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This contribution reprints the Executive Summary from a technical report issued by the National Partnership for WomenFamilies within its larger Improving Our Maternity Care Now project. This project identifies the priority of continuing the long, challenging work of maternity care system transformation, while also increasing access to high-performing care models that can help meet current urgent, dire needs for equitable high-quality care now. The Community Birth Settings report (encompassing birth center and planned home birth care) is the second in a series of four reports on these care models, which share distinctive features. They reliably provide highly appropriate services that minimize both underuse of beneficial practices and overuse of unneeded, often harmful practices. They prioritize relationship-based, whole person care that builds trust, confidence and resilience and helps meet the varied needs of birthing families. They incorporate skills and knowledge to support the innate physiologic processes of birthing people and their fetuses/newborns. They achieve remarkable results for consequential outcomes relative to standard maternity care. And childbearing people greatly desire access to these forms of care relative to current access and use. Community-based versions offering trustworthy, respectful, culturally-congruent care are especially powerful. The community birth settings report includes recommendations for federal policymakers, state policymakers, and private sector decision makers to increase access to these settings. It was carried out in partnership with the American Association of Birth Centers, American College of Nurse-Midwives, Birth Center Equity, National Association of Certified Professional Midwives, and National Black Midwives Alliance. Access the full project through https://www.nationalpartnership.org/improvingmaternitycare/. The project is supported by the Yellow Chair Foundation. Reproduced with permission of the National Partnership for WomenFamilies.

BACKGROUND: Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes.METHODS: We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299.FINDINGS: Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture INTERPRETATION: Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence.FUNDING: Patient-Centered Outcomes Research Institute.

Introduction Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians. Methods This study was a secondary analysis of data from the population-based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife-attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates. Results Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making. Discussion Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

BACKGROUND The World Health Organization's recent recommendations on intrapartum care regard women's experience of care as an essential aspect of high-quality maternity care. A better understanding of women's perspectives on their childbirth experiences in the United States is needed to place women in the center of care and optimize their experience of childbirth. METHODS This study analyzed data from the Listening to Mothers in California survey completed by a representative sample of women who gave birth in 2016 in California hospitals. Responses to one or both open-ended questions about the best and worst part of respondent's hospital stay for childbirth were subject to a content analysis. RESULTS Findings from 2539 participants included 2336 best and 1410 worst part responses. References to the attitudes and behaviors of health care practitioners were the most commonly reported (47% best and 29.1% worst part). Nurses were the most frequently mentioned practitioner type. Additional best part categories in rank order included the quality of physical care of the mom and feelings about the care experience. Additional worst part categories in rank order included the quality of the facility and food, delays in care, infant feeding, the quality of physical care of the mom, and lack of privacy. DISCUSSION Women's hospital experiences during childbirth, while multidimensional in nature, are primarily shaped by their relationships with health care practitioners, the care provided, and the facility in which childbirth occurs. Women's feedback provides actionable information to promote a positive birth experience.

BACKGROUND In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions. METHODS Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean. RESULTS Almost half (N = 163; 47%) of women who were told their baby might be large reported engaging in a discussion concerning possible labor induction vs waiting for labor, while a large majority (N = 321; 82%) of women with a prior cesarean discussed the option of a repeat cesarean or a planned vaginal birth after cesarean (VBAC). Women who engaged in discussions received disproportionate information about having the interventions and were more likely to experience the interventions (68% induction, 87% repeat cesarean) than women who did not. After adjustment, women who reported that their provider recommended scheduling a repeat cesarean were 14 times more likely to give birth via cesarean compared with those whose providers recommended planning VBAC (AOR 14.2; 95% CI: 3.2, 63.0). CONCLUSION Our findings suggest that, for the decisions in question, established standards of shared decision-making are not being reliably implemented in maternity care despite opportunities to do so. Provider recommendations and the disproportionate conveyance of reasons for an intervention appear to be related to higher levels of intervention.

Knowledge of the hormonal physiology of childbearing is foundational for all who care for childbearing women and newborns. When promoted, supported, and protected, innate, hormonally driven processes optimize labor and birth, maternal and newborn transitions, breastfeeding, and mother-infant attachment. Many common perinatal interventions can interfere with or limit hormonal processes and have other unintended effects. Such interventions should only be used when clearly indicated. High-quality care incorporates salutogenic nursing practices that support physiologic processes and maternal-newborn health.

