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Background UK maternity policy advocates a choice of birthplace in an obstetric-led unit (OU), a midwife-led unit (MLU) or at home. Although robust evidence supports the safety of birth in midwife-led settings, particularly for women with uncomplicated pregnancies, most births are in the OU. Women and babies from ethnic minority communities experience major health disparities and inequitable care, but there is limited research examining birthplace choices through an ethnicity lens. This study investigated the association between ethnicity and place of birth at an urban NHS Trust in England. Methods A mixed-methods sequential explanatory study. Analysis of births from 2014–2023 at a London NHS Trust included multivariable logistic regression analysis of birthplace by ethnicity. Planned or pre-labour Caesareans, pre-term, and multiple births were excluded. Significant disparities between White and South Asian women were identified which informed the focus of the qualitative study. Semi-structured interviews with 10 women of South Asian heritage who had given birth in the OU, the alongside MLU or at home were conducted and analysed thematically. Results More White women gave birth in midwife-led settings (27.5%) than all other ethnicities, particularly South Asian women (20.6%). South Asian women had fewer homebirths (0.8%) than White women (2.7%) and were much less likely to birth in a midwife-led setting after adjusting for parity, maternal age, BMI, previous Caesarean, presence of diabetes or hypertensive disorders and onset of labour (aOR 0.61, 95% CI 0.51–0.73, p  < 0.001). Places of birth were similar for Black and White women, although the number of Black women in the population was too low to detect significant differences. Themes generated from interviews included the assumption that birth is hospital-based and doctor-led; choosing a midwife-led birth setting went against the cultural norm, but felt safe – physically, psychologically and culturally. Conclusions There are ethnic disparities in place of birth. Cultural factors seem influential, but barriers to choice, such as limited evidence-sharing by midwives, may disproportionately affect women from ethnic minority communities, who may particularly benefit from midwife-led birth settings. Women need personalised information about options. Improving choice of birthplace is a step towards reducing health inequalities and promoting optimal health.

ObjectivesTo compare neonatal mortality in English hospitals by time of day and day of the week according to care pathway.DesignRetrospective cohort linking birth registration, birth notification and hospital episode data.SettingNational Health Service (NHS) hospitals in England.Participants6 054 536 liveborn singleton births from 2005 to 2014 in NHS maternity units in England.Main outcome measuresNeonatal mortality.ResultsAfter adjustment for confounders, there was no significant difference in the odds of neonatal mortality attributed to asphyxia, anoxia or trauma outside of working hours compared with working hours for spontaneous births or instrumental births. Stratification of emergency caesareans by onset of labour showed no difference in mortality by birth timing for emergency caesareans with spontaneous or induced onset of labour. Higher odds of neonatal mortality attributed to asphyxia, anoxia or trauma out of hours for emergency caesareans without labour translated to a small absolute difference in mortality risk.ConclusionsThe apparent ‘weekend effect’ may result from deaths among the relatively small numbers of babies who were coded as born by emergency caesarean section without labour outside normal working hours. Further research should investigate the potential contribution of care-seeking and community-based factors as well as the adequacy of staffing for managing these relatively unusual emergencies.

IntroductionChoice of birth setting is important and it is valuable to know how reconfiguring available settings may affect midwifery staffing needs. COVID-19-related health system pressures have meant restriction of community births. We aimed to model the potential of service reconfigurations to offset midwifery staffing shortages.MethodsWe adapted the Birthrate Plus method to develop a tool that models the effects on intrapartum and postnatal midwifery staffing requirements of changing service configurations for low-risk births. We tested our tool on two hypothetical model trusts with different baseline configurations of hospital and community low-risk birth services, representing those most common in England, and applied it to scenarios with midwifery staffing shortages of 15%, 25% and 35%. In scenarios with midwifery staffing shortages above 15%, we modelled restricting community births in line with professional guidance on COVID-19 service reconfiguration. For shortages of 15%, we modelled expanding community births per the target of the Maternity Transformation programme.ResultsExpanding community births with 15% shortages required 0.0 and 0.1 whole-time equivalent more midwives in our respective trusts compared with baseline, representing 0% and 0.1% of overall staffing requirements net of shortages. Restricting home births with 25% shortages reduced midwifery staffing need by 0.1 midwives (–0.1% of staffing) and 0.3 midwives (–0.3%). Suspending community births with 35% shortages meant changes of –0.3 midwives (–0.3%) and –0.5 midwives (–0.5%) in the two trusts. Sensitivity analysis showed that our results were robust even under extreme assumptions.ConclusionOur model found that reconfiguring maternity services in response to shortages has a negligible effect on intrapartum and postnatal midwifery staffing needs. Given this, with lower degrees of shortage, managers can consider increasing community birth options where there is demand. In situations of severe shortage, reconfiguration cannot recoup the shortage and managers must decide how to modify service arrangements.

