Birth Settings Research Articles

Teaming in Translation: training interpreting, medical, and midwifery students in simulated birth settings

This paper reports on the TeamTra – Teaming in Translation project, conceived in response to calls for improved training of both professional interpreters and healthcare providers. TeamTra is a cooperation among the Medical Faculty, the University Hospital, the Institute for Applied Linguistics and Translation Studies (IALT), and the Oriental Institute (OIL) at Leipzig University. The program is aimed at medical, midwifery, and interpreting students and draws upon interprofessional and simulation education models to provide students with a hands-on experience for different professions using simulated patient-physician/midwife encounters in maternal health. Special attention is devoted to cultural differences, varying degrees of health literacy and challenges of triadic communication. The course was carried out for approximately 80 students in the 2022/2023 winter semester and in the 2023 summer semester. This paper reports on the first year of the project, which included a pre-kick-off survey, a satisfaction survey, and feedback sessions.

Parity Moderates the Socioeconomic Predictors of Birth Setting Choice.

The increase in the number of people choosing community birth has raised interest in understanding the factors that influence birth setting choices. This study investigates how parity influences the association between maternal socioeconomic factors and choice of community versus hospital birth. We used 2009-2021 US birth certificate data to identify community births (planned home or birth center births), parity, and maternal characteristics, including Women, Infants, and Children (WIC) program participation, race, ethnicity, educational attainment, marital status, body mass index (BMI), and age. Parity was interacted with each covariate in a multivariable logistic regression model of birth setting. Among 26,526,010 eligible births, 58% were to multiparous mothers, with 1.9% occurring in a birth center or at home. For most maternal characteristics, associations with community birth were stronger in the multiparous group compared to the nulliparous group. For example, being married was associated with greater odds of community birth in both groups, but the strength of this association was greater within the multiparous group (odds ratio 4.00 vs. 1.94, interaction p < 0.001). The same pattern (stronger association with community birth in the multiparous group than in the primiparous group) was observed for race/ethnicity, educational attainment, and WIC participation, all of which were associated with lower odds of community birth. This study shows that parity significantly moderates associations between maternal socioeconomic characteristics and birth setting, implying studies of decision-making in this context should purposively stratify samples and analyses by parity.

Discrimination at Health Center: Experiences of Tribal Women and Midwives in Jharkhand, India

The pivotal concern of this study is to investigate how age, social status, language, and cultural background interact to affect women’s control over and susceptibility to disrespect during birth setting in Jharkhand, India. Women, particularly, belonging from tribal community were directly impacted by disrespect during birth settings, which happens during pregnancy, labor, and the first few weeks following delivery. Hence, the article aims to uncover the effects of disrespect during birth setting on patient’s trust in birth setting facilities and health care teams. Besides, this study also adds to challenge the culture of silence that currently surrounds this issue. The study was conducted in the Sisai block of Jharkhand’s Gumla district, where focus group discussion (FGD) with the assistance of 18 public health midwives (PHMs) and 24 individuals with prior parturition experience were involved. The qualitative data was categorized and analyzed using an intersectional framework, which facilitated the identification of significant themes and patterns. The results show that power dynamics and repressive institutions associated with gender, ethnicity, social, linguistic, and cultural inequality were intertwined with disrespect during birth setting, especially with tribal women. In conclusion, the standard of birthing treatment in India needs to be improved, especially in tribal regions.

Child growth and refugee status: evidence from Syrian migrants in Turkey

Abstract This study examines disparities in health and nutrition among native and Syrian refugee children in Turkey. To understand the need for targeted programs addressing child well-being among the refugee population, we analyze the Turkey Demographic and Health Survey (TDHS) – which provides representative data for a large refugee and native population. We find no evidence of a difference in infant or child mortality between refugee children born in Turkey and native children. However, refugee infants born in Turkey have lower birthweight and age-adjusted weight and height than native infants. When we account for a rich set of birth and socioeconomic characteristics that display substantial differences between natives and refugees, the gaps in birthweight and age-adjusted height persist, but the gap in age-adjusted weight disappears. Moreover, the remaining gaps in birthweight and anthropometric outcomes are limited to the lower end of the distribution. The observed gaps are even larger for refugee infants born before migrating to Turkey, suggesting that the remaining deficits reflect conditions in the source country before migration rather than deficits in access to health services within Turkey. Finally, comparing children by the country of their first trimester, we find evidence of the detrimental effects of stress exposure during pregnancy.

