travel time/distance and other attributes of care (e.g. the full choice of birthplace options is rarely available locally). This study assesses the preferences and trade-offs of recent mothers who live in remote and rural areas of Great Britain.

METHODS

An online survey, informed by qualitative research, was administered to women living in rural areas who had given birth in the preceding 3 years. The survey included a discrete choice experiment (DCE) to elicit women's preferences and trade-offs for place of birth. The DCE presented women with a series of eight choice tasks in which place of birth was defined by four attributes: (1) type of facility, (2) familiarity with staff, (3) understanding options and feel relaxed and reassured and (4) the travel time to the place of intrapartum care. DCE data were analysed using an error components logit model to identify preferences.

RESULTS

Across 251 survey responses, holding everything else equal, respondents preferred: intrapartum care in locations with more specialist staff and equipment, locations where they understood their options and felt reassured and where travel time was minimal. Women were willing to travel (92-183 min) to a well-staffed and equipped facility if they understood their options and felt relaxed and reassured. Willingness to travel was reduced if the care received at the specialist facility was such that they did not understand their options and felt tense and powerless (41-132 min).

CONCLUSION

These insights into the preferences of recent mums from remote and rural areas could inform future planning of rural intrapartum care.

Designing a Midwife-Led Birth Center Program Based on the MAP-IT Model: A Sequential Explanatory Mixed-Methods Study

BACKGROUND

In recent decades, medical supervision of the labor and delivery process has expanded beyond its boundaries to the extent that in many settings, childbirth has become a medical event. This situation has influenced midwifery care. One of the significant barriers to midwives providing care to pregnant women is the medicalization of childbirth. So far, the policies and programs of the Ministry of Health to reduce medical interventions and cesarean section rates have not been successful. Therefore, the current study aims to be conducted with the purpose of "Designing a Midwife-Led Birth Center Program Based on the MAP-IT Model".

METHODS/DESIGN

The current study is a mixed-methods sequential explanatory design by using the MAP-IT model includes 5 steps: Mobilize, Assess, Plan, Implement, and Track, providing a framework for planning and evaluating public health interventions in a community. It will be implemented in three stages: The first phase of the research will be a cross-sectional descriptive study to determine the attitudes and preferences towards establishing a midwifery-led birthing center focusing on midwives and women of childbearing age by using two researcher-made questionnaires to assess the participants' attitudes and preferences toward establishing a midwifery-led birthing center. Subsequently, extreme cases will be selected based on the participants' average attitude scores toward establishing a midwifery-led birthing center in the quantitative section. In the second stage of the study, qualitative in-depth interviews will be conducted with the identified extreme cases from the first quantitative phase and other stakeholders (the first and second steps of the MAP-IT model, namely identifying and forming a stakeholder coalition, and assessing community resources and real needs). In this stage, the conventional qualitative content analysis approach will be used. Subsequently, based on the quantitative and qualitative data obtained up to this stage, a midwifery-led birthing center program based on the third step of the MAP-IT model, namely Plan, will be developed and validated using the Delphi method.

DISCUSSION

This is the first study that uses a mixed-method approach for designing a midwife-led maternity care program based on the MAP-IT model. This study will fill the research gap in the field of improving midwife-led maternity care and designing a program based on the needs of a large group of pregnant mothers. We hope this program facilitates improved eligibility of midwifery to continue care to manage and improve their health easily and affordably.

ETHICAL CODE

IR.MUMS.NURSE.REC. 1403. 014.

Lack of autonomy and professional recognition as major factors for burnout in midwives: A systematic mixed-method review

AIM

The aim of this study was to review the existing evidence on burnout levels in midwives and the main related factors.

DESIGN

Mixed studies systematic review.

DATA SOURCES

PubMed, Scopus and Web of Science were sourced from 2018 and 2023.

REVIEW METHODS

Inclusion criteria: quantitative cross-sectional or qualitative articles published in English within the last 5 years.

EXCLUSION CRITERIA

studies with undergraduate or trainee midwives, studies examining the factors in a pandemic setting and those not answering the research question. Potential risk of bias was assessed using the Mixed Methods Assessment Tool (MMAT). A convergent synthesis design was followed through a thematic synthesis using Thomas and Harden's three-step method: inductive coding of the text, development of descriptive themes and generation of analytical themes. Qualitative approaches adopted exploratory descriptive studies and participatory action research.

RESULTS

Thirty-six studies were included, with a total of 17,364 participants. There were higher levels of burnout in midwives who were single, under 35-40 years of age, with less than 10 years of experience and those with young children. Stress, anxiety and depression, as well as the emotional impact of traumatic events, have been described as related psychological factors.

CONCLUSION

Although extrinsic work factors such as shifts, workload, pay and interpersonal relationships increase burnout, intrinsic factors such as lack of autonomy and recognition are the main factors related to it.

IMPACT

What problem did the study address? Burnout among healthcare workers has been recognized as a global crisis requiring urgent attention, specifically in midwives. What were the main findings? There is a persistent shortage of midwives that is attributed in part to chronic retention difficulties related to job burnout expressed by these professionals. Where and on whom will the research have an impact? We seek to address the paucity of research on burnout in midwives in the current crisis in the profession. Work factors such as lack of autonomy or recognition in the profession carry an associated risk of burnout and job attrition. Understanding the factors that contribute to burnout will enable healthcare organizations to reduce the current problem.

REPORTING METHOD

PREFERRED: Reporting items for systematic review and meta-analyses (PRISMA).

PATIENT OF PUBLIC CONTRIBUTION

No patient or public contribution.

How pregnant women with diabetes experience telemonitoring of the fetal heart rate - An interview study

OBJECTIVES

The use of telemonitoring in healthcare is generally increasing. Women with complicated pregnancies are using telemonitoring as an alternative to conventional management, encompassing hospitalization or frequent outpatient clinic visits. However, there is sparse evidence on how pregnant women experience monitoring of their unborn babies at home. Women might feel uncomfortable with this responsibility, and moreover they might miss face-to-face contact with healthcare personnel.

STUDY DESIGN

The study setting was a Danish hospital with a tertiary obstetric unit attending approximately 3400 births annually. A qualitative study design with interview as method included 11 pregnant women with type 1 diabetes or Gestational Diabetes Mellitus. This design was used to investigate how pregnant women with complicated pregnancies experienced telemonitoring of the fetus. Reflexive thematic analysis was used to analyze the pregnant women's experiences of telemonitoring.

RESULTS

Women with type 1 diabetes or Gestational Diabetes Mellitus found the advantages of telemonitoring to outweigh the disadvantages. They experienced telemonitoring as time-saving and that telemonitoring decreased the level of stress. Moreover, telemonitoring supports positive collaboration with healthcare professionals. The women also experienced a lack of coordination of consultations between different departments at the hospital and challenges with timing, feedback, and technical issues. Moreover, the women requested an opportunity to discuss family formation and emotions.

