Evaluation of a public-private certified nurse-midwife maternity program for indigent women

Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review

BACKGROUND

Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences.

METHODS

Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care.

RESULTS

Forty six index studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms.

CONCLUSION

Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42020218357.

Competitive effects of scope of practice restrictions: Public health or public harm?

The demand for healthcare professionals is predicted to grow significantly over the next decade. Securing an adequate workforce is of primary importance to ensure the health and wellbeing of the population in an efficient manner. Occupational licensing laws and related restrictions on scope of practice (SOP) are features of the market for healthcare professionals and are also controversial. At issue is a balance between protecting the public health and removing anticompetitive barriers to entry and practice. In this paper, we examine the case of SOP restrictions for certified nurse midwives (CNMs) and evaluate the effects of changes in states' SOP laws on markets for CNMs and on maternal and infant outcomes. We find that SOP laws are neither helpful nor harmful in regards to health outcomes but states that have no SOP-based barriers have lower rates of induced labor and Cesarean section births. We discuss the implications for state policy.

Midwifery care at a freestanding birth center: a safe and effective alternative to conventional maternity care

OBJECTIVE

To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care.

DATA SOURCES/STUDY SETTING

Birth certificate data for women who gave birth in Washington D.C. and D.C. residents who gave birth in other jurisdictions.

STUDY DESIGN

Using propensity score modeling and instrumental variable analysis, we compare maternal and infant outcomes among women who receive prenatal care from birth center midwives and women who receive usual care. We match on observable characteristics available on the birth certificate, and we use distance to the birth center as an instrument.

DATA COLLECTION/EXTRACTION METHODS

Birth certificate data from 2005 to 2008.

PRINCIPAL FINDINGS

Women who receive birth center care are less likely to have a C-section, more likely to carry to term, and are more likely to deliver on a weekend, suggesting less intervention overall. While less consistent, findings also suggest improved infant outcomes.

CONCLUSIONS

For women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes.

The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review

BACKGROUND

Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated.

METHODS

We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)) RESULTS: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'.

CONCLUSIONS

There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

Midwifery Care of Poor and Vulnerable Women, 1925-2003

A systematic literature review of research on midwifery care of poor and vulnerable women from 1925 to 2003, which included topics studied, research methods used, and special issues and implications for future research, was performed; 44 studies published between 1955 and 2003 were identified. The majority were retrospective, descriptive studies. Outcomes examined included prenatal care visits, vaginal versus operative births, labor interventions, maternal and neonatal mortality and morbidity, birth weight, and cost-effectiveness. Studies showed that midwives predominantly serve vulnerable women who are young, poor, immigrants, or members of racial and ethnic minorities. Preterm birth prevention is emerging as a midwifery research focus. Health system changes are making it more difficult to provide effective care and counseling to disadvantaged women, especially in managed care settings. Extensive evidence documents excellent outcomes of midwifery care for the poor in urban and rural settings over the past three quarters of a century. Future research should include more intervention studies and use both qualitative and quantitative methods to investigate midwifery processes of care and the process-outcome connection. The research focus should broaden beyond childbirth to include gynecology, family planning, and primary care issues. Health disparities, cultural studies, obstetric interventions, and poor women's experiences of childbirth and midwifery care are important topics for future research.

The role of early newborn discharge legislation in influencing policy development: understanding the Kansas experience

Early newborn discharge legislation began a movement in health policy towards incremental changes in how medical consumers receive services. While well intentioned, these initiatives may undermine national efforts to address problems through more comprehensive reform, while stifling smaller efforts to address the problems locally. This paper discusses early newborn discharge legislation in Kansas: its origins, apparent impact, and implications. Findings from a hospital survey and two-year follow-up suggest a minimal effect of the legislation on health services in the state. Though acute hospital care appeared to replace home-based programs in many hospitals we spoke with, the more longstanding impact of the legislation seems to have been its precedent in how health policy is now made.

Midwifery care research: what questions are being asked? What lessons have been learned?

PURPOSE

To create and critically evaluate a research database about midwifery care that identifies topics studied, research methods, results, funding, publication data, and implications for a future midwifery research agenda.

METHODS

Systematic literature review. Studies included were 1) data-based research; 2) about midwifery care or practice; 3) in the United States; and 4) published between 1984-1998. The CINAHL and MEDLINE electronic databases were searched using a defined strategy, and relevant journals and bibliographies were searched by hand.

RESULTS

This 15-year review identified 140 studies of midwifery care published in 161 papers. A midwife was the lead author on 60%. Sixty percent were published in the Journal of Nurse-Midwifery. Six to 15 studies were published each year, and both the number of publications and funding increased over the time period. The six major areas of focus were: 1) midwifery management, 2) structure of care, 3) midwifery practice, 4) midwife-physician comparisons, 5) place of birth, and 6) care of vulnerable populations.

DISCUSSION

Although retrospective descriptive studies still predominate, more prospective studies, randomized controlled trials, multi-site studies, and quasi-experimental designs are being conducted. Qualitative methods are helping to measure nontraditional outcomes. A research agenda should be established based on discussion and debate within the profession. Midwife investigators need to build research teams and collaborate with other disciplines. Key areas for future research include alternative therapies, breastfeeding, cost-effectiveness, cultural studies, gynecology, health policy, menopause, postpartum care, substance abuse interventions, and the woman's experience of birth and midwifery care.