Search

Objective: Investigate maternal and neonatal outcomes following waterbirth. Design: Retrospective cohort study, with propensity score matching to address confounding. Setting: Community births, United States. Sample: Medical records‐based registry data from low‐risk births were used to create waterbirth and land birth groups (n = 17 530 each), propensity score‐matched on >80 demographic and pregnancy risk covariables. Methods: Logistic regression models compared outcomes between the matched waterbirth and land birth groups. Main outcome measures: Maternal: immediate postpartum transfer to a hospital, any genital tract trauma, severe (3rd/4th degree) trauma, haemorrhage >1000 mL, diagnosed haemorrhage regardless of estimated blood loss, uterine infection, uterine infection requiring hospitalisation, any hospitalisation in the first 6 weeks. Neonatal: umbilical cord avulsion; immediate neonatal transfer to a hospital; respiratory distress syndrome; any hospitalisation, neonatal intensive care unit (NICU) admission, or neonatal infection in the first 6 weeks; and neonatal death. Results: Waterbirth was associated with improved or no difference in outcomes for most measures, including neonatal death (adjusted odds ratio [aOR] 0.56, 95% CI 0.31–1.0), and maternal or neonatal hospitalisation in the first 6 weeks (aOR 0.87, 95% CI 0.81–0.92 and aOR 0.95, 95% CI 0.90–0.99, respectively). Increased morbidity in the waterbirth group was observed for two outcomes only: uterine infection (aOR 1.25, 95% CI 1.05–1.48) (but not hospitalisation for infection) and umbilical cord avulsion (aOR 1.57, 95% CI 1.37–1.82). Our results are concordant with other studies: waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. New study demonstrates #waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. @TheUpliftLab @BovbjergMarit @31415926abc @NICHD_NIH. New study demonstrates #waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim. @TheUpliftLab @BovbjergMarit @31415926abc @NICHD_NIH. [ABSTRACT FROM AUTHOR]

Cedar Rapids, IA, offers a unique case study in planning for increased resilience. In 2008, Cedar Rapids experienced severe flooding. Rather than simply rebuilding, the city of Cedar Rapids began to invest in a resilient flood control system and in the revitalization of its Downtown neighborhood. This paper develops a Computable General Equilibrium (CGE) model for the regional economy of Cedar Rapids to quantify 'resilience dividends': net co-benefits of investing in increased resilience. A resilience dividend includes benefits to the community even if another disaster does not occur. We build a CGE model of Cedar Rapids at two different time periods: one in 2007, before the flooding, and one in 2015, after the flooding and initial investment in resilience. We show that a positive economic shock to the economy results in larger co-benefits for key economic indicators in 2015 than in 2007. Our approach illustrates how co-benefits are distributed throughout the economy. [ABSTRACT FROM AUTHOR]

Young adults enrolled in collegiate agricultural programs are a critical audience for agricultural health and safety training. Understanding the farm tasks that young adults engage in is necessary for tailoring health and safety education. The project analyzed evaluation survey responses from the Gear Up for Ag Health and Safety™ program, including reported agricultural tasks, safety concerns, frequency of discussing health and safety concerns with healthcare providers, safety behaviors, and future career plans. The most common tasks reported included operation of machinery and grain-handling. Most participants intended to work on a family-owned agricultural operation or for an agribusiness/cooperative following graduation. Reported safety behaviors (hearing protection, eye protection, and sunscreen use when performing outdoor tasks) differed by gender and education type. Male community college and university participants reported higher rates of “near-misses” and crashes when operating equipment on the roadway. One-third of participants reported discussing agricultural health and safety issues with their medical provider, while 72% were concerned about the health and safety of their family and co-workers in agriculture. These findings provide guidance for better development of agricultural health and safety programs addressing this population—future trainings should be uniquely tailored, accounting for gender and educational differences. [ABSTRACT FROM AUTHOR]

There is limited research exploring agricultural workers' own perspectives on the relative importance of the hazards and stressors they experience. There is also a lack of evidence on whether this reporting differs by method of elicitation. Finally, very little research exists on how to improve mail survey response rates among agricultural workers. We examined health and safety concerns and psychological stressors among Midwestern farmers. We assessed whether these reports varied by survey mode (mail survey versus inperson survey). The efficacy of two different types of incentives to enhance mail survey response rates among agricultural workers was also investigated. In 2018, a needs assessment survey was developed and mailed to a random sample of farm owner-operators in Iowa, Ohio, and Missouri, with randomly assigned prepaid or promised monetary incentives. In-person surveys were conducted among farm owner-operators and hired workers at three regional farm shows in Iowa, Minnesota, and Nebraska. The mail survey response rates were compared by incentive type. Content analysis was used to generate themes associated with health and safety concerns and psychological stressors, which were then ranked by frequency counts. Chi-square tests were used to analyze variation in the distribution of these themes by survey mode. The response rate for the $1 prepaid incentive was double that of the $10 promised incentive. Content analysis identified 13 health and safety concerns and eight psychological stressors. Chemicals, equipment/tools, and health outcomes were the most frequently noted health and safety concerns. Finances, climate/weather, and farm workload and management were the most frequently noted psychological stressors. Although there was considerable overlap in survey responses across mail and in-person respondents, important differences by sample and survey mode characteristics were observed. The results can support a variety of stakeholders in prioritizing and developing interventions and educational resources to address health and safety concerns and psychological stressors among Midwestern farmers. Our findings also contribute to the evidence base on primary data collection methods for agricultural workers. [ABSTRACT FROM AUTHOR]