Severe adverse maternal and neonatal outcomes according to the planned birth setting being midwife-led birth centers or obstetric-led units.

The establishment of midwife-led birth centers (MLBCs) is still being debated. The study aimed to compare severe adverse outcomes and mode of birth in low-risk women according to their birth planned in MLBCs or in obstetric-led units (OUs) in France. We used nationwide databases to select low-risk women at the start of care in labor in MLBCs (n = 1294) and in OUs (n = 5985). Using multilevel logistic regression, we compared severe adverse maternal and neonatal morbidity as a composite outcome and as individual outcomes. These include severe postpartum hemorrhage (≥1000 mL of blood loss), obstetrical anal sphincter injury, maternal admission to an intensive care unit, maternal death, a 5-minute Apgar score <7, neonatal resuscitation at birth, neonatal admission to an intensive care unit, and stillbirth or neonatal death. We also studied the mode of birth and the role of prophylactic administration of oxytocin at birth in the association between birth settings and severe postpartum hemorrhage. Severe adverse maternal and neonatal outcome indicated a slightly higher rate in women in MLBCs compared to OUs according to unadjusted analyses (4.6% in MLBCs vs. 3.4% in OUs; cOR 1.36; 95%CI [1.01-1.83]), but the difference was not significant between birth settings after adjustment (aOR 1.37 [0.92-2.05]). Severe neonatal morbidity alone was not different (1.7% vs. 1.6%; aOR 1.17 [0.55-2.47]). However, severe maternal morbidity was significantly higher in MLBCs than in OUs (3.0% vs. 1.9%; aOR 1.61 [1.09-2.39]), mainly explained by higher risks of severe postpartum hemorrhage (2.4 vs. 1.1%; aOR 2.37 [1.29-4.36]), with 2 out of 5 in MLBCs partly explained by the low use of prophylactic oxytocin. Cesarean and operative vaginal births were significantly decreased in women with a birth planned in MLBCs. In France, 3 to 4% of low-risk women experienced a severe adverse maternal or neonatal outcome regardless of the planned birth setting. Results were favorable for MLBCs in terms of mode of birth but not for severe postpartum hemorrhage, which could be partly addressed by revising practices of prophylactic administration of oxytocin.

Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study.

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). Planned community birth (homes and birth centers), United States. Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Rates of bronchopulmonary dysplasia in very low birth weight neonates: a systematic review and meta-analysis

ImportanceLarge-scale estimates of bronchopulmonary dysplasia (BPD) are warranted for adequate prevention and treatment. However, systematic approaches to ascertain rates of BPD are lacking.ObjectiveTo conduct a systematic review and meta-analysis to assess the prevalence of BPD in very low birth weight (≤ 1,500 g) or very low gestational age (< 32 weeks) neonates.Data sourcesA search of MEDLINE from January 1990 until September 2019 using search terms related to BPD and prevalence was performed.Study selectionRandomized controlled trials and observational studies evaluating rates of BPD in very low birth weight or very low gestational age infants were eligible. Included studies defined BPD as positive pressure ventilation or oxygen requirement at 28 days (BPD28) or at 36 weeks postmenstrual age (BPD36).Data extraction and synthesisTwo reviewers independently conducted all stages of the review. Random-effects meta-analysis was used to calculate the pooled prevalence. Subgroup analyses included gestational age group, birth weight group, setting, study period, continent, and gross domestic product. Sensitivity analyses were performed to reduce study heterogeneity.Main outcomes and measuresPrevalence of BPD defined as BPD28, BPD36, and by subgroups.ResultsA total of 105 articles or databases and 780,936 patients were included in this review. The pooled prevalence was 35% (95% CI, 28-42%) for BPD28 (n = 26 datasets, 132,247 neonates), and 21% (95% CI, 19-24%) for BPD36 (n = 70 studies, 672,769 neonates). In subgroup meta-analyses, birth weight category, gestational age category, and continent were strong drivers of the pooled prevalence of BPD.Conclusions and relevanceThis study provides a global estimation of BPD prevalence in very low birth weight/low gestation neonates.

Birth "outside of guidance"-An exploration of a Birth Choices Clinic in the United Kingdom.