Continuous labor support by a trained doula has proven benefits and is recognized as an effective strategy to improve maternal and infant health, enhance engagement and satisfaction with maternity care, and reduce spending. Community-based doula programs can also reduce or eliminate health disparities by providing support to women most at risk for poor outcomes. The most effective way to increase use of this evidence-based service would be to eliminate cost barriers. Key recommendations identify numerous pathways to pursue Medicaid and private insurance coverage of doula care. This comprehensive and up-to-date inventory of reimbursement options provides the doula, childbirth, and quality communities, as well as policy makers, with many approaches to increasing access to this high-value form of care.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

Objective To determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures. Data Sources/Study Setting Listening to Mothers III, a nationally representative survey of women 18–45 years who delivered a singleton infant in a U.S. hospital July 2011–June 2012 (N = 2,400). Study Design Multivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure. Principal Findings Overall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5–5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3–3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2–8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4–11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0–11.3). Conclusions Patient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider–patient miscommunication and minimize potentially unnecessary procedures may be warranted.

Published in 1981, "The Maximin Strategy in Modern Obstetrics" offered two claims: first, that obstetrical interventions ought to be assessed not singly, but rather as packages of interconnected measures that could cumulatively increase risks of harm; and second, that many of these interventions, considered either singly or as a package, lacked a sound evidence base. The first claim has been well supported by later literature, although the term "cascade effect" has proven a more felicitous descriptor for the phenomenon of interventions that trigger the use of other interventions to monitor, prevent, or treat possible side-effects. The second claim was initially supported in a very inadequate way, since the "Maximin" article appeared before an understanding of the methods of systematic reviews of medical evidence had been widely promulgated. Despite these defects, subsequent, rigorously conducted systematic reviews have tended to confirm the impression first offered in 1981, that practices that support physiologic childbearing and the innate, hormonally driven capacities of childbearing women and their fetuses/newborns are much more in keeping with the available evidence than practices involving common or routine high-technology interference with physiologic processes. Harm may occur either directly, through high-technology interventions, or when such procedures distract attention and resources from safe, effective biological processes and lower-technology measures. Surveys indicate a lack of knowledge of this evidence among childbearing women, signaling a serious ethical deficiency in shared decision-making processes and perhaps the skills and knowledge of maternity care clinicians.

Background This paper summarizes a new report presenting the best available research about the impact of the liability environment on maternity care, and policy options for improving this environment. Improved understanding of these matters can help to transcend polarized discourse and guide policy intervention. Methods We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable. Findings The best available research does not support a series of widely held beliefs about maternity care and liability, including the economic impact of liability insurance premiums on maternity care clinicians, the existence of extensive defensive maternity care practice, and the impact of limiting the size of awards for non-economic damages in a malpractice lawsuit. In the practice of an average maternity caregiver, negligent injury of mothers and newborns seems to occur more frequently than any claim and far more frequently than a payout or trial. Many important gaps in knowledge relating to maternity care and liability remain. Some improvement strategies are likely to be more effective than others. Conclusions Empirical research does not support many widely held beliefs about maternity care and liability. The liability system does not currently serve well childbearing women and newborns, maternity care clinicians, or those who pay for maternity care. A number of promising strategies might lead to a higher functioning liability system, whereas others are unlikely to contribute to needed improvements.

A concrete and useful way to create an action plan for improving the quality of maternity care in the United States is to start with a view of the desired result, a common definition and a shared vision for a high-quality, high-value maternity care system. In this paper, we present a long-term vision for the future of maternity care in the United States. We present overarching values and principles and specific attributes of a high-performing maternity care system. We put forth the "2020 Vision for a High-Quality, High-Value Maternity Care System" to serve as a positive starting place for a fruitful collaborative process to develop specific action steps for broad-based maternity care system improvement.