CONCLUSIONS

Pregnant women with type 1 diabetes or Gestational Diabetes Mellitus benefit from the use of telemonitoring. To further improve the implementation and use of telemonitoring clinical implications, consider how timing and coordination of care, technical equipment, and feedback mechanisms could be improved.

Association between decision-making during pregnancy and woman-centred care among Tanzanian pregnant women: A cross-sectional survey

BACKGROUND

Many women in Tanzania lack autonomy in decision-making for their pregnancy and childbirth. Woman-centred care (WCC) seeks to provide each woman with the appropriate information that promotes participation and highlights their informed decision-making. Thus, decision-making has been proposed as an essential determinant of WCC. This study aimed to assess the association between decision-making and WCC among Tanzanian pregnant women.

METHODS

We conducted a cross-sectional study among 710 pregnant women in Tanzania. The 23-item Woman-Centred Care English version questionnaire was used to assess how women perceived the care provided by midwives. Participants were categorized into two decision-making groups: decision-making for the birthing place by pregnant women themselves and by others. The pre-defined cut-off point of the top 20 percentile was used to indicate a high level of WCC. Binary logistic regression models were used to determine the association between decision-making and WCC.

RESULTS

The median score (interquartile range) of WCC was 97 (92-103) points when decisions were made by pregnant women, compared to 92 (88-96) points when decisions were made by others (p<0.001). There was a significant association between decision-maker and WCC in both unadjusted (p<0.001) and multivariable-adjusted (p=0.006) analyses. The unadjusted odds were approximately 5 times higher in the pregnant women decision-making group (OR: 4.80, 95% CI: 2.74-8.43) and 3 times higher (OR:2.90, 95% CI: 1.36-6.07) after the adjustment for covariates. We observed no significant interaction between decision-making and parity on the level of WCC (p for interaction=0.52).

CONCLUSION

Pregnant women who made decisions for the birthing place had a higher likelihood of having a high level of WCC compared with their counterparts. Our findings suggest that women should be empowered to be involved in decision-making to increase their satisfaction with the care provided by healthcare providers and foster a positive childbirth experience.

Examining the validity and reliability of the COMcareSS (Continuity of Midwifery Care Satisfaction Survey)

BACKGROUND

Continuity of midwifery care has been proven to show an improvement in clinical outcomes for women and greater maternal satisfaction with maternity care. Several questionnaires have been developed to measure satisfaction with maternity services although few are suitable for continuity of midwifery maternity care models, and many have not been validated.

AIMS

The purpose of this study was to test the reliability and validity of the newly developed Continuity of Midwifery Care Satisfaction Survey (COMcareSS) with a cohort of women who have recently experienced continuity of midwifery care.

METHODS

The COMcareSS was distributed to women in Australia who had experienced a live birth within a continuity model of midwifery care and were up to two months postpartum. Factor analysis was conducted, and Cronbach's alpha coefficient calculated for the 34-item scale.

FINDINGS

In total 272 completed responses were recorded. Cronbach's alpha coefficient for the scale was 0.96 suggesting some redundancy in items. There was a lack of variation in responses. In factor analysis, only one factor could feasibly be attempted. This accounted for 76 % of variation in responses.

CONCLUSION

The COMcareSS scale is the first to be developed to measure maternal satisfaction with continuity of midwifery led care. The 34-item scale has good internal consistency. The scale may be unidimensional though the lack of variation in responses means that other possible latent constructs, were not able to be detected. Use of a standardised scale such as the COMcareSS will facilitate benchmarking between services and, comparison and meta-analysis in research studies.

Indigenous maternal and infant outcomes and women's experiences of midwifery care: A mixed-methods systematic review

BACKGROUND

The impact of midwifery, and especially Indigenous midwifery, care for Indigenous women and communities has not been comprehensively reviewed. To address this knowledge gap, we conducted a mixed-methods systematic review to understand Indigenous maternal and infant outcomes and women's' experiences with midwifery care.

METHODS

We searched nine databases to identify primary studies reporting on midwifery and Indigenous maternal and infant birth outcomes and experiences, published in English since 2000. We synthesized quantitative and qualitative outcome data using a convergent segregated mixed-methods approach and used a mixed-methods appraisal tool (MMAT) to assess the methodological quality of included studies. The Aboriginal and Torres Strait Islander Quality Appraisal Tool (ATSI QAT) was used to appraise the inclusion of Indigenous perspectives in the evidence.

RESULTS

Out of 3044 records, we included 35 individual studies with 55% (19 studies) reporting on maternal and infant health outcomes. Comparative studies (n = 13) showed no significant differences in mortality rates but identified reduced preterm births, earlier prenatal care, and an increased number of prenatal visits for Indigenous women receiving midwifery care. Quality of care studies indicated a preference for midwifery care among Indigenous women. Sixteen qualitative studies highlighted three key findings - culturally safe care, holistic care, and improved access to care. The majority of studies were of high methodological quality (91% met ≥80% criteria), while only 14% of studies were considered to have appropriately included Indigenous perspectives.

CONCLUSION

This review demonstrates the value of midwifery care for Indigenous women, providing evidence to support policy recommendations promoting midwifery care as a physically and culturally safe model for Indigenous women and families.

Academic education of midwives in Germany (part 2): Opportunities and challenges for the further development of the profession of midwifery. Position paper of the Midwifery Science Committee (AHW) in the DACH Association for Medical Education (GMA)

The objective of academic training is to prepare midwives as independent healthcare professionals to make a substantial contribution to the healthcare of women in their reproductive years as well as to the health of their children and families. This article therefore describes the professional and educational requirements derived from the legal midwifery competencies within the new midwifery act. Furthermore, it identifies the conditions that need to be established to enable midwives in Germany to practise to their full scope in compliance with statutory responsibilities. Educational science, academic efforts, policymaking and accompanying research should work in synergy. This in turn enables midwives to achieve the maximum scope of their skills, with the objective of promoting physiological pregnancies and births. Consequently, it can strengthen early parenthood in alignment with the national health objectives of "health around childbirth". The academisation of the midwifery profession presents a profound opportunity for professional development in Germany. It is essential that midwives receive training based on the principles of educational science and care structures that are yet to be developed. This can enable them to perform within the wide range of their professional tasks to the highest standards, thereby ensuring the optimal care of their clients. Moreover, there is a chance to implement sustainable improvements in healthcare provision for women and their families during the reproductive phase and the period of parenthood in Germany.

A qualitative evaluation of a student midwife placement teaching English to speakers of other languages (ESOL)

INTRODUCTION

A shortage of UK midwives has put pressure on clinical placements and supervision of student midwives. Alternative placement solutions are needed to provide students with meaningful learning experiences. One such learning experience was a placement undertaken by student midwives who attended a program teaching English to speakers of other languages (ESOL). This study evaluated the impact of the placement on student midwife learning and experiences of the ESOL participants.