The purpose of this study was to identify cultural models of breast cancer held by Saudi women and to explore how these may influence early detection and treatment-seeking behaviors. Data were collected via semi-structured interviews with breast cancer survivors (n=20) from two Western cities in Saudi Arabia. Respondents were recruited through social networking, using purposive, snowball sampling. Illness narratives elicited during interviews were transcribed, coded and then analyzed using a modified grounded theory approach. Results suggest that fatalism, perceived threats to traditional role fulfillment, and a preference for traditional therapies commonly mark the breast cancer experiences of Saudi women, influencing their early detection and treatment-seeking behaviors. A more nuanced understanding of emic viewpoints could help to improve public health messaging and intervention strategies in Saudi Arabia. [ABSTRACT FROM AUTHOR]

In this article, I examine the clinical practices engaged in by U.S. homebirth midwives and their clients from the beginning of pregnancy through to the immediate postpartum period, deconstructing them for their symbolic and ritual content. Using data collected from open-ended, semistructured interviews and intensive participant-observation, I describe the roles ritual plays in the construction, performance, and maintenance of birth at home as a transgressive rite of passage. As midwives ritually elaborate approaches to care to capitalize on their semiotic power to transmit a set of counterhegemonic values to participants, they are attempting, quite self-consciously, to peel away the fictions of medicalized birthing care. Their goal: to expose strong and capable women who "grow" and birth babies outside the regulatory and self-regulatory processes naturalized by modern, technocratic obstetrics. Homebirth practices are, thus, not simply evidence-based care strategies. They are intentionally manipulated rituals of technocratic subversion designed to reinscribe pregnant bodies and to reterritorialize childbirth spaces (home) and authorities (midwives and mothers). [ABSTRACT FROM AUTHOR]

Objective: There are lingering concerns in the United States about home birth. We used 2 large (n = 50,043; n = 62,984), national community birth registries to compare maternal and neonatal outcomes for planned home versus planned birth center births., Methods: To compare outcomes by intended birth site, we used logistic regressions, controlling for demographic and pregnancy risk variables. Maternal outcomes included intrapartum or postpartum transfer to hospital, hospitalization, cesarean, and hemorrhage; neonatal outcomes included neonatal transfer, hospitalization, neonatal intensive care unit admission, and intrapartum or neonatal death. Analyses were conducted twice, once in each dataset., Results: Individuals who planned home births had a lower incidence of all types of transfers, compared with those who planned birth center births, but in one dataset only, experienced more cesareans [adjusted odds ratio (95% CI): 1.32 (1.02-1.70); 0.95 (0.88-1.03)]. Planned home birth was associated with lower adjusted odds of maternal hospitalization in one dataset but not the other [0.97 (0.54-1.74); 0.85 (0.76-0.95)], and was not associated with hemorrhage. Neonatal outcomes likewise were either not associated with a planned birthplace or suggested home birth was safer: hospitalization [0.77 (0.53-1.11), 0.90 (0.82-0.98)], neonatal intensive care unit admission [0.54 (0.28-1.00), 0.97 (0.86-1.10)]. There was no observable association with intrapartum or neonatal death: 1.07 (0.68-1.67; only calculated once because of small numbers of events)., Conclusions: Planned home births are as safe as planned birth center births for low-risk pregnancies. Current guidelines advising against planned home births are not supported by these data., Competing Interests: M.C.: Honoraria for talks about waterbirth, midwifery, and birthplace. J.B.: Oregon Health & Science University School of Nursing, statistics consultant. S.V.: Honoraria for talks about midwifery and birthplace. The remaining authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Farmers experience high rates of mental health conditions and suicide. It is within occupational therapy's scope to address mental health conditions in patients as it pertains to their participation in meaningful occupations. The aim of this study is to assess the efficacy of training provided to occupational therapy practitioners and students on addressing farmer mental health. Participants were directly recruited from occupational therapy state associations and graduate programs in the American Midwest to attend a 1-hour presentation and complete pre- and post-training surveys. A total of 119 participants completed the pre- and post-training surveys. Both occupational therapy practitioners and students significantly increased their confidence in assessing and addressing mental health concerns and providing resources to farmers following the training. Occupational therapy-specific training can increase therapists' confidence in addressing farmer mental health. Further research should assess multi-faceted interventions related to farmers' mental health in occupational therapy practice., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: 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)., Design: Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats)., Setting: Planned community birth (homes and birth centers), United States., Sample: Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset., Methods: Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes., Main Outcome Measures: 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., Results: 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., Conclusions: 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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Schafer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Increasingly, pregnant people in the United States are choosing to give at birth at home, and certified professional midwives (CPMs) often attend these births. Care by midwives, including home birth midwives, has the potential to decrease unnecessary medical interventions and their associated health care costs, as well as to improve maternal satisfaction with care. However, lack of integration into the health care system affects the ability of CPMs to access standard medications and testing for their clients, including prenatal screening. Genetics and genomics are now a routine part of prenatal screening, and genetic testing can contribute to identifying candidates for planned home birth. However, research on genetics and midwifery care has not, to date, included the subset of midwives who attend the majority of planned home births, CPMs. The purpose of this study was to examine CPMs' access to, and perspectives on, one aspect of prenatal care, genetic counselors and genetic counseling services. Using semi-structured interviews and a modified grounded theory approach to narrative analysis, we identified three key themes: (1) systems-level issues with accessing information about genetic counseling and genetic testing; (2) practice-level patterns in information delivery and self-awareness about knowledge limitations; and (3) client-level concerns about the value of genetic testing relative to difficulties with access and stress caused by the information. The results of this study can be used to develop decision aids that include information about genetic testing and genetic counseling access for pregnant people intending home births in the United States., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In this article, we present findings from a qualitative narrative analysis that examined the pregnancy, primary cesarean, and subsequent birth experiences of women in the United States. Using a maximal variation sampling strategy, we recruited participants via social media and networking to participate in semistructured interviews. Twenty-five women from diverse backgrounds and geographic locations across the U.S. participated, eight self-identified as racialized and seventeen as non-Hispanic, White. Data were analyzed iteratively using Clandinin and Connelly's approach to Narrative Inquiry. Across their narratives, participants described their experiences of maternity care that were either generally negative (dehumanizing care) or positive (humanized care). They further described how their experiences of dehumanizing or humanized care impacted their decision-making for subsequent births, mental health, relationships with the healthcare system, early parenting birth satisfaction, and family planning. Findings suggest that regardless of ultimate mode of birth, what was most important to women was how they are treated by their maternity care team. We suggest practice changes that may improve the experience of maternity care for primary cesarean and subsequent births, especially among those made marginal by systems of oppression.

