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Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on women's use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other important determinants. Using a geographic information system (GIS), we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC), basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682 rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility, and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%-40%). Independently, each step increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%-48%). The population impact of poor geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy. Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy. Please see later in the article for the Editors' Summary.

ABSTRACT Objectives: to report nurse-midwives’ autonomy in implementing Hospital Admission Authorization in Birth Centers. Methods: this is a case study in an intra-hospital Birth Centers in Ceará, Brazil, of events that occurred between 2018 and 2023. The organization of the description followed the stages of thematic analysis according to Nowell. Results: the autonomy and freedom of nurse-midwives’ action in care and management practices in labor, delivery and birth provide the professional category with a leading role in the obstetric scenario, highlighting its need to guarantee women’s rights and reduce maternal-fetal complications. Final Considerations: the issuance of Hospital Admission Authorization by nurse-midwives in Birth Centers represents a significant advance for nursing teams’ ethical and healthcare actions, contributing to effective results in maternal and child health and in achieving progress in advanced practice in the profession of nursing-midwifery. RESUMEN Objetivos: informar la autonomía de los enfermeros obstétricos en la implementación de la Autorización de Ingreso Hospitalario en Centros de Parto Natural. Métodos: se trata de un estudio de caso en un Centros de Parto Natural intrahospitalaria de Ceará, Brasil, de eventos ocurridos entre 2018 y 2023. La organización de la descripción siguió los pasos del análisis temático según Nowell. Resultados: la autonomía y libertad de acción del enfermero obstétrico en las prácticas de atención y gestión en el trabajo de parto, parto y parto otorgan el protagonismo de la categoría profesional en el escenario obstétrico y resaltan su necesidad de garantizar los derechos de las mujeres y reducir las complicaciones materno-fetales. Consideraciones Finales: la emisión de Autorización de Ingreso Hospitalario por parte del enfermero obstétrico del Centros de Parto Natural representa un avance significativo para el accionar ético y asistencial del equipo de enfermería, contribuyendo para resultados efectivos en la salud materno infantil y en el logro de avances en la práctica avanzada de la profesión de enfermería obstetra. RESUMO Objetivos: relatar a autonomia de enfermeiros obstetras na implementação da Autorização de Internação Hospitalar em Centros de Parto Normal. Métodos: trata-se de estudo de caso em Centros de Parto Normal intrahospitalares no Ceará, Brasil, de eventos ocorridos entre 2018 e 2023. A organização da descrição seguiu as etapas da análise temática conforme Nowell. Resultados: a autonomia e a liberdade de atuação do enfermeiro obstetra nas práticas de cuidado e gestão no trabalho de parto, parto e nascimento propiciam o protagonismo da categoria profissional no cenário obstétrico, ressaltando sua necessidade para garantir direitos femininos e minorar complicações materno-fetais. Considerações Finais: a emissão de Autorização de Internação Hospitalar pelos enfermeiros obstetras em Centros de Parto Normal representa avanço significativo para as ações éticas e de cuidado em saúde da equipe de enfermagem, contribuindo para resultados efetivos em saúde materno-infantil e alcance de progressos na prática avançada na profissão da enfermagem obstetra.

In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes. We used data from the nationwide district-level household surveys done in 2002–04 and 2007–09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths. Implementation of JSY in 2007–08 was highly variable by state—from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3·7 (95% CI 2·2–5·2) perinatal deaths per 1000 pregnancies and 2·3 (0·9–3·7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4·1 (2·5–5·7) perinatal deaths per 1000 pregnancies and 2·4 (0·7–4·1) neonatal deaths per 1000 livebirths. The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies. Bill & Melinda Gates Foundation.

