Journal of Midwifery & Women's Health

Today nearly 9 out of 10 certified nurse‐midwives/certified midwives (CNMs/CMs) attend births in hospitals. As the demand for hospital midwifery care has increased over the last quarter century, CNM/CMs' scope of practice has expanded to include care for high‐risk patients. Hospital CNMs/CMs are faced with the challenge of balancing support for physiologic birth with an increasingly complex pregnant population cared for in a medicalized ecosystem. Varied perceptions of patient risk and unique philosophies of care can lead to complex discussions between midwives and physicians on the most appropriate care plan for patients. This article shares the experiences and successes of a hospital midwifery practice in the Alaska Native Tribal Health System and explores strategies for promoting the midwifery model of care (MMOC). Midwives in this Tribal Health System experience robust interprofessional collaboration and an organizational focus on patient‐centered relationship‐based care. Interprofessional collaboration is noted to be among the most critical elements for protecting a MMOC in a hospital setting. Although distinct from one another, the medical and midwifery models can be complementary in the care of high‐risk patients, and the Indigenous concept of Two‐Eyed Seeing is offered as an approach to integrating the 2 models of care to achieve optimal care for birthing people and their families.

Introduction According to the Centers for Disease Control and Prevention, the state of Florida became the epicenter of the COVID‐19 delta variant during the summer of 2021. There is limited knowledge on how the pandemic impacted postpartum women's lived experiences in the United States. The purpose of the study was to explore the lived experiences of postpartum women living in South Florida during the COVID‐19 pandemic and their responses. Methods A descriptive qualitative study design was used. Study participants included 26 postpartum women living in South Florida who had given birth to a live newborn from March 2020 to May 2022. We used purposeful sampling and social media recruitment methods. Sociodemographic information was collected using REDCap, and live face‐to‐face in‐depth interviews were conducted on Webex using a semistructured questionnaire. Content analysis was used to analyze the research data and develop themes and subthemes. Results The first central theme, raising an infant during a pandemic, included 3 subthemes: (1) protecting the infant, (2) feeling isolated, and (3) food for thought. The second central theme, maternal needs during a pandemic, included 3 subthemes: (1) mental health needs, (2) support needs, and (3) health care needs. Conclusion Findings suggest women experienced significant challenges in caring for themselves and their infants during the COVID‐19 pandemic. Findings highlight the need for policy reform that secures comprehensive and quality postpartum health care for women that includes mental health screenings.

Introduction A growing number of families are using exclusive breastmilk expression to feed their newborns. They need accurate information and support from their providers. Methods The purpose of this integrative review was to explore the prevalence, characteristics, practices, and outcomes of families who fed exclusively expressed breastmilk to their infants. The electronic databases of CINAHL, Scopus, PubMed, Web of Science, and article reference lists for articles on expressing human milk for infants were searched. Results were filtered to glean published studies between 2012 and 2022, academic journals, human studies, and English language journals while excluding secondary reviews and expert opinions. Both authors screened records within Covidence systematic review management software. Selected studies were evaluated for quality of evidence using the Johns Hopkins Research Evidence Appraisal Tool. Results Twenty‐seven studies were included in this review. Most families who exclusively expressed originally planned to directly breastfeed their newborns and only began pumping after encountering problems. The most frequently recurring theme was that advice from health care personnel was inconsistent. Women described a knowledge deficit and received more help with exclusive expression from informal social media groups than their providers. Prevalence of exclusive breastmilk expression is highest in Asian countries and in the neonatal intensive care unit environment. These women had a shorter duration of human milk feeding and higher likelihood of cessation compared with women who both fed expressed milk and directly breastfed. Discussion Only recently have breastfeeding researchers begun distinguishing the type of milk (human milk or artificial formula) from the feeding method in their publications. This approach allows clinicians to provide better guidance on the outcomes of each feeding method. As clinicians, we can help families by encouraging them and providing consistently accurate information. Solely feeding expressed human milk is a valid option when the lactating person is unable or unwilling to directly breastfeed.

