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Evidence-based recommendations for preventive health.

Background: Intermittent fetal monitoring (IFM) is a recommended strategy for intrapartum fetal heart rate assessment in low-risk pregnancies; however, this "high touch, low tech" approach is underutilized., Objective: The aim of the study was to examine the relationships between labor and delivery nurses' intellectual capital and their perceptions of barriers to research utilization in the work setting., Methods: A cross-sectional correlational design using data derived from a larger study of labor and delivery nurses (N = 248) was used. Covell's theory of nursing intellectual capital was used as the conceptual and analytic framework to examine labor and delivery nurses' intellectual capital and their perceived barriers to research utilization., Results: Nurses who receive paid time off from their employer to attend conferences (p < .01) and nurses who do not report nurse-to-patient ratios as a problem in providing IFM (p < .01) perceive fewer barriers to research utilization., Discussion: Time, especially available time, has an effect on labor and delivery nurses' attitude toward IFM and their perceptions of barriers to research utilization.

Background: Nearly a third of women in the United States deliver by cesarean at first childbirth. The extent to which women's prenatal mode of delivery preference contributes to the cesarean decision is not clear. Little research has measured pregnant nulliparous women's prelabor mode of delivery preference in relation to actual mode of delivery in the United States. Materials and Methods: A total of 3006 pregnant nulliparous women were asked about mode of delivery preference during pregnancy as part of the First Baby Study, a prospective study of women delivering in Pennsylvania hospitals, 2009-2011. Multivariable regression models were used to assess the association between women's preference for cesarean delivery and two decision stages: (1) the decision to have planned prelabor cesarean and (2) the intrapartum decision to have unplanned cesarean among those attempting vaginal delivery, adjusting for confounders. Results: Overall, 3.1% preferred cesarean delivery, 3.0% had no preference, and 93.9% preferred vaginal. Among those who preferred vaginal delivery, 4% had a planned cesarean; among those with no preference, 13.3% did; and among those who preferred cesarean, 33.7% did. In adjusted models, preference for cesarean was strongly associated with having planned prelabor cesarean (adjusted odds ratio [aOR] = 6.02; 95% confidence interval [CI] = 3.26-11.12), but was not significantly associated with unplanned cesarean among those who attempted vaginal delivery (aOR = 1.35; 95% CI = 0.77-2.38). Conclusions: Although preference for cesarean delivery among nulliparous women was uncommon, women who preferred cesarean were more likely to have planned prelabor cesarean delivery than those who preferred vaginal delivery.

The postpartum period represents a critical window to initiate targeted interventions to improve cardiometabolic health following pregnancies complicated by gestational diabetes mellitus and/or a hypertensive disorder of pregnancy. The purpose of this systematic review was to examine studies published since 2011 that report rates of postpartum follow-up and risk screening for women who had gestational diabetes and/or a hypertensive disorder of pregnancy and to identify disparities in care. Nine observational studies in which postpartum follow-up visits and/or screening rates were measured among US women following pregnancies complicated by gestational diabetes and/or a hypertensive disorder of pregnancy were reviewed. Rates of postpartum follow-up ranged from 5.7% to 95.4% with disparities linked to black race and Hispanic ethnicity, low level of education, and coexisting morbidities such as mental health disorders. Follow-up rates were increased if the provider was an obstetrician/endocrinologist versus primary care. Payer source was not associated with follow-up rates. The screening rate for diabetes in women who had gestational diabetes did not exceed 58% by 4 months across the studies analyzed, suggesting little improvement in the last 10 years. While women who had a hypertensive disorder appear to have had a postpartum blood pressure measured, it is unclear whether follow-up intervention occurred. Overall, postpartum screening rates for at-risk women remain suboptimal and vary substantially. Further research is warranted including reliable population-level data to inform equitable progress to meeting the evidence-informed guidelines.

Introduction: Postponing hospital admission until the active phase of labor is a recommended strategy to safely reduce the incidence of primary cesarean births. Success of this strategy depends on women's decisions about when to transfer from home to the hospital, a process that is largely absent from research about childbirth. This study aimed to determine the decision-making criteria used by women about when to go to the hospital after the self-identification of labor onset at home., Methods: A qualitative study was conducted at an academic medical center with a sample of 21 nulliparous women who went into spontaneous labor at home and had term, singleton, and vertex-presentation births. The purposive sample consisted of women who decided to stay at home or go to the hospital in early labor. Birth narratives from in-depth interviews conducted in the postpartum period using a semistructured interview guide were subjected to content analysis. The verbatim transcriptions of the interviews were coded and categorized into a set of decision criteria., Results: Criteria used by women in deciding to go to the hospital or stay at home in early labor included the degree of certainty with the self-identification of labor onset, ability to cope with labor pain, influence of social network members, health care provider advice, and concerns about travel to the hospital. Perception of childbirth risk and the need for reassurance about the normalcy of symptoms and fetal well-being also influenced women's decisions., Discussion: Women use a common set of criteria in deciding when to arrive at the hospital during labor. Antenatal education and telephone triage interventions that incorporate the considerations of women deciding to seek or delay hospital admission in childbirth may facilitate health seeking in more advanced labor. Symptom recognition education about early labor onset and progression could reduce decisional uncertainty., (© 2018 by the American College of Nurse-Midwives.)