India accounts for 19% of global maternal deaths, three-quarters of which come from nine states. In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery. Increased institutional births are expected to reduce MMR. Thus, JSY is expected to (a) increase institutional births and (b) reduce MMR in states with high proportions of institutional births. We examine the association between (a) service uptake, i.e., institutional birth proportions and (b) health outcome, i.e., MMR. Data from Sample Registration Survey of India were analysed to describe trends in proportion of institutional births before (2005) and during (2006-2010) the implementation of the JSY. Data from Annual Health Survey (2010-2011) for all 284 districts in above- mentioned nine states were analysed to assess relationship between MMR and institutional births. Proportion of institutional births increased from a pre-programme average of 20% to 49% in 5 years (p<0.05). In bivariate analysis, proportion of institutional births had a small negative correlation with district MMR (r = -0.11).The multivariate regression model did not establish significant association between institutional birth proportions and MMR [CI: -0.10, 0.68]. Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.

Background A better understanding of the processes of collaboration between midwives who work in the birthing centers, and hospital-based obstetricians, family physicians and nurses may promote cooperation among professionals providing maternity care in both institutions. The aim of this research was to explore the barriers and facilitators of the interprofessional and interorganizational collaboration between midwives in birthing centers and other health care professionals in hospitals in Quebec. Methods A case study design was adopted. Data were collected through semi-structured interviews with midwives, multidisciplinary professionals and administrators, through direct observation of activities in maternity units and field notes, and a variety of organizational and policy documents and archives. A qualitative thematic analysis method was used for analyzing transcribed verbatim. Results The study suggests the close intertwinement between interactional, organizational and systemic factors in regard to barriers and opportunities for collaboration between midwives in birthing centers, and physicians and nurses in hospitals in Quebec. At interactional level, our findings show a conflict in scope of midwifery practice, myth about midwives, pre-judgment, and lack of communication skills between health care providers in the studied birthing center and hospital. At the organizational level, this investigation shows that although midwives have complete access to the hospital with which a formal agreement was signed, they were not integrated in hospital because of lack of interest of midwives and differences in philosophy and scope of practice among healthcare professionals as well as the culture of organizations. At a systemic level, in spite of excessive demand for midwifery care, there are not enough midwives to cover these demands. Conclusion Maternity care professionals require taking a collaborative approach in working and the boundaries of responsibility need to be redrawn. The inter-professional collaborative work between midwives and other maternity care professionals is crucial to improve access and women’s choices for maternity care in Canada. Although having collaborative and multidisciplinary teamwork is a goal of maternity care systems, it is hard to achieve.

In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home. We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed \"not necessary\" by a household decision maker. Among the poorest women, \"not necessary\" was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.

ObjectiveThe purpose of this health system’s study is to assess the availability of Emergency Obstetric Care (EmOC) services in birthing centres in Taplejung District of eastern Nepal.MethodsA cross-sectional survey was conducted in 2018 in all 16 public health facilities providing delivery services in the district. Data collection comprised: (1) quantitative data collected from health workers; (2) observation of key items; and (3) record data extracted from the health facility register. Descriptive statistics were used to calculate readiness scores using unweighted averages.ResultsAlthough key health personnel were available, EmOC services at the health facilities assessed were below the minimum coverage level recommended by the World Health Organisation. Only the district hospital provided the nine signal functions of Comprehensive EmOC. The other fifteen had only partially functioning Basic EmOC facilities, as they did not provide all of the seven signal functions. The essential equipment for performing certain EmOC functions was either missing or not functional in these health facilities.Conclusions for PracticeThe Ministry of Health and Population and the federal government need to ensure that the full range of signal functions are available for safe deliveries in partially functioning EmOC health facilities by addressing the issues related to training, equipment, medicine, commodities and policy.