Introduction Perinatal depression is a leading cause of preventable US maternal morbidity and mortality. Although Mindfulness‐Based Cognitive Therapy for Perinatal Depression (MBCT‐PD) is highly effective, it faces significant scalability challenges. Center M, a brief, group‐based, mindfulness‐based cognitive behavioral therapy (CBT) intervention, is an adaptation of MBCT‐PD designed to overcome these challenges. The purpose of this pilot study was to evaluate Center M's preliminary acceptability, feasibility, mechanisms of action, and efficacy. Methods In this mixed‐methods pilot study, data were collected from 99 pregnant people at 3 time points: preintervention, postintervention, and 6‐weeks postpartum (Clinical Trials no. NCT06525922). Participants engaged in 4 one‐hour, weekly group telehealth Center M sessions facilitated by social workers. Participants strengthened mindfulness CBT skills using home practice materials between group sessions. Data included self‐report measures evaluating depressive symptoms, mindfulness skills, and emotion regulation. Satisfaction was assessed via focus groups or surveys. Results Depressive symptoms significantly decreased preintervention to postintervention (Patient Health Questionnaire‐8 score: preintervention mean [SD] 5.02 [3.52], postintervention mean [SD] 4.23 [2.84]; P = .03), and mindfulness capacity significantly increased preintervention to 6 weeks postpartum (Five Facets of Mindfulness Questionnaire score: preintervention mean [SD] 125.56 [18.68], 6 weeks postpartum mean [SD] 130.10 [17.15]; P = .004). Linear regression analyses indicate that higher mindfulness at 6 weeks postpartum significantly predicted fewer depression symptoms at 6 weeks postpartum (β, −0.07; 95% CI, −0.123 to −0.021, R² = 0.22; P = .006). Reduction in the use of maladaptive emotion regulation was significantly associated with decreased depressive symptoms at 6 weeks postpartum (β, 0.21; 95% CI, 0.048 to 0.376, R² = .21; P = .012). Qualitative themes indicated high Center M acceptability and appeal. Discussion Our findings support the feasibility, acceptability, and appeal of Center M. Results suggest Center M may be effective in reducing depression and enhancing mindfulness skills. Future research must confirm these initial findings to more widely address Center M implementation capacity and sustainability.

Introduction Perinatal substance use continues to rise across the United States presenting unique challenges to providing antepartum care. Polysubstance use, limited and late engagement in health care, co‐occurring mood disorders, and several social barriers are well documented. This review seeks to summarize these barriers and present novel approaches to caring for this high‐risk population. Methods Inclusion criteria for this study focused on peer‐reviewed articles that explicitly detailed a direct impact on the provision or receipt of antenatal care in the setting of substance use within the United States that were published in the last 5 years. PubMed and Web of Science were used to find applicable articles. Of the 156 articles found, 10 relevant articles were selected for the final empirical integrative review that entailed data evaluation using the Mixed Methods Appraisal Tool (MMAT) and thematic analysis. Results 10 review articles met inclusion; 3 were qualitative, 6 were quantitative and nonrandomized, and one was quantitative descriptive. Six articles met MMAT quality criteria, and there were significant limitations in every article. Topics included opioid use disorder (n = 6), general substance use (n = 3), and tobacco use (n = 1). Themes included integrated models of prenatal care, colocated care, resource coordination, and peer support along with the role of the perinatal health care professional and consistent use of a substance use screening tool. Discussion A comprehensive and multidisciplinary care model is necessary to meet the complex and urgent needs of individuals with perinatal substance use that not only meets recommendations for opioid maintenance therapy or substance use cessation but the important areas of accessibility and interpersonal support. Future research should focus on the development, implementation, and evaluation of new models of care for this vulnerable population.

Introduction Preterm birth and small for gestational age (SGA) are significant public health concerns in the United States, with pronounced disparities across racial and ethnic groups. Traditional prenatal care adequacy indices have limitations in fully capturing their multifaceted nature. Our study introduces the Comprehensive Prenatal Care Index (CPCI) to provide a more holistic assessment of prenatal care by integrating key elements of prenatal counseling and health promotion. Methods This cross‐sectional study used the Pregnancy Risk Assessment Monitoring System 2016‐2021 data. The CPCI was developed based on a comprehensive literature review, incorporating components such as timing, frequency, and content of prenatal visits. The index was validated using Item Response Theory (IRT) and compared with the Kotelchuck and Kessner Indices. Results The study included 139,181 pregnant women. The CPCI demonstrated strong internal consistency (Cronbach's α, 0.75; ω total, 0.81). IRT analysis confirmed the index's ability to capture variability in the quality of prenatal care, with item difficulty parameters ranging from −2.93 to +2.10. CPCI scores were significantly associated with reduced odds of adverse birth outcomes. Adequate CPCI care was linked to a 63% reduction in the odds of preterm birth among non‐Hispanic White women, with similar reductions observed in Hispanic women (odds ratio [OR], 0.59) and Asian women (OR, 0.38). For SGA, adequate care was protective among non‐Hispanic White (OR, 0.86) and Hispanic women (OR, 0.82) but showed mixed results in other groups. Discussion The CPCI provides a more inclusive measure of the quality of prenatal care compared with traditional indices. The study's findings suggest a significant role of comprehensive prenatal care in reducing adverse birth outcomes and addressing racial and ethnic disparities. Future research should focus on refining the CPCI and exploring its applicability in diverse populations to inform targeted and culturally sensitive prenatal care strategies.