Background: Preventing postpartum depression (PPD) is the most common self-reported motivation for human maternal placentophagy, yet very little systematic research has assessed mental health following placenta consumption. Our aim was to compare PPD screening scores of placenta consumers and non-consumers in a community birth setting, using propensity score matching to address anticipated extensive confounding., Methods: We used a medical records-based data set (n = 6038) containing pregnancy, birth, and postpartum information for US women who planned and completed community births. We first compared PPD screening scores as measured by the Edinburgh Postpartum Depression Scale (EPDS) of individuals who consumed their placenta to those who did not, with regard to demographics, pregnancy characteristics, and history of mental health challenges. Matching placentophagic (n = 1876) and non-placentophagic (n = 1876) groups were then created using propensity scores. The propensity score model included more than 90 variables describing medical and obstetric history, demographics, pregnancy characteristics, and intrapartum and postpartum complications, thus addressing confounding by all of these variables. We then used logistic regression to compare placentophagic to non-placentophagic groups based on commonly-cited EPDS cutoff values (≥ 11; ≥ 13) for likely PPD., Results: In the unmatched and unadjusted analysis, placentophagy was associated with an increased risk of PPD. In the matched sample, 9.9% of women who ate their placentas reported EPDS ≥ 11, compared to 8.4% of women who did not (5.5% and 4.8%, respectively, EPDS ≥ 13 or greater). After controlling for over 90 variables (including prior mental health challenges) in the matched and adjusted analysis, placentophagy was associated with an increased risk of PPD between 15 and 20%, depending on the published EPDS cutoff point used. Numerous sensitivity analyses did not alter this general finding., Conclusions: Placentophagic individuals in our study scored higher on an EPDS screening than carefully matched non-placentophagic controls. Why placentophagic women score higher on the EPDS remains unclear, but we suspect reverse causality plays an important role. Future research could assess psychosocial factors that may motivate some individuals to engage in placentophagy, and that may also indicate greater risk of PPD., (© 2023. The Author(s).)

Objective: Hair cortisol is a noninvasive, long-term biomarker of human stress. Strengths and weaknesses of this biomarker as a proxy measure of perinatal stress are not yet well understood. Hair cortisol data were collected from pregnant women in Puerto Rico to investigate maternal cortisol level variance across pregnancy., Methods: In 2017, we recruited 86 pregnant women planning to birth at a large urban hospital. We aimed to collect four hair samples from each participant, one in each trimester and one in the postpartum period., Results: Median cortisol in the first trimester (n = 82) was 5.7 picograms/milligram (pg/mg) (range: 1.0-62.4). In the second, third, and postpartum periods, the medians were 6.8 pg/mg (1.0-69.5), (n = 46), 20.1 pg/mg (5.6-89.0), (n = 30), and 14.1 pg/mg (1.7-39.8), (n = 9), respectively. These medians disguise a 10-fold and 50-fold variability for two participants. Our sample sizes declined sharply when Hurricane Maria caused major disruptions in services and participants' lives., Conclusion: Maternal hair cortisol concentrations were lower in the first and second trimester than the third trimester and early postpartum period. We also observed a wide range of variation in cortisol levels throughout pregnancy and in the postpartum period., (© 2022 Wiley Periodicals LLC.)

Objective: High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S., Methods: Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother's Autonomy in Decision Making Scale; MADM)., Results: Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician., Conclusion: Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes., Competing Interests: The authors have declared that no competing interests exist.

