Introduction: Health care needs of pregnant women are met by a variety of clinicians in a changing policy and practice environment. This study documents recent trends in types of clinicians providing care to pregnant women in the United States.Methods: We used a repeat cross-sectional design and data from the Integrated Health Interview Series (2000-2009), a nationally representative data set, for respondents who reported being pregnant at the time of the survey (N = 3204). Using longitudinal logistic regression models, we analyzed changes over time in pregnant women's reported use of care from 1) obstetrician-gynecologists; 2) midwives, nurse practitioners (NPs), or physician assistants (PAs); or 3) both an obstetrician-gynecologist and a midwife, NP, or PA.Results: The percentage of pregnant women who reported seeing an obstetrician-gynecologist (87%) remained steady from 2000 through 2009. After controlling for demographic and clinical variables, the percentage who reported receiving care from a midwife, NP, or PA increased 4% annually (yearly adjusted odds ratio [AOR] 1.04; P < .001), indicating a cumulative increase of 48% over the decade. The percentage of pregnant women who received care from both an obstetrician-gynecologist and a midwife, NP, or PA also increased (AOR 1.027; P < .001), for a cumulative increase of 30%.Discussion: The increasing role of midwives, NPs, and PAs in the provision of maternity care suggests changes in the perinatal workforce and practice models that may promote collaborative care and quality improvement. However, better data collection is required to gather detailed information on specific provider types, these trends, and their implications.

Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jersey's policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.

OBJECTIVE: To evaluate the impact of switching from an HMO to a high-deductible health plan on the costs and utilization of maternity care. STUDY DESIGN: Pre-post design, with a control group. METHODS: We compared 229 women who delivered babies before or after their employers mandated a switch from HMO coverage to a high-deductible health plan, with a control group of 2180 matched women who delivered babies while their employers remained in an HMO plan. Administrative claims from a large Massachusetts-based health insurance program were used in a difference-in-differences regression analysis. RESULTS: Mean out-of-pocket maternity care costs for high-deductible group members increased from $356 for women who delivered before the insurance transition (n = 86) to $942 for women who delivered after the transition (n = 143), compared with a change from $262 (n = 711) to $282 (n = 1569) for HMO members, a relative increase of 106% (P <.001) for high-deductible members. Delivery after transition to a high-deductible plan was not associated with changes in the odds of receiving early prenatal care (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.32-3.19), recommended prenatal visits (OR, 1.64; 95% CI, 0.89-3.02), or postpartum care (OR, 0.74; 95% CI, 0.42-1.32). CONCLUSIONS: Switching from an HMO to a high-deductible plan with exemptions for routine care increased out-of-pocket member costs for maternity care, but had no apparent adverse impacts on receipt of recommended prenatal and postpartum care.

Introduction: Introduction: Racial and ethnic disparities in perinatal health outcomes are among the greatest threats to population health in the United States. Black birthing communities are most impacted by these inequities due to structural racism throughout society and within health care settings. Although multiple studies have shown that structural racism and the disrespect associated with this system of inequity are the root causes of observed perinatal inequities, little scholarship has centered the needs of Black birthing communities to create alternative care models. Leaning on reproductive justice and critical race theoretical frameworks, this study explores good birth experiences as described by Black birthing people. Methods: Methods: Thematic analysis of two focus groups and three one-on-one interviews conducted with clients at a Black-owned free-standing culturally-centered birth center (n=10). Results: Results: We found that Black birthing persons' concerns centered on three main themes: agency, historically-and culturally-safe birthing experiences, and relationship-centered care. Many participants pointed directly to past experiences of medical mistreatment and obstetric racism when defining their ideal birth experience. Conclusion: Conclusion: Black birthing people seeking care from culturally-informed providers often do so because they have been mistreated, disregarded, and neglected within traditional care settings. The needs articulated by our study participants provide a powerful framework for understanding alternative patient-centered models of care that can be developed to improve the care experiences of Black birthing people in the pursuit of birth equity.

<h2>Abstract</h2><h3>Objectives</h3><p>Between 1990 and 2013, maternal mortality nearly doubled in the United States and rural residents experienced decreasing access to obstetric care. To improve maternal health, many states have established maternal mortality and morbidity review committees (MMRCs). We assessed the extent of rural representation in state policy efforts related to MMRCs.</p><h3>Methods</h3><p>We reviewed publicly available information on MMRCs (websites, statutes, bills, media) in all 50 states and the District of Columbia, separately identifying highly rural states (with >30% of the population being rural residents). We assessed whether each state 1) had established an MMRC, 2) had passed legislation requiring an MMRC, 3) had considered, but not passed, legislation requiring an MMRC, 4) mentioned rural populations in MMRC legislation, 5) required representation on the MMRC from any particular groups, and 6) required rural representation on the MMRC.</p><h3>Results</h3><p>As of December 2018, MMRCs were established in 45 states and the District of Columbia, an increase from 23 in 2010. Legislation was in place in 27 states, up from 6 in 2010. Only three states specifically mentioned rurality in legislation (including one highly rural state), and only two states required rural representation among their MMRC members (neither of which were highly rural states).</p><h3>Conclusions</h3><p>Recent growth in MMRCs has had a limited focus on rural residents, despite their worse health outcomes and more limited access to health care, including obstetric services. Lack of rural representation may hamper geographically tailored efforts to reverse rising rates of maternal morbidity and mortality nationally.</p>