Midwifery Practice Leaders' Experiences of Practice Changes Early in the COVID-19 Pandemic: A Qualitative Exploration

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic generated considerable upheaval in all sectors of the US health care system, including maternity care. We focused this inquiry on midwifery practice leaders' experiences and perspectives on changes that occurred in their practices early in the pandemic.

METHODS

This was a qualitative descriptive study using thematic analysis. The data were responses to an open-ended question in a survey of pandemic-related employment and clinical practice changes. Findings are presented from a constructivist perspective, describing the experiences and perspectives of a group of US midwifery practice leaders during the initial phase of the COVID-19 pandemic.

RESULTS

Two main themes emerged from the analysis: demands on midwives and driving forces. Demands on midwives were 3-fold: clients' needs, modification of care, and midwives' needs. These encompassed the psychological, physical, and emotional toll that caring for women during the pandemic placed on midwives. Driving forces were those entities that spurred and directed change and included regulations, institutions, financial logistics, and team dynamics. Survey respondents in community (home and birth center) practices reported substantial increases in inquiries and client volume, and many respondents expressed concern about withdrawal of students from clinical placements.

DISCUSSION

Midwifery practices experienced profound changes in their work environments during the COVID-19 pandemic, with both positive and negative characteristics. These challenges in providing birth care were similar to those reported in other countries. Results indicated existing guidance for maternity care during emergencies did not meet clients' needs. Coordinated planning for maternity care in future prolonged health emergencies should incorporate best practices and include midwives in the process.

[Impact of hospital architecture on the birthing experience: a phenomenological study with mothers-to-be who are design experts]

BACKGROUND

The birthplace has a crucial role in shaping the childbirth experience and mothers' satisfaction levels. This study aimed to identify the experiences and perceptions that may have an impact in the long-term on mothers' birthing experience, considering hospital design features in the birthing environment until discharge.

METHODS

Inductive thematic analysis of twenty-five hospital labor testimonies employing a phenomenological research approach and utilizing a biographical method. Participants were women with a professional background in architecture, landscape architecture, engineering, or interior design.

RESULTS

The results are organized into four themes and seven subthemes. The first theme is "First sight and long term impression" which is subdivided into the subthemes "Depersonalized itinerary in entrances and corridors" and "Instinctive search for connection with nature". The second theme deals with "Accompaniment and tucking in during the birthing process", subdivided into "Hotel-like: space for movement and personalized adaptation" and "Helplessness, cold and uncertainty: spaces to be against one's will". The third theme is "Damage in collateral rooms", which includes "The integration of toilets in the birthing process", "Operating rooms unchangeable in the face of cesarean delivery" and "Neonatal units that do not integrate families". Finally, the fourth theme includes "Improvement proposals for new designs".

CONCLUSIONS

This study contributes to the existing literature by deepening the understanding of the design features identified in hospitals in recent studies. Further research incorporating the experiences of women in the birthing process is needed to facilitate evidence-based design policies.

Birth setting decisions during COVID-19: A comparative qualitative study

BACKGROUND

The COVID-19 pandemic resulted in an increased number of out-of-hospital births in the United States and other nations. While many studies have sought to understand the experiences of pregnant and birthing people during this time, few have compared experiences across birth locations.

OBJECTIVE

The purpose of this study is to compare the narratives and decision-making processes of those who gave birth in and out of hospitals during the pandemic.

DESIGN

We conducted semi-structured narrative interviews with 24 women who gave birth during the COVID-19 pandemic.

METHODS

Interviews were transcribed and coded, and a thematic narrative analysis was employed. Final themes and exemplary quotes were determined in discussion among the research team.

RESULTS

Results from narrative analysis revealed three themes that played into participants' birth location decisions: (1) birth efficacy and values, (2) diverse definitions of safety, and (3) childcare and other logistics. In each of these themes, participants who gave birth in birthing centers, at the hospital, and at home describe their individualized approach to achieving a supportive birth environment while mitigating the risk of labor complications and COVID-19 infection.

CONCLUSION

Our study suggests that for some childbearing people, the pandemic did not change birthing values or decisions but rather brought enhanced clarity to their individual needs during birth and perceived risks, benefits, and limitations of each birthing space. This study further highlights the need for improved structural support for birthing people to access a range of safe and supportive birthing environments.

Factors influencing birth setting decision making in the United States: An integrative review

BACKGROUND

The United States has the highest perinatal morbidity and mortality (M&M) rates among all high-resource countries in the world. Birth settings (birth center, home, or hospital) influence clinical outcomes, experience of care, and health care costs. Increasing use of low-intervention birth settings can reduce perinatal M&M. This integrative review evaluated factors influencing birth setting decision making among women and birthing people in the United States.