Decision-making around birthplace is complex and multifactorial. The role of clinicians is to provide unbiased, evidence-based information to support women and birthing people to make decisions based on what matters to them. Some decisions may fall outside of clinical guidance and recommendations. Birth Choices Clinics can provide an opportunity for extended discussion and personalized birthplace planning. This study aimed to explore the rationale behind choosing birthplace "outside of guidance" and examine the outcomes for women who attended a Birth Choices Clinic. The study was descriptive using data extracted from clinical documentation and consultation. The data included demographic information, maternal characteristics, reason for choosing a midwifery-led birth setting, birthplace preference, and outcome. Eighty-two women used the Birth Choices Clinic between April 2022 and February 2023 in one large maternity unit in the UK. Reasons for choosing birth in a midwifery-led setting included having access to a birthing pool, to reduce the chance of obstetric interventions and pragmatic reasons. Sixty-five percent of women experienced a spontaneous vaginal birth, 10% experienced an assisted vaginal birth, and 23% experienced a cesarean birth. Of the 33 women who ultimately commenced labor care in a midwifery-led setting, 76% (n = 25/33) birthed in this setting without complications. Transfer rates in labor were similar to those in a "low-risk" pregnant population. Birth choice clinics may facilitate an understanding of material risk and support individualizing birth planning. There is evidence that women changed their planned birthplace, possibly in recognition of a move along the risk spectrum.

Neonatal morbidity and mortality in birth centers in the United States 2018-2021: An observational study of low-risk birthing individuals.

Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed. Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics. The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001). Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

Intrapartum Quality of Care among Healthy Women: A Population-Based Cohort Study in an Italian Region.

Although the quality of care during childbirth is a maternity service's goal, less is known about the impact of the birth setting dimension on provision of care, defined as evidence-based intrapartum midwifery practices. This study's aim was to investigate the impact of hospital birth volume (≥1000 vs. <1000 births/year) on intrapartum midwifery care and perinatal outcomes. We conducted a population-based cohort study on healthy pregnant women who gave birth between 2018 and 2022 in Lombardy, Italy. A total of 145,224 (41.14%) women were selected from nationally linked databases. To achieve the primary aim, log-binomial regression models were constructed. More than 70% of healthy pregnant women gave birth in hospitals (≥1000 births/year) where there was lower use of nonpharmacological coping strategies, higher likelihood of epidural analgesia, episiotomy, birth companion's presence at birth, skin-to-skin contact, and first breastfeeding within 1 h (p-value < 0.001). Midwives attended almost all the births regardless of birth volume (98.80%), while gynecologists and pediatricians were more frequently present in smaller hospitals. There were no significant differences in perinatal outcomes. Our findings highlighted the impact of the birth setting dimension on the provision of care to healthy pregnant women.

Respiratory syncytial virus vaccination during pregnancy for improving infant outcomes.

Respiratory syncytial virus vaccination during pregnancy for improving infant outcomes.

High Risk Pregnancy and its Outcome in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

High-risk pregnancy is defined as one which is complicated by factors or factors that adversely affect the pregnancy outcome (maternal, perinatal or both). Early detection and effectivemanagement of high risk pregnancy helps in achieving favorable maternal and perinatal outcomes. This study aimed to find the prevalence of high risk pregnancy and its outcome among pregnant women admitted for delivery in the obstetrics and gynecology department of a tertiary care hospital Methods: A descriptive cross sectional study was conducted in a tertiary care hospital among high risk pregnant women admitted for delivery using structured proforma, from April 2023 to September 2023 after obtaining ethical approval from the Institutional Review Committee. Convenience sampling was used among pregnant women who met the inclusion criteria. Data was entered in excel and analysis was done using IBM SPSS Statistics. Point estimate was calculated at 95% Confidence Interval Results: Among 350 deliveries, high risk pregnancy was seen in 91 (26%) (16.15-32.00, 95% Confidence Interval). The high risk factors were previous history of cesarean section 25 (27.47 %) followed by hypothyroidism 19 (20.87%) and gestational diabetes mellitus 15 (16.48%). Out of 90 high risk pregnancy, 84 (92.30%) had term delivery. Lower segment cesarean section was done in 69 (75.82%) patients of which 26 (28.57%) underwent emergency cesarean section. The total number of births among high risk preganancies were 93 with two sets of twin births. A total of 13 (13.97%) of the babies had low-birth weight. The prevalence of high risk pregnancy was found to be similar as compared to studies done in similar settings.