METHODS

The 2022 study employed a qualitative design using Kolb's model of experiential learning as a framework. Ten student midwives placed with the ESOL program and three women enrolled in the program participated. Data were collected via online focus groups with the student midwives and a face-to-face focus group with the women. Data were analyzed using thematic analysis and Kolb's model of experiential learning.

RESULTS

Four themes were constructed: 'Putting the scripts aside: expectations versus the reality of being an educator', 'Adapting and personalizing teaching', 'We are learning too: an environment for mutual learning', and 'Taking our learning forwards'. Students faced barriers during their placement and had to adapt their teaching accordingly. They gained crucial knowledge of the challenges faced by women who speak other languages. The women valued the students' input and together they forged a reciprocal learning environment.

CONCLUSIONS

This study demonstrates how placing student midwives in a unique non-maternity setting has benefits for student learning which are transferrable to future practice. Importantly, it confirms that quality of learning during a novel placement is not compromised for students or participants.

Early warning tools and clinician 'agency' for strengthening safety culture: An integrative review

AIM

Identify and analyse literature investigating nurses' and midwives' use of early warning tools during the care of adult inpatients.

DESIGN

An integrative literature review.

METHODS

Whittemore and Knafl's (2005) framework guided this integrative review. PubMed, CINAHL, EMCARE and Google Scholar were systematically searched. The authors assessed the methodological quality of 21 papers meeting inclusion criteria and thematically analysed key data.

RESULTS

Three main themes were identified, each with further sub-themes.

CONCLUSION

Early warning tools operate within various systems and cultural contexts. However, their potential for improved patient safety may be hindered. Protocols influencing tool usage may make nurses and midwives distanced from patients and their expertise. For early warning tools to enhance patient safety, assessing their integration into practice is crucial to maximizing effectiveness.

IMPACT

This review emphasizes the importance of integrating human relationships with early warning tools for patient safety.

PATIENT OR PUBLIC CONTRIBUTION

This integrative literature review does not include patient or public input.

IMPLICATIONS FOR PRACTICE/POLICY

Adapting early warning tools to balance standardization for safety and efficiency and promoting nurses' and midwives' expertise and autonomy is required to optimize delivery of quality care and uphold patient safety.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used.

Examining Cesarean Among Individuals of Advanced Maternal Age in Nurse-Midwifery Care

INTRODUCTION

Cesarean rates are rising, especially for individuals of advanced maternal age (AMA), defined as aged 35 or older. The Robson 10-Group Classification System (TGCS) facilitates assessment and comparison of cesarean rates among individuals in different settings. In midwifery-led care, in which pregnant people are typically healthier and seek a vaginal birth, it is unknown whether individuals of AMA have different antecedents leading to cesarean compared with younger counterparts. This study aimed to examine antecedents contributing to cesarean using Robson TGCS for individuals across age groups in midwifery care.

METHODS

This study was a secondary analysis of 2 cohort data sets from Oregon Health & Science University (OHSU) and University of Michigan Health Systems (UMHS) hospitals. The samples were individuals in midwifery-led care birthing at either OHSU from 2012 to 2019 or UMHS from 2007 to 2019.

RESULTS

A total of 11,951 individuals were studied. Overall cesarean rates were low; however, the rate for individuals of AMA was higher than the rate of their younger counterparts (18.30% vs 15.10%). The Robson groups were similar; however, the primary contributor among AMA individuals was group 5 (multiparous with previous cesarean), followed by group 2 [nulliparous with labor induced or prelabor cesarean], and group 1 [nulliparous with spontaneous labor]. In contrast, the primary contributors for younger individuals were groups 1, 2, and 5, respectively. In addition, prelabor cesarean and induced labor partly mediated the relationship between AMA and cesarean among nulliparous individuals, whereas prelabor cesarean was the key contributor to cesarean among multiparous people.

DISCUSSION

The cesarean rate in midwifery-led care was low. Using Robson TGCS provided additional insight into the antecedents to cesarean, rather than viewing cesarean as a single outcome. Future studies should continue to use Robson TGCS and investigate antecedents to cesarean, including factors influencing successful vaginal birth after cesarean in individuals of AMA.

Midwifery practice in Mongolia: Policy implications for accelerating care delivery transformation

Midwives can play a significant role in reducing maternal and neonatal mortality rates as well as in improving maternal and perinatal health outcomes in low- and middle-income countries such as Mongolia. However, the shortage of midwives in Mongolia is severe. Despite the evidence indicating numerous challenges associated with substandard midwifery education and practice in Mongolia, there is a need for policy recommendations to accelerate the improvement of midwifery care delivery in the country. Therefore, we identified three main topics as key issues in Mongolian midwifery care: 1) the current training and service delivery in midwifery; 2) the potential for the development of the midwifery role; and 3) content requirements for the postgraduate certificate in midwifery. The World Health Organization report made forty recommendations to enhance the midwife's role to professional status. However, the absence of senior nursing/midwifery leadership in the Ministry of Health in Mongolia has hindered the implementation of the recommendations. To strengthen midwifery at a national level, it is imperative to make multilevel investments in supporting educators and clinical practitioners to ensure the delivery of high-quality midwifery care. This article represents an initial in-depth exploration of issues in Mongolian midwifery practice, with the aim of providing suggestions for practical avenues for enhancing midwifery care in Mongolia.

Systematic review and meta-analysis examining the effects of midwife care on cesarean birth

BACKGROUND

The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.

METHODS

We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs).

RESULTS

We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence.

CONCLUSIONS

Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.

Roles and challenges encountered by midwives in the management of postpartum haemorrhage following normal vaginal delivery: A scoping review

AIMS

To establish a comprehensive understanding of the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of postpartum haemorrhage (PPH) following normal vaginal delivery.

DESIGN

We conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR) recommendations.

METHODS

We considered studies related to the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of PPH during vaginal delivery. We excluded guidelines, consensuses, abstracts of meetings and non-English language studies. Databases, including the Cochrane Library, PubMed, Web of Science, Ovid, Medline, Embase, JBI EBP and BIOSIS Previews, were searched on January 1, 2023, with no time limitations.

RESULTS

We included 28 publications. Midwives play important roles in the prevention, diagnosis and management of postpartum haemorrhage during vaginal delivery. In the prevention of PPH, midwives' roles include identifying and managing high-risk factors, managing labour and implementing skin-to-skin contact. In the diagnosis of PPH, midwives' roles include early recognition and blood loss estimation. In the management of PPH, midwives are involved in mobilizing other professional team members, emergency management, investigating causes, enhancing uterine contractions, the repair of perineal tears, arranging transfers and preparation for surgical intervention. However, midwives face substantial challenges, including insufficient knowledge and skills, poor teamwork skills, insufficient resources and the need to deal with their negative emotions. Midwives must improve their knowledge, skills and teamwork abilities. Health care system managers and the government should give full support to midwives. Future research should focus on developing clinical practice guidelines for midwives for preventing, diagnosing and managing postpartum haemorrhage.