METHODS

A search strategy was implemented within the CINAHL, PubMed, PsycInfo, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. The Whittemore and Knafl integrative review framework informed the extraction and analysis of the data and generation of findings.

RESULTS

We identified 23 articles that met inclusion criteria. Four analytical themes were generated that described factors that influence birth setting decision making in the United States: "Birth Setting Safety vs. Risk," "Influence of Media, Family, and Friends on Birth Setting Awareness," "Presence or Absence of Choice and Control," and "Access to Options."

DISCUSSION

Supporting women and birthing people to make informed decisions by providing information about birth setting options and variations in models of care by birth setting is a critical patient-centered strategy to ensure equitable access to low-intervention birth settings. Policies that expand affordable health insurance to cover midwifery care in all birth settings are needed to enable people to make informed choices about birth location that align with their values, individual pregnancy characteristics, and preferences.

Choosing a Birth Setting: A Shared Decision-Making Approach

Perinatal outcomes vary widely depending on individual birth settings (birth center, home, and hospital). The purpose of this case study is to explore a patient-centered, shared decision-making approach to achieve an informed, values-based choice about birth settings. Engaging in a shared decision-making approach regarding birth setting options would support people to have the information and ability to judge for themselves how benefits and risks across birth center, home, and hospital settings would best fit with their values and personal health. A patient decision aid about birth setting options could facilitate increased equity regarding access to birth settings that offer improved perinatal health outcomes, helping to reduce perinatal health disparities in the United States.

Women's reasons and motivations around planning a home birth with a qualified midwife in Spain

AIMS

The aim of this study was to describe and understand the reasons and motivations that lead a woman to choose home birth in Spain.

DESIGN

A qualitative study based on Gadamer's hermeneutic phenomenology was carried out.

METHODS

In-depth interviews were conducted with 24 women who had planned a home birth in the last year. The recruitment phase was carried out over a 3-week period during the month of March 2021. Inductive analysis was used to find themes based on the data obtained.

RESULTS

Four main themes emerged from the data analysis: (1) Women's home birth decision making, (2) Partner as the main support, (3) Need to prepare for childbirth and (4) Reasons for choosing home birth.

CONCLUSION

The women in this study spent a lot of time and dedication to choose the place where they would give birth. According to this research, decision making is influenced by multiple factors, both positive and negative, such as women's individual beliefs and values. The main reasons why women chose a home birth were the intimacy and security of the home, the accompaniment and the desire for a natural and free birth.

IMPACT

This study adds knowledge about the factors that influence the decision of women who choose home birth in Spain and the reasons and motivations that lead them to do so. In addition, it raises new questions about the satisfaction of women giving birth in the hospital as well as outside the hospital, and the quality of service provided by health professionals in the current Spanish public maternity system.

Factors Associated With Normal Physiologic Birth for Women Who Labor In Water: A Secondary Analysis of A Prospective Observational Study

Introduction

Research to understand factors associated with normal physiologic birth (unassisted vaginal birth, spontaneous labor onset without epidural analgesia, spinal, or general anesthetic, without episiotomy) is required. Laboring and/or giving birth in water has been shown to be associated with a high proportion of physiologic birth but with little understanding of factors that may influence this outcome. This study explored factors associated with normal physiologic birth for women who labored in water.

Methods

We conducted a secondary analysis of a UK‐based prospective observational study of 8064 women at low risk of childbirth complications who labored in water. Consecutive women were recruited from birth settings in England, Scotland, and Northern Ireland. Planned place of birth, maternal characteristics, intrapartum events, and maternal and neonatal outcomes were measured. Univariable and multivariable logistic regression modelling explored factors associated with normal physiologic birth.

Results

In total, 5758 (71.4%) of women who labored in water had a normal physiologic birth. Planned birth in the community (adjusted odds ratio [aOR], 2.58; 95% CI, 2.22‐2.99) or at an alongside midwifery unit (aOR, 1.21; 95% CI, 1.04‐1.41) was positively associated with normal physiologic birth compared with planned birth in an obstetric unit. Duration of second stage (aOR, 0.66; 95% CI, 0.62‐0.70), duration in the pool [aOR, 0.93; 95% CI, 0.90‐0.96), and birth weight of the neonate (aOR, 0.74; 95% CI, 0.65‐0.85) were negatively associated with normal physiologic birth. Parity was not associated with normal physiologic birth in multivariate analyses.

Discussion

Our findings largely reflected wider research, both in and out of water. We found midwifery‐led birth settings may increase the likelihood of normal physiologic birth among healthy women who labor in water, irrespective of parity. This association supports growing evidence demonstrating the importance of planned place of birth on reducing intervention rates and adds to research on labor and birth in water.