Background: Low birthweight (LBW) and preterm birth (PTB) are more common among Black infants than white infants in the United States. Although multiple hypotheses have been proposed to explain elevated rates of PTB and LBW, the perspectives of Black midwives who serve Black communities are largely missing from the literature., Methods: Using semi-structured interviews and focus groups with a purposive sample of midwives (n = 29), we elicited midwives' perceptions of PTB and LBW causation, as well as insights on culturally congruent strategies for prevention. We used consensus coding and reciprocal ethnography to increase the rigor of our analyses., Results: Midwives identified three intersecting and predisposing root causes: (1) systemic racism; (2) the epigenetic legacy of enslavement; and (3) ongoing cultural loss. In response to these stressors, midwives recommended variants of two additional themes-(4) community building; and (5) culturally centered care-as essential to reversing mortality trends among Black babies., Discussion: Midwives' perspectives, which are supported by relevant literature, provide critical insights that should inform both research and policy aimed at promoting birth justice in the United States and beyond., (© 2022 Wiley Periodicals LLC.)

Background: Friedman's curve, despite acknowledged limitations, has greatly influenced labour management. Interventions to hasten birth are now ubiquitous, challenging the contemporary study of normal labour. Our primary purpose was to characterise normal active labour and pushing durations in a large, contemporary sample experiencing minimal intervention, stratified by parity, age, and body mass index (BMI)., Methods: This is a secondary analysis of the national, validated Midwives Alliance of North America 4·0 (MANA Stats) data registry ( n  = 75,243), prospectively collected between Jan 1, 2012 and Dec 31, 2018 to describe labour and birth in home and birth center settings where common obstetric interventions [i.e., oxytocin, planned cesarean] are not available. The MANA Stats cohort includes pregnant people who intended birth in these settings and prospectively collects labour and birth processes and outcomes regardless of where birth or postpartum care ultimately occurs. Survival curves were calculated to estimate labour duration percentiles (e.g. 10th, 50th, 90th, and others of interest), by parity and sub-stratified by age and BMI., Findings: Compared to multiparous women ( n  = 32,882), nulliparous women ( n  = 15,331) had significantly longer active labour [e.g., median 7.5 vs. 3.3 h; 95th percentile 34.8 vs. 12.0 h] and significantly longer pushing phase [e.g., median 1.1 vs. 0.2 h; 95th percentile 5.5 vs. 1.1 h]. Among nulliparous women, maternal age >35 was associated with longer active first stage of labour and longer pushing phase, and BMI >30 kg/m² was associated with a longer active first stage of labour but a shorter pushing phase. Patterns among multiparous women were different, with those >35 years of age experiencing a slightly more rapid active labour and no difference in pushing duration, and those with BMI >30 kg/m² experiencing a slightly longer active labour but, similarly, no difference in pushing duration., Interpretation: Nulliparous women had significantly longer active first stage and pushing phase durations than multiparous women, with further variation noted by age and by BMI. Contemporary US women with low-risk pregnancies who intended birth in settings absent common obstetric interventions and in spontaneous labour with a live, vertex, term, singleton, non-anomalous fetus experienced labour durations that were often longer than prior characterizations, particularly among nulliparous women. Results overcome prior and current sampling limitations to refine understanding of normal labour durations and time thresholds signaling 'labour dystocia'., Funding: OHSU Nursing Innovation and OHSU University Shared Resources., Competing Interests: ET declares the following interests: Co-Owner and Chief Scientific Officer for CenterMom, Inc. She has stock ownership in this company. Consultant and Director of Maternity Care for Stork Club, Inc. She receives payment for her work with Stork Club. JS, MC, MB, JL, JW, and AC have nothing to disclose., (© 2022 The Author(s).)

Despite persistent efforts to advance infant death investigation, most sudden unexpected infant deaths (SUIDs) remain unexplained. Law enforcement officials contribute to SUID investigations throughout the United States, but their impacts on these investigations have not been adequately examined. In this exploratory study, 26 law enforcement officials were interviewed about their experiences and perspectives with SUID investigations. Thematic analysis of qualitative data revealed three specific difficulties law enforcement encounter during SUID investigations: (1) inadequate preparation; (2) overwhelming emotions; and (3) a victim-suspect dilemma. Findings indicate that these barriers may inhibit consistent and reliable investigation of infant death and, therefore, may impede the cause and manner of death determinations. Participants' narratives also offered insights into potential solutions, including expanded SUID training for law enforcement and use of checklists, such as the Sudden Unexpected Infant Death Investigation Reporting Form. The impacts of overwhelming emotions confronted during SUID investigation warrant further study. The victim-suspect dilemma stems from the inability of law enforcement to conclusively eliminate the possibility of homicide. This dilemma may be resolved through a clear distinction between interactions with potential evidence and interactions with the family. Law enforcement must be trained to treat all SUID families in a compassionate and non-accusatory manner, while investigating all SUID with careful attention to detail that is essential in any potential homicide investigation. A consistent, meticulous, and compassionate approach to SUID investigations will improve the reliability of information obtained and offer the best opportunity for providing answers to grieving parents., (© 2022 American Academy of Forensic Sciences.)

The authors' purpose in conducting this study was to identify barriers faced by survivors of intimate partner violence (IPV) in accessing services in Gaza. We collected data via in-depth interviews with women (ages 18-49; n   =   25). Respondents were recruited through convenience sampling from women's organizations. Interviews were transcribed, translated, and coded using an inductive approach. Results indicate three main factors that influence help-seeking: perceived transgression of traditional gender roles; distrust of women's centers; and contextual acceptance of IPV. An understanding of emic perceptions of IPV can inform the design and delivery of support services and increase access to interventions for women in Gaza.

