Childbirth Connection Research Articles

Reducing Implicit Bias in Maternity Care: A Framework for Action

Reducing Implicit Bias in Maternity Care: A Framework for Action

Paradox lost on the U.S.-Mexico border: U.S. Latinas and cesarean rates

BackgroundWe apply Intersectional Theory to examine how compounded disadvantage affects the odds of women having a cesarean in U.S.-Mexico border hospitals and in non-border hospitals. We define U.S. Latinas with compounded disadvantage as those who have neither a college education nor private health insurance.ResultsAnalyzing quantitative and qualitative data from Childbirth Connection’s Listening to Mothers III Survey, we find that, consistent with the notion of the Latinx Health Paradox, compounded disadvantage serves as a protective buffer and decreases the odds of cesarean among women in non-border hospitals. However, the Latinx Health Paradox is absent on the border.ConclusionOur data show that women with compounded disadvantage who give birth on the border have significantly higher odds of a cesarean compared to women without such disadvantage. Further, women with compounded disadvantage who give birth in border hospitals report receiving insufficient prenatal, pregnancy, and postpartum information, providing a direction for future research to explain the border disparity in cesareans.

Playing Pregnancy: The Ludification and Gamification of Expectant Motherhood in Smartphone Apps

Like other forms of embodiment, pregnancy has increasingly become subject to representation and interpretation via digital technologies. Pregnancy and the unborn entity were largely private, and few people beyond the pregnant women herself had access to the foetus growing within her (Duden). Now pregnant and foetal bodies have become open to public portrayal and display (Lupton The Social Worlds of the Unborn). A plethora of online materials – websites depicting the unborn entity from the moment of conception, amateur YouTube videos of births, social media postings of ultrasounds and self-taken photos (‘selfies’) showing changes in pregnant bellies, and so on – now ensure the documentation of pregnant and unborn bodies in extensive detail, rendering them open to other people’s scrutiny. Other recent digital technologies directed at pregnancy include mobile software applications, or ‘apps’. In this article, we draw on our study involving a critical discourse analysis of a corpus of pregnancy-related apps offered in the two major app stores. In so doing, we discuss the ways in which pregnancy-related apps portray pregnant and unborn bodies. We place a particular focus on the ludification and gamification strategies employed to position pregnancy as a playful, creative and fulfilling experience that is frequently focused on consumption. As we will demonstrate, these strategies have wider implications for concepts of pregnant and foetal embodiment and subjectivity. It is important here to make a distinction between ludification and gamification. Ludification is a broader term than gamification. It is used in the academic literature on gaming (sometimes referred to as ‘ludology’) to refer to elements of games reaching into other aspects of life beyond leisure pursuits (Frissen et al. Playful Identities: The Ludification of Digital Media Cultures; Raessens). Frissen et al. (Frissen et al. "Homo Ludens 2.0: Play, Media and Identity") for example, claim that even serious pursuits such as work, politics, education and warfare have been subjected to ludification. They note that digital technologies in general tend to incorporate ludic dimensions. Gamification has been described as ‘the use of game design elements in non-game contexts’ (Deterding et al. 9). The term originated in the digital media industry to describe the incorporation of features into digital technologies that not explicitly designed as games, such as competition, badges, rewards and fun that engaged and motivated users to make them more enjoyable to use. Gamification is now often used in literatures on marketing strategies, persuasive computing or behaviour modification. It is an important element of ‘nudge’, an approach to behaviour change that involves persuasion over coercion (Jones, Pykett and Whitehead). Gamification thus differs from ludification in that the former involves applying ludic principles for reasons other than the pleasures of enjoying the game for their own sake, often to achieve objectives set by actors and agencies other than the gamer. Indeed, this is why gamification software has been described by Bogost (Bogost) as ‘exploitationware’.