Cost analysis of planned out-of-hospital births in Italy

BACKGROUND AND AIM

In Italy, the main birthplace is a hospital, and only a few women choose an out-of-hospital setting. This study assessed the costs related to delivery in different birthplaces in Italy.

METHODS

The cost analysis considered direct and amortizable costs associated with mother-child care in physiological conditions. An analysis of the hospital births considered the Diagnoses-Related Groups 373 and 391. To estimate the cost of the births assisted privately by freelance midwives, an evaluation based on an experts' opinion was carried out.

RESULTS

Childbirth hospital care in Italy amounts to € 1832.00, and birth in an out-of-hospital setting accredited with the National Health System has a full cost of € 1345.19 in the 'maternity home' and € 909.60 at home. The average cost of the birth in 'private maternity homes' amounted to € 3260.00, while at-home births amounted to € 2910.00.

CONCLUSIONS

Any accreditation of out-of-hospital settings by the NHS would considerably reduce the waste of economic resources compared to hospital childbirth.

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.

Exploring Why Birth Center Clients Choose Hospitalization for Labor and Birth

OBJECTIVE

To identify demographic and clinical factors associated with birth center clients electing hospitalization for labor and birth and to explore the timing and rationale for elective hospitalization via health records.

DESIGN

A secondary analysis of multiyear data from a quality assurance project at a single birth center. We compared two subsamples-birth center preference group and hospital preference group-and described the apparent rationale for transfers among clients in the latter group.

SETTING

A single freestanding birth center where all midwives have admitting privileges at a local hospital and can accompany labor transfers.

PARTICIPANTS

All cases included in the analytic sample represent women with low-risk pregnancies who were eligible for birth center birth. The birth center preference group represents clients planning to give birth at the center, and the hospital preference group consists of clients who elected for hospitalization.

MEASUREMENTS

Relevant demographic and clinical information was provided for the entire analytic sample and was matched with available data collected systematically by birth center staff via chart review. The data set also included anonymous responses to an e-mailed questionnaire from clients identified by birth center staff.

RESULTS

Approximately 56.1% (N = 1,155) of the cases in the data set were eligible for comparative analysis. The birth center preference and hospital preference groups included 899 (77.8%) and 256 (22.2%) individuals, respectively. In the hospital preference group, Black clients (n = 23), those who were publicly insured (n = 49), and primiparas (n = 101) were significantly overrepresented. Chart review data and questionnaire responses highlighted insurance restrictions, family preferences, pain relief options, and postpartum care as influential factors among members of the hospital preference subsample.

CONCLUSION

The present analysis shows associations between certain individual characteristics and elective hospitalization during labor for birth center clients. Health record data and questionnaire responses indicated a variety of reasons for electing hospitalization, illustrating the complexity of clients' decision-making during pregnancy and birth.

Distance to Hospital-based Intrapartum Care and Planned Home Birth in Minnesota

INTRODUCTION

Loss of hospital-based intrapartum services is associated with increases in out-of-hospital births, but less is known about associations with planned home birth. This study explores the impact of distance to hospital-based intrapartum care on planned home birth.

METHODS

Public-use Minnesota birth certificate data were merged with Minnesota Hospital Annual Report data (2011-2016) to test the relationship of miles from maternal residence to hospital-based intrapartum care with planned home birth in Minnesota. Logistic regression models estimated the odds of a planned home birth versus hospital birth as a function of miles to hospital-based intrapartum care.

RESULTS

The number of hospitals offering birth services in Minnesota declined by 11% from 2011 to 2016. Moderate (>20-50 miles) and great (>50 miles) distances to nearest hospital-based intrapartum care were associated with increased odds of planned home birth compared with short distances (≤20 miles). Adjusted odds ratios were 3.31 (95% CI, 3.04-3.61) and 3.89 (95% CI, 2.37-6.37), respectively, after adjusting for maternal education, age, and race. Planned home birth was the intended birth setting in 4.3% of births among those living great distances from hospital-based intrapartum care, compared with 1.0% among those living a short distance from hospital-based intrapartum care.

DISCUSSION

Better understanding of how geographical barriers affect preferred birth settings can inform efforts to reduce the impact of hospital-based intrapartum service loss on rural women and their birth outcomes.

Vaginal birth after cesarean: neonatal outcomes and United States birth setting

BACKGROUND

Women who seek vaginal birth after cesarean delivery may find limited in-hospital options. Increasing numbers of women in the United States are delivering by vaginal birth after cesarean delivery out-of-hospital. Little is known about neonatal outcomes among those who deliver by vaginal birth after cesarean delivery in- vs out-of-hospital.