'Medical iatrogenesis' was first defined by Illich as injuries 'done to patients by ineffective, unsafe, and erroneous treatments'. Following Lokumage's original usage of the term, this paper explores 'obstetric iatrogenesis' along a spectrum ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym 'UHDVA' for this spectrum. This paper draws attention to the systemic maltreatment rooted in the technocratic model of birth, which includes UH normalized forms of mistreatment that childbearers and providers may not recognize as abusive. Equally, this paper assesses how obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC childbearers. Much of the work on 'obstetric violence' that documents the most detrimental end of the UHDVA spectrum has focused on low-to-middle income countries in Latin America and the Caribbean. Based on a dataset of 62 interviews and on our personal observations, this paper shows that significant UHDVA also occurs in the high-income U.S., provide concrete examples, and suggest humanistic solutions.

Background: Vaginal birth after cesarean (VBAC) is safe, cost-effective, and beneficial. Despite professional recommendations supporting VBAC and high success rates, VBAC rates in the United States (US) have remained below 15% since 2002. Very little has been written about access to VBAC in the United States from the perspectives of birthing people. We describe findings from a mixed methods study examining experiences seeking a VBAC in the United States., Methods: Individuals with a history of cesarean and recent subsequent birth were recruited through social media groups. Using an online questionnaire, we collected sociodemographic and birth history information, qualitative accounts of participants' experiences, and scores on the Mothers on Respect Index, the Mothers Autonomy in Decision Making Scale, and the Generalized Self-Efficacy Scale., Results: Participants (N = 1711) representing all 50 states completed the questionnaire; 1151 provided qualitative data. Participants who planned a VBAC reported significantly greater decision-making autonomy and respectful treatment in their maternity care compared with those who did not. The qualitative theme: "I had to fight for my VBAC" describes participants' accounts of navigating obstacles to VBAC, including finding a supportive provider and traveling long distances to locate a clinician and/or hospital willing to provide care. Participants cited support from providers, doulas, and peers as critical to their ability to acquire the requisite knowledge and power to effectively self-advocate., Discussion: Findings highlight the difficulties individuals face accessing VBAC within the context of a complex health system and help to explain why rates of attempted VBAC remain low., (© 2020 Wiley Periodicals LLC.)

Objectives : The National Institute for Occupational Safety and Health (NIOSH) Agriculture, Forestry, and Fishing Centers (AFF Centers) collaborated to initiate a joint YouTube channel in order to raise awareness of agricultural, forestry, and fishing occupational hazards; provide information to prevent AFF injuries and illnesses; increase the visibility and influence of the AFF Centers; and establish a collaborative model that can be replicated by other organizations. Methods : The collaborators sought to produce a structured channel with high scientific standards. Policies, procedures, and a standard review process were established. Representatives from the AFF Centers coordinated the review process and the procedures by which videos were uploaded to the site. A marketing plan was created including a press release and ideas to promote new videos. Promotions are targeted to agricultural cooperative extension agents, educators, producers, owners, operators, first responders, families and community organizations. Viewership was tracked using YouTube metrics. Results : The site was launched in November 2013. Over a 6-year period, the channel grew from 48 videos to 125 videos with over 10,500 cumulative watch time hours. The channel is promoted by the AFF Centers through email, social media, conference presentations and outreach exhibits. The channel is also publicized during coordinated national outreach events. Conclusion : Each AFF Center benefitted from increased exposure of their content and the collaboration provided an opportunity to achieve labor efficiencies. YouTube metrics demonstrated that coordinated marketing increases views, watch time and subscriptions. In addition, the success of the channel communicates the benefits to collaboration among organizations with common missions.

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of the WHO's new Labour Care Guide and commentaries on reviews focused on prevention of mastitis in women during the postpartum period and a comparison of outcomes for fresh versus frozen embryos for in vitro fertilization., (Copyright © 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Fetal macrosomia is associated with negative outcomes, although less is known about how severities of macrosomia influence these outcomes. Planned community births in the United States have higher rates of gestational age-adjusted macrosomia than planned hospital births, providing a novel population to examine macrosomia morbidity., Methods: Maternal and neonatal outcomes associated with grade 1 (4000-4499 g), grade 2 (4500-4999 g), and grade 3 (≥5000 g) macrosomia were compared to normal birthweight newborns (2500-3999 g), using data from the MANA Statistics Project-a registry of planned community births, 2012-2018 (n = 68 966). Outcomes included perineal trauma, postpartum hemorrhage, cesarean birth, neonatal birth injury, shoulder dystocia, neonatal respiratory distress, neonatal intensive care unit (NICU) stay >24 hours, and perinatal death. Logistic regressions controlled for parity and mode of birth, obesity, gestational diabetes, and preeclampsia., Results: Sixteen percent of the sample were grade 1 macrosomic, 3.3% were grade 2 macrosomic, and 0.4% were grade 3 macrosomic. Macrosomia grades 1-3 were associated in a dose-response fashion with higher odds of all outcomes, compared to non-macrosomia. The adjusted odds ratios and 95% confidence intervals for postpartum hemorrhage for grade 1, grade 2, and grade 3 macrosomia vs normal birthweight were 1.75 (1.56-1.96), 2.12 (1.70-2.63), and 5.18 (3.47-7.74), respectively. Other outcomes had similar patterns., Discussion: The adjusted odds of negative outcomes increase as grade of macrosomia increases in planned community births; results are comparable with the published literature. Pre-birth fetal weight estimation is imprecise; prenatal supports and shared decision-making processes should reflect these complexities., (© 2020 Wiley Periodicals LLC.)