Trisomy 18 (T18) is the second‐most common autosomal trisomy and includes multiple anomalies, growth restriction, and a severely shortened life span, often lasting only hours or days. Côté‐Arsenault and Denney‐Koelsch extended Reva Rubin's work, describing the psychosocial stages of pregnancy by describing the stages and developmental tasks for a pregnancy altered by a life‐limiting fetal condition such as T18. When a diagnosis of T18 is made prenatally, the pregnancy changes dramatically, although it remains a psychosocial developmental process. The extended stages of pregnancy with T18 or another life‐limiting fetal condition are: Pre‐Diagnosis, Learning the Diagnosis, Living With the Diagnosis, Birth and Death, and Post Death. As they navigate these stages, parents must also address 7 developmental tasks of pregnancy, which are (1) Navigating Relationships, (2) Comprehending Implications of the Condition, (3) Revising Goals of Pregnancy, (4) Making the Most of Time With Baby, (5) Preparing for Birth and Inevitable Death, (6) Advocating for Baby With Integrity, and (7) Adjusting to Life in Absence of Baby. Knowledgeable health care providers can do much more than support parents through grief and facilitate discussions about birth planning. This case report highlights the importance of a knowledgeable provider who can help parents navigate the stages and tasks of pregnancy, empowering them to make choices consistent with their values so they have no regrets.

Introduction Among Black birthing people, high‐quality, respectful care throughout pregnancy and postpartum is hindered by distrust, racial discrimination, and unsatisfactory care. The purpose of this integrative review was to examine prenatal and postpartum care experiences among Black birthing people in the United States. Methods A literature search, spanning from inception through October 6, 2022, across 4 research databases, used a combination of keywords to capture reports on care experiences among Black birthing people. We included quantitative and qualitative studies in the United States with people who self‐identified as Black or African American and reported prenatal or postpartum health care experiences. Intrapartum experiences were excluded. All studies were evaluated with the Mixed‐Methods Appraisal Tool, National Institutes of Health Study Quality Assessment tool, or Joanna Briggs Institute critical appraisal checklist. Data were analyzed and synthesized using the Joanna Briggs Institute convergent integrated approach to incorporate quantitative and qualitative research. Results A total of 16 studies published over 27 years met the inclusion criteria. All studies examined the health care experiences of Black birthing people during prenatal or postpartum care. None of the studies focused solely on postpartum care experiences. The 2 most prominent themes were models of care and patient‐provider interactions, encompassing both positive and negative experiences. Positive care experiences included collaborative patient‐provider interactions, continuity of care, and culturally centered care. Adverse experiences were more frequently noted and involved discriminatory treatment during patient‐provider interactions, fragmented care models, and a lack of cultural awareness. Discussion Black birthing people in the United States report some positive but more negative health care experiences during pregnancy and postpartum care, which may play an important role in health inequities. Promoting prenatal and postpartum care models that provide continuity and are high‐quality, collaborative, and culturally centered were identified as high‐priority targets to foster patient safety and improve clinical outcomes.

