Using a Birth Center Model of Care to Improve Reproductive Outcomes in Informal Settlements-a Case Study

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.

Listening to Black Women's Perspectives of Birth Centers and Midwifery Care: Advocacy, Protection, and Empowerment

INTRODUCTION

Black women in Texas experience high rates of adverse maternal outcomes that have been linked to health inequities and structural racism in the maternal care system. Birth centers and midwifery care are highlighted in the literature as contributing to improved perinatal care experiences and decreased adverse outcomes for Black women. However, compared with White women, Black women underuse birth centers and midwifery care. Black women's perceptions in Texas of birth center and midwifery care are underrepresented in research. Thus, this study aimed to highlight the views of Black women residing in Texas on birth centers and midwifery care to identify their needs and explore ways to increasing access to perinatal care.

METHODS

Semistructured interviews were conducted with 10 pregnant and postpartum Black women residing in Texas. Questions focused on the women's access, knowledge, and use of birth centers and midwifery care in the context of their lived maternal care experiences. Interview transcripts were reviewed and analyzed using inductive, qualitative content analysis.

RESULTS

The Black women interviewed all shared experiences of discrimination and bias while receiving obstetric care that affected their interest in and overall perceptions of birth center and midwifery care. Participants also discussed financial and institutional barriers that impacted their ease of access to birth center and midwifery care services. Additionally, participants highlighted the need for culturally sensitive and respectful perinatal health care.

DISCUSSION

The Black women interviewed in this study emphasized the prevalence of racism and discrimination in perinatal health care encounters, a reflection consistent with current literature. Black women also expressed a desire to use birth centers and midwifery care but identified the barriers in Texas that impede access. Study findings highlight the need to address barriers to promote equitable perinatal health care access for Black women.

Exploring networks of care in implementing midwife-led birthing centres in low- and middle-income countries: A scoping review

The evidence for the benefits of midwifery has grown over the past two decades and midwife-led birthing centres have been established in many countries. Midwife-led care can only make a sustained and large-scale contribution to improved maternal and newborn health outcomes if it is an integral part of the health care system but there are challenges to the establishment and operation of midwife-led birthing centres. A network of care (NOC) is a way of understanding the connections within a catchment area or region to ensure that service provision is effective and efficient. This review aims to evaluate whether a NOC framework-in light of the literature about midwife-led birthing centres-can be used to map the challenges, barriers and enablers with a focus on low-to-middle income countries. We searched nine academic databases and located 40 relevant studies published between January 2012 and February 2022. Information about the enablers and challenges to midwife-led birthing centres was mapped and analysed against a NOC framework. The analysis was based on the four domains of the NOC: 1) agreement and enabling environment, 2) operational standards, 3) quality, efficiency, and responsibility, 4) learning and adaptation, which together are thought to reflect the characteristics of an effective NOC.Of the 40 studies, half (n = 20) were from Brazil and South Africa. The others covered an additional 10 countries. The analysis showed that midwife-led birthing centres can provide high-quality care when the following NOC elements are in place: a positive policy environment, purposeful arrangements which ensure services are responsive to users' needs, an effective referral system to enable collaboration across different levels of health service and a competent workforce committed to a midwifery philosophy of care. Challenges to an effective NOC include lack of supportive policies, leadership, inter-facility and interprofessional collaboration and insufficient financing. The NOC framework can be a useful approach to identify the key areas of collaboration required for effective consultation and referral, to address the specific local needs of women and their families and identify areas for improvement in health services. The NOC framework could be used in the design and implementation of new midwife-led birthing centres.

Which low- and middle-income countries have midwife-led birthing centres and what are the main characteristics of these centres? A scoping review and scoping survey

