<p>Background A recent document by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine introduced the concept of uniform levels of maternal care (LMCs).</p>

A mother's death in the 1950s tears a family apart; sixty years later, maternal mortality is on the rise again.

OBJECTIVE To evaluate whether busy days on a labour and delivery unit are associated with maternal and neonatal complications of childbirth in California hospitals, accounting for weekday/weekend births. DESIGN This is a population-based retrospective cohort study. SETTING Linked vital statistics/patient discharge data for California births between 2009 and 2010 from the Office of Statewide Health Planning and Development. PARTICIPANTS All singleton, cephalic, non-anomalous California births between 2009 and 2010 (N=724 967). MAIN OUTCOMES The key exposure was high daily obstetric volume, defined as giving birth on a day when the number of births exceeded the hospital-specific 75th percentile of daily delivery volume. Outcomes were a range of maternal and neonatal complications. RESULTS Several maternal and neonatal complications were increased on high-volume days and weekends following adjustment for maternal demographics, annual hospital birth volume and teaching hospital status. For example, compared with low-volume weekdays, the odds of Apgar <7 on low-volume weekend days and high-volume weekend days were 11% (adjusted OR (aOR) 1.11, CI 1.03 to 1.21) and 29% higher (aOR 1.29, CI 1.10 to 1.52), respectively. High volume was associated with increased odds of neonatal seizures on weekdays (aOR 1.33, CI 1.01 to 1.71) and haemorrhage on weekends (aOR 1.11, CI 1.01 to 1.22). After accounting for between-hospital variation, weekend delivery remained significantly associated with increased odds of Apgar score <7, neonatal intensive care unit admission, prolonged maternal length of stay and the odds of neonatal seizures remained increased on high-volume weekdays. CONCLUSIONS Our findings suggest that weekend delivery is a consistent risk factor for a range of perinatal complications and there may be variability in how well hospitals handle surges in volume.

The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.

OBJECTIVES Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status. METHODS Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms. RESULTS Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured. CONCLUSIONS There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth.

BACKGROUND The gap between publishing and implementing guidelines differs based on practice setting, including hospital geography and teaching status. On March 31, 2006, a Practice Bulletin published by the American College of Obstetricians and Gynecologists (ACOG) recommended against the routine use of episiotomy and urged clinicians to make judicious decisions to restrict the use of the procedure. OBJECTIVE This study investigated changes in trends of episiotomy use before and after the ACOG Practice Guideline was issued in 2006, focusing on differences by hospital geographic location (rural/urban) and teaching status. METHODS In a retrospective analysis of discharge data from the Nationwide Inpatient Sample (NIS)-a 20% sample of US hospitals-5,779,781 hospital-based births from 2002 to 2011 (weighted N = 28,067,939) were analyzed using multivariable logistic regression analysis to measure odds of episiotomy and trends in episiotomy use in vaginal deliveries. RESULTS The overall episiotomy rate decreased from 20.3% in 2002 to 9.4% in 2011. Across all settings, a comparatively larger decline in episiotomy rates preceded the issuance of the ACOG Practice Guideline (34.0% decline), rather than following it (23.9% decline). The episiotomy rate discrepancies between rural, urban teaching, and urban nonteaching hospitals remained steady prior to the guideline's release; however, differences between urban nonteaching and urban teaching hospitals narrowed between 2007 and 2011 after the guideline was issued. CONCLUSION Teaching status was a strong predictor of odds of episiotomy, with urban nonteaching hospitals having the highest rates of noncompliance with evidence-based practice. Issuance of clinical guidelines precipitated a narrowing of this discrepancy.

Many hospitals are adopting quality improvement strategies in obstetrics. This study characterized rural U.S. hospitals based on their hospital staffing and clinical management policies for labor induction and cesarean delivery, and assessed the relationship between policies and performance on maternity care quality. We surveyed all 306 rural maternity hospitals in nine states and used data from the Healthcare Cost and Utilization Project Statewide Inpatient Database hospital discharge database. We found staffing policies were more prevalent at lower-volume hospitals (92% vs. 86% for cesarean and 82% vs. 79%, both p &lt; .01). Using multivariable logistic regression, we found hospitals with policies for cesarean delivery had up to 24% lower odds of low-risk cesarean (adjusted odds ratio = 0.76; 95% confidence interval=[0.67-0.86]) and non-indicated cesarean (0.78 [0.70-0.88]), with variability across birth volume. Clinical management and staffing policies are common, but not universal, among rural U.S. hospitals providing obstetric services and are generally positively associated with quality.

Structural racism leads to increased rates of premature death and reduced levels of overall health and well-being — an epidemic affecting our whole society. As clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism.

Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals. Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection. Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56-2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26-1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80-0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13-1.53). Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.