IntroductionScreening to identify traumatic births and childbirth-related post-traumatic stress disorder (CB-PTSD) is critical for reducing the global burden of maternal mental health challenges. Despite this, no brief, validated tools exist for international use. This study therefore developed and validated a short version of the City Birth Trauma Scale (City BiTS) to provide a brief, globally relevant screening tool.MethodsThe City BiTS-Short was developed in three stages. In stage 1, exclusive lasso statistical analyses were conducted on survey data of 11 302 postpartum women in 31 countries to identify the most effective items for the City BiTS-Short, ensuring all four CB-PTSD symptom domains were represented. In stage 2, stakeholder reviews were conducted with researchers, health professionals (midwives, health visitors, psychiatrist, psychologist) and representatives of women who experienced traumatic birth. In stage 3, the City BiTS-Short was finalised and psychometric properties examined across diverse geographical settings.ResultsThe City BiTS-Short comprises one item assessing traumatic birth and four items assessing CB-PTSD symptoms: re-experiencing, avoidance, negative cognitions and mood and hyperarousal. The scale had strong psychometric properties, including good internal consistency (α=0.78) and high correlations with the original City BiTS (r=0.90), birth trauma ratings (r=0.50), distress (r=0.56), impairment (r=0.47) and CB-PTSD diagnoses (r=0.54). It identified 90% of participants with a CB-PTSD diagnosis. Women who had operative births (F(3,2174)=127.38, p<0.001), maternal complications (F(2,2163)=212.84, p<0.001), infant complications (F(2,1100)=138.93, p<0.001) or depression (t(3209.5)=−30.96, p<0.001) had higher scores. Psychometric properties were consistent across most international contexts, with stakeholders affirming its utility.ConclusionThe City BiTS-Short offers a brief, validated screening tool for identifying birth trauma and CB-PTSD symptoms. Its widespread adoption can enhance early detection and support for women, potentially reducing the global burden of birth trauma and improving maternal mental health outcomes worldwide. Further research is needed to explore its use in specific contexts.

We created a dataset to generate estimates of donor-reported ‘official development assistance’ and private grants (ODA+) to reproductive, maternal, newborn and child health (RMNCH) by donor, recipient country and activity type over the period 2003–2013. We collected disbursement information from the Organisation for Economic Co-operation and Development Creditor Reporting System (CRS) in January 2015. All 2.1 million records across all sectors were coded based on donor name, project title, short and long descriptions, and CRS code describing the purpose of the disbursement. We classified records according to the degree to which they would promote attainment of Millennium Development Goals 4 and 5 (reproductive and sexual health, maternal and newborn health, and child health). We also classified records according to whether they supported prenatal and neonatal health (PNH). The dataset includes project funding as well as allocating shares of general budget support, health sector support and basket funding. The data can be used to analyse resource flows to RMNCH or to other purposes or beneficiaries of ODA+. Design Type(s) data integration objective • database creation objective Measurement Type(s) healthcare financing Technology Type(s) digital curation Factor Type(s) Machine-accessible metadata file describing the reported data (ISA-Tab format)

