Pregnancy experiences of transgender and gender-expansive individuals: A systematic scoping review from a critical midwifery perspective.

BACKGROUND: Evidence suggests that transgender and gender-expansive people are more likely to have suboptimal pregnancy outcomes compared with cisgender people. The aim of this study was to gain a deeper understanding of the role of midwifery in these inequities by analyzing the pregnancy experiences of transgender and gender-expansive people from a critical midwifery perspective. METHODS: We conducted a systematic scoping review. We included 15 papers published since 2010 that reported on pregnancy experiences of people who had experienced gestational pregnancy at least once, and were transgender, nonbinary, or had other gender-expansive identities. RESULTS: Three themes emerged from our analysis: "Navigating identity during pregnancy," "Experiences with mental health and wellbeing," and "Encounters in the maternal and newborn care system." Although across studies respondents reported positive experiences, both within healthcare and social settings, access to gender-affirmative (midwifery) care and daily social realities were often shaped by trans-negativity and transphobia. DISCUSSION: To improve care outcomes of transgender and gender-expansive people, it is necessary to counter anti-trans ideologies by "fixing the knowledge" of midwifery curricula. This requires challenging dominant cultural norms and images around pregnancy, reconsidering the way in which the relationship among "sex," "gender," and "pregnancy" is understood and given meaning to in midwifery, and applying an intersectional lens to investigate the relationship between gender inequality and reproductive inequity of people with multiple, intersecting marginalized identities who may experience the accumulated impacts of racism, ageism, and classism. Future research should identify pedagogical frameworks that are suitable for guiding implementation efforts.

Elements of organisation of integrated maternity care and their associations with outcomes: a scoping review protocol.

INTRODUCTION: Integrated care is seen as an enabling strategy in organising healthcare to improve quality, finances, personnel and sustainability. Developments in the organisation of maternity care follow this trend. The way care is organised should support the general aims and outcomes of healthcare systems. Organisation itself consists of a variety of smaller 'elements of organisation'. Various elements of organisation are implemented in different organisations and networks. We will examine which elements of integrated maternity care are associated with maternal and neonatal health outcomes, experiences of women and professionals, healthcare spending and care processes. METHODS AND ANALYSIS: We will conduct this review using the JBI methodology for scoping reviews and the reporting guideline PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews). We will undertake a systematic search in the databases PubMed, Scopus, Cochrane and PsycINFO. A machine learning tool, ASReview, will be used to select relevant papers. These papers will be analysed and classified thematically using the framework of the Rainbow Model of Integrated Care (RMIC). The Population Concept Context framework for scoping reviews will be used in which 'Population' is defined as elements of the organisation of integrated maternity care, 'Context' as high-income countries and 'Concepts' as outcomes stated in the objective of this review. We will include papers from 2012 onwards, in Dutch or English language, which describe both 'how the care is organised' (elements) and 'outcomes'. ETHICS AND DISSEMINATION: Since this is a scoping review of previously published summary data, ethical approval for this study is not needed. Findings will be published in a peer-reviewed international journal, discussed in a webinar and presented at (inter)national conferences and meetings of professional associations.The findings of this scoping review will give insight into the nature and effectiveness of elements of integrated care and will generate hypotheses for further research.

(Un)warranted variation in local hospital protocols for neonatal referral to the pediatrician: An explorative study in the Netherlands.

BACKGROUND: Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium-stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth. METHODS: We conducted a nationwide cross-sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments. RESULTS: There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines. CONCLUSIONS: To reduce unwarranted variation in local protocols, evidence-based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence-based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care.

Maternal characteristics as indications for routine induction of labor: A nationwide retrospective cohort study.

BACKGROUND: Maternal characteristics, such as parity and age, are increasingly considered indications for routine induction of labor of otherwise healthy women to prevent fetal and neonatal mortality. To fully balance the risks and benefits of induction of labor, we examined the association of additional relevant maternal characteristics and gestational age with fetal and neonatal mortality. METHODS: We conducted a nationwide retrospective cohort study among a healthy Dutch population consisting of all singleton pregnancies in midwife-led care after 37 weeks of gestation in the period 2000-2018. We examined the association of maternal ethnicity, age, parity, and socioeconomic status with fetal and neonatal mortality, stratified by gestational age. The association of single characteristics was examined using descriptive statistics, and univariable and multivariable logistics regression analyses. The associations of multiple characteristics were examined using inter-categorical analyses and using interaction terms in the multivariable logistic regression analyses. RESULTS: The results showed that ethnicity, age, parity, socioeconomic status, and gestational age did not act as single determinant of fetal and neonatal mortality. The probability of fetal and neonatal mortality differed among subgroups of women depending on which determinants were considered and the number of determinants included. CONCLUSIONS: Decision-making about induction of labor to prevent fetal and neonatal mortality based on a single determinant may lead to overuse or underuse of IOL. A value-based health care strategy, addressing social inequity, and investing in better screening and diagnostic methods that employ an individualized and multi-determinant approach may be more effective at preventing fetal and neonatal mortality.

Models of Risk Selection in Maternal and Newborn Care: Exploring the Organization of Tasks and Responsibilities of Primary Care Midwives and Obstetricians in Risk Selection across The Netherlands.

An effective system of risk selection is a global necessity to ensure women and children receive appropriate care at the right time and at the right place. To gain more insight into the existing models of risk selection (MRS), we explored the distribution of different MRS across regions in The Netherlands, and examined the relation between MRS and primary care midwives' and obstetricians' satisfaction with different MRS. We conducted a nationwide survey amongst all primary midwifery care practices and obstetrics departments. The questionnaire was completed by 312 (55%) primary midwifery care practices and 53 (72%) obstetrics departments. We identified three MRS, which were distributed differently across regions: (1) primary care midwives assess risk and initiate a consultation or transfer of care without discussing this first with the obstetrician, (2) primary care midwives assess risk and make decisions about consultation or transfer of care collaboratively with obstetricians, and (3) models with other characteristics. Across these MRS, variations exist in several aspects, including the routine involvement of the obstetrician in the care of healthy pregnant women. We found no significant difference between MRS and professionals' level of satisfaction. An evidence- and value-based approach is recommended in the pursuit of the optimal organization of risk selection. This requires further research into associations between MRS and maternal and perinatal outcomes, professional payment methods, resource allocation, and the experiences of women and care professionals.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review.

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Which level of risk justifies routine induction of labor for healthy women?

Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (and their offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or even uncertain. Characteristics such as an advanced maternal age, a non-native ethnicity, a high Body Mass Index, an artificially assisted conception, and even nulliparity are increasingly considered an indication for induction of labor. Because induction of labor has many disadvantages, a debate is urgently needed on which level of risk justifies routine induction of labor for healthy women, only based on characteristics that are associated with statistically significant small absolute risk differences, compared to others without these characteristics. This commentary contributes to this debate by arguing why induction of labour should not routinely be offered to all women where there is a small increase in absolute risk, and no any other medical risks or complications during pregnancy. To underpin our statement, national data from the Netherlands were used reporting stillbirth rates in groups of women based on their characteristics, for each gestational week from 37 weeks of gestation onwards.