The Hormonal Physiology of Women and their Fetuses and Mothers and their Infants

In January 2015, Childbirth Connection released a report titled Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care ( Buckley, 2015 Buckley S.J. Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Childbirth Connection Programs, National Partnership for Women & Families, Washington, DC2015 Google Scholar ). In this commissioned report, author Sarah Buckley summarized research evidence to describe current understanding of the physiology of childbearing in four hormonal systems: oxytocin, beta‐endorphins, the stress‐related systems of epinephrine‐norepinephrine and cortisol, and prolactin. For each hormonal system, the author described the normal physiology and how common maternity care practices may affect that specific physiology on the basis of research evidence. Dr. Buckley argued that despite incomplete knowledge, what is known “reveals profound interconnections between mothers and babies, among hormone systems, and across childbearing processes and the life course” (p. i). Although this idea may not be new for many of us, Dr. Buckley concluded, “A growing body of research finds that common maternity care interventions may disturb hormonal processes, reduce their benefits, and create new challenges and concerns, including the possibility of adverse longer‐term developmental and epigenetic effects” (p. i). An important contemporary field of biology, epigenetics is the study of how external influences can switch genes on or off to affect the specific proteins transcribed independent of the individual's DNA sequence. Such changes may make the individual more or less prone to certain diseases or more or less likely to experience specific developmental alterations.

Longitudinal perspective is needed to improve postpartum health

Our attention in maternity care research and practice is focused primarily on short-term outcomes. A systematic review of randomised controlled trials evaluating perinatal interventions concluded that only a minority of trials reported offspring outcomes following hospital discharge (Teune et al. BJOG 2013;120:15–22). A parallel analysis would perhaps yield an even lower proportion of studies measuring medium to longer term maternal outcomes. This is troubling, as frameworks such as epigenetics, developmental origins of health and disease, life-course health development, and the human microbiome highlight the importance of long-term impacts of exposures during early sensitive windows of most rapid human development, with long-term impacts on childbearing women increasingly identified as well. When we shine the light on just a small area, what are we missing out there in the dark? McDonald and colleagues' Maternal Health Study investigated first-time mothers' experience of postpartum dyspareunia and the results are illuminating. Experiences of dyspareunia soared above baseline prepregnancy levels, with more than one in four participants reporting persistent dyspareunia. In the adjusted analysis emergency caesarean section was associated with persistent dyspareunia. Professional recognition of the overuse of caesarean section, calls for safely preventing such procedures, and identification of well-supported ways to do so point to opportunities to prevent persistent dyspareunia (American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine Obstet Gynecol 2014;123:693–711). Mothers and babies have the rest of their lives ahead of them, and high performing healthcare systems cannot rely primarily on myopic knowledge. With a longer view, notable proportions of women experience a range of new-onset morbidities in the weeks after giving birth, persisting in many to 6 months and beyond (Declercq et al. Listening to Mothers III: New Mothers Speak Out. New York: Childbirth Connection; 2013). We need long-term follow up in randomised controlled trials and complementary well-conducted observational studies. It is important to monitor and treat postpartum morbidity in clinical practice. In a national survey in the USA, excluding infection, more than seven out of ten participants did not seek help from a health professional for various new-onset postpartum problems (Declercq et al. Listening to Mothers; Report of the First National U.S. Survey of Women's Childbearing Experiences. New York: Maternity Center Association, 2002). A high-quality patient-reported outcome measure of composite maternal morbidity captured 4–8 weeks postpartum could improve maternal health in several ways. It could engender discussion, counselling and treatment during postpartum care. Relevant information would be captured in the health record for continued attention within primary care in settings with the capacity to share health records from other providers. More generally, such a measure could inform professionals and the public regarding maternity-care outcomes, fostering quality improvement and patient choice. Better research, measurement, prevention and treatment are needed to address issues of great interest and consequence to women during a phase of maternity care and the life cycle that have received incommensurate attention. I am a co-investigator of the Listening to Mothers surveys. I have no financial interests in matters discussed in this commentary.

Major Survey Findings of Listening to MothersSM III: Pregnancy and Birth

To understand the experiences and views of childbearing women in the United States and trends over time, Childbirth Connection carried out the third national Listening to Mothers survey among 2,400 women who gave birth in U.S. hospitals to a single baby from mid-2011 to mid-2012 and could participate in English. Harris Interactive conducted the survey using a validated methodology that includes data weighting to ensure that results closely reflect the target population. Results of the initial survey describe experiences from before pregnancy through the early postpartum period, and were reported in Listening to Mothers III: Pregnancy and Birth. A follow-up survey directed to the same participants explored postpartum experiences, attitudes about maternity care, and some additional pregnancy and birth items.

