"I had no choice": A mixed-methods study on access to care for vaginal breech birth.

INTRODUCTION: Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth. METHODS: We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care. RESULTS: Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system. CONCLUSION: Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Applying Lessons Learned from the COVID-19 Pandemic to Future Threats to the Perinatal Care System.

INTRODUCTION: Health care systems will continue to face unpredictable challenges related to climate change. The COVID-19 pandemic tested the ability of perinatal care systems to respond to extreme disruption. Many childbearing people in the United States opted out of the mainstream choice of hospital birth during the pandemic, leading to a 19.5% increase in community birth between 2019 and 2020. The aim of the study was to understand the experiences and priorities of childbearing people as they sought to preserve a safe and satisfying birth during the time of extreme health care disruption caused by the pandemic. METHODS: This exploratory qualitative study recruited participants from a sample of respondents to a national-scope web-based survey that explored experiences of pregnancy and birth during the COVID-19 pandemic. Maximal variation sampling was used to invite survey respondents who had considered a variety of birth setting, perinatal care provider, and care model options to participate in individual interviews. A conventional content analysis approach was used with coding categories derived directly from the transcribed interviews. RESULTS: Interviews were conducted with 18 individuals. Results were reported around 4 domains: (1) respect and autonomy in decision-making, (2) high-quality care, (3) safety, and (4) risk assessment and informed choice. Respect and autonomy varied by birth setting and perinatal care provider type. Quality of care and safety were described in relational and physical terms. Childbearing people prioritized alignment with their personal philosophies toward birth as they weighed safety. Although levels of stress and fear were elevated, many felt empowered by the sudden opportunity to consider new options. DISCUSSION: Disaster preparedness and health system strengthening should address the importance childbearing people place on the relational aspects of care, need for options in decision-making, timely and accurate information sharing, and opportunity for a range of safe and supported birth settings. Mechanisms are needed to build system-level changes that respond to the self-expressed needs and priorities of childbearing people.

Does the ARRIVE trial merit changing obstetric practice? Some reflections four-year postrelease.

BACKGROUND: It has been 4 years since the release of the study Labor Induction versus Expectant Management in Low-Risk Nulliparous Women, also known as the ARRIVE trial. As researchers and speakers who frequently present to the United States and international audiences about models of care and strategies to support normal physiologic labor and birth, we have had ample opportunity to engage with practitioners who consistently ask about our perspectives on the ARRIVE trial's findings and methods. Many note the marked increase in pressure they feel to induce at 39 weeks since the study's publication in 2018. METHODS: In this commentary, we discuss some of the concerns that have been brought up during these conversations. RESULTS/CONCLUSION: We focus on the trial's key findings and reflect on factors critical to consider as translation into clinical practice is negotiated.

Learning from women: Improving experiences of respectful maternity care during unplanned caesarean birth for women with diverse ethnicity and racial backgrounds.

PROBLEM: Women from diverse ethnicity and racial backgrounds have few opportunities to share birth experiences to inform improvements in care. BACKGROUND: Respectful maternity care is recognised as a global women's health priority. Integrating that framework into diverse care systems and models may help bridge care gaps for women who had unexpected birth experiences, including unplanned caesarean birth. AIM: To describe the experiences of women who had unplanned caesarean births and use knowledge gained to inform best practice recommendations that embody respectful maternity care. METHODS: Qualitative data were analysed from focus groups involving a convenience sample of 11 English speaking women, from diverse ethnic and racial backgrounds, with prior unplanned caesarean experience. Respectful maternity care was used as the lens for interpreting women's narratives using Thorne's interpretive description. The study site was an outpatient prenatal clinic within an urban academic, tertiary-care medical centre in the United States. FINDINGS: Two predominant, contrasting themes emerged: "not feeling well cared for" and "feeling well supported". Positive experiences included sources of support and strength from the midwifery practice, group prenatal care, and a doula program. Eight domains of respectful maternity care were applied to findings, highlighting current positive institutional practices and proposing areas for future quality improvement. CONCLUSION: Key practices promoting respectful maternity care include adequate communication and information sharing between pregnancy care providers and women, and a more robust informed consent process. Further emphasis on respectful maternity care is needed to support women to make shared decisions that best fit their circumstances and preferences.

