Moving from Interprofessional Disarticulation to Transformative Dialogue and Action: Examining a Transdisciplinary Process to Address Equitable Access to High Quality Maternity Care in North America

Maternity providers in North America are in conflict about birth place, debating issues related to safety, autonomy, and quality of care. Very little is known about how birth place interacts with experience and outcomes of maternity care, or about how to resolve these differences among provider disciplines within established health care systems. A multi-stakeholder group of leaders convened at a series of Home Birth Summits in the United States to delineate a Common Ground Agenda, including nine priority areas for action and research. The aim of this doctoral study was to examine how and why this transdisciplinary process generated new evidence and tools that can improve maternity services. Methods I synthesized the results of four original research studies using a range of methodologies as appropriate to the study topic. In the Canadian Birth Place Study, I examine mixed methods data on provider attitudes to place of birth. In the Changing Childbirth in British Colombia (BC) and Giving Voice to Mothers studies, psychometric analysis cross-sectional survey data led to development of four new person-centered measures of experience of maternity care. In the Access and Integration Maternity Care Mapping Study, a Delphi study created a scoring system (MISS) to assess midwifery integration. Correlation and regression analyses elicit linkages between integration and key maternal-newborn outcomes. Finally, I triangulated results of these studies within the Taming Wicked Problems Framework, to elicit an underlying and contributory factor for effective transdisciplinary action. Results Among maternity care providers (n=825), 84% of variance in attitudes to home birth was attributable to provider type alone. Women from diverse backgrounds (n=2051, 3586 pregnancies) reported reduced autonomy and respect when cared for by physicians and when 9 giving birth in institutional settings. Among women in the United States (US) (n=2700), disparities in experiences of care, including mistreatment, links to race, socioeconomic status, place of birth and type of provider. U.S. states with higher midwifery integration and greater access to home birth reported significantly fewer adverse maternal-newborn outcomes and significantly higher rates of physiologic birth. Discussion The participatory approach and synthesis of outcomes of these studies was essential to understand and address inequities in experience and access to quality maternity health services in the US. Person-centered care emerged as a hidden common value that informed a transdisciplinary research process, and community-responsive knowledge translation outputs. Conclusion Increasing knowledge among all types of providers about quality and safety of birth place, and person-centered care, could improve outcomes across birth settings. The Summit process of transdisciplinary engagement reduced interprofessional conflict and facilitated cocreation of evidence and tools that improve quality, safety, and accountability in North American maternity care

Community Versus Out-of-Hospital Birth: What's in a Name?

The term out‐of‐hospital has long been used as a kind of shorthand to refer collectively to births that occur in birth centers or at home. However, this term has also been a persistent cause of concern among health care providers who attend births in these settings, and researchers and midwives are increasingly adopting the term community birth instead to refer to planned home and birth center births. Some who resist the term out‐of‐hospital have argued that it reifies hospital birth as normative and community birth as other, marginal, or alternative. Here we propose community birth as a preferable term because it labels the practice for what it is—instead of for what it is not. This argument is similar to those made by communities of color who have critiqued the use of nonwhite as a demographic category that elevates Euro‐Americans as the default race. Medical anthropologists have also compared the use of the term out‐of‐hospital to the tendency to call nonallopathic forms of healing complementary or alternative. Yet, many so‐called complementary and alternative medicine practitioners prefer to identify their forms of healing as holistic, integrative, or functional to indicate that modalities such as acupuncture, Ayurveda, chiropractic, and so on are autonomous approaches that may exist outside of, but are not subservient to or less than, allopathic and biomedical modalities. These health care providers, too, commonly choose to refer to their practice with terms that convey what it is, rather than what it is not, just as persons of color choose to be identified for who they are, not for who they are not

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

INTRODUCTION: Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009. METHODS: We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth. RESULTS: Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (< 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1000, respectively. DISCUSSION: For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.This is the publisher’s final pdf. The article is copyrighted by the American College of Nurse-Midwives and published by John Wiley & Sons, Inc. It can be found at: http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291542-2011.Keywords: pregnancy outcomes, home childbirth, midwifery, midwife, birth place, perinatal outcom

Development and Validation of a National Data Registry for Midwife-Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset

INTRODUCTION: In 2004, the Midwives Alliance of North America's (MANA's) Division of Research developed a Web-based data collection system to gather information on the practices and outcomes associated with midwife-led births in the United States. This system, called the MANA Statistics Project (MANA Stats), grew out of a widely acknowledged need for more reliable data on outcomes by intended place of birth. This article describes the history and development of the MANA Stats birth registry and provides an analysis of the 2.0 dataset's content, strengths, and limitations. METHODS: Data collection and review procedures for the MANA Stats 2.0 dataset are described, along with methods for the assessment of data accuracy. We calculated descriptive statistics for client demographics and contributing midwife credentials, and assessed the quality of data by calculating point estimates, 95% confidence intervals, and kappa statistics for key outcomes on pre- and postreview samples of records. RESULTS: The MANA Stats 2.0 dataset (2004-2009) contains 24,848 courses of care, 20,893 of which are for women who planned a home or birth center birth at the onset of labor. The majority of these records were planned home births (81%). Births were attended primarily by certified professional midwives (73%), and clients were largely white (92%), married (87%), and college-educated (49%). Data quality analyses of 9932 records revealed no differences between pre- and postreviewed samples for 7 key benchmarking variables (kappa, 0.98-1.00). DISCUSSION: The MANA Stats 2.0 data were accurately entered by participants; any errors in this dataset are likely random and not systematic. The primary limitation of the 2.0 dataset is that the sample was captured through voluntary participation; thus, it may not accurately reflect population-based outcomes. The dataset's primary strength is that it will allow for the examination of research questions on normal physiologic birth and midwife-led birth outcomes by intended place of birth.This is the publisher’s final pdf. The article is copyrighted by the American College of Nurse-Midwives and published by John Wiley & Sons, Inc. It can be found at: http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291542-2011.Keywords: registry, data collection, research design, birth center, cohort study, home childbirth, parturition, midwifer

The Mothers on Respect (MOR) index: measuring quality, safety, and human rights in childbirth

Background: Abuse of human rights in childbirth are documented in low, middle and high resource countries. A systematic review across 34 countries by the WHO Research Group on the Treatment of Women During Childbirth concluded that there is no consensus at a global level on how disrespectful maternity care is measured. In British Columbia, a community-led participatory action research team developed a survey tool that assesses women's experiences with maternity care, including disrespect and discrimination. Methods: A cross-sectional survey was completed by women of childbearing age from diverse communities across British Columbia. Several items (31/130) assessed characteristics of their communication with care providers. We assessed the psychometric properties of two versions of a scale (7 and 14 items), among women who described experiences with a single maternity provider (n=2514 experiences among 1672 women). We also calculated the proportion and selected characteristics of women who scored in the bottom 10th percentile (those who experienced the least respectful care). Results: To demonstrate replicability, we report psychometric results separately for three samples of women (S1 and S2) (n=2271), (S3, n=1613). Analysis of item-to-total correlations and factor loadings indicated a single construct 14-item scale, which we named the Mothers on Respect index (MORi). Items in MORi assess the nature of respectful patient-provider interactions and their impact on a person's sense of comfort, behavior, and perceptions of racism or discrimination. The scale exhibited good internal consistency reliability. MORi- scores among these samples differed by socio-demographic profile, health status, experience with interventions and mode of birth, planned and actual place of birth, and type of provider. Conclusion: The MOR index is a reliable, patient-informed quality and safety indicator that can be applied across jurisdictions to assess the nature of provider-patient relationships, and access to person-centered maternity care