ABSTRACT Objectives: to analyze the factors related to eligibility and discontinuation of prenatal care in a freestanding birth center (FBC). Methods: a cross-sectional study, conducted at the Casa Angela FBC, SP, Brazil, involving 9,954 women registered between 2020-2022. Descriptive analysis was performed, including odds ratios. Results: 43.6% were eligible for prenatal care and 62.9% had their care discontinued. A higher level of education, higher income, Asian/Indigenous ethnicity, and living with a partner increased the chance of eligibility; older maternal age, a higher number of pregnancies, brown/black skin, and private health insurance decreased this chance. Brown/black skin and Indigenous ethnicity increased the chance of prenatal care discontinuation; older maternal age, a higher number of pregnancies, higher education, higher income, Asian ethnicity, living with a partner, and private health insurance decreased this chance. Conclusions: sociodemographic factors and clinical and obstetric history influence both the ineligibility and discontinuation of prenatal care in CPN. RESUMEN Objetivos: analizar los factores relacionados con la elegibilidad e interrupción del seguimiento prenatal en un centro de parto normal peri-hospitalario (CPNp). Métodos: estudio transversal realizado en el CPNp Casa Angela, SP, Brasil, con 9.954 mujeres registradas entre 2020-2022. Se realizaron análisis descriptivo y cálculo de la razón de probabilidades. Resultados: el 43,6% eran elegibles para el cuidado prenatal y el 62,9% tuvieron una interrupción del seguimiento. Mayor nivel educativo, ingresos elevados, etnia asiática/indígena y vivir con pareja aumentaron la probabilidad de elegibilidad; mayor edad, número de embarazos, color de piel parda/negra y seguro de salud disminuyeron esta probabilidad. Color de piel parda/negra y etnia indígena aumentaron la probabilidad de interrupción del cuidado prenatal; mayor edad, número de embarazos, mayor nivel educativo, ingresos elevados, etnia asiática, vivir con pareja y seguro de salud disminuyeron esta probabilidad. Conclusiones: factores sociodemográficos e historial clínico y obstétrico influyen en la inelegibilidad y en la interrupción del seguimiento prenatal en CPNp. RESUMO Objetivos: analisar os fatores relacionados à elegibilidade e interrupção do acompanhamento pré-natal em um centro de parto normal peri-hospitalar (CPNp). Métodos: estudo transversal, realizado no CPNp Casa Angela, São Paulo, SP, com 9.954 mulheres cadastradas entre 2020-2022. Realizada análise descritiva, com cálculo da razão de chances. Resultados: 43,6% das mulheres eram elegíveis para o pré-natal e 62,9% tiveram interrupção do acompanhamento. Maior escolaridade, renda elevada, etnia asiática/indígena e residir com companheiro(a) aumentaram a chance de elegibilidade; maior idade materna, número de gestações, cor da pele parda/preta e convênio de saúde diminuíram essa chance. Cor da pele parda/preta e etnia indígena aumentaram a chance de interrupção do pré-natal; maior idade materna, número de gestações, maior escolaridade, renda elevada, etnia asiática, residir com companheiro(a) e convênio de saúde diminuíram essa chance. Conclusões: fatores sociodemográficos e história clínica e obstétrica influenciam a inelegibilidade e interrupção do acompanhamento pré-natal em CPNp.

Background Current guidelines for second stage management do not provide guidance for community birth providers about when best to transfer women to hospital care for prolonged second stage. Our goal was to increase the evidence base for these providers by: 1) describing the lengths of second stage labor in freestanding birth centers, and 2) determining whether proportions of postpartum women and newborns experiencing complications change as length of second stage labor increases. Methods This study is a retrospective analysis of de-identified client-level data collected in the American Association of Birth Centers Perinatal Data Registry, including women giving birth in freestanding birth centers January 1, 2007 to December 31, 2016. We plotted proportions of postpartum women and newborns transferred to hospital care against length of the second stage of labor, and assessed significance of these with the Cochran-Armitage test for trend or chi-square test. Secondary maternal and newborn outcomes were compared for dyads with normal and prolonged second stages of labor using Fisher’s exact test. Results Second stage labor exceeded 3 hours for 2.3% of primiparous women and 2 hours for 6.6% of multiparous women. Newborn transfers increased as second stage increased from < 15 minutes to > 2 hours (0.6% to 6.33%, p for trend = 0.0008, for primiparous women, and 1.4% to 10.6%, p for trend < 0.0001, for multiparous women.) Postpartum transfers for multiparous women increased from 1.4% after second stage < 15 minutes to greater than 4% for women after second stage exceeding 2 hours (p for trend < 0.0001.) Conclusions Complications requiring hospitalization of postpartum women and newborns become more common as the length of the second stage increases. Birth center guidelines should consider not just presence of progress but also absolute length of time as indications for transfer.

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). Planned community birth (homes and birth centers), United States. Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.