Introduction This study explored perinatal health care providers’ perspectives on the recruitment of pregnant participants and integrating clinical research into their practice, with a particular emphasis on the complexities introduced by the COVID‐19 pandemic. Methods From May to September 2021, semistructured interviews were conducted with 10 perinatal health care providers from an urban US health center. The interview transcripts were analyzed using Braun and Clarke's thematic analysis framework, a rigorous method for analyzing qualitative data by identifying, coding, and reporting themes. This approach allowed us to systematically code the data and identify key themes related to recruitment strategies and integration of clinical trials during prenatal care. Results Barriers to integrating clinical trials into the perinatal infrastructure included pandemic‐related restrictions, heavy workloads, time constraints, ineffective communication and coordination, and maintaining the relevance of the research among providers. Facilitators included the use of communication tools, collaboration with multidisciplinary teams and stakeholders, creation of detailed study information for clinic staff, and fostering commitment to supporting research among providers. Discussion The perspectives of perinatal health care providers uncover barriers and facilitators regarding the recruitment of pregnant individuals for clinical trials and shed light on the unprecedented challenges of research in this population during the COVID‐19 pandemic and lessons learned postpandemic. This information can support the development of evidence‐based solutions and strategies to improve the recruitment of pregnant individuals, as well as enhance clinical research integration into infrastructure in perinatal health clinics.

Introduction During the COVID‐19 pandemic, birthing parents were identified as a high‐risk group with greater vulnerability to the harms associated with SARS‐CoV‐2. This led to necessary changes in perinatal health policies but also to experiences of maternal isolation and loneliness, both in hospital settings, due to infection mitigation procedures, and once home, due to social distancing. Methods In this study, we qualitatively explored birthing and postpartum experiences in New York City during the early days of the pandemic when lockdowns were in effect and policies and practices were rapidly changing. Using thematic analysis, our focus was on experiences of isolation, navigating these experiences, and the potential impacts of isolation and loneliness on maternal health for 55 birthing people. Results Participants described numerous stressors related to isolation during the birthing process, including reconciling their hopes for their birth with the realities of the unknown and separation from partners, family, and friends in the hospital. During the postpartum period, loneliness manifested as having limited or no contact with family and friends, which led to feelings of a need for strengthened social support systems. The impact of these negative experiences shaped mental health. Overall, we found that solitary experiences during birthing and postpartum isolation were major sources of stress for participants in this study. Discussion To support impacted families and prepare for future crisis events, clinicians and researchers must prioritize the development of strong clinical and social support structures for perinatal people to ensure both maternal and child health.

The use of telehealth prenatal care increased exponentially during the coronavirus disease 2019 (COVID‐19) pandemic, but there is no literature describing its use for group prenatal care during this time. The COVID‐19 pandemic also exacerbated structural barriers to care that disproportionately affect Black and Latinx people. Telehealth enabled pregnant people to access health care and minimize infectious risks. Telehealth group prenatal care (T‐GPNC) incorporated the essential elements of CenteringPregnancy with telehealth is an innovative care delivery method borne out of necessity during the COVID‐19 pandemic that has potential to mitigate structural barriers to care. Mary's Center is a federally qualified health center (FQHC) in Washington, DC, and Maryland that rapidly pivoted to individual telehealth prenatal care early in the pandemic. Mary's Center used our experience with group care and guidance from the Centering Healthcare Institute on virtual Centering to launch T‐GPNC. This new model included home self‐monitoring equipment and video classrooms, mixed with in‐person individual care visits. We used a team‐based approach with nurses, midwives, and community health workers to provide holistic care to pregnant people. Our robust care coordination team also connected them to home visiting, mental health services, and nutrition counseling. The purpose of this article is to describe how Mary's Center modified the CenteringPregnancy model of group prenatal care for telehealth, following the hallmarks of CenteringPregnancy, and met the needs of Spanish‐speaking clients, henceforth Latinx clients. A secondary purpose is to demonstrate how telehealth can expand access to health care and remove structural barriers that may prevent pregnant people from attending in‐person appointments. We also discuss the structural inequities in digital access and literacy in the context of program implementation.

Management of acute cystitis in a transfeminine patient is discussed as an example of treatment of urinary tract infections (UTIs). The case is an introduction for clinicians who typically care for cisgender women and wish to expand the populations they serve to include care of gender‐diverse individuals. This is supportive of the 2021 American College of Nurse‐Midwives Position Statement on Health Care for Transgender and Gender Non‐Binary People. Possible differential diagnoses for urinary symptoms in transfeminine patients are discussed, as well as relevant history taking, examination skills, and treatment guidelines for acute cystitis of patients with penises along with discussion of basic care for transgender individuals seeking midwifery or primary care services.