Evidence about the safety and benefits of midwife-led care during childbirth has led to midwife-led settings being recommended for women with uncomplicated pregnancies. However, most of the research on this topic comes from high-income countries. Relatively little is known about the availability and characteristics of midwife-led birthing centres in low- and middle-income countries (LMICs). This study aimed to identify which LMICs have midwife-led birthing centres, and their main characteristics. The study was conducted in two parts: a scoping review of peer-reviewed and grey literature, and a scoping survey of professional midwives' associations and United Nations Population Fund country offices. We used nine academic databases and the Google search engine, to locate literature describing birthing centres in LMICs in which midwives or nurse-midwives were the lead care providers. The review included 101 items published between January 2012 and February 2022. The survey consisted of a structured online questionnaire, and responses were received from 77 of the world's 137 low- and middle-income countries. We found at least one piece of evidence indicating that midwife-led birthing centres existed in 57 low- and middle-income countries. The evidence was relatively strong for 24 of these countries, i.e. there was evidence from at least two of the three types of source (peer-reviewed literature, grey literature, and survey). Only 14 of them featured in the peer-reviewed literature. Low- and lower-middle-income countries were more likely than upper-middle-income countries to have midwife-led birthing centres. The most common type of midwife-led birthing centre was freestanding. Public-sector midwife-led birthing centres were more common in middle-income than in low-income countries. Some were staffed entirely by midwives and some by a multidisciplinary team. We identified challenges to the midwifery philosophy of care and to effective referral systems. The peer-reviewed literature does not provide a comprehensive picture of the locations and characteristics of midwife-led birthing centres in low- and middle-income countries. Many of our findings echo those from high-income countries, but some appear to be specific to some or all low- and middle-income countries. The study highlights knowledge gaps, including a lack of evidence about the impact and costs of midwife-led birthing centres in low- and middle-income countries.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales)

BACKGROUND

In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+.

METHODS

We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff.

RESULTS

During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere.

CONCLUSION

The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.

[Good practices, interventions, and results: a comparative study between a birthing center and hospitals of the Brazilian Unified National Health System in the Southeastern Region, Brazil]

This study aims to compare obstetric care in a birthing center and in hospitals of the Brazilian Unified National Health System (SUS) considering good practices, interventions, and maternal and perinatal results in the Southeast Region of Brazil. A cross-sectional study was conducted with comparable retrospective data from two studies on labor and birth. A total of 1,515 puerperal women of usual risk of birthing centers and public hospitals in the Southeast region were included. Propensity score weighting was used to balance the groups according to the following covariates: age, skin-color, parity, membrane integrity, and cervix dilation at hospitalization. Logistic regressions were used to estimate odds ratios (OR) and 95% confidence intervals (95%CI) between the place of birth and outcomes. In birthing centers, compared to hospitals, the puerperal woman had a higher chance of having a companion (OR = 86.31; 95%CI: 29.65-251.29), eating or drinking (OR = 862.38; 95%CI: 120.20-6,187.33), walking around (OR = 7.56; 95%CI: 4.65-12.31), using non-pharmacological methods for pain relief (OR = 27.82; 95%CI: 17.05-45.40), being in an upright position (OR = 252.78; 95%CI: 150.60-423.33), and a lower chance of using oxytocin (OR = 0.22; 95%CI: 0.16-0.31), amniotomy (OR = 0.01; 95%CI: 0.01-0.04), episiotomy (OR = 0.01; 95%CI: 0.00-0.02), and Kristeller maneuvers (OR = 0.01; 95%CI: 0.00-0.02). Also, in birthing centers the newborn had a higher chance of exclusive breastfeeding (OR = 1.84; 95%CI: 1.16-2.90) and a lower chance of airway (OR = 0.24; 95%CI: 0.18-0.33) and gastric aspiration (OR = 0.15; 95%: 0.10-0.22). Thus, birthing centers offers a greater supply of good practices and fewer interventions in childbirth and birth care, with more safety and care without influence on the outcomes.

Making cesarean delivery SAFE in low- and middle-income countries

Cesarean birth (CB) rates are rising, globally. The global burden of CB is having a mixed effect on pregnancy outcomes and requires significant clinical and economic resources. The context of CB care in low- and middle-income countries is further complicated by barriers to facility-based care itself, followed by issues with quality and delivery of care in these resource-limited settings. The objective of this commentary is to propose an original, new, flexible, comprehensive care model for delivering SAFE cesarean delivery care in very low-resource settings. This model, the SAFEmodel for cesarean delivery care in low- and middle-income countries, developed by the authors, does not assume the current care model is working. It does not assume that even traditional hospital settings are what is needed to solve the problem of delivering high-quality, easily accessible CB care in the most remote and geographically isolated communities. The novel model promotes a decentralized care program that brings emergency obstetric care to women instead of the converse through four concepts: the care should be cloSe (community-based), it should be very dedicated to Action (transfer of care), it should be Focused on and highly specific to labor and delivery (cesarean birth center), and finally, it should be committed to high-quality care through iterative Evidence-based quality improvement programming and data collection.