Continuity obstetric care demonstrates greater vaginal birth after caesarean success

BACKGROUND

Australia's caesarean rate is higher than Organisation for Economic Co-operation and Development (OECD) average, and is rising. Vaginal birth after caesarean (VBAC) is safe for selected women. Midwifery continuity of care (CoC) is associated with higher rates of vaginal birth compared to other models; however, impacts on VBAC attempts and success are unknown.

AIMS

The primary aim was to determine if there is a difference in achieving VBAC between CoC and non-CoC (NCoC) models. The secondary aim was to determine if there is a difference in the proportion of women attempting VBAC between these models.

MATERIALS AND METHODS

Retrospective review of antenatal records and birthing data of all women who birthed in 2021 with one or more previous caesareans. Women were included if they had two or fewer caesareans. Women were excluded if contraindications to VBAC existed.

RESULTS

There were 142/1109 (12.8%) women who had previous caesareans and were eligible to attempt VBAC. There were 47/109 (43.1%) women who attempted vaginal birth after one caesarean with 78.7% success. After one caesarean, women in CoC were more likely to achieve VBAC than NCoC (45.2% vs 26.1%; relative risk (RR) 1.76, 95% CI 1.04-3.00), although when stratified by private and midwifery CoC models, women in midwifery CoC models were more likely to be successful (private RR 0.69, 95% CI 0.23-2.07 vs midwifery RR 2.48, 95% CI 1.50-4.11). Women in CoC were more likely to attempt VBAC (54.7% vs 34.8%; RR 1.57, 95% CI 1.02-2.41), and receive counselling about VBAC (92.5% vs 62%; RR 1.48, 95% CI 1.41-3.11).

CONCLUSION

CoC improves the rate of attempted and successful VBAC through several factors, including increased counselling and greater provision of birth choices.

IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation (The IMPART Study)

BACKGROUND

In the UK, 7.6% of babies are born preterm, which the Department of Health aims to decrease to 6% by 2025. To advance this, NHS England released Saving Babies Lives Care Bundle Version 2 Element 5, recommending the Preterm Birth Pathway for women at risk of preterm birth. The success of this new pathway depends on its implementation. The IMPART (IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation) study aimed to research how, why, for whom, to what extent and in what contexts the prediction and prevention aspects of Preterm Birth Surveillance Pathway is implemented through a realist evaluation. Realist implementation studies are growing in popularity.

METHODS

Initial programme theories were developed through a realist informed literature scope, interviews with developers of the NHS England guidance, and a national questionnaire of current practice. Implementation theory was utilised in developing the programme theories. Data (interviews and observations with staff and women) were undertaken in 3 case sites in England to 'test' the programme theories. Substantive theory was utilised during data analysis to interpret and refine the theories on how implementation could be improved.

RESULTS

Three explanatory areas were developed: risk assessing and referral; the preterm birth surveillance clinic; and women centred care. Explanatory area 1 dealt with the problems in correct risk assessment and referral to a preterm clinic. Explanatory area 2 focused on how once a correct referral has been made to a preterm clinic, knowledgeable and supported clinicians can deliver a well-functioning clinic. Explanatory area 3 concentrated on how the pathway delivers appropriate care to women.

CONCLUSIONS

The IMPART study provides several areas where implementation could be improved. These include educating clinicians on knowledge of risk factors and the purpose of the preterm clinic, having a multidisciplinary preterm team (including a preterm midwife) with specialist preterm knowledge and skills (including transvaginal cervical scanning skills), and sites actively working with their local network. This multidisciplinary preterm team are placed to deliver continuity of care for women at high-risk of preterm birth, being attentive to their history but also ensuring they are not defined by their risk status.

TRIAL REGISTRATION

ISRCTN57127874.

Exploring the feasibility of conducting a randomised controlled trial of group-based pregnancy care and education: a pilot randomised controlled trial in Melbourne, Australia

BACKGROUND

In group-based pregnancy models, antenatal care and childbirth/parenting education are provided in groups of eight to 10 women, usually with two midwives, and six to eight sessions. Current evidence is inconclusive regarding potential benefit or harm. We aimed to explore the feasibility of implementing an adequately powered randomised controlled trial (RCT).

METHODS

A two-arm pilot RCT was conducted in a tertiary maternity hospital in Melbourne, Australia. Women were randomly allocated to either the intervention to receive group-based antenatal care and education (group care) or to usual care, which included hospital-based midwife, caseload midwifery, team midwifery, or GP shared care. Participants were English-speaking, primiparous, low risk, and < 24 weeks gestation at booking.

DATA COLLECTION

feasibility measures throughout pilot, baseline questionnaire at recruitment, clinical outcome data from the medical record, and a telephone-administered questionnaire 6 weeks postpartum. A focus group explored midwives' views.

RESULTS

Seventy-four women were recruited from May to June 2017 (group care = 40, usual care = 34). Study uptake was 35%. Women allocated to group care rated their overall pregnancy care more highly (88% good/very good vs 77% in usual care). There was no evidence of harm related to group care. Overarching themes from the midwives were that group care helped 'build connections' and 'empower women'. All midwives would work in the model again and believed it should be expanded.

CONCLUSION

Group care was acceptable to both women and midwives with no evidence of harm. The pilot demonstrated the feasibility of undertaking a large adequately powered RCT, important given the inconclusive evidence on clinical outcomes regarding the model, and its current relatively widespread implementation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000858695.

The challenge of adopting a collaborative information system for independent healthcare workers in France: a comprehensive study

This study aimed to explore the perception of an underutilised collaborative information system through qualitative research, utilizing semi-structured, in-depth interviews with independent midwives and physician. PROSPERO, is a collaborative information system designed to bridge the communication gap between community-based healthcare workers and hospital-based care teams for parturients in Lyon, France. Through 27 semi-structured in-depth interviews with midwives, obstetricians, and general practitioners, we identified key themes related to the system's adoption: implementation challenges, utilisation barriers, interprofessional dynamics, and hidden variables affecting system use. Participants recognised the potential of PROSPERO to improve information sharing and care coordination but expressed concerns about the system's integration into existing workflows, time constraints, and the need for adequate training and technical support. Interprofessional dynamics revealed differing perspectives between hospital and independent practitioners, emphasising the importance of trust-building and professional recognition. Hidden variables, such as hierarchical influences and confidentiality concerns, further complicated the system's adoption. Despite the consensus on the benefits of a collaborative information system, its implementation was hindered by mistrust between healthcare workers (i.e. between independent practitioners and hospital staff). Our findings suggest that fostering trust and addressing the identified barriers are crucial steps towards successful system implementation. The study contributes to understanding the complex interplay of factors influencing the adoption of collaborative healthcare technologies and highlights the need for strategies that support effective interprofessional collaboration and communication.ClinicalTrials ID NCT02593292.