AimPotential ‘weekend effects’ in healthcare prompt concerns that care could be of lower quality during non-working hours, but may reflect differences in case mix or other factors. To investigate this we compared neonatal mortality in English hospitals from 2005 to 2014 by time of day and day of the week.MethodsWe analysed data from a retrospective cohort of 6,054,536 singleton live births in England 2005—2014, created by linking Office for National Statistics’ birth and death registration and birth notification data with Hospital Episode Statistics.Working hours were defined as 07:00—19:00 on weekdays, and non-working hours were all other times on weekdays and all weekends and public holidays.The primary outcome was neonatal mortality attributed to asphyxia, anoxia or trauma. On advice through our public involvement and engagement strategy, analysis was stratified by mode of onset of labour and mode of birth. We fitted logistic regression models in R to estimate odds ratios for mortality, adjusting for covariates.ResultsAfter adjustment, the odds of neonatal mortality outside of working hours were similar to those during working hours for spontaneous births (OR: 1.09, 95% CI: 0.87—1.35), instrumental births (0.96, 0.70—1.32) and emergency caesareans following spontaneous (1.06, 0.83—1.34) or induced (1.14, 0.74—1.76) onset of labour. Emergency caesarean births without labour had a higher risk of neonatal mortality attributed to anoxia, asphyxia or trauma during non-working hours compared with working hours.Further stratification showed that this higher risk was at night-time (weeknight: 1.56, 1.15—2.11; weekend/holiday: 1.75, 1.24—2.47) and that risk during the daytime on weekends and holidays was not significantly higher than on weekdays (0.95, 0.63—1.46). Even then, the number needed to harm was 1258 for weeknights and 933 for weekend/holiday nights, indicating very low absolute risk.ConclusionWe found no significant association between time of birth and neonatal mortality. The apparent ‘weekend effect’ may be caused by deaths among the relatively small number of babies who were born by caesarean section apparently without labour outside normal working hours. Obstetric staffing should be planned to allow for these relatively unusual emergencies, although reorganisation has opportunity costs and these findings would not warrant major changes. Continuous updating of the data linkage would facilitate ongoing monitoring of these findings.

Donor financing to low- and middle-income countries for reproductive, maternal, newborn, and child health increased substantially from 2008 to 2013. However, increased spending by donors might not improve outcomes, if funds are delivered in ways that undermine countries' public financial management systems and incur high transaction costs for project implementation. We combined quantitative and qualitative methods to examine the quality of funding for reproductive, maternal, newborn, and child health globally and in Tanzania, based on two principles of aid effectiveness: the alignment of donor financing with the recipient country's public health financial management systems, and donor harmonization for coordinated, transparent, and collectively effective actions. We found that alignment of donor financing deteriorated throughout the period, with the proportion of funds channeled through governments decreasing from 47 percent to 39 percent. Tanzania-based donors attributed the change to the pressure donors were under to achieve and show results. Donor harmonization was low overall and remained relatively constant, although it increased in sub-Saharan Africa and decreased in South Asia. Bilateral funding agencies were the most harmonized donors. We recommend that future assessments of Sustainable Development Goals financing include measures of harmonization and alignment of funding.

Childbirth-related post-traumatic stress disorder (CB-PTSD) is an underrecognized condition with consequences for mothers and infants. This study aimed to determine risk factors for CB-PTSD symptoms across countries within a stress-diathesis framework, focusing on antenatal, birth-related, and postpartum predictors. The INTERSECT cross-sectional survey (April 2021-January 2024) included 11,302 women at 6-12 weeks postpartum. The study was carried out across maternity services in 31 countries. Outcomes were CB-PTSD diagnosis, symptom severity, and perceived traumatic birth, assessed with the City Birth Trauma Scale. Multiple risk factors were assessed, including preexisting vulnerability, pregnancy, birth, and infant-related factors. All models were adjusted for country-level variation as a random effect. Models explained substantial variance across all outcomes (conditional  = 0.53-0.58). Negative birth experience was the strongest predictor (e.g. odds ratio [OR] = 0.82, 95% confidence interval [CI] = 0.80-0.84 for diagnosis). Ongoing maternal complications predicted both CB-PTSD diagnosis and symptoms (e.g. OR = 1.61, 95% CI = 1.41-1.84), and major infant complications were associated with CB-PTSD diagnosis (OR = 1.63, 95% CI = 1.29-2.07). Reports of perceived danger to self or infant (criterion A) were linked to higher CB-PTSD symptoms and traumatic birth ratings (e.g., =0.25, 95% CI = 0.21-0.29). Other predictors reached significance but showed small effects. Findings support a stress-diathesis framework, showing that while pre-existing vulnerabilities contribute, birth-related stressors exert the strongest influence. Trauma-informed maternity care should prioritize these factors, with attention to women's appraisals of birth.