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of whether it is ethical not to offer doula care to all women, and commentaries on reviews focused on folic acid and autism spectrum disorder, and timing of influenza vaccination during pregnancy., (Copyright © 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Cedar Rapids, IA, offers a unique case study in planning for increased resilience. In 2008, Cedar Rapids experienced severe flooding. Rather than simply rebuilding, the city of Cedar Rapids began to invest in a resilient flood control system and in the revitalization of its Downtown neighborhood. This paper develops a Computable General Equilibrium (CGE) model for the regional economy of Cedar Rapids to quantify 'resilience dividends': net co-benefits of investing in increased resilience. A resilience dividend includes benefits to the community even if another disaster does not occur. We build a CGE model of Cedar Rapids at two different time periods: one in 2007, before the flooding, and one in 2015, after the flooding and initial investment in resilience. We show that a positive economic shock to the economy results in larger co-benefits for key economic indicators in 2015 than in 2007. Our approach illustrates how co-benefits are distributed throughout the economy., Competing Interests: Disclosure statement No potential conflict of interest was reported by the author(s).

Although Apgar scores are commonly used as proxy outcomes, little evidence exists in support of the most common cutpoints (<7, <4). We used 2 data sets to explore this issue: one contained planned community births from across the United States (n = 52,877; 2012-2016), and the other contained hospital births from California (n = 428,877; 2010). We treated 5-minute Apgars as clinical "tests," compared against 18 known outcomes; we calculated sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for each. We used 3 different criteria to determine optimal cutpoints. Results were very consistent across data sets, outcomes, and all subgroups: The cutpoint that maximizes the trade-off between sensitivity and specificity is universally <9. However, extremely low positive predictive values for all outcomes at <9 indicate more misclassification than is acceptable for research. The areas under the receiver operating characteristic curves (which treat Apgars as quasicontinuous) were generally indicative of adequate discrimination between infants destined to experience poor outcomes and those not; comparing median Apgars between groups might be an analytical alternative to dichotomizing. Nonetheless, because Apgar scores are not clearly on any causal pathway of interest, we discourage researchers from using them unless the motivation for doing so is clear., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Radiocarbon dating of the earliest occupational phases at the Cooper's Ferry site in western Idaho indicates that people repeatedly occupied the Columbia River basin, starting between 16,560 and 15,280 calibrated years before the present (cal yr B.P.). Artifacts from these early occupations indicate the use of unfluted stemmed projectile point technologies before the appearance of the Clovis Paleoindian tradition and support early cultural connections with northeastern Asian Upper Paleolithic archaeological traditions. The Cooper's Ferry site was initially occupied during a time that predates the opening of an ice-free corridor (≤14,800 cal yr B.P.), which supports the hypothesis that initial human migration into the Americas occurred via a Pacific coastal route., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Background: Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study., Methods: Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables., Results: Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment., Conclusion: This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

There has been a small, but significant, increase in community births (home and birth-center births) in the United States in recent years. The rate increased by 20% from 2004 to 2008, and another 59% from 2008 to 2012, though the overall rate is still low at less than 2%. Although the United States is not the only country with a large majority of births occurring in the hospital, there are other high-resource countries where home and birth-center birth are far more common and where community midwives (those attending births at home and in birth centers) are far more central to the provision of care. In many such countries, the differences in perinatal outcomes between hospital and community births are small, and there are lower rates of maternal morbidity in the community setting. In the United States, perinatal mortality appears to be higher for community births, though there has yet to be a national study comparing outcomes across settings that controls for planned place of birth. Rates of intervention, including cesarean delivery, are significantly higher in hospital births in the United States. Compared with the United States, countries that have higher rates of community births have better integrated systems with clearer national guidelines governing risk criteria and planned birth location, as well as transfer to higher levels of care. Differences in outcomes, systems, approaches, and client motivations are important to understand, because they are critical to the processes of person-centered care and to risk reduction across all birth settings.

Objective Periviable birth accounts for a very small percentage of preterm deliveries but a large proportion of perinatal and neonatal morbidity. Understanding parental experiences during and after periviable deliveries may help healthcare providers determine how to best support women during these medically complex, emotionally charged clinical encounters. Methods This is a qualitative study with a voluntary sample of women who delivered between 22 and 25 weeks gestation at an academic medical center from 2014 to 2016. Women's narratives of each periviable birth experience were transcribed and analyzed using consensus coding and a grounded theory approach to identify key themes that describe parental experiences. Results A total of 10 women were interviewed. Four emergent temporal themes: (1) the time preceding admission: feeling dismissed; (2) transfer or admission to a tertiary care center: anxiety and doubt; (3) the birth itself: fear of the outcome; and (4) the postpartum period: reflection and communication. Conclusions for practice Women that experience a periviable birth may benefit from continuous support and clear communication. Overall, care for these patients should be expanded to address the specific psychosocial needs identified during the distinctive, periviable temporal themes that emerged during interviews. Continuous longitudinal support in the form of a designated person or team should be provided to women experiencing a potential periviable birth in order to help mitigate the fear and anxiety associated with these complex birth experiences.