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

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

Objectives. We sought to assess whether breastfeeding-related hospital practices reported by mothers were associated with achievement of their intentions to exclusively breastfeed. Methods. We used data from Listening to Mothers II, a nationally representative survey of 1573 mothers who had given birth in a hospital to a singleton in 2005. Mothers were asked retrospectively about their breastfeeding intention, infant feeding at 1 week, and 7 hospital practices. Results. Primiparas reported a substantial difference between their intention to exclusively breastfeed (70%) and this practice at 1 week (50%). They also reported hospital practices that conflicted with the Baby-Friendly Ten Steps, including supplementation (49%) and pacifier use (45%). Primiparas who delivered in hospitals that practiced 6 or 7 of the steps were 6 times more likely to achieve their intention to exclusively breastfeed than were those in hospitals that practiced none or 1 of the steps. Mothers who reported supplemental feedings to their infant were less likely to achieve their intention to exclusively breastfeed: primiparas (adjusted odds ratio [AOR] = 4.4; 95% confidence interval [CI] = 2.1, 9.3); multiparas (AOR = 8.8; 95% CI = 4.4, 17.6). Conclusions. Hospitals should implement policies that support breastfeeding with particular attention to eliminating supplementation of healthy newborns.

Chaillet et al. (2006 ) recently published what may be the fi rst systematic review to identify effective strategies for improving the quality of maternity care. Although the title references “ guidelines, ” some of the 33 included studies measured a desired change rather than implementation of a formal guideline. The review included randomized controlled trial and observational designs. Most studies examined physicians, and some considered other health professionals. Educational strategies were generally ineffective with physicians and had mixed results with other health professionals. Other strategies with mixed results across the included studies were use of opinion leaders, academic detailing (topically focused outreach to individual clinicians), and modifi cation of existing systems and structures. Both audit and performance feedback and multifaceted interventions combining two or more strategies to address a specifi c barrier were generally effective. Overall, studies that identifi ed and addressed barriers were far more likely to lead to demonstrated improvement than those that did not. The authors identifi ed possible differences between obstetric and general medical contexts: whereas education achieved some success with nonphysician maternity providers, it has generally been unsuccessful in other contexts; audit and feedback appear to be more successful in obstetrics than other contexts; and academic detailing has been more successful in other contexts than obstetrics. REFERENCE

PREFACE: Normal childbirth has become jeopardized by inexorably rising interventions around the world. In many countries and settings, cesarean surgery, labor induction, and epidural analgesia continue to increase beyond all precedent, and without convincing evidence that these actions result in improved outcomes (1,2). Use of electronic fetal monitoring is endemic, despite evidence of its ineffectiveness and consequences for most parturients (1,3); ultrasound examinations are too often done unnecessarily, redundantly, or for frivolous rather than indicated reasons (4); episiotomies are still routine in many settings despite clear evidence that this surgery results in more harm than good (5); and medical procedures, unphysiological positions, pubic shaving and enemas, intravenous lines, enforced fasting, drugs, and early mother-infant separation are used unnecessarily (1). Clinicians write and talk about the ideal of evidence-based obstetrics, but do not practice it consistently, if at all. Why do women go along with this stuff? In this Roundtable Discussion, Part 2, we asked some maternity care professionals and advocates to discuss this question. (BIRTH 33:3 September 2006)

To refl ect its contemporary focus, Maternity Center Association recently changed its name to Childbirth Connection. Childbirth Connection con-tinues the national not-for-profi t organization ’ s 88-year role as a voice for the needs and interests of childbearing families and focus on improving the quality of maternity care, by promoting evidence-based maternity care. This commentary summarizes resources that are available for health professionals on Childbirth Connection ’ s redesigned and ex-panded Web site. The Childbirth Connection Web site ( http://www.childbirthconnection.org ) has separate substantial areas for childbearing families and health profession-als. The health professional area includes the follow-ing sections: • Evidence-Based Maternity Care Resource Di-rectory: continuously updated topically orga-nized inventory of Web sites, articles, books, organizations, and so forth, to help identify, ap-praise, and apply better quality evidence for maternal-newborn care • Evidence Columns: collected PDF fi les of this column from the 1st in early 2003 through new ones as they become available • Systematic Reviews: key resources from system-atic reviews that Childbirth Connection has commissioned, participated in, or carried out • A Guide to Effective Care in Pregnancy and Childbirth: the full text of the 3rd edition of this acclaimed manual • Listening to Mothers: resources from the 1st na-tional U.S. survey of women ’ s childbearing expe-riences (2002) and the new 2006 second survey and follow-up postpartum mother ’ s survey • Alerts and Responses: occasional bulletins from Childbirth Connection to help interpret new re-ports or recent events of great importance to mothers and newborns • Resources for Women: overview of the exten-sive resources in the women ’ s area of the site to help childbearing women become active participants in their care and make informed decisions • The Rights of Childbearing Women: Childbirth Connection ’ s highly regarded rights statement, which applies core human rights to childbearing and indicates the legal status of individual rights. These evolving resources can lend a hand with the challenging responsibility 21st century health professionals have to understand, provide and foster care that is consistent with results of best available research.