Listen Up: What We Can Learn From Women’s Birth and Postpartum Experiences

In 2013, Childbirth Connection published findings from a U.S. study of women’s pregnancy, childbirth, and postpartum experiences, Listening to Mothers III. In this issue of The Journal of Perinatal Education, we publish the major survey findings of both the pregnancy and birth survey and the postpartum survey. This editorial discusses some of the major findings of the childbirth survey. Listening to what mothers have to say about their experiences suggests a mandate to “listen up” to what mothers are telling us and continue to advocate for evidence-based maternity care. Articles in this issue of the journal are presented.

Major Survey Findings of Listening to MothersSM III: New Mothers Speak Out

To understand the experiences and views of childbearing women in the United States and trends over time, Childbirth Connection carried out the third national Listening to Mothers survey among 2,400 women who gave birth in U.S. hospitals to a single baby from mid-2011 to mid-2012 and could participate in English. A follow-up survey directed to the same participants explored postpartum experiences, in depth and well into the second year after birth; views about maternity care; and some additional pregnancy and birth items. Harris Interactive conducted the surveys using a validated methodology that includes data weighting to ensure that results closely reflect the target population. The follow-up survey was reported in Listening to Mothers III: New Mothers Speak Out.

A Policy Matters Focus on Maternity Care and Liability

Three years ago, Women's Health Issues published a special Transforming Maternity Care supplement with two direction-setting consensus reports: “2020 Vision for a High-Quality, High-Value Maternity Care System” and a “Blueprint for Action” to chart the path toward such a system. These reports emerged by consulting and involving leaders from across the U.S. health care system in multi-stakeholder, multidisciplinary, deliberative processes. The project, which continues in its implementation phase as Childbirth Connection's Transforming Maternity Care Partnership (available: http://transform.childbirthconnection.org), fosters a system that reliably delivers optimal maternity care to the nation's women, newborns, and families. From the initial Transforming Maternity Care key informant interviews and steering committee deliberations, there was consensus that work to improve liability matters is a core focal area for achieving a high-performing maternity care system. This Policy Matters section on Maternity Care and Liability advances the Blueprint's priority recommendations for Improved Functioning of the Liability System. The three articles in this section are derived from a larger report that Childbirth Connection is issuing simultaneously: Maternity Care and Liability: Pressing Problems, Substantive Solutions. Part I of that report looks broadly at how the liability system is impacting maternity care—with respect to liability insurance underwriting, availability, and affordability; claims and lawsuits involving maternity care; incidence of negligent injury and compensation for claims; defensive maternity care practice; career satisfaction and maternity care quality; and impact on maternal and newborn health outcomes (deterrent effect). This broad look led us to identify seven aims of a high-functioning liability system for maternity care as a framework for assessing merits of possible interventions. Part II holds 25 possible interventions up to this framework, identifying 15 that have not contributed or are not likely to contribute to diverse aims of a well-functioning liability system, and 10 that hold promise for meeting multiple aims and either preventing or responding well to possible harm. The report's best evidence approach uses empirical legal studies and health services research specific to maternity care when available, and other studies when unavailable. A lengthy appendix identifies many important questions that warrant further research, and a second provides concise fact sheets about a series of key issues for policy makers and other stakeholders. The full report is available at http://transform/childbirthconnection.org/reports/liability/. The open access Policy Matters articles published here make results of the full report readily accessible to a large audience. The first of three articles presents an overview of the full report (minus appendices), with key citations. The second article considers the strategies for improvement that do not hold up well to the seven criteria for a high-functioning liability system in maternity care. The third article considers strategies that seem to meet multiple aims of a high-functioning system and are candidates for demonstration and evaluation within states, health systems, or other appropriate entities. We are honored that Professors Sara Rosenbaum and William Sage have contributed a thoughtful and insightful commentary on these papers. We are once again grateful for the opportunity to work with editor Anne Markus and her Women's Health Issues team on pressing maternity care policy issues. We are also grateful to the Milbank Memorial Fund for financial support for the full report and to the many policy, academic, and clinical leaders who provided thoughtful appreciated feedback on a draft of the full report. For their helpful feedback, which enabled us to further improve our work, we thank the referees of the three articles that appear here, Paul Gluck, MD, and Kathleen Rice Simpson, PhD, RNC. These national quality and safety leaders served on the Transforming Maternity Care Steering Committee and Vision Team, respectively, and have again helped to further those efforts toward a high-functioning maternity care system. Carol Sakala, PhD, MSPH, is Director of Programs at Childbirth Connection, New York, where she works to improve the quality and value of maternity care through consumer engagement and health system transformation.