"I was able to take it back": Seeking VBAC after experiencing dehumanizing maternity care in a primary cesarean.

In this article, we present findings from a qualitative narrative analysis that examined the pregnancy, primary cesarean, and subsequent birth experiences of women in the United States. Using a maximal variation sampling strategy, we recruited participants via social media and networking to participate in semistructured interviews. Twenty-five women from diverse backgrounds and geographic locations across the U.S. participated, eight self-identified as racialized and seventeen as non-Hispanic, White. Data were analyzed iteratively using Clandinin and Connelly's approach to Narrative Inquiry. Across their narratives, participants described their experiences of maternity care that were either generally negative (dehumanizing care) or positive (humanized care). They further described how their experiences of dehumanizing or humanized care impacted their decision-making for subsequent births, mental health, relationships with the healthcare system, early parenting birth satisfaction, and family planning. Findings suggest that regardless of ultimate mode of birth, what was most important to women was how they are treated by their maternity care team. We suggest practice changes that may improve the experience of maternity care for primary cesarean and subsequent births, especially among those made marginal by systems of oppression.

Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean.

OBJECTIVE: High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S. METHODS: Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother's Autonomy in Decision Making Scale; MADM). RESULTS: Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician. CONCLUSION: Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.

How to Foster Effective Midwife-Obstetrician Collaboration on Labor and Birth Units: Qualitative Analysis of Experiences of Clinicians in the United States.

INTRODUCTION: Effective collaboration between midwives and obstetricians on labor and birth units in hospitals has been shown to improve birth outcomes and quality of care. Guidelines for collaborative care in the United States exist; however, studies describing the actual lived experiences of midwives and obstetricians in collaborative practice are lacking. The goal of this study was to explore the experiences and perspectives of midwives and obstetricians working in collaborative practices on labor and birth units across the United States and to identify strategies that foster effective collaboration between them. METHODS: We performed qualitative analyses of open-ended comments obtained in an instrument validation survey assessing collaboration between midwives and obstetricians on labor and birth in the United States. Certified nurse-midwives, certified midwives, attending general obstetricians, maternal-fetal medicine attending physicians, and fellows across the United States were included in this study, herein called midwives and obstetricians. The final sample in the original validation survey included 232 midwives and 471 obstetricians (n = 703). Of these, 79 midwives and 132 obstetricians (n = 211) provided narrative comments on their perspectives and experiences with collaborative practice on labor and birth units in the United States. The narrative comments were analyzed using inductive techniques derived from grounded theory. RESULTS: Four themes around how to foster effective collaboration were identified: (1) developing trust and respect, (2) promoting effective communication, (3) individual variability and need for clear guidelines, and (4) balancing autonomy. The midwives and obstetricians shared lived experiences that they perceived affected their work satisfaction and clinical outcomes in collaborative practices. DISCUSSION: These findings hold potential to inform clinicians and health care leaders on ways to foster effective collaboration between midwives and obstetricians on labor and birth units. This in turn can improve quality of care for birthing persons, perinatal outcomes and clinician job satisfaction.

"Un abrazo a la distancia": An Exploration of Spanish-Speaking Women's Experiences with Pregnancy and Social Isolation in an Urban U.S. Setting.

Introduction: Research on Spanish-speaking Latina/Hispanic women's experiences during pregnancy is limited. Methods: We recruited women from urban, walk-in pregnancy testing clinics from June 2014 to June 2015. Women aged 16-44 years, at less than 24 weeks gestational age, who spoke either English or Spanish were eligible and completed an enrollment questionnaire and individual interview according to language preference. During qualitative interviews, we explored pregnancy intentions, initial reactions to a new pregnancy, and feelings about the impact of this pregnancy on relationships and daily life. Qualitative narrative content analysis was conducted using Atlas.ti software. Results: Among interviews with 31 Spanish-speaking Latina/Hispanic pregnant women, participants' average age was 28 years old with a mean gestational age of 7 weeks. We identified social isolation as the most common theme, characterized by four interwoven and overlapping subthemes: (1) sola-the experience of feeling alone; (2) familismo cercano-the importance of close relationships; (3) familismo lejano-overcoming long distance relationships; and (4) mi patria-preserving homeland cultural connectedness. Conclusions: Spanish-speaking Latina/Hispanic pregnant women described experiencing multiple aspects of social isolation. Language preference may suggest risk of social isolation, necessitating provider awareness and support initiatives to improve social support and lessen social isolation among newly pregnant, Spanish-speaking Latina women.