An online survey of women's views of respectful and disrespectful pregnancy and early labour care in the Czech Republic

OBJECTIVE

To ascertain and explore the views of women and their partners, giving birth in the Czech Republic, of the level of respectful or disrespectful care provided during pregnancy and early labour.

DESIGN

Ethical approval was granted for a descriptive, online anonymous survey of 65 questions, with quantitative and qualitative responses.

SETTING

The Czech Republic.The survey was completed by 8,767 women and 69 partners in 2018.

MEASUREMENTS AND FINDINGS

Descriptive statistics and thematic analysis were used to present results. The majority of women were aged 26-35 years. Most had birthed in one of 93 hospitals, with 1.5% home births. Almost 40% never had an abdominal examination.in pregnancy. Quantitative data analysis revealed that less than half were given information on place of birth, or how to keep labour normal or non-interventionist. Almost 60% did not get information on positions for birth. Most (68%) commenced labour naturally, 25% had labour induced, 40% of them before term, and 7% had an elective caesarean section; 55% stated they had not been given any choice in the decision. Over half of those who had a membrane sweep said permission had not been sought. Half (54%) only had 'checking' visits from the midwife in labour.

KEY CONCLUSIONS

Findings reveal a lack of information-giving, discussion and shared decision-making from healthcare professionals during pregnancy and early labour. Some practices were non-evidenced-based, and interventions were sometimes made without consent.

IMPLICATIONS FOR PRACTICE

The examples of disrespectful care described in this study caused women distress during childbirth, which may result in an increased fear of childbirth or an increase in free-birthing.

Psychometric properties of the experiences of maternity care scale among Iranian women

BACKGROUND

Assessing women's perceptions of the care they receive is crucial for evaluating the quality of maternity care. Women's perceptions are influenced by the care received during pregnancy, labour and birth, and the postpartum period, each of which with unique conditions, expectations, and requirements. In England, three Experience of Maternity Care (EMC) scales - Pregnancy, Labour and Birth, and Postnatal - have been developed to assess women's experiences from pregnancy through the postpartum period. This study aimed to validate these scales within the Iranian context.

METHODS

A methodological cross-sectional study was conducted from December 2022 to August 2023 at selected health centers in Tabriz, Iran. A panel of 16 experts assessed the qualitative and quantitative content validity of the scales and 10 women assessed the face validity. A total of 540 eligible women, 1-6 months postpartum, participated in the study, with data from 216 women being used for exploratory factor analysis (EFA) and 324 women for confirmatory factor analysis (CFA) and other analyses. The Childbirth Experience Questionnaire-2 was employed to assess the convergent validity of the Labour and Birth Scale, whereas women's age was used to assess the divergent validity of the scales. Test-retest reliability and internal consistency were also examined.

RESULTS

All items obtained an impact score above 1.5, with Content Validity Ratio and Content Validity Index exceeding 0.8. EFA demonstrated an excellent fit with the data (all Kaiser-Meyer-Olkin measures > 0.80, and all Bartlett's p < 0.001). The Pregnancy Scale exhibited a five-factor structure, the Labour and Birth Scale a two-factor structure, and the Postnatal Scale a three-factor structure, explaining 66%, 57%, and 62% of the cumulative variance, respectively, for each scale. CFA indicated an acceptable fit with RMSEA ≤ 0.08, CFI ≥ 0.92, and NNFI ≥ 0.90. A significant correlation was observed between the Labour and Birth scale and the Childbirth Experience Questionnaire-2 (r = 0.82, P < 0.001). No significant correlation was found between the scales and women's age. All three scales demonstrated good internal consistency (all Cronbach's alpha values > 0.9) and test-retest reliability (all interclass correlation coefficient values > 0.8).

CONCLUSIONS

The Persian versions of all three EMC scales exhibit robust psychometric properties for evaluating maternity care experiences among urban Iranian women. These scales can be utilized to assess the quality of current care, investigate the impact of different care models in various studies, and contribute to maternal health promotion programs and policies.

Midwives' practices on perineal protection and episiotomy decision-making: A qualitative and descriptive study

INTRODUCTION

Perineal trauma is associated with both short- and long-term morbidity which in turn relates to the degree of trauma. The objective of this study was to understand midwives' practices regarding perineal protection during the second phase of labor, emphasizing decision-making to perform an episiotomy.

METHODS

A descriptive and explanatory study was conducted with an intentional sample of twenty-two midwives working in the labor ward of a tertiary hospital in a metropolitan location and in the public service, in Portugal. A semi-open interview was applied to collect the data from 5 to 15 January 2019. The computer software package, NVivo version 10, was used to perform the thematic analysis.

RESULTS

Four main themes arose from the midwives' data: 1) Factors affecting the application of perineal protection techniques', 2) Birth position, 3) Techniques for perineal protection, and 4) Episiotomy. The reasons for performing an episiotomy were the presence of tense perineum, large weight baby, previous obstetric anal sphincter injury, and Kristeller maneuver.

CONCLUSIONS

Midwives' practices regarding perineal protection techniques and reasons for performing an episiotomy were not all in line with the evidence. Perineal massage was not mentioned as a perineal protection technique.

Stress perception, coping behaviors and work-privacy conflict of student midwives in times of COVID-19 pandemic: the "Healthy MidStudents" study in Germany

BACKGROUND

Student midwives deliver care for women under challenging job demands, which may affect their mental health- thus creating a high need for health promotion. Given the lack of research addressing this topic, the aim of this study is to examine the links between stress perception, coping behaviors, work-privacy conflict, and perception of COVID-19 pandemic impact on studies of student midwives in northern Germany.

METHODS

Data were collected using a cross-sectional online-survey at nine midwifery study sites in northern Germany from October 2022 to January 2023. 342 student midwives (response rate: 61.3%) were surveyed on stress perception, coping behaviors, work-privacy conflict, and perceived impact of the COVID-19 pandemic on their studies. Descriptive, linear regression and moderation analyses were run to test explorative assumptions.

RESULTS

Results revealed that higher levels of perceived stress were reported by 13.4% of student midwives. Social support (M = 13.76, SD = 2.19) and active stress coping (M = 10.72, SD = 2.01) were identified as most prevalent coping behaviors in the present sample. It was found that work-privacy conflict was positively associated with stress perception (ß = 0.53, p =.001) and maladaptive coping behaviors (alcohol and cigarette consumption: ß = 0.14, p =.015), and negatively associated with adaptive coping behaviors (positive thinking: ß = - 0.25, p =.001, social support: ß = - 0.23, p =.001). Students with children reported significantly lower levels of social support than students without children. 55.6% of student midwives perceived a negative impact of the COVID-19 pandemic on their studies (mostly on lectures, seminars, and contact with fellow students).