Evaluating the relationship between conditional cash transfer programme on preterm births: a retrospective longitudinal study using the 100 million Brazilian cohort

BackgroundPreterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births, including their severity categories, and explored how this association differs according to prenatal care and the quality of Bolsa Familia Programme management.MethodsA retrospective cohort study was performed involving the first live singleton births to mothersenrolled in the 100 Million Brazilian Cohort from 2004 to 2015, who had at least one child before cohort enrollment. Only the first birth during the cohort period was included, but born from 2012 onward. A deterministic linkage with the Bolsa Familia Programme payroll dataset and a similarity linkage with the Brazilian Live Birth Information System were performed. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age < 37 weeks: (i) all preterm births, (ii) moderate-to-late (32–36), (iii) severe (28–31), and (iv) extreme (< 28) preterm births compared to at-term newborns. We combined propensity score-based methods and weighted logistic regressions to compare newborns to mothers who did and did not receive Bolsa Familia, controlling for socioeconomic conditions. We also estimated these effects separately, according to the adequacy of prenatal care and the index of quality of Bolsa Familia Programme management.Results1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63–0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59–0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43–0.74).ConclusionsAn income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.

U.S. Healthcare Provider Views and Practices Regarding Planned Birth Setting.

We conducted 19 in-depth, semistructured, qualitative interviews of eight obstetricians, eight midwives, and three pediatricians from across the United States. Interviews explored healthcare providers' interpretation of the current evidence and their personal and professional experiences with childbirth within the existing medical, ethical, and legal context in the United States. Themes emerged concerning risks and benefits, decision-making, and patient-provider power dynamics. Collectively, the narratives illuminated fundamental ideological tensions between in- and out-of-hospital providers arising from divergent assignment of value to described risks and benefits. The majority of physicians focused on U.S.-specific data demonstrating increased neonatal morbidity and mortality associated with delayed access to hospital-based interventions, thereby justifying hospital birth as the standard of care. By contrast, midwives emphasized data demonstrating fewer interventions and superior maternal and neonatal outcomes in high-income European countries, where out-of-hospital birth is more common for low-risk birthing people. A key gap in counseling was revealed, as no interviewees offered anticipatory counseling regarding birth setting options. Providers directly and indirectly illustrated the propensity for asymmetric power relations between birth providers and pregnant people, especially in hospital settings. The narratives highlight the common goal of optimizing maternal and neonatal outcomes despite tensions arising from divergent prioritization of specific maternal and neonatal risks. Our findings suggest opportunities to foster collaboration and optimize outcomes via mutual respect and improved integration of care.

Home Birth in the United States: An Evidence-Based Ethical Analysis.

AbstractThe assumption in current U.S. mainstream medicine is that birthing requires hospitalization. In fact, while the American College of Obstetricians and Gynecologists supports the right of every birthing person to make a medically informed decision about their delivery, they do not recommend home birth owing to data indicating greater neonatal morbidity and mortality. In this article, we examine the evidence surrounding home birth in the United States and its current limitations, as well as the ethical considerations around birth setting.

Influence of the Physical Environment on Maternal Care for Culturally Diverse Women: A Narrative Review.

This narrative literature review aims to develop a framework that can be used to understand, study, and design maternal care environments that support the needs of women from diverse racial and ethnic groups. Childbirth and the beginning of life hold particular significance across many cultures. People's cultural orientation and experiences influence their preferences within healthcare settings. Research suggests that culturally sensitive care can help improve the experiences and outcomes and reduce maternal health disparities for women from diverse cultures. At the same time, the physical environment of the birth setting influences the birthing experience and maternal outcomes such as the progression of labor, the use of interventions, and the type of birth. The review synthesizes articles from three categories: (a) physical environment of birthing facilities, (b) physical environment and culturally sensitive care, and (c) physical environment and culturally sensitive birthing facilities. Fifty-five articles were identified as relevant to this review. The critical environmental design features identified in these articles were categorized into different spatial scales: community, facility, and room levels. Most studies focus on maternal or culturally sensitive care settings outside the United States. Since the maternal care environment is an important aspect of their culturally sensitive care experience, further studies exploring the needs and perspectives of racially and ethnically diverse women within maternal care settings in the United States are necessary. Such research can help future healthcare designers contribute toward addressing the ongoing maternal health crisis within the country.