Reflections on obesity-related health behaviors over time and suggestions for health promotion programs from African American women.

African American (AA) women have the highest rate of obesity in the United States. To date, there are mixed findings on AA women's perception on obesity and their perceived changes in health behaviors over time that may have contributed to obesity. Therefore, the aims of this current qualitative descriptive study were to explore: 1) AA women's perception on obesity and perceived changes in health behaviors related to obesity through their reflection on life; 2) AA women's perceived facilitators and barriers to maintaining healthy behaviors; and 3) AA women's suggestions for future health promotion programs to manage obesity. Semi-structured interviews with ended questions were conducted with 21 AA women. Luborsky's method for thematic analysis was used to analyze data. Three main themes with subthemes were identified. First main theme was the AA culture that served as a facilitator and barrier to maintaining healthy lifestyle from childhood to young adulthood. Second main theme was gradual changes in their healthy lifestyle due to social and physical environment from young adulthood to middle adulthood. Third main theme was AA women's various suggestions for future health promotion programs. This study found obesity to be a multifactorial phenomenon that is a result of complex interaction of culture, environment, and social networks. Therefore, clinicians need to address the issue of obesity from a holistic perspective for AA women to actively engage with their primary health care. Future health promotion programs should incorporate culturally tailored lifestyle components and increase knowledge on healthy lifestyle against obesity through community-based programs.

Narrative Inquiry Into Nursing Care of Pregnant Women and Families in Specialized Fetal Diagnosis and Treatment Settings.

OBJECTIVE: To examine how nurses describe caring for women and families in specialized fetal diagnosis and treatment settings. DESIGN: We used narrative inquiry. SETTING: A secure online survey platform. PARTICIPANTS: We recruited 26 nurses from the Fetal Therapy Nurse Network as a subsample from a prior Delphi study on the essential structures, processes, outcomes, and challenges of nursing practice in the emerging field of fetal diagnosis and treatment. METHODS: We used narrative inquiry and Clandinin's three-dimensional space narrative analysis to interpret the stories provided by participants to illustrate their practice and the relationship between their practice and care quality and health outcomes. RESULTS: Participants described three primary types of fetal diagnoses and management scenarios: prenatal intervention (maternal-fetal surgery to treat a fetal anomaly), postnatal intervention (neonatal surgery), and perinatal palliative care (continuation of a pregnancy after a life-limiting fetal diagnosis). We identified three overarching themes related to nursing processes: A Sounding Board: Counseling the Pregnant Woman and Family, A Care Coordinator: Orchestrating a Complex Journey, and A Constant Presence: Being With the Pregnant Woman and Family. We also identified specific outcomes related to nursing care. CONCLUSION: We used narrative inquiry to expand on prior research and advance the conceptualization of a model of nursing practice in fetal diagnosis and treatment settings. Our results provide a basis to begin to test theories that connect nursing practice to care quality and outcomes in clinical practice settings. To comprehensively evaluate and enhance care as it evolves and expands, the immediate and long-term effects of nursing practice must be identified.

Experiences of Quality Perinatal Care During the US COVID-19 Pandemic.

INTRODUCTION: Quality perinatal care is recognized as an important birth process and outcome. During the coronavirus disease 2019 (COVID-19) pandemic, quality of perinatal care was compromised as the health care system grappled with adapting to an ever-changing, uncertain, and unprecedented public health crisis. METHODS: The aim of this study was to explore the quality of perinatal care received during the COVID-19 pandemic in the United States. Data were collected via an online questionnaire completed by people who gave birth in the United States after March 15, 2020. The questionnaire included the Mothers on Respect Index and the Mothers Autonomy in Decision Making validated measures. Low-quality perinatal care was defined as decreased respect and/or autonomy in the perinatal care received. Responses were geocoded by zip code to determine COVID-19 case-load in the county on the date of birth. Multivariate regression analyses described associations between respect and autonomy in decision-making for perinatal care and levels of COVID-19 outbreak across the United States. RESULTS: Participants (N = 707) from 46 states and the District of Columbia completed the questionnaire. As COVID-19 cases increased, participants' experiences of autonomy in decision-making for perinatal care decreased significantly (P = .04). Participants who identified as Black, Indigenous, and people of color, those who had an obstetrician provider, and those who gave birth in a hospital were more likely to experience low-quality perinatal care. Those with a midwife provider or who had a home birth were more likely to experience high-quality perinatal care in adjusted models. DISCUSSION: Variability in experiences of high-quality perinatal care by sociodemographic characteristics, birth setting, and provider type may relate to implicit bias, structural racism, and inequities in maternal health and COVID-19 outcomes for birthing people from marginalized communities.