OBJECTIVE

The purpose of this study was to compare neonatal outcomes between women who deliver via vaginal birth after cesarean delivery in-hospital vs out-of-hospital (home and freestanding birth center).

STUDY DESIGN

We conducted a retrospective cohort study using 2007-2010 linked United States birth and death records to compare singleton, term, vertex, nonanomolous, and liveborn neonates who delivered by vaginal birth after cesarean delivery in- or out-of-hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth-setting risk differences. Analyses were stratified by parity and history of vaginal birth. Sensitivity analyses that involved 3 transfer status scenarios were conducted.

RESULTS

Of women in the United States with a history of cesarean delivery (n=1,138,813), only a small proportion delivered by vaginal birth after cesarean delivery with the subsequent pregnancy (n=109,970; 9.65%). The proportion of home vaginal birth after cesarean delivery births increased from 1.78-2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out-of-hospital setting (neonatal seizures, 23 [0.02%] vs 6 [0.19%; P<.001]; Apgar score <7, 2859 [2.68%] vs 139 [4.42%; P<.001; Apgar score <4, 431 [0.4%] vs 23 [0.73; P=.01]). A similar, but nonsignificant, pattern of increased risk was observed for neonatal death and ventilator support among those neonates who were born in the out-of-hospital setting. Multivariate regression estimated that neonates who were born in an out-of-hospital setting had higher odds of poor outcomes (neonatal seizures [adjusted odds ratio, 8.53; 95% confidence interval, 2.87-25.4); Apgar score <7 [adjusted odds ratio, 1.62; 95% confidence interval, 1.35-1.96]; Apgar score <4 [adjusted odds ratio, 1.77; 95% confidence interval, 1.12-2.79]). Although the odds of neonatal death (adjusted odds ratio, 2.1; 95% confidence interval, 0.73-6.05; P=.18) and ventilator support (adjusted odds ratio, 1.36; 95% confidence interval, 0.75-2.46) appeared to be increased in out-of-hospital settings, findings did not reach statistical significance. Women birthing their second child by vaginal birth after cesarean delivery in out-of-hospital settings had higher odds of neonatal morbidity and death compared with women of higher parity. Women who had not birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery had higher odds of neonatal morbidity and mortality compared with women who had birthed vaginally prior to out-of-hospital vaginal birth after cesarean delivery. Sensitivity analyses generated distributions of plausible alternative estimates by outcome.

CONCLUSION

Fewer than 1 in 10 women in the United States with a previous cesarean delivery delivered by vaginal birth after cesarean delivery in any setting, and increasing proportions of these women delivered in an out-of-hospital setting. Adverse outcomes were more frequent for neonates who were born in an out-of-hospital setting, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availability of in-hospital vaginal birth after cesarean delivery and suggests that there may be benefit associated with increasing options that support physiologic birth and may prevent primary cesarean delivery safely. Results may inform evidence-based recommendations for birthplace among women who seek vaginal birth after cesarean delivery.

The validity of the variable "NICU admission" as an outcome measure for neonatal morbidity: a retrospective study

OBJECTIVE

To determine whether "neonatal intensive care unit (NICU) admission" is a valid surrogate outcome measure to assess neonatal condition in clinical studies.

DESIGN

Retrospective study.

SETTING

Tertiary hospital in the Netherlands.

POPULATION

Neonates admitted to NICU during a 10-year period. Inclusion was restricted to singletons born beyond 37 weeks of gestation, and admitted to NICU in the first 24 h for delivery-related morbidity.

METHODS

Patient characteristics and admission data were compared for four groups based on the line of care during delivery, i.e. home birth (Ia), midwife-led hospital delivery (Ib), secondary care (II), tertiary care (III).

MAIN OUTCOME MEASURES

Percentage of neonates/infants that died during NICU admission, diagnosis on admission, treatment received and a Neonatal Therapeutic Intervention Score System (NTISS).

RESULTS

We studied 776 newborns (Ia 52, Ib 25, II 160, III 512, 27 unknown). The mortality rate differed significantly (Ia 15%, Ib 12%, II 22%, III 1%, p < 0.01), as did the NTISS morbidity scores at admission [Ia 12.0 (6.0-23.0), Ib 8.5 (6.3-10.0), II 21.0 (15.0-30.0), III 6.0 (4.0-9.0); p < 0.01], diagnosis at admission, received treatment and the duration of admission.

CONCLUSIONS

The severity of neonatal illness after 37 weeks of gestation differed depending on the line of care in which they were born, with neonates born in secondary care consistently having the highest morbidity, and those born in tertiary care having the lowest. NICU admission should not be used as an outcome measure for neonatal morbidity, specifically not when comparing different birth settings.