Background: Research translation models are needed to demonstrate a process for identifying and communicating high-quality scientific evidence that enables informed involvement of relevant stakeholders, including informed consumer participation in healthcare decision making. Purpose: To describe the rationale for, and elements of, a research translation model, as it is being applied to inform and support diverse end users with respect to decisions relating to vaginal versus cesarean birth. Methods: The Matemity Center Association (MCA), the oldest national United States organization advocating on behalf of mothers and babies, identified the need to clarify and translate into practice best evidence about relative harms of cesarean and vaginal birth. MCA developed a model that included engaging leading stakeholder groups, conducting a systematic review to fill research gaps, and initiating an education and advocacy campaign to reach consumers, health professionals, and the general public with review results and related information and guidance. International standards for systematic reviews and evidence about effective professional practice, use of decision aids, and risk communication were used. Results: Dozens of harms that differ by mode of delivery, with nearly all favoring vaginal birth, were found during review. Without clear, compelling, and well-supported justification for cesarean section, vaginal birth is the safest way for women to give birth and babies to be born. Despite modest resource expenditure, the implemented model is bringing review results to many individuals and organizations, incorporating elements that have been shown to be effective. The next step is to formally evaluate the decision aid in clinical settings. Discussion: Advocacy organizations are uniquely positioned to carry out research translation. Given the importance of research translation and the challenges of carrying out this work, programs and policies should be established to support and evaluate advocacy organizations in this role.

New Systematic Reviews • Altered dietary salt for preventing preeclampsia, and its complications • Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth • Antioxidants for preventing pre-eclampsia • Bed rest with or without hospitalisation for hypertension during pregnancy • Continuous infusion versus intermittent fl ushing to prevent loss of function of peripheral intravenous catheters used for drug administration in newborn infants • Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity • Effi cacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1 • Home visits during pregnancy and after birth for women with an alcohol or drug problem • Intrauterine insemination versus timed intercourse for cervical hostility in subfertile couples • Nonsteroidal anti-infl ammatory drugs for pain in women with endometriosis • Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour • Prophylactic antibiotics to reduce morbidity and mortality in neonates with umbilical venous catheters Current Resources for Evidence-Based Practice, March/April 2006

Are clinical guidelines valid tools for evidencebased practice? The quality of guidelines varies widely, and they should be assessed on a case-bycase basis. This commentary points to some leading initiatives and resources for excellence in and access to guidelines. Major assessments of guidelines respectively published in peer-reviewed journals and issued by specialty societies raised serious concerns about their quality (Grilli, Magrini, Pena, Mura, & Liberati, 2000; Shaneyfelt, Mayo-Smith, & Rothwangl, 1999). Evaluations of obstetrician-gynecologist specialty society guidelines confirmed concerns about the rigor of development, quality of content, and applicability of clinical practice guidelines published for this specialty (Coomarasamy, Ola, Gee, & Khan, 2003; McDonagh, White, Singh, & Mohide, 2004). Various initiatives to improve the situation have been established, and a more recent assessment found that evidence-based principles dominate leading guidelines programs (Burgers, Grol, Klazinga, Makela, & Zaat, 2003). An international collaborative of guideline developers and researchers created the AGREE (Appraisal of Guidelines Research and Evaluation) checklist to help policy makers, providers, and educators assess the process and recommendations of individual guidelines (see www.agreecollaboration.org). The U.S. government has established a searchable National Guidelines Clearinghouse (www.guide line.gov), and the U.K. National Health Service offers a Guidelines Finder (libraries.nelh.nhs .uk/guidelinesFinder/default.asp?page=INTER&&n odecatID=5715). The Geneva Foundation for Medical Education and Research maintains an inventory of guidelines pertaining to women’s health (http://www.gfmer.ch/Guidelines/Obstetrics_gynecology _guidelines.php). Membership in the Guidelines International Network (www.g-i-n.net/) provides access to an International Guideline Library.