Background: Limited systematic research on maternal placentophagy is available to maternity care providers whose clients/patients may be considering this increasingly popular practice. Our purpose was to characterize the practice of placentophagy and its attendant neonatal outcomes among a large sample of women in the United States., Methods: We used a medical records-based data set (n = 23 242) containing pregnancy, birth, and postpartum information for women who planned community births. We used logistic regression to determine demographic and clinical predictors of placentophagy. Finally, we compared neonatal outcomes (hospitalization, neonatal intensive unit admission, or neonatal death in the first 6 weeks) between placenta consumers and nonconsumers, and participants who consumed placenta raw vs cooked., Results: Nearly one-third (30.8%) of women consumed their placenta. Consumers were more likely to have reported pregravid anxiety or depression compared with nonconsumers. Most (85.3%) placentophagic mothers consumed their placentas in encapsulated form, and nearly half (48.4%) consumed capsules containing dehydrated, uncooked placenta. Placentophagy was not associated with any adverse neonatal outcomes. Women with home births were more likely to engage in placentophagy than women with birth center births. The most common reason given (73.1%) for engaging in placentophagy was to prevent postpartum depression. [Corrections added on 16 May 2018, after first online publication: The percentage values in the Results sections were updated.] CONCLUSIONS: The majority of women consumed their placentas in uncooked/encapsulated form and hoping to avoid postpartum depression, although no evidence currently exists to support this strategy. Preparation technique (cooked vs uncooked) did not influence adverse neonatal outcomes. Maternity care providers should discuss the range of options available to prevent/treat postpartum depression, in addition to current evidence with respect to the safety of placentophagy., (© 2018 Wiley Periodicals, Inc.)

This is the largest study to-date to report on outcomes of care for a national sample of doula-supported adolescent births ( n = 1,892, birth years 2000 to 2013). Descriptive statistics were calculated for maternal demographics, risk profiles, labor/birth interventions and occurrences, and birth outcomes. In this national sample, childbearing adolescents and their neonates experienced improved health outcomes and lower rates of intervention relative to national statistics for adolescent deliveries in the United States. Key findings are consistent with previous studies on the effects of doula care for marginalized and medically underserved communities. Results strengthen the case for doulas as a perinatal care strategy for improving maternal and infant health outcomes and decreasing inequities among childbearing adolescents.

Background: Approximately 22% of women in the United States live in rural areas with limited access to obstetric care. Despite declines in hospital-based obstetric services in many rural communities, midwifery care at home and in free standing birth centers is available in many rural communities. This study examines maternal and neonatal outcomes among planned home and birth center births attended by midwives, comparing outcomes for rural and nonrural women., Methods: Using the Midwives Alliance of North America Statistics Project 2.0 dataset of 18 723 low-risk, planned home, and birth center births, rural women (n = 3737) were compared to nonrural women. Maternal outcomes included mode of delivery (cesarean and instrumental delivery), blood transfusions, severe events, perineal lacerations, or transfer to hospital and a composite (any of the above). The primary neonatal outcome was a composite of early neonatal intensive care unit or hospital admissions (longer than 1 day), and intrapartum or neonatal deaths. Analysis involved multivariable logistic regression, controlling for sociodemographics, antepartum, and intrapartum risk factors., Results: Rural women had different risk profiles relative to nonrural women and reduced risk of adverse maternal and neonatal outcomes in bivariable analyses. However, after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal (adjusted odds ratio [aOR] 1.05 [95% confidence interval {CI} 0.93-1.19]) or neonatal (aOR 1.13 [95% CI 0.87-1.46]) outcomes between rural and nonrural pregnancies., Conclusion: Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status., (© 2017 Wiley Periodicals, Inc.)

Uganda has one of the highest obstetric fistula rates in the world with approximately 200,000 women currently suffering. Surgical closure successfully treats fistula in the majority of cases, yet there is a severe shortage of facilities and trained surgeons in low-resource countries. The purpose of this study was to examine Ugandan women's experiences of obstetric fistula with the aim of adding narrative depth to the clinical literature on this devastating birth injury. Data were collected through semistructured interviews, focus groups, and participant observation. Resulting narratives were consensus coded, and key themes were member-checked using reciprocal ethnography. Women who suffered from fistula described barriers in accessing essential obstetric care during labor-barriers that are consistent with the three delays framework developed by Thaddeus and Maine. In this article, we extend this scholarship to discuss a fourth, critical delay experienced by fistula survivors-the delay in the diagnosis and treatment of their birth injury.

Methods: Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race., Results: MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state., Conclusion: The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Background: There is little agreement on who is a good candidate for community (home or birth center) birth in the United States., Methods: Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education., Results: The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups., Discussion: The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting., (© 2017 Wiley Periodicals, Inc.)