Patient Engagement and Shared Decision Making in Maternity Care

Louisiana State University Departments of Health Policy and Management and Obstetrics and Gynecology, Schools of Public Health and Medicine, New Orleans, Louisiana; and Childbirth Connection, New York, New York. Corresponding author: Rebekah E. Gee, MD, MPH, 2020 Gravier Street, New Orleans, LA 70112; e-mail: [email protected]. The authors thank Amy Romano, CNM, MSN and Carol Sakala, PhD, MSPH from Childbirth Connection for providing editorial assistance and comments on the manuscript. Financial Disclosure Ms. Corry discloses a partnership between Childbirth Connection and the Informed Medical Decisions Foundation (IMDF) to develop shared decision-making resources. The partnership includes a grant from the IMDF to Childbirth Connection. No grant funds were used in preparation of this manuscript. The other author did not report any potential conflicts of interest.

Postpartum Depressive Symptomatology: Results from a Two‐Stage US National Survey

Up to 19% of new mothers have major or minor depression sometime during the first 3 months after birth. This article reports on the prevalence of postpartum depressive symptoms and risk factors obtained from a 2-stage US national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey. The weighted survey results are based on an initial sample of 1573 women (1373 online, 200 telephone interviews) who had given birth in the year prior to the survey and repeat interviews with 902 women (859 online, 44 telephone) 6 months later. Three main instruments were used to collect data: the Postpartum Depression Screening Scale (PDSS), the Patient Health Questionnaire-2 (PHQ-2), and the Posttraumatic Stress Disorder Symptom Scale-Self Report (PSS-SR). Sixty-three percent of the women in the LTM II sample screened positive for elevated postpartum depressive symptoms with the PDSS, and 6 months later 42% of the women in this sample screened positive for elevated postpartum depressive symptoms with the PHQ-2. A stepwise, multiple regression revealed 2 variables that significantly explained 54% of the variance in postpartum depressive symptom scores: posttraumatic stress symptom scores on the PSS-SR and health promoting behaviors of healthy diet, managing stress, rest, and exercise. The high percentage of mothers who screened positive for elevated postpartum depressive symptoms in this 2-stage national survey highlights the need for prevention and routine screening during the postpartum period and follow-up treatment.

Current Resources for Evidence‐Based Practice July/August, 2011

An overarching goal of the Affordable Care Act is to increase access to high‐quality, affordable health care for all Americans. To meet this goal, the Secretary of the Department of Health and Human Services has established a National Strategy for Quality Improvement in Health Care.1 The National Quality Strategy sets priorities for quality improvement efforts in the US health care system as well as provides a strategic plan for achieving quality goals. Developed with input from stakeholders across the United States, including patients and health care providers, representing community level to state and federal agencies, the National Quality Strategy will pursue three broad aims: better care, affordable care, and healthy people/healthy communities.

Current Resources for Evidence‐based Practice, July/August 2011

Cathy Emeis, PhD, CNM, is an assistant professor in the School of Nursing at Oregon Health & Science University, Portland, OR. Childbirth Connection’s New Transforming Maternity Care Web Site is Timely As US Strategy for Quality Improvement in Health Care Begins An overarching goal of the Aiordable Care Act is to increase access to high-quality, aiordable health care for all Americans. To meet this goal, the Secretary of the Department of Health and Human Services has established a National Strategy for Quality Improvement in Health Care. The National Quality Strategy sets priorities for quality improvement eiorts in the US health care system as well as provides a strategic plan for achieving quality goals. Developed with input from stakeholders across the United States, including patients and health care providers, representing community level to state and federal agencies, the National Quality Strategy will pursue three broad aims: better care, aiordable care, and healthy people/healthy communities.