CONCLUSIONS

Key findings highlighted moderate stress levels among student midwives during theoretical study stage. Based on current research, prevalence of high stress levels among student midwives remains unclear. Given the overall heterogeneous, limited research on student midwives' stress perception, coping behaviors, work-privacy conflict and perceptions of COVID-19 pandemic impact on studies, implications for research are suggested, e.g. longitudinal studies at different time points and settings and interventional studies. Findings provide a starting point for implementation of workplace health promotion in theoretical and practical stages of midwifery science study programs, e.g. training courses on stress prevention and adaptive coping, and for improvement of working conditions.

Perceptions and Attitudes Toward Genetic Counselors and Genetic Testing Among Certified Professional Midwives in Vermont: A Modified Grounded Theory Study

Increasingly, pregnant people in the United States are choosing to give at birth at home, and certified professional midwives (CPMs) often attend these births. Care by midwives, including home birth midwives, has the potential to decrease unnecessary medical interventions and their associated health care costs, as well as to improve maternal satisfaction with care. However, lack of integration into the health care system affects the ability of CPMs to access standard medications and testing for their clients, including prenatal screening. Genetics and genomics are now a routine part of prenatal screening, and genetic testing can contribute to identifying candidates for planned home birth. However, research on genetics and midwifery care has not, to date, included the subset of midwives who attend the majority of planned home births, CPMs. The purpose of this study was to examine CPMs' access to, and perspectives on, one aspect of prenatal care, genetic counselors and genetic counseling services. Using semi-structured interviews and a modified grounded theory approach to narrative analysis, we identified three key themes: (1) systems-level issues with accessing information about genetic counseling and genetic testing; (2) practice-level patterns in information delivery and self-awareness about knowledge limitations; and (3) client-level concerns about the value of genetic testing relative to difficulties with access and stress caused by the information. The results of this study can be used to develop decision aids that include information about genetic testing and genetic counseling access for pregnant people intending home births in the United States.

Identifies Current Trends in Vaginal Birth after Cesarean Section in IRAN: A Qualitative Study

Background

The growing prevalence of Cesarean Sections (CS), particularly repeated CS, is a major issue in contemporary midwifery. This study seeks to gain a comprehensive understanding of the experiences of pregnant women and specialists with vaginal delivery after CS, as well as the obstacles that may arise.

Materials and Methods

From March 2020 to May 2021, 10 women, 12 midwives, and 8 obstetricians and obstetricians affiliated with Qom University of Medical Sciences were interviewed to investigate the experiences and challenges associated with Vaginal Birth After Cesarean section (VBAC). We used the content analysis method, and the sampling was purposive. Semi-structured interviews were conducted to collect data, which were then analyzed using qualitative content analysis based on conventional content analysis.

Results

The results show that subcategories "individual aspects of VBAC" and "family-social aspects of VBAC" formed "positive aspects of VBAC." Subcategories "self-efficacy" and "decision-making participation" formed the "empowerment for the woman." Subcategories "technical team challenges" and "woman's challenges" formed the main category of "upcoming challenges."

Conclusions

Positive relationships, choice-making ability, and self-confidence impact a woman's decision to choose VBAC. Informing women of alternative delivery options after a CS and pursuing their dreams increases the likelihood of successful VBAC.

"Safe, connected, supported in a complex system." Exploring the views of women who had a First Nations baby at one of three maternity services offering culturally tailored continuity of midwife care in Victoria, Australia. A qualitative analysis of free-text survey responses

BACKGROUND

In Australia, continuity of midwife care is recommended for First Nations women to address the burden of inequitable perinatal outcomes experienced by First Nations women and newborns.

AIMS

This study aimed to explore the experiences of women having a First Nations baby who received care at one of three maternity services in Naarm (Melbourne), Victoria, where culturally tailored midwife continuity models had been implemented.

METHODS

Women having a First Nations baby who were booked for care at one of three study sites were invited to participate in an evaluation of care. Thematic analysis was used to analyse qualitative data from responses to free-text, open ended questions that were included in a follow-up questionnaire at 3-6 months after the birth.

RESULTS

In total, 213 women (of whom 186 had continuity of midwife care) participated. The global theme for what women liked about their care was 'Safe, connected, supported' including emotional and clinical safety, having a known midwife and being supported 'my way'. The global theme for what women did not like about their care was 'A complex, fragmented and unsupportive system' including not being listened to, things not being explained, and a lack of cultural safety.

CONCLUSIONS

Culturally tailored caseload midwifery models appear to make maternity care feel safer for women having a First Nations baby, however, the mainstream maternity care system remained challenging for some. These models should be implemented for First Nations women, and evidence-based frameworks, such as the RISE framework, should be used to facilitate change.

[Postpartum Care by Midwives: Socioeconomic Status has a Strong Influence on the Amount of Care Received An Analysis with Routine Data from BARMER Health Insurance]

BACKGROUND

Socio-economic situation is associated with inequalities in access to health care and health-related resources. This also applies to pregnancy, birth and the postpartum period. Compared to other European countries, Germany has very good care options for the postpartum period. It has an unique system of postpartum care, which comprises home visits by midwives for 12 weeks after birth and beyond in problem cases and thus has structurally good care options. So far, however, there are hardly any studies based on routine data that show which mothers receive homevisits in postpartum care and to what extent.

METHOD

The study population comprised 199,978 women insured with BARMER who gave birth to at least one child in the years 2017-2020. Some women were pregnant several times in this period of time. The services billed by freelance midwives for outreach midwifery care in the puerperium were considered for 227,088 births, taking into account the socioeconomic situation of the mothers.

RESULTS

According to the definition of the German Institute for Economic Research, 26% of the mothers belonged to a low income group, 46% to a medium income group and 29% to a high income group. Similar to what was shown for midwifery care during pregnancy, large differences were also found with regard to postpartum care: While 90.5% of the women with a high income received home visits, only 83.5% of women with a medium income did so, and only 67.9% of women with a low income. The groups did not differ with regard to other characteristics such as rate of caesarean section, preterm births, twins, age or concomitant diseases to an extent that could explain the differences in care. Women who had received midwifery services in pregnancy were much more likely to receive home visits by a midwife in the postpartum period. Furthermore, there was a correlation with the density of midwives in the respective region.

CONCLUSIONS

The results suggest that access to home-based postpartum care by freelance midwives is significantly limited for low-income women. In contrast to antenatal care, women in the postpartum period cannot switch to other service providers, as outreach postpartum care is a reserved activity of midwives. Women with low incomes thus receive less midwifery care, although they have a higher need for support (Eickhorst et al. 2016).