In summer 2015, the Iowa Supreme Court unanimously struck down a restriction that would have prevented physicians from administering a medication abortion remotely through video teleconferencing. In its ruling, the Iowa Supreme Court stated that the restriction would have placed an undue burden on a woman's right to access abortion services. It is crucially important for clinicians--especially primary care clinicians, obstetrician-gynecologists (ob-gyns), and all health care providers of telemedicine services--to understand the implications of this recent ruling, especially in rural settings. The Court's decision has potential ramifications across the country, for both women's access to abortion and the field of telemedicine. Today telemedicine abortion is available only in Iowa and Minnesota; 18 states have adopted bans on it. If telemedicine abortions are indeed being unconstitutionally restricted as the Iowa Supreme Court determined, court decisions reversing these bans could improve access to abortion services for the 21 million reproductive-age women living in these 18 states, which have a limited supply of ob-gyns, mostly concentrated in urban, metropolitan areas. Beyond the potential effects on abortion access, we argue that the Court's decision also has broader implications for telemedicine, by limiting the role of state boards of medicine regarding the restriction of politically controversial medical services when provided through telemedicine. The interplay between telemedicine policy, abortion politics, and the science of medicine is at the heart of the Court's decision and has meaning beyond Iowa's borders for reproductive-age women across the United States.

INTRODUCTION The imperative to diversify the health care workforce is evident: increased diversity contributes to the overall health of the nation. Given persistent racial and ethnic disparities in birth outcomes, workforce diversity is particularly urgent in the context of clinical and supportive care during pregnancy and childbirth. The goal of this analysis was to characterize the intentions and motivations of racially and ethnically diverse women who chose to become doulas (maternal support professionals) and to describe their early doula careers, including the experiences that sustain their work. METHODS In 2014, 12 women of color in the Minneapolis, Minnesota, metropolitan area (eg, African American, Somali, Hmong, Latina, American Indian) applied and were selected (from a pool of 58) to receive doula training and certification. In January and February 2015, we conducted semistructured interviews (30 to 90 minutes) with the newly trained doulas. We used an inductive qualitative approach to analyze key themes related to motivation and satisfaction with doula work. RESULTS For many of the women of color we interviewed, the underlying motivation for becoming a doula was related directly to a desire to support women from the doula's own racial, ethnic, and cultural community. Other key themes related to both motivation and satisfaction included perceiving birth work as a calling, easing women's transitions to motherhood by "holding space," honoring the ritual and ceremony of childbirth, and providing culturally competent support, often as the sole source of cultural knowledge during labor and birth. DISCUSSION Doulas of color have a strong commitment to supporting women from their communities. Given the evidence linking doula support to improved birth outcomes, successful recruitment and retention of women of color as doulas may support broader efforts to reduce long-standing disparities in birth outcomes.

PURPOSE The goal of this study was to assess perspectives of racially/ethnically diverse, low-income pregnant women on how doula services (nonmedical maternal support) may influence the outcomes of pregnancy and childbirth. METHODS We conducted 4 in-depth focus group discussions with low-income pregnant women. We used a selective coding scheme based on 5 themes (agency, personal security, connectedness, respect, and knowledge) identified in the Good Birth framework, and we analyzed salient themes in the context of the Gelberg-Anderson behavioral model and the social determinants of health. RESULTS Participants identified the role doulas played in mitigating the effects of social determinants. The 5 themes of the Good Birth framework characterized the means by which nonmedical support from doulas influenced the pathways between social determinants of health and birth outcomes. By addressing health literacy and social support needs, pregnant women noted that doulas affect access to and the quality of health care services received during pregnancy and birth. CONCLUSIONS Access to doula services for pregnant women who are at risk of poor birth outcomes may help to disrupt the pervasive influence of social determinants as predisposing factors for health during pregnancy and childbirth.

BACKGROUND One in nine US infants is born before 37 weeks' gestation, incurring medical costs 10 times higher than full-term infants. One in three infants is born by cesarean; cesarean births cost twice as much as vaginal births. We compared rates of preterm and cesarean birth among Medicaid recipients with prenatal access to doula care (nonmedical maternal support) with similar women regionally. We used data on this association to mathematically model the potential cost-effectiveness of Medicaid coverage of doula services. METHODS Data came from two sources: all Medicaid-funded, singleton births at hospitals in the West North Central and East North Central US (n = 65,147) in the 2012 Nationwide Inpatient Sample, and all Medicaid-funded singleton births (n = 1,935) supported by a community-based doula organization in the Upper Midwest from 2010 to 2014. We analyzed routinely collected, de-identified administrative data. Multivariable regression analysis was used to estimate associations between doula care and outcomes. A probabilistic decision-analytic model was used for cost-effectiveness estimates. RESULTS Women who received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries regionally (4.7 vs 6.3%, and 20.4 vs 34.2%). After adjustment for covariates, women with doula care had 22 percent lower odds of preterm birth (AOR 0.77 [95% CI 0.61-0.96]). Cost-effectiveness analyses indicate potential savings associated with doula support reimbursed at an average of $986 (ranging from $929 to $1,047 across states). CONCLUSIONS Based on associations between doula care and preterm and cesarean birth, coverage reimbursement for doula services would likely be cost saving or cost-effective for state Medicaid programs.