"I had to fight for my VBAC": A mixed methods exploration of women's experiences of pregnancy and vaginal birth after cesarean in the United States.

BACKGROUND: Vaginal birth after cesarean (VBAC) is safe, cost-effective, and beneficial. Despite professional recommendations supporting VBAC and high success rates, VBAC rates in the United States (US) have remained below 15% since 2002. Very little has been written about access to VBAC in the United States from the perspectives of birthing people. We describe findings from a mixed methods study examining experiences seeking a VBAC in the United States. METHODS: Individuals with a history of cesarean and recent subsequent birth were recruited through social media groups. Using an online questionnaire, we collected sociodemographic and birth history information, qualitative accounts of participants' experiences, and scores on the Mothers on Respect Index, the Mothers Autonomy in Decision Making Scale, and the Generalized Self-Efficacy Scale. RESULTS: Participants (N = 1711) representing all 50 states completed the questionnaire; 1151 provided qualitative data. Participants who planned a VBAC reported significantly greater decision-making autonomy and respectful treatment in their maternity care compared with those who did not. The qualitative theme: "I had to fight for my VBAC" describes participants' accounts of navigating obstacles to VBAC, including finding a supportive provider and traveling long distances to locate a clinician and/or hospital willing to provide care. Participants cited support from providers, doulas, and peers as critical to their ability to acquire the requisite knowledge and power to effectively self-advocate. DISCUSSION: Findings highlight the difficulties individuals face accessing VBAC within the context of a complex health system and help to explain why rates of attempted VBAC remain low.

Does Perceived Quality of Care Moderate Postpartum Depression? A Secondary Analysis of a Two-Stage Survey.

OBJECTIVE: The purpose of this study was to examine if women's perceptions of the quality of hospital care during childbirth moderate their risks for symptoms of postpartum depression (PPD). METHODS: This cross-sectional secondary analysis analyzed data from the Listening to Mothers III (2013) series surveys with a weighted sample size of 1057 of women surveyed from across the United States. PPD symptoms were defined according the Patient Health Questionnaire-2. Associations between risk factors and PPD symptoms were tested using logistic regressions with the moderating variable of perceived quality of care then added to models with significant risk factors. RESULTS: Of the 22 potential risk factors for PPD symptoms, 10 were found to be significantly associated with PPD symptoms in this sample of women. Very good perceived quality of care moderated the following risk factors for PPD symptoms in a protective direction: relationship status (p = 0.01), pre-pregnancy BMI (p = 0.02), and pain that interfered with routine activities 2 months postpartum (p = 0.003). CONCLUSIONS: These findings suggest risk factors for PPD symptoms are moderated by perceived quality of care and therefore, maternity providers can influence women's psychological wellbeing postpartum by providing very good perceived quality of care during the hospital stay for birth. However, these findings should be interpreted cautiously due to a lack of a direct, proven relationship between provider action and women's perceived quality of care.

Modified Delphi Study on Nursing Practice and Science in Fetal Care.

OBJECTIVE: To identify essential structures, processes, outcomes, and challenges of nursing practice in fetal care and to identify research priorities for nurses in fetal care. DESIGN: We used a modified Delphi method to achieve consensus. SETTING: A secure online survey platform. PARTICIPANTS: The expert panel included nurses from the Fetal Therapy Nurse Network. In addition, a multidisciplinary research jury included members of the North American Fetal Therapy Network (NAFTNet). METHODS: We collected data in three consecutive rounds with online questionnaires that were e-mailed to panelists. We used content analysis to generate statements from an initial round of open-ended questions. Statements met consensus if 75% of the panelists ranked it as greater than or equal to 6 on a 1-to-7 Likert scale. RESULTS: The 48 nurse panelists and 11 multidisciplinary jury members described a range of nursing processes. Consensus was reached on 96 statements related to the structure, processes, outcomes, and research priorities of nurses in fetal care. CONCLUSION: The participants agreed that an expert fetal care nursing team is necessary to provide care to women and families during fetal diagnosis and treatment. Ideally, these nurses should coordinate care and provide direct clinical care (e.g., patient counseling) in outpatient prenatal settings and inpatient settings when fetal surgery is involved. Nurses should be supported to take on leadership roles in program development, research, quality improvement, and professional development with relevant professional organizations.