Cesarean births and associated morbidity and mortality have reached near epidemic proportions. The National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care responded by developing a patient safety bundle to reduce the number of primary cesarean births. Safety bundles outline critical practices to implement in every maternity unit. This National Partnership for Maternity Safety bundle, as with other bundles, is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Bundle components may be adapted to individual facilities, but standardization within an institution is advised. Evidence-based resources and recommendations are provided to assist implementation.

Background: Mode of delivery at first childbirth largely determines mode of delivery at subsequent births, so it is particularly important to understand risk factors for cesarean delivery at first childbirth. In this study, we investigated risk factors for cesarean delivery among nulliparous women, with focus on the association between labor induction and cesarean delivery., Methods: A prospective cohort study of 2851 nulliparous women with singleton pregnancies who attempted vaginal delivery at hospitals in Pennsylvania, 2009-2011, was conducted. We used nested logistic regression models and multiple mediational analyses to investigate the role of three groups of variables in explaining the association between labor induction and unplanned cesarean delivery-the confounders of maternal characteristics and indications for induction, and the mediating (intrapartum) factors-including cervical dilatation, labor augmentation, epidural analgesia, dysfunctional labor, dystocia, fetal intolerance of labor, and maternal request of cesarean during labor., Results: More than a third of the women were induced (34.3%) and 24.8% underwent cesarean delivery. Induced women were more likely to deliver by cesarean (35.9%) than women in spontaneous labor (18.9%), unadjusted OR 2.35 (95% CI 1.97-2.79). The intrapartum factors significantly mediated the association between labor induction and cesarean delivery (explaining 76.7% of this association), particularly cervical dilatation <3 cm at hospital admission, fetal intolerance of labor, and dystocia. The indications for labor induction only explained 6.2%., Conclusions: Increased risk of cesarean delivery after labor induction among nulliparous women is attributable mainly to lower cervical dilatation at hospital admission and higher rates of labor complications., (© 2017 Wiley Periodicals, Inc.)

We conducted a cross-sectional, descriptive, qualitative study, set in a postpartum unit, of 21 nulliparous women who spontaneously went into term labor at home. Our aim was to characterize symptoms of labor onset and progression to active labor before hospital admission for childbirth. The most frequent symptoms reported at labor onset were contractions, pain, ruptured membranes, cramping, and feelings of nervousness and excitement. Women reported that as labor progressed to the active phase, their pain increased, length and strength of contractions increased, and labor symptoms became more difficult to tolerate. Women's descriptions of symptoms of labor onset can aid the development of criteria to help women identify active labor and support decisions about timing of hospital admission for childbirth., (© 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses.)

Objective: To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses., Design: Retrospective cohort study., Setting: One high-volume labor and delivery unit at an academic medical center in a major metropolitan area., Participants: Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation., Methods: Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses., Results: Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile., Conclusion: The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed., (Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore public health nurses' knowledge, perceptions, and practices under the Affordable Care Act (ACA)., Design and Sample: A cross-sectional, web-based survey was completed by a sample of 1,143 public health nurses (PHNs) in the United States., Measures: Descriptive statistics were analyzed for variables related to general knowledge and perception of the ACA and for the extent of involvement in activities related to the implementation of the ACA. Qualitative analysis was conducted on free text comments to two open-ended questions about current and future PHNs involvement in the ACA., Results: Approximately 45% of PHNs reported changes in their daily work due to the ACA. PHNs reported being very or somewhat involved in these activities of the ACA: integration of primary care and public health (62%), provision of clinical preventive services (60.3%), care coordination (55.4%), patient navigation (55.3%), establishment of private-public partnerships (55.3%), population health strategies (53.6%), population health data assessment and analysis (53.8%), community health assessments (49%), involvement in medical homes (37.8%), provision of maternal and child health home visiting services (32.1%), and involvement in Accountable Care Organizations (29.2%)., Conclusion: PHNs are making substantial contributions to implementation of the ACA., (© 2016 The Authors. Public Health Nursing Published by Wiley Periodicals, Inc.)