The International Conference on Population and Development in 1994 set targets for donor funding to support family planning programmes, and recent initiatives such as FP2020 have renewed focus on the need for adequate funding to rights-based family planning. Disbursements supporting family planning disaggregated by donor, recipient country and year are not available for recent years. We estimate international donor funding for family planning in 2003–13, the period covering the introduction of reproductive health targets to the Millennium Development Goals and up to the beginning of FP2020, and compare funding to unmet need for family planning in recipient countries. We used the dataset of donor disbursements to support reproductive, maternal, newborn and child health developed by the Countdown to 2015 based on the Organization for Economic Cooperation and Development Creditor Reporting System. We assessed levels and trends in disbursements supporting family planning in the period 2003–13 and compared this to unmet need for family planning. Between 2003 and 2013, disbursements supporting family planning rose from under $ 400 m prior to 2008 to $ 886 m in 2013. More than two thirds of disbursements came from the USA. There was substantial year-on-year variation in disbursement value to some recipient countries. Disbursements have become more concentrated among recipient countries with higher national levels of unmet need for family planning. Annual disbursements of donor funding supporting family planning are far short of projected and estimated levels necessary to address unmet need for family planning. The reimposition of the US Global Gag Rule will precipitate an even greater shortfall if other donors and recipient countries do not find substantial alternative sources of funding. La Conférence internationale sur la population et le développement de 1994 a fixé les objectifs de financement des donateurs pour soutenir les programmes de planification familiale, et des initiatives récentes telles que FP2020 ont réaffirmé la nécessité d’un financement adéquat de la planification familiale fondée sur les droits. Les décaissements en faveur de la planification familiale ventilés par donateur, pays bénéficiaire et année ne sont pas disponibles pour les années récentes. Nous estimons le financement des donateurs internationaux pour la planification familiale en 2003-13, période couvrant l’introduction des objectifs de santé génésique dans les objectifs du Millénaire pour le développement et jusqu’au début du FP2020, et comparons le financement aux besoins non satisfaits de la planification familiale dans les pays bénéficiaires. Nous avons utilisé l’ensemble des données sur les décaissements des donateurs en faveur de la santé génésique, maternelle, néonatale et infantile élaboré par le forum « Compte à rebours pour 2015 » sur la base du Système de notification des pays créanciers de l’Organisation de coopération et de développement économiques. Nous avons évalué les niveaux et les tendances des décaissements en faveur de la planification familiale au cours de la période 2003-13 et l’avons comparé aux besoins non satisfaits de planification familiale. Entre 2003 et 2013, les décaissements en faveur de la planification familiale sont passés de moins de 400 millions de dollars avant 2008 à 886 millions de dollars en 2013. Plus des deux tiers des décaissements provenaient des États-Unis. Dans certains pays bénéficiaires, on a observé une variation considérable de la valeur des décaissements d’une année à l’autre. Les décaissements se sont davantage concentrés au sein des pays bénéficiaires dont les besoins en matière de planification familiale sont plus élevés. Les décaissements annuels des bailleurs de fonds en faveur de la planification familiale sont très inférieurs aux niveaux prévus et estimés nécessaires pour répondre aux besoins non satisfaits en matière de planification familiale. La réimposition de la Règle américaine du bâillon mondial (US Global Gag Rule) va entraîner un déficit encore plus important si les autres donateurs et pays bénéficiaires ne trouvent pas d’autres substantielles sources de financement. 1994年国际人口与发展会议设定了捐助资金资助计划生育项 目的目标, EP2020等近期项目也重新关注获得充分资金支持 以权利为基础的计划生育。目前没有近年来不同捐助者、受 捐国和年份的计划生育捐助支付数据。我们估算2003年至 2013年计划生育的国际捐助资金, 该时期涵盖了千年发展目标 中引入生殖健康目标的阶段, 一直到EP2020开始, 比较资助和 受捐国未满足的计划生育需求。使用经济合作与发展组织债 权人报告体系2015倒计时的生殖、孕产妇、新生儿和儿童健 康捐助者资金支付数据。我们评估了2003至2013年计划生育 资金的水平和趋势, 与未满足的计划生育需求相比较。2003至 2013年, 计划生育资金由2008年前的不足4亿美元增加到2013 年的八亿八千六百万美元。2/3以上的资金来自美国。部分受 捐国不同年份之间的资助波动较大。资助已更多集中在计划 生育需求未满足程度较高的受捐国。年均计划生育捐助资金 远远低于预测和估计的满足计划生育需求所需金额。如果其 他捐助者和受捐国不寻找其他资金来源, 美国恢复全球禁令将 加速计划生育资金短缺。 La Conferencia Internacional sobre Población y Desarrollo en 1994 estableció objetivos para el financiamiento de donantes para apoyar programas de planificación familiar, y las iniciativas recientes como el FP2020 han renovado su enfoque en la necesidad de una financiación adecuada para la planificación familiar basada en los derechos. Los desembolsos que respaldan la planificación familiar desagregados por donante, país receptor y año no están disponibles para los últimos años. Estimamos el financiamiento de los donantes internacionales para planificación familiar en 2003-13, el período que cubre la introducción de objetivos de salud reproductiva a los Objetivos de Desarrollo del Milenio hasta el comienzo del FP2020, y comparamos los fondos con la necesidad insatisfecha de planificación familiar en los países receptores. Usamos el conjunto de datos de los desembolsos de los donantes para apoyar la salud reproductiva, materna, del recién nacido y del niño, desarrollado por ‘Cuenta Regresiva al 2015’ basado en el Sistema de Informes de los Acreedores de la Organización para la Cooperación y el Desarrollo Económico. Evaluamos los niveles y las tendencias en los desembolsos que respaldan la planificación familiar en el período 2003-13 y lo comparamos con la necesidad insatisfecha de planificación familiar. Entre 2003 y 2013, los desembolsos que respaldaron la planificación familiar aumentaron de menos de $400 millones antes de 2008 a $886 millones en 2013. Más de dos tercios de los desembolsos provinieron de E.E.U.U. Hubo una variación interanual sustancial en el valor del desembolso para algunos países receptores. Los desembolsos se han concentrado más entre los países receptores con niveles nacionales más altos de necesidad insatisfecha de planificación familiar. Los desembolsos anuales de fondos de donantes que apoyan la planificación familiar son inferiores a los niveles proyectados y estimados como necesarios para dirigir la necesidad insatisfecha de planificación familiar. La reimposición de la Regla Global de Censura de E.E.U.U. precipitará un déficit aún mayor si otros donantes y países receptores no encuentran fuentes de financiación alternativas sustanciales.

