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Social determinants of health and adverse childhood experiences have been implicated as driving causes of maternal mortality but the empirical evidence to substantiate those relationships is lacking. We aimed to understand the prevalence and intersection of social determinants of health and adverse childhood experiences among maternal deaths in Colorado based on a review of records obtained for our state's maternal mortality review committee.A 5-member interdisciplinary team adapted the Protocol for Responding to and Assessing Patients' Assets, Risk, and Experiences and the Adverse Childhood Experiences tools to create a data collection tool. The team reviewed records collected for the purpose of maternal mortality review for pregnancy-associated deaths that occurred in Colorado between 2014 and 2016 (N = 94).The review identified an overwhelming lack of information regarding social determinants of health or adverse childhood experiences in the records used to review maternal deaths. The most common finding of the social determinants of health was a lack of conclusive evidence in the record (35.1-94.7%). Similarly, the reviewers were unable to make a determination from the available records for 92.1% of adverse childhood experience indicators.The lack of social and contextual information in the records points to challenges of relying on medical records for identification of non-medical causes of maternal mortality. Maternal mortality review committees would be well served to invest in alternative data sources, such as community dashboards and informant interviews, to inform a more comprehensive understanding of causes of maternal mortality.

BACKGROUNDMidwives are a vital component of addressing maternal mortality crisis in the United States (US); however, there is scant understanding of the elements of midwifery practice that affect patient outcomes and the stability of the midwifery workforce in the country. This study investigates US midwives’ perceptions of factors influencing their practice and willingness to stay in the profession.METHODSWe applied a pragmatic qualitative design using summative content analysis techniques to code 1,035 comments from a national sample of 2,887 certified nurse-midwives and certified midwives. Two coders identified categories and themes of midwives’ perceptions of their practice environments, which were confirmed by an independent auditor.RESULTSEight themes emerged from the data: I love midwifery but…; feeling valued and respected…or not; workload; time and its consequences; the multilevel geography of midwifery practice; changes at odds with quality midwifery care; midwives withdrawing from practice to cope; and the ambiguity of “I just want to practice like a midwife.”CONCLUSIONMidwives readily identified aspects of their practice environment that negatively impact quality of care and stability of the midwifery workforce, including not valuing midwives, high workload, regulatory restrictions, and moral distress; however, respondents expressed strong commitment to the profession of midwifery. The findings also demonstrated the lack of a universally accepted definition of midwifery care within respondents’ professional communities and among respondents. Initiatives to increase integration of midwifery into the US perinatal health system will benefit from taking these findings into consideration.

To determine the prevalence of burnout among the midwifery workforce and the association between fixed personal and practice characteristics and modifiable organizational factors, specifically practice environment, to burnout among midwives in the United States.Primary data collection was conducted via an online survey of the complete national roster of certified nurse-midwives and certified midwives over 3 weeks in April 2017.The study was a cross-sectional observational survey consisting of 95 items about personal and practice characteristics, respondents' practice environments, and professional burnout.The inclusion criterion was actively practicing midwifery in the United States. Data were analyzed with bivariate analyses to determine the association between personal and practice characteristics and burnout. A hierarchal multilinear regression evaluated the interrelationship between personal and practice characteristics, practice environment, and burnout.Of the almost one third (30.9%) of certified nurse-midwives and certified midwives who responded to the survey, 40.6% met criteria for burnout. Weak negative correlations existed between burnout and indicators of career longevity: age (r(2256) = -0.09, p 0.01), years as a midwife (r(2267) = -0.07, p = 0.01), and years with employer (r(2271) = -0.05, p = 0.02). There were significant relationships between burnout score and patient workload indicators: patients per day in outpatient setting (F(5,2292) = 13.995, p 0.01), birth volume (F(3,1864) = 8.35, p 0.01), and patient acuity (F(2,2295) = 20.21, p 0.01). When the practice environment was entered into the model with personal and practice characteristics, the explained variance increased from 6.4% to 26.5% (F(20,1478) = 27.98, p 0.01).Our findings suggested that a key driver of burnout among US midwives was the practice environment, specifically practice leadership and participation and support for the midwifery model of care. Structural and personal characteristics contributed less to burnout score than the practice environment, implying that prevention of burnout may be achieved through organizational support and does not require structural changes to the provision of perinatal health.