Cesarean deliveries are a common surgical procedure in the United States, accounting for 1 in 3 US births. The primary purpose of this guideline is to provide clinicians with evidence to guide planning for labor and vaginal birth after cesarean (LAC/VBAC). A multidisciplinary guideline development group representing family medicine, epidemiology, obstetrics, midwifery, and consumer advocacy used a high quality systematic review by the Agency for Healthcare Research and Quality (AHRQ) as the primary evidence source. The evidence report was updated to include research published through September 2012 with an additional key question on facilities and resources needed for LAC/VBAC. The guideline development group developed recommendations using a modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The panel recommended that an individualized assessment of risks and benefits be discussed with pregnant women with a history of 1 or more prior cesarean births who are deciding between a planned LAC/VBAC and a repeat cesarean birth. A planned LAC/VBAC is an appropriate option for most women with a history of prior cesarean birth. Increased access to providers and facilities capable of managing LAC/VBAC are required to reduce the US cesarean rate and associated maternal morbidity while increasing choice for childbearing women and their families.

This report describes the background and process for a rigorous project to improve understanding of labor pain and its management, and summarizes the main results and their implications. Labor pain and methods to relieve it are major concerns of childbearing women, with considerable implications for the course, quality, outcome, and cost of intrapartum care. Although these issues affect many women and families and have major consequences for health care systems, both professional and public discourse reveal considerable uncertainty about many questions, including major areas of disagreement. An evidence-based framework, including commissioned papers prepared according to carefully specified scopes and guidelines for systematic review methods, was used to develop more definitive and authoritative answers to many questions in this field. The papers were presented at an invitational symposium jointly sponsored by the Maternity Center Association and the New York Academy of Medicine, were peer-reviewed, and are published in full in this issue of the journal. The results have implications for policy, practice, research, and the education of both health professionals and childbearing women.

Chaillet et al. (2006 ) recently published what may be the fi rst systematic review to identify effective strategies for improving the quality of maternity care. Although the title references “ guidelines, ” some of the 33 included studies measured a desired change rather than implementation of a formal guideline. The review included randomized controlled trial and observational designs. Most studies examined physicians, and some considered other health professionals. Educational strategies were generally ineffective with physicians and had mixed results with other health professionals. Other strategies with mixed results across the included studies were use of opinion leaders, academic detailing (topically focused outreach to individual clinicians), and modifi cation of existing systems and structures. Both audit and performance feedback and multifaceted interventions combining two or more strategies to address a specifi c barrier were generally effective. Overall, studies that identifi ed and addressed barriers were far more likely to lead to demonstrated improvement than those that did not. The authors identifi ed possible differences between obstetric and general medical contexts: whereas education achieved some success with nonphysician maternity providers, it has generally been unsuccessful in other contexts; audit and feedback appear to be more successful in obstetrics than other contexts; and academic detailing has been more successful in other contexts than obstetrics. REFERENCE

With permission from Childbirth Connection, the concise version of the Listening to Mothers II “Survey Methodology” is reprinted here. Harris Interactive® conducted Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences on behalf of Childbirth Connection. The survey consisted of 1,373 online interviews and 200 telephone interviews with women who had given birth in U.S. hospitals in 2005, with weighting of data to reflect the target population. Interviews were conducted from January 20 through February 21, 2006. The methods used to conduct the survey and analyze the data collected are described.

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

s are available without charge athttp://www.york.ac.uk/inst/crd/darehp.htm Evidence-Based Reviews From Other Sources Featured review: Green, J. M., Hewison, J., Bekker, H.L., Bryant, L. D., & Cuckle, H. S. (2004). Psychosocialaspects of genetic screening of pregnant women and new-borns: A systematic review. Health Technology Assess-ment , 8 (33), 1-124. Available without charge athttp://www.ncchta.org/ProjectData/1_project_record_published.asp?PjtId=1152&status=6 This systematic review addressed questions aboutgenetic screening from mothers’ points of view. Thereview summarizes a growing body of research aboutknowledge, anxiety and other emotional aspects of screen-ing, factors associated with participation in screeningprograms, and consequences of receiving false-positive, false-negative, true-positive, and true-negative results. Theauthors conclude that pressing policy matters, in order ofpriority, are need to achieve adequate informed consent,costs associated with quality services, unmet needs ofwomen receiving false-positive test results, and unmetneeds of women’s partners (especially related to carrierscreenings).