Posttraumatic Stress Disorder in New Mothers: Results from a Two-Stage U.S. National Survey

Prevalence rates of women in community samples who screened positive for meeting the DSM-IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two-stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP). In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale-Self Report (PSS-SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire-2 (PHQ-2). Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS-SR. A total of 18 percent of women scored above the cutoff score on the PSS-SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health-promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well-being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ-2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey. In this two-stage national survey the high percentage of mothers who screened positive for meeting all the DSM-IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic.

Transforming Maternity Care: Action Steps Toward a High-Quality, High-Value Maternity Care System

In the eight years since publication of the Institute of Medicine’s Crossing the Quality Chasm: A New Health System for the 21st Century (2001), the United States has taken big leaps forward in understanding and addressing broad consequential deficits in health care quality. Until recently, these efforts have largely bypassed a major segment of the health care system, namely, the maternity care delivered to women, newborns, and families who experience over 4.3 million births annually. This oversight is an inadvertent result of current trends, such as a focus on Medicare beneficiaries and a focus on chronic disease. Maternity care holds a major position in the health care system. In 2007, it was the leading reason for hospitalization in the nation, with childbearing women and newborns accounting for 25% of all discharges. Six of the ten most common hospital procedures were maternity related, and cesarean section was the most common operating room procedure (Levit, Wier, Stranges, Ryan, & Elixhauser, 2009). Maternal and newborn hospital charges exceeded $86 billion in 2006, with employers and private insurers paying for 50% of all births and taxpayers/Medicaid paying for 42% (Russo, Wier, & Steiner, 2009). Although most childbearing women and their babies are healthy and at low risk, the current style of maternity care is procedure-intensive and costly. Deficiencies include overuse of many interventions and practices associated with harm and waste; underuse of beneficial practices that would improve outcomes; broad unwarranted geographic, facility, and caregiver practice

Steps Toward Innovative Childbirth Education: Selected Strategies From the <I>Blueprint for Action</I>

To mark the 50th anniversary of Lamaze International, Childbirth Connection celebrates landmark accomplishments in education for childbearing women and families, and takes stock of the changing educational needs and preferences of current childbearing families in looking toward the future. Childbirth Connection's multi-year, multi-stakeholder Transforming Maternity Care initiative resulted in two landmark reports: 2020 Vision for a High-Quality, High-Value Maternity Care System and Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System. Selected recommendations of greatest relevance to the field of childbirth education are discussed, and the new Transforming Maternity Care Partnership is introduced.

Transforming Maternity Care: A High-Value Proposition: Summary of Childbirth Connection 90th Anniversary Symposium Proceedings

On April 3, 2009, in Washington, DC, close to 250 participants gathered at the invitation of Childbirth Connection, in partnership with the Jacobs Institute of Women's Health, at a symposium entitled Transforming Maternity Care: A High-Value Proposition, to share concrete solutions intended to improve the state of the U.S. maternity care system. This paper summarizes the reports that were presented at the symposium, along with responses to each report prepared by invited panelists, and audience comments that were made throughout the event. Papers presented include five stakeholder workgroup reports that will be published online on the Childbirth Connection website, as well as the "2020 Vision for a High-Quality, High-Value Maternity Care System", and "The Role of Medicaid in Promoting Access to High-Quality, High-Value Maternity Care,"" both of which are published in full in the current issue. Participating in the symposium were consumers and advocates, maternity care clinicians and educators, hospital and health system administrators, measurement and quality experts, liability insurers, and private and public maternity care payors and purchasers, as well as policy makers, legislators, journalists and other stakeholders.

Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The “Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System”, issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, “Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?” Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term “2020 Vision for a High Quality, High Value Maternity Care System”, also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the “Blueprint for Action” presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Women’s health—what’s new worldwide

Women’s health—what’s new worldwide

Doing the Right Thing for Women and Babies: Policy Initiatives to Improve Maternity Care Quality and Value

When defined within the context of maternity care, the Institute of Medicine's six aims for health-care quality improvement provide a framework for Childbirth Connection's Maternity Quality Matters Initiative, a multipronged program agenda intended to foster a maternity care system that delivers care of the highest quality and value in order to achieve optimal health outcomes and experiences for mothers and babies. These aims also provide childbirth educators and others in the maternity care community with an ethical framework for efforts to serve childbearing women and families and ensure the best outcomes for women, babies, and families.