Introduction A supportive work climate is associated with decreased burnout and attrition, and increased job satisfaction and employee health. A review of the literature was conducted in order to determine the unique attributes of a supportive practice climate for midwives. Methods The midwifery literature was reviewed and synthesized using concept analysis technique guided by literature from related professions. The search was conducted primarily in PubMed, CINAHL, Web of Science, and Google Scholar. Articles were included if they were conducted between 2006 and 2016 and addressed perceptions of the midwifery practice climate as it related to patient, provider, and organizational outcomes. Results The literature identified 5 attributes consistent with a supportive midwifery practice climate: effective leadership, adequate resources, collaboration, control of one's work, and support of the midwifery model of care. Effective leadership styles include situational and transformational, and 9 traits of effective leaders are specified. Resources consist of time, personnel, supplies, and equipment. Collaboration encompasses relationships with all members of the health care team, including midwives inside and outside of one's practice. Additionally, the patients are considered collaborating members of the team. Characteristics of effective collaboration include a shared vision, role clarity, and respectful communication. Support for the midwifery model of care includes value congruence, developing relationships with women, and providing high-quality care. Discussion The attributes of a supportive midwifery practice climate are generally consistent with theoretical models of supportive practice climates of advanced practice nurses and physicians, with the exception of a more inclusive definition of collaboration and support of the midwifery model of care. The proposed Midwifery Practice Climate Model can guide instrument development, determining relationships between the attributes of the practice climate and outcomes, and creating interventions to improve the practice climate, workforce stability, and patient outcomes.

INTRODUCTION A supportive practice climate is demonstrated to improve patient outcomes, health care provider well-being, and workforce stability. Midwives are an integral component to improving maternal health care; however, there has been limited research into the qualities and measurement of a supportive practice climate for midwives. METHODS The Midwifery Practice Climate Scale is a self-report instrument designed to measure midwives' perceptions of their work environments. We tested the scale's validity and reliability in multiphase, national cross-sectional survey of the full roster of certified nurse-midwives and certified midwives practicing in the United States. To test structural validity and reliability testing, 2 subsamples of 330 participants were randomly extracted from the sample of 2887 for exploratory and confirmatory factor analyses and internal consistency determination. Convergent validity was tested in the remaining sample of 1673 respondents. RESULTS Exploratory factor analysis revealed 2 5-subscale structures consistent with the loading values and theoretical structure. Confirmatory factor analysis revealed a mediocre fit of the models identified in the exploratory analysis. Consequently, items were systematically reviewed for redundancy, skew, and generalizability and 24 items were removed from the scale. The resulting structure is a 10-item scale comprising 2 subscales: Practice Leadership and Participation and Support for the Midwifery Model of Care. The revised Midwifery Practice Climate Scale was a good fit with the data demonstrating adequate construct validity (χ2 = 60.397, df = 34, P < 0.001; comparative fit index, 0.987; root mean square of approximation, 0.049) and internal consistency (α = 0.89-0.84). DISCUSSION These findings indicate that the Midwifery Practice Climate Scale accurately and reliably measures the midwives' perceptions of their practice environment. The next steps include determining the scale's sensitivity to change and assessing the relationship with maternal health outcomes.

A supportive practice climate is demonstrated to improve patient outcomes, health care provider well-being, and workforce stability. Midwives are an integral component to improving maternal health care; however, there has been limited research into the qualities and measurement of a supportive practice climate for midwives.The Midwifery Practice Climate Scale is a self-report instrument designed to measure midwives' perceptions of their work environments. We tested the scale's validity and reliability in multiphase, national cross-sectional survey of the full roster of certified nurse-midwives and certified midwives practicing in the United States. To test structural validity and reliability testing, 2 subsamples of 330 participants were randomly extracted from the sample of 2887 for exploratory and confirmatory factor analyses and internal consistency determination. Convergent validity was tested in the remaining sample of 1673 respondents.Exploratory factor analysis revealed 2 5-subscale structures consistent with the loading values and theoretical structure. Confirmatory factor analysis revealed a mediocre fit of the models identified in the exploratory analysis. Consequently, items were systematically reviewed for redundancy, skew, and generalizability and 24 items were removed from the scale. The resulting structure is a 10-item scale comprising 2 subscales: Practice Leadership and Participation and Support for the Midwifery Model of Care. The revised Midwifery Practice Climate Scale was a good fit with the data demonstrating adequate construct validity (χThese findings indicate that the Midwifery Practice Climate Scale accurately and reliably measures the midwives' perceptions of their practice environment. The next steps include determining the scale's sensitivity to change and assessing the relationship with maternal health outcomes.