Objective Our objective was to examine the likelihood of vaginal birth after cesarean (VBAC) for women in Massachusetts. Methods We used birth certificate data among term, singleton, vertex presentation births by repeat cesarean or VBAC to conduct logistic regression models to examine the likelihood of VBAC for women categorized into standard classifications of race and ethnicity and into 31 detailed ethnicities. Data were analyzed for the entire study period (1996-2010, N = 119,752) and for the last 5 years (2006-2010, N = 46,081). Results The adjusted odds of VBAC were lowest for non-Hispanic Black mothers (0.91, CI [0.85, 0.98]) and highest for Asian/Pacific Islander mothers (1.41, CI [1.31, 1.53]) relative to non-Hispanic White women. VBAC rates ranged from 5.8 % among Brazilians to 29.3 % among Cambodians. The adjusted odds of VBAC were lower for 7 of the 30 ethnic groups (range of AORs 0.40-0.89) and higher for 8 of the 30 ethnic groups (range of AORs 1.18-2.11) relative to self-identified American mothers. For the last 5 years, Asian/Pacific Islander mothers had a higher adjusted VBAC rate (1.39, CI [1.21, 1.60]), as did 9 of the 30 ethnic groups (range of 1.25-1.84). Only Brazilian mothers had lower rates (0.37, CI [0.27, 0.50]), relative to self-identified American mothers. Conclusions Detailed maternal ethnicity explains the variation in VBAC rates more precisely than broad race/ethnicity categories. Improvements in our public health data infrastructure to capture detailed ethnicity are recommended to identify and address disparities and improve the quality of maternity care.

Background: Fear of birth and mode of delivery preferences are similar among pregnant and nonpregnant women, suggesting that attitudes toward birth are formed in young adulthood or earlier. Understanding why some young women fear birth and prefer obstetric interventions can inform public health initiatives aimed at reducing fear and promoting birth as a normal life event., Methods: We conducted an online survey with 752 American nulliparous young women to assess their preferences and attitudes toward childbirth. We identified explanatory variables associated with reported fear of childbirth and cesarean delivery (CD) preferences., Results: A preference for CD was reported by 14 percent of young women and 27 percent had scores indicating elevated fear of birth. Fear of birth increased the likelihood of cesarean preference (adjusted relative risk (ARR) 3.84 [95% CI 2.49-5.95]) as did a family history of CD (ARR 1.65 [95% CI 1.13-2.42]). The likelihood of reporting elevated childbirth fear was increased among young women who reported concerns about the physical changes pregnancy and birth have on women's bodies (ARR 2.04 [95% CI 1.50-2.78]). Young women who reported a high degree of confidence in their knowledge about childbirth were significantly less likely to report childbirth fear (ARR 0.61 [95% CI 0.42-0.87]). Access to childbirth information was also associated with a decreased likelihood of fear of birth (ARR 0.75 [95% CI 0.59-0.95])., Conclusions: Young women reporting high levels of childbirth fear are nearly four times more likely to prefer a CD. Specific fears, such as worries over the influence of pregnancy and birth on the female body, need to be addressed before pregnancy., (© 2015 Wiley Periodicals, Inc.)

The childbirth preferences and attitudes of young women prior to pregnancy (N = 758) were explored in a cross-sectional survey. Sources of influential childbirth information and self-reported childbirth learning needs were described. Young women's attitudes about childbirth, including the degree of confidence in coping with a vaginal birth, whether birth is considered a natural event, and expectations of labor pain were associated with their mode of birth preference. Conversations with friends and family were the most influential source of childbirth information. Gaps in knowledge about pregnancy and birth were identified. An improved understanding of women's preferences and attitudinal profiles can inform the structure and content of educational strategies that aim to help the next generation of maternity care consumers participate in informed decision making.

Background: Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts., Methods: Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research., Results: While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women., Conclusions: Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture., (© 2014 Wiley Periodicals, Inc.)

Cesarean birth is the most common surgical procedure in the United States and is associated with increased morbidity and mortality when compared to vaginal birth. Of the more than 4 million births a year, one in three is now a cesarean. A better understanding of the clinical indications contributing to the current prevalence in primary cesarean rates can inform prevention strategies. This column takes a second look at two recent studies in which researchers evaluated the clinical indications associated with primary cesarean birth rates., (© 2014 AWHONN.)