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

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

The Vertical Birthing Positions and Their Perinatal Outcomes in Hilly Tribal Home Birth Settings: A Qualitative Observational Study

This study aims to document the cultural significance of vertical birthing positions and knowledge of easing complicated deliveries among the Porja hilly tribal group, Visakhapatnam district, Andhra Pradesh, India. With the purposive sampling method, 31 postpartum mothers were selected on the inclusion criteria of having been given childbirth in the last six months. The socio-demographic profile of the respondents was presented to understand the socio-cultural living conditions. The qualitative data collection involved 31 face-to-face in-depth interviews with postpartum women and two focus group discussions involving six to eight traditional birth attendants (TBAs) on the cultural efficacy of upright positions. Handwritten transcripts of the interviews and conversations were transcribed and coded into themes and categories. Qualitative themes reveal that the pregnant women with anaemia and morbidity conditions had been exposed to maternal distress and foetal distress (breathing problems and loss of consciousness) but had managed by adopting immediate alternative vertical birthing positions with the suggestion of TBAs. The findings suggest that vertical birth positions are age-old childbirth customs which have been adopted as as a priority option by labouring women, especially in socio-economically disadvantaged societies where medical facilities are unavailable.

Race, ethnicity, and indications for primary cesarean birth: Associations within a national birth center registry.

Racial and ethnic disparities in cesarean rates in the United States are well documented. This study investigated whether cesarean inequities persist in midwife-led birth center care, including for individuals with the lowest medical risk. National registry records of 174,230 childbearing people enrolled in care in 115 midwifery-led birth center practices between 2007 and 2022 were analyzed for primary cesarean rates and indications by race and ethnicity. The lowest medical risk subsample (n = 70,521) was analyzed for independent drivers of cesarean birth. Primary cesarean rates among nulliparas (15.5%) and multiparas (5.7%) were low for all enrollees. Among nulliparas in the lowest-risk subsample, non-Latinx Black (aOR = 1.37; 95% CI, 1.15-1.63), Latinx (aOR = 1.51; 95% CI, 1.32-1.73), and Asian participants (aOR = 1.48; 95% CI, 1.19-1.85) remained at higher risk for primary cesarean than White participants. Among multiparas, only Black participants experienced a higher primary cesarean risk (aOR = 1.49; 95% CI, 1.02-2.18). Intrapartum transfers from birth centers were equivalent or lower for Black (14.0%, p = 0.345) and Latinx (12.7%, p < 0.001) enrollees. Black participants experienced a higher proportion of primary cesareans attributed to non-reassuring fetal status, regardless of risk factors. Place of admission was a stronger predictor of primary cesarean than race or ethnicity. Place of first admission in labor was the strongest predictor of cesarean. Racism as a chronic stressor and a determinant of clinical decision-making reduces choice in birth settings and may increase cesarean rates. Research on components of birth settings that drive inequitable outcomes is warranted.

Facilitating positive birth experience when preferences are not met: A qualitative analysis.

High-quality health systems rely on care that centers on patient preferences. Realization of patient preferences can improve the birth experience. However, in the dynamic setting of birth, birth preferences can diverge from what is medically indicated. Through studying women and birthing peoples' experiences of unplanned labor procedures, we aimed to identify ways in which practitioners can support women and birthing people through unexpected or unwanted aspects of their delivery. Specifically, we focused on labor induction. In one large US academic center, women and birthing people participated in prenatal and postpartum surveys regarding their desires, expectations, and experiences of labor induction. From April to November 2021, participants were eligible if they showed discordance between having labor induction and whether it was initially wanted or expected. Interviews focused on attitudes toward birth preferences and outcomes, with attention to discordances. We analyzed interviews through a modified grounded theory approach. Of 22 participants, our sample was predominantly white (91%). Participants in this sample reported discordance between wanting and experiencing (73%) and/or expecting and experiencing (54%) an induction. We identified two themes: "Discordance without mitigation is perceived as a negative experience" and "Practitioner interaction can buffer against negative experience" which includes three ways in which participants prefer support in instances of discordance: preparation, communication, and care and comfort. These methods of support foster patient autonomy and can lead to positive patient experiences. While medical systems should work to support patient preferences, our results suggest that patients can still have positive birth experiences, even when preferences are not fulfilled. Early practitioner preparation, positive communication, and responsive care and comfort may help to improve patient birth experience when challenges arise.