BackgroundIn 2015, 5.3 million babies died in the third trimester of pregnancy and first month following birth. Progress in reducing neonatal mortality and stillbirth rates has lagged behind the substantial progress in reducing postneonatal and maternal mortality rates. The benefits to prenatal and neonatal health (PNH) from maternal and child health investments cannot be assumed.MethodsWe analysed donor funding for PNH over the period 2003–2013. We used an exhaustive key term search followed by manual review and classification to identify official development assistance and private grant (ODA+) disbursement records in the Countdown to 2015 ODA+ Database.ResultsThe value of ODA+ mentioning PNH or an activity that would directly benefit PNH increased from $105 million in 2003 to $1465 million in 2013, but this included a 3% decline between 2012 and 2013. Projects exclusively benefitting PNH reached just $6 million in 2013. Records mentioning PNH accounted for 3% of the $2708 million disbursed in 2003 for maternal, newborn and child health (MNCH) and increased to 13% of the $9287 million disbursed for MNCH in 2013. In 11 years, only nine records ($6 million) mentioned stillbirth, miscarriage, or the fetus, although the two leading infectious causes of stillbirth were mentioned in records worth $832 million. The USA disbursed the most ODA+ mentioning PNH ($2848 million, 40% of the total) and Unicef disbursed the most ODA+ exclusively benefitting PNH ($18 million, 30%). We found evidence that funding mentioning and exclusively benefitting PNH was targeted to countries with greater economic needs, but the evidence of targeting to health needs was weak and inconsistent.ConclusionsNewborn health rose substantially on the global agenda between 2003 and 2013, but prenatal health received minimal attention in donor funding decisions. Declines in 2013 and persistently low funding exclusively benefitting PNH indicate a need for caution and continued monitoring of donors' support for newborn health.