Background: Cesarean sections are the most common surgical procedure for women in the United States. Of the over 4 million births a year, one in three are now delivered in this manner and the risk adjusted prevalence rates appear to vary by race and ethnicity. However, data from individual studies provides limited or contradictory information on race and ethnicity as an independent predictor of delivery mode, precluding accurate generalizations. This study sought to assess the extent to which primary, unscheduled cesarean deliveries and their indications vary by race/ethnicity in one academic medical center., Methods: A retrospective, cross-sectional cohort study was conducted of 4,483 nulliparous women with term, singleton, and vertex presentation deliveries at a major academic medical center between 2006-2011. Cases with medical conditions, risk factors, or pregnancy complications that can contribute to increased cesarean risk or contraindicate vaginal birth were excluded. Multinomial logistic regression analysis was used to evaluate differences in delivery mode and caesarean indications among racial and ethnic groups., Results: The overall rate of cesarean delivery in our cohort was 16.7%. Compared to White women, Black and Asian women had higher rates of cesarean delivery than spontaneous vaginal delivery, (adjusted odds ratio {AOR}: 1.43; 95% CI: 1.07, 1.91, and AOR: 1.49; 95% CI: 1.02, 2.17, respectively). Black women were also more likely, compared to White women, to undergo cesarean for fetal distress and indications diagnosed in the first stage as compared to the second stage of labor., Conclusions: Racial and ethnic differences in delivery mode and indications for cesareans exist among low-risk nulliparas at our institution. These differences may be best explained by examining the variation in clinical decisions that indicate fetal distress and failure to progress at the hospital-level.

Objective: To examine the role of the labor and delivery nurse in a nurse-managed practice model and nurses' perceived ability to influence decisions about mode of delivery and outcomes., Design: Cross-sectional, descriptive, qualitative study., Setting: One nurse-managed labor and delivery unit in a community-based hospital near a major metropolitan area., Participants: A purposeful sample of 13 registered nurses with intrapartum experience., Methods: Qualitative, in-depth interview data were subjected to content analysis., Results: Experienced labor and delivery nurses perceived their role to be influential in decisions about mode of delivery. Negotiating for more time was integral to the way nurses exerted their influence, allowing for the time needed to implement practices that promote vaginal delivery. Knowledge of labor and physician practice patterns shaped the specific communication strategies used by nurses in their roles as negotiators., Conclusions: The responses of experienced, intrapartum nurses to actual and perceived time pressures and the subsequent impact on nurse-physician communication patterns and delivery mode outcomes are significant. Findings indicate the need to further explore how individual nursing practice may function as an independent predictor of delivery mode and how shared decision making among physicians, laboring women, and nurses affects rates of cesarean delivery., (© 2012 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: to test the predictive value of women's self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available., Design: a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires., Setting: the service area of Matlab, Bangladesh., Participants: women 18-49 years who had an uncomplicated pregnancy and delivery resulting in a live birth., Findings: a women's intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use., Key Conclusions: the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

This paper examines the association of women's social networks with the use of skilled birth attendants in uncomplicated pregnancy and childbirth in Matlab, Bangladesh. The network-episode model was applied to determine if network structure variables (density/kinship homogeneity/strength of ties) together with network content (endorsement for or against a particular type of birth attendant) explain the type of birth attendant used by women above and beyond the variance explained by women's individual attributes. Data were collected by interviewing a representative sample of 246 women, 18-45 years of age, using survey and social network methods between October and December 2008. Logistic regression models were used to examine the associations. Results suggest that the structural properties of networks did not add to explanatory value but instead network content or the perceived advice of network members add significantly to the explanation of variation in service use. Testing aggregate network variables at the individual level extends the ability of the individual profile matrix to explain outcomes. Community health education and mobilization interventions attempting to increase demand for skilled attendants need to reflect the centrality of kinship networks to women in Bangladesh and the likelihood of women to heed the advice of their network of advisors with regard to place of birth., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Early recognition can reduce maternal disability and deaths due to postpartum haemorrhage. This study identified cultural theories of postpartum bleeding that may lead to inappropriate recognition and delayed care-seeking. Qualitative and quantitative data obtained through structured interviews with 149 participants living in Matlab, Bangladesh, including women aged 18-49 years, women aged 50+ years, traditional birth attendants (TBAs), and skilled birth attendants (SBAs), were subjected to cultural domain. General consensus existed among the TBAs and lay women regarding signs, causes, and treatments of postpartum bleeding (eigenvalue ratio 5.9, mean competence 0.59, and standard deviation 0.15). Excessive bleeding appeared to be distinguished by flow characteristics, not colour or quantity. Yet, the TBAs and lay women differed significantly from the SBAs in beliefs about normalcy of blood loss, causal role of the retained placenta and malevolent spirits, and care practices critical to survival. Cultural domain analysis captures variation in theories with specificity and representativeness necessary to inform community health intervention.