Demographic, Socioeconomic, Health Systems, and Geographic Factors Associated with Vaginal Birth After Cesarean: An Analysis of 2017 U.S. Birth Certificate Data.

OBJECTIVES: In order to better understand the current rates of vaginal birth after cesarean (VBAC) in the United States, 2017 U.S. birth certificate data were used to examine sociodemographic and geographic factors associated with the outcome of a VBAC. METHODS: The 2017 Natality Limited Geography Dataset and block sequential logistic regression were used to examine sociodemographic and geographic factors associated with subsequent births in 2017 in the United States to women with a history of 1 or 2 cesareans (N = 540,711). RESULTS: The adjusted odds of VBAC were 6% higher for Black women (1.06; 95% CI: 1.04, 1.08) and 18% higher for American Indian/Alaska Native women (aOR 1.18; 95% CI: 1.10, 1.27) relative to white women. Asian/Pacific Islander women were 9% less likely to have a VBAC (aOR 0.91; 95% CI: 0.88, 0.94) than similar white women with a history of cesarean delivery. Latina women had a 10% less likelihood of a VBAC (aOR 0.90; 95% CI: 0.88, 0.92) when compared with non-Latina women. Women with a high school education (aOR 0.85; 95% CI: 0.83, 0.88) or some college (aOR 0.85; 95% CI: 0.84, 0.87) were less likely to have a VBAC than women educated at a baccalaureate level or higher. Women whose births were paid for by Medicaid had a 5% increased likelihood of VBAC over women with private insurance (aOR 1.05, 95% CI: 1.03, 1.07). Women who self-pay have twice the likelihood of VBAC (aOR 1.99; 95% CI: 1.92, 2.07) compared to women with private insurance. The adjusted odds of VBAC were lowest for women giving birth in Southern states (aOR 0.72; 95% CI: 0.71, 0.74) and highest for women giving birth in the Midwest (aOR 1.19; 95% CI: 1.16, 1.22) relative to women in the Northeastern U.S. Thirteen percent (13%) of women who had a VBAC had a certified nurse-midwife (CNM) birth attendant, which is 44% higher than the national CNM-attended birth rate. CONCLUSIONS FOR PRACTICE: Significant variation exists in VBAC rates based on a number of sociodemographic and geographic factors, likely reflecting disparities in access to vaginal birth after cesarean and differences in preference regarding mode of birth after cesarean. Further research is recommended to better understand and address these disparities to improve maternity care.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries.

BACKGROUND: The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States. METHOD: We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system. RESULTS: The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems. CONCLUSIONS: The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

Women's Perceptions of Barriers and Facilitators to Vaginal Birth After Cesarean in the United States: An Integrative Review.

INTRODUCTION: The purpose of this integrative review was to synthesize the literature on women's perceived barriers and facilitators to achieving a vaginal birth after cesarean. METHODS: A search of Scopus and PubMed databases and relevant citations from 2000 to 2018 was conducted to identify resources meeting inclusion criteria. Conclusion drawing and verification were completed using data displays, data analysis, and comparison. RESULTS: Sixteen resources met inclusion criteria. Factors identified by women with a history of cesarean that act as facilitators or barriers to achieving a vaginal birth after cesarean included (1) individual factors (knowledge, body, and psychological), (2) social factors (culture and social support), and (3) systemic factors (perinatal care provider, health system, and financial). Some factors related to barriers and facilitators reflected opposing aspects of the same phenomenon on a continuum. DISCUSSION: Enhancing facilitators identified by women, while addressing perceived barriers, may increase access to labor after cesarean for women in the United States. Increasing access to labor after cesarean may subsequently improve women's experiences of care and decrease the US cesarean rate, positively affecting individual health outcomes and overall health of childbearing women in the United States.