An implementation analysis of a quality improvement project to reduce cesarean section in Brazilian private hospitals

BACKGROUND

Brazil has one of the highest prevalence of cesarean sections in the world. The private health system is responsible for carrying out most of these surgical procedures. A quality improvement project called Adequate Childbirth Project ("Projeto Parto Adequado"- PPA) was developed to identify models of care for labor and childbirth, which place value on vaginal birth and reduce the frequency of cesarean sections without a clinical indication. This research aims to evaluate the implementation of PPA in private hospitals in Brazil.

METHOD

Evaluative hospital-based survey, carried out in 2017, in 12 private hospitals, including 4,322 women. We used a Bayesian network strategy to develop a theoretical model for implementation analysis. We estimated and compared the degree of implementation of two major driving components of PPA-"Participation of women" and "Reorganization of care" - among the 12 hospitals and according to type of hospital (belonging to a health insurance company or not). To assess whether the degree of implementation was correlated with the rate of vaginal birth data we used the Bayesian Network and compared the difference between the group "Exposed to the PPA model of care" and the group "Standard of care model".

RESULTS

PPA had a low degree of implementation in both components "Reorganization of Care" (0.17 - 0.32) and "Participation of Women" (0.21 - 0.34). The combined implementation score was 0.39-0.64 and was higher in hospitals that belonged to a health insurance company. The vaginal birth rate was higher in hospitals with a higher degree of implementation of PPA.

CONCLUSION

The degree of implementation of PPA was low, which reflects the difficulties in changing childbirth care practices. Nevertheless, PPA increased vaginal birth rates in private hospitals with higher implementation scores. PPA is an ongoing quality improvement project and these results demonstrate the need for changes in the involvement of women and the care offered by the provider.

Advanced Midwifery Practice in Switzerland: Development and challenges

Midwifery is undergoing increasing complexity attributed to global epidemiological, socio-economic and technological shifts. Coupled with a shortage of workforce and the imperative for cost-effectiveness and high-quality care, there is an ongoing international discourse and establishment of new care models and specialized roles, notably Advanced Midwifery Practice (AMP). While countries like the UK and Ireland have embraced AMP roles, Switzerland lags behind with only a few pioneering roles. The absence of regulatory frameworks for AMP within the Swiss legal and healthcare system, hinders the evolution of APM roles necessary to address contemporary needs in perinatal healthcare provision. To effectively harness the midwifery workforce and mitigate premature attrition, Switzerland must formulate distinct career trajectories for postgraduate midwives, particularly for Advanced Practice Midwives (APM). This involves establishing legal standards for educational and clinical prerequisites, delineating guidelines for APM responsibilities and competencies, and devising compensation schemes that mirror the autonomy and leadership competencies integral to these advanced roles within inpatient and outpatient perinatal care models. The incorporation of evaluation and research into AMP is indispensable, contributing to improved patient outcomes and the ongoing professionalization of midwifery. In conjunction with the Swiss Federation of Midwives, all Universities of Applied Sciences in Switzerland have collaboratively drafted a national position paper underscoring the significance of developing APM roles to ensure the provision of high-quality perinatal care. This article aims to elucidate current developments in perinatal care within the Swiss context, providing a comprehensive definition for AMP, delineating its contribution to enhancing and sustaining the quality of care.

Effect of implementation of the WHO intrapartum care model on maternal and neonatal outcomes: a randomized control trial

BACKGROUND

In 2018, the World Health Organization published a set of recommendations for further emphasis on the quality of intrapartum care to improve the childbirth experience. This study aimed to determine the effects of the WHO intrapartum care model on the childbirth experience, fear of childbirth, the quality of intrapartum care (primary outcomes), as well as post-traumatic stress disorder symptoms, postpartum depression, the duration of childbirth stages, the frequency of vaginal childbirth, Apgar score less than 7, desire for subsequent childbearing, and exclusive breastfeeding in the 4 to 6 weeks postpartum period (secondary outcomes).

METHODS

This study was a randomized controlled trial involving 108 pregnant women admitted to the maternity units of Al-Zahra and Taleghani hospitals in Tabriz-Iran. Participants were allocated to either the intervention group, which received care according to the ' 'intrapartum care model, or the control group, which received the' 'hospital's routine care, using the blocked randomization method. A Partograph chart was drawn for each participant during pregnancy. A delivery fear scale was completed by all participants both before the beginning of the active phase (pre-intervention) and during 7 to 8 cm dilation (post-intervention). Participants in both groups were followed up for 4 to 6 weeks after childbirth and were asked to complete questionnaires on childbirth experience, postpartum depression, and post-traumatic stress disorder symptoms, as well as the pregnancy and childbirth questionnaire and checklists on the desire to have children again and exclusive breastfeeding. The data were analyzed using independent T and Mann-Whitney U tests and analysis of covariance ANCOVA with adjustments for the parity variable and the baseline scores or childbirth fear.

RESULTS

The average score for the childbirth experience total was notably higher in the intervention group (Adjusted Mean Difference (AMD) (95% Confidence Interval (CI)): 7.0 (0.6 to 0.8), p < 0.001). Similarly, the intrapartum care quality score exhibited a significant increase in the intervention group (AMD (95% CI): 7.0 (4.0 to 10), p < 0.001). Furthermore, the post-intervention fear of childbirth score demonstrated a substantial decrease in the intervention group (AMD (95% CI): -16.0 (-22.0 to -10.0), p < 0.001). No statistically significant differences were observed between the two groups in terms of mean scores for depression, PTSD symptoms, duration of childbirth stages, frequency of vaginal childbirth, Apgar score less than 7, and exclusive breastfeeding in the 4 to 6 weeks postpartum (p > 0.05).

CONCLUSION

The intrapartum care model endorsed by the World Health Organization (WHO) has demonstrated effectiveness in enhancing childbirth experiences and increasing maternal satisfaction with the quality of obstetric care. Additionally, it contributes to the reduction of fear associated with labor and childbirth. Future research endeavors should explore strategies to prioritize and integrate respectful, high-quality care during labor and childbirth alongside clinical measures.

Midwife continuity of care models versus other models of care for childbearing women

BACKGROUND

Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016.

OBJECTIVES

To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence.

MAIN RESULTS

We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models.

AUTHORS' CONCLUSIONS

Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

A concurrent mixed-method study exploring the experiences of interprofessional collaboration among Canadian midwives and obstetricians

AIM

This study explores the experiences of interprofessional collaboration of Canadian midwives and obstetricians from midwives' perspective.

DESIGN

A concurrent mixed-methods approach that combined a small validation study and qualitative thematic analysis was used to provide evidence of the nature and importance of collaboration between Registered Midwives (RMs) and obstetricians.

METHOD

Eighteen RMs across Canada completed a demographic survey and the Midwifery-Obstetrician Collaboration (MOC) scale in 2023. The quantitative analyses were conducted to assess the reliability of the Midwifery-Obstetrician Collaboration (MOC) and accumulate preliminary evidence to support its validity. Semi-structured interviews were conducted with 13 participants. After completing the interviews, themes were identified using thematic analysis.