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Data on the safety of waterbirth in the United States are lacking., Methods: We used data from the Midwives Alliance of North America Statistics Project, birth years 2004 to 2009. We compared outcomes of neonates born underwater waterbirth (n = 6534), neonates not born underwater nonwaterbirth (n = 10,290), and neonates whose mothers intended a waterbirth but did not have one intended waterbirth (n = 1573). Neonatal outcomes included a 5-minute Apgar score of less than 7, neonatal hospital transfer, and hospitalization or neonatal intensive care unit (NICU) admission in the first 6 weeks. Maternal outcomes included genital tract trauma, postpartum hospital transfer, and hospitalization or infection (uterine, endometrial, perineal) in the first 6 weeks. We used logistic regression for all analyses, controlling for primiparity., Results: Waterbirth neonates experienced fewer negative outcomes than nonwaterbirth neonates: the adjusted odds ratio (aOR) for hospital transfer was 0.46 (95% confidence interval [CI], 0.32-0.68; P < .001); the aOR for infant hospitalization in the first 6 weeks was 0.75 (95% CI, 0.63-0.88; P < .001); and the aOR for NICU admission was 0.59 (95% CI, 0.46-0.76; P < .001). By comparison, neonates in the intended waterbirth group experienced more negative outcomes than the nonwaterbirth group, although only 5-minute Apgar score was significant (aOR, 2.02; 95% CI, 1.40-2.93; P < 0001). For women, waterbirth (compared to nonwaterbirth) was associated with fewer postpartum transfers (aOR, 0.65; 95% CI, 0.50-0.84; P = .001) and hospitalizations in the first 6 weeks (aOR, 0.72; 95% CI, 0.59-0.87; P < 0.001) but with an increased odds of genital tract trauma (aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Waterbirth was not associated with maternal infection. Women in the intended waterbirth group had increased odds for all maternal outcomes compared to women in the nonwaterbirth group, although only genital tract trauma was significant (aOR, 1.67; 95% CI, 1.49-1.87; P < .001)., Discussion: Waterbirth confers no additional risk to neonates; however, waterbirth may be associated with increased risk of genital tract trauma for women., (© 2016 by the American College of Nurse-Midwives.)

In the past month, two new studies have been released-one in The New England Journal of Medicine (NEJM; Snowden et al., 2015) and the other in the Canadian Medical Association Journal (Hutton et al., 2015)-comparing out-of-hospital birth outcomes to hospital birth outcomes. These studies join a growing body of literature that consistently shows high rates of obstetric intervention in hospitals and also show low risk to neonates regardless of setting. However, the recent NEJM study found a small but statistically significant increase in risk for perinatal mortality for babies born out of hospital. Jeanette McCulloch of BirthSwell (http://www.birthswell.com) interviews Melissa Cheyney, PhD, CPM, LDM, medical anthropologist, chair of the Midwives Alliance Division of Research, and lead author on the largest study of outcomes for planned home births in the United States to date (Cheyney et al., 2014a), and Jonathan Snowden, PhD, epidemiologist and assistant professor in the Department of Obstetrics and Gynecology and School of Public Health at Oregon Health and Science University. Snowden is also the lead author of the recent NEJM study.

Background: In the United States, the number of planned home vaginal births after cesarean (VBACs) has increased. This study describes the maternal and neonatal outcomes for women who planned a VBAC at home with midwives who were contributing data to the Midwives Alliance of North America Statistics Project 2.0 cohort during the years 2004-2009., Method: Two subsamples were created from the parent cohort: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. Descriptive statistics were calculated for maternal and neonatal outcomes for both groups. Sensitivity analyses comparing women with a prior vaginal birth and those who were at the lowest risk with various subgroups in the parent cohort were also conducted., Results: Women with a prior cesarean had a VBAC rate of 87 percent, although transfer rates were higher compared with women without a prior cesarean (18% vs 7%, p < 0.001). The most common indication for transfer was failure to progress. Women with a prior cesarean had higher proportions of blood loss, maternal postpartum infections, uterine rupture, and neonatal intensive care unit admissions than those without a prior cesarean. Five neonatal deaths (4.75/1,000) occurred in the prior cesarean group compared with 1.24/1,000 in multiparas without a history of cesarean (p = 0.015)., Conclusion: Although there is a high likelihood of a vaginal birth at home, women planning a home VBAC should be counseled regarding maternal transfer rates and potential for increased risk to the newborn, particularly if uterine rupture occurs in the home setting., (© 2015 Wiley Periodicals, Inc.)

Introduction: No data describing certified professional midwives (CPMs) currently exist in the literature, although CPMs attend the majority of home births in the United States. This study addresses this gap by assessing the demographics, education levels, routes to certification, and practice characteristics of currently practicing CPMs., Methods: Data were collected from a survey of CPMs conducted by the North American Registry of Midwives (NARM) between July and October 2011. In order to assess generalization to the entire population of practicing CPMs, we also completed a nonresponse bias analysis. We examined midwives' demographic, education, certification, and practice characteristics using descriptive and nonparametric, bivariable statistics., Results: More than 90% of the 568 respondents attended at least some college, and 47.1% hold a bachelor's degree or greater. CPMs spent a median of 3 years (interquartile range, 2-5 years) in training before attending births as a primary midwife. However, 38.9% of currently practicing CPMs had less than 3 years of training. Regarding pathways to certification, 48.5% utilized the portfolio evaluation process (PEP); 36.9% graduated from a Midwifery Education and Accreditation Council (MEAC)-accredited school; 14.5% were already licensed by a state as a direct-entry midwife; and 0.7% were already a certified nurse-midwife or certified midwife, although many CPMs reported a blended education pathway. One-fifth (21%) of respondents identified as midwives of color. Whereas nearly one-third (31.8%) of CPM respondents reported that 95% or more of their clients were white, 5.2% serve populations that are 90% or more nonwhite. CPMs of color are significantly more likely to serve clients of color (P < .001)., Discussion: Training and nonmidwifery education levels of most CPMs practicing in the United States align with the Global Standards for Midwifery Education established by the International Confederation of Midwives, although there are still clear areas for improvement., (© 2015 by the American College of Nurse-Midwives.)