RESULTS

The primary themes identified were knowledge of midwifery scope affects collaboration, collaboration is necessary for effective patient care, midwife-physician collaboration is impacted by power differentials and hierarchies, and proposed methods to improve physician-midwife collaboration. Although a small sample size did not permit extensive statistical testing, the quantitative results supported the reliability of the MOC scale. In addition, a strong correlation between the MOC and the communication subscale of the Inter-Professional Collaboration (IPC) scale provided evidence of the MOC's concurrent validity as a measure of collaboration between midwives and physicians.

CONCLUSION

This study provides support for the Midwifery-Obstetrics Collaboration (MOC) Scale as an assessment tool to evaluate collaboration between midwives and OB/GYNs in obstetrics care. While the 18 RMs recruited for this study provided a fulsome analysis for the qualitative portion, a larger study is necessary to provide more extensive quantitative analysis to validate the MOC scale for continued use among RMs and OBs.

IMPLICATIONS

The implications of this study are to foster strong interprofessional relationships between midwives and OBs and to improve the health outcomes of pregnant women and newborns.

REPORTING METHOD

The authors adhered to Consolidated criteria for reporting qualitative research (COREQ).

"You and Me Do It for the Love of Teaching": Exploring the Expansion of Clinical Training Opportunities for Midwives

PURPOSE

To better understand the barriers and facilitators to precepting midwifery students from across the healthcare ecosystem in New Jersey.

BACKGROUND

Growing the midwifery workforce is a crucial step to alleviating disparately poor perinatal health outcomes and expanding access to care. Difficulty recruiting and retaining preceptors has been identified as a barrier to graduating more midwives.

METHODS

In-depth qualitative interviews were conducted with 19 individuals involved in different stages of the clinical training process: midwives, physicians, and administrators. Transcripts were coded using the tenets of qualitative description and thematic analysis. Analysis was guided by the Promoting Action on Research Implementation in Health Services framework.

RESULTS

The following themes were identified and organized within the domains identified by our conceptual framework. Evidence: (mis)understanding the benefits of midwifery care and impacts on patient care. Context: the time and energy it takes to precept and practice considerations. Facilitations: developing the next generation of healthcare providers and the quiet and ever-present role of money in healthcare.

CONCLUSIONS

Findings from this study support the importance of approaching midwifery precepting as a multifaceted endeavor, one that necessitates the full support of individuals within many different roles in an organization.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Getting buy-in from various levels of the healthcare ecosystem requires a flexible approach but must include a targeted effort toward showing the value of midwifery care in terms of patient outcomes, satisfaction, and cost.

The association between midwifery staffing and reported harmful incidents: a cross-sectional analysis of routinely collected data

BACKGROUND

Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies.

METHODS

We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm.

RESULTS

The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed.

CONCLUSION

When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.

Mediating processes underlying the associations between maternal obesity and the likelihood of cesarean birth

BACKGROUND

Pregnant women with obesity are more likely to experience cesarean birth compared to women without obesity. Yet, little is known about the underlying mechanisms. The objective of this study was therefore to evaluate how mediators contribute to the association between obesity and prelabor/intrapartum cesarean birth.

METHODS

We retrospectively analyzed Swiss cohort data from 394,812 singleton, cephalic deliveries between 2005 and 2020. Obesity (BMI ≥ 30 kg/m2 ) was defined as the exposure and prelabor or intrapartum cesarean birth as the outcomes. Hypothesized mediators included gestational comorbidities, large-for-gestational-age infant, pregnancy duration >410/7 weeks, slower labor progress, labor induction, and history of cesarean birth. We performed path analyses using generalized structural equation modeling and assessed mediation by a counterfactual approach.

RESULTS

Women with obesity had a cesarean birth rate of 39.36% vs. 24.12% in women without obesity. The path models mainly showed positive direct and indirect associations between obesity and cesarean birth. In the total sample, the mediation models explained up to 39.47% (95% CI 36.92-42.02) of the association between obesity and cesarean birth, and up to 57.13% (95% CI 54.10-60.16) when including history of cesarean birth as mediator in multiparous women. Slower labor progress and history of cesarean birth were found to be the most clinically significant mediators.

CONCLUSIONS

This study provides empirical insights into how obesity may increase cesarean birth rates through mediating processes. Particularly allowing for a slower labor progress in women with obesity might reduce cesarean birth rates and prevent subsequent repeat cesarean births in multiparous women.

The Birth Bundle Project: A Rainier Valley Midwifery-led Collaborative Care Initiative Offering Patients and Providers a Paradigm Shift to Impact Health Equity

Innovative midwifery-led collaborative care models have the potential to build on grassroots approaches to make transformative change within systems that work with families. Rainier Valley Midwives operates the Bundle Birth Project, a successful program that serves communities who are at higher risk for poor birth outcomes and face barriers to adequate medical, prenatal, and postpartum care, including Black, Indigenous, and persons of color. This project offers wraparound perinatal care services to provide a missing community of support to traditionally marginalized families before, during, and after birth while also bridging the gaps between midwives and physicians who attend births in different settings. By strengthening and formalizing the relationships between different types of perinatal providers including community-based doulas and lactation support professionals, this midwifery-led initiative improves the continuity and quality of care available to families including immigrant, refugee, and families of color in south Seattle, Washington.

Continuity of Clinician Type and Intrapartum Experiences During the Perinatal Period in California

INTRODUCTION

Continuity of care with an individual clinician is associated with increased satisfaction and better outcomes. Continuity of clinician type (ie, obstetrician-gynecologist or midwife) may also impact care experiences; however, it is unknown how common it is to experience discontinuity of clinician type and what its implications are for the birth experience. We aimed to identify characteristics associated with having a different clinician type for prenatal care than for birth and to compare intrapartum experiences by continuity of clinician type.

METHODS

For this cross-sectional study, data were from the 2017 Listening to Mothers in California survey. The analytic sample was limited to individuals with vaginal births who had midwifery or obstetrician-gynecologist prenatal care (N = 1384). Bivariate and multivariate analysis examined characteristics of individuals by continuity of clinician type. We then examined associations of clinician type continuity with intrapartum care experiences.

RESULTS

Overall, 74.4% of individuals had the same type of clinician for prenatal care and birth. Of individuals with midwifery prenatal care, 45.1% had a different birth clinician type, whereas 23.5% of individuals who had obstetrician-gynecologist prenatal care had a different birth clinician type. Continuity of clinician type was positively associated with having had a choice of perinatal care clinician. There were no statistically significant associations between clinician type continuity and intrapartum care experiences.

DISCUSSION

Findings suggest individuals with midwifery prenatal care frequently have a different type of clinician attend their birth, even among those with vaginal births. Further research should examine the impact of multiple dimensions of continuity of care on perinatal care quality.