Screening for substance use disorder (SUD) is an essential part of antepartum care. Best practice for screening requires the use of a validated tool early in pregnancy to identify those at risk and to connect them with counseling and treatment. In many health systems and practices, urine toxicology testing is erroneously employed as a SUD screening tool despite consistent recommendations against its routine use. The results are often misinterpreted as diagnostic of SUD and can have harmful downstream effects for pregnant and birthing people. This Clinical Rounds reviews the tools available for evidence‐based SUD screenings in pregnancy care, pitfalls of urine toxicology testing, and ways in which midwifery care is well‐positioned to implement evidence‐based screening practices in pregnancy care.

Introduction In the United States, maternal mortality is high and patterned by race and socioeconomic status (SES). Patient‐provider relationships and societal discrimination have been separately associated with poor maternal outcomes, but it is not clear how such mechanisms may be interrelated. Thus, the present study investigates how societal experiences of discrimination are associated with and manifest in patient‐provider relationship quality among perinatal women. Methods The study uses a mixed methods design with an explanatory‐sequential approach. First, a path analysis using structural equation modeling of a cross‐sectional representative survey of 244 perinatal women in Kalamazoo County, Michigan, was conducted. Second, a thematic qualitative analysis was conducted of focus groups composed of survey participants (n = 34). Results In the quantitative analyses, race and SES were associated with experiences of societal discrimination in the expected directions (race: b, 1.87; SE, 0.58; P = .001; SES: b, 2.18; SE, 0.60; P < .001), discrimination positively predicted vigilant behaviors (b, 0.81; SE, 0.15; P < .001), and more vigilant behaviors predicted worse patient‐provider relationship quality (b, 0.18; SE, 0.07; P < .001). In the qualitative findings, we found detailed accounts linking provider discrimination, vigilance, and patient‐provider relationships among focus groups composed of only women of color (n = 9). Discussion Overall, the quantitative analyses find support for the conceptual model showing race and SES are associated with societal discrimination, which is associated with vigilant behaviors and, in turn, quality of patient‐provider relationships. The qualitative analyses provide preliminary evidence for how these pathways manifest in care settings and demonstrate the importance of establishing trust in patient‐provider relationships, especially among women of color.

Introduction Approximately 50% to 60% of all pregnant women suffer from insomnia during pregnancy. Pregnancy‐related insomnia has been associated with severe outcomes for both mother and child postnatally. Currently, the treatment of pregnancy‐related insomnia is often neglected due to a lack of suitable treatments. This online assessor‐masked randomized controlled trial aimed to evaluate the effectiveness of music listening and sleep hygiene for treating pregnancy‐related insomnia. Methods We recruited first‐time pregnant women at the end of the second trimester with a report of poor sleep. Participants in the music and sleep hygiene (MSH) group received standard sleep hygiene advice and were instructed to listen to music daily at bedtime for 4 weeks. They could choose from 6 sleep playlists of different genres. Participants randomized to the sleep hygiene alone (SH) group received standard sleep hygiene only. Primary outcomes were sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) and insomnia severity measured with the Insomnia Severity Index. ClinicalTrials.gov Identifier: NCT04633395. Results Among the 98 participants receiving the online intervention, 31 participants in the MSH group (62%) and 40 participants in the SH group (80%) completed the postintervention measurements. Both groups experienced improved sleep quality during the intervention period (PSQI change, −2.10; 95% CI, −3.27 to −0.93; P < .001), with no significant difference between the groups. Similarly, insomnia symptoms were reduced (Insomnia Severity Index change, −3.42; 95% CI, −5.02 to −1.83; P < .001) with no significant difference in the effect between groups. There was a significant difference in adherence to sleep hygiene between the MSH and SH groups (42% vs 8%; P = .007). Discussion Sleep quality and insomnia severity can be improved in pregnant women with relatively simple interventions like music listening and sleep hygiene advice. These results align with previous research, but larger trials are recommended to support introduction into clinical practice.

Background Adherence to study interventions is critical to the conduct of randomized controlled trials (RCTs). The relationships between participant characteristics and intervention adherence are understudied in pregnant populations. The purpose of this study was to conduct a secondary analysis of adherence to study capsules in a double‐masked, placebo‐controlled RCT of a probiotic intervention to reduce antenatal Group B Streptococcus colonization, in relationship to participant characteristics. Methods We analyzed the relationship between capsule adherence rates and demographic characteristics among 81 RCT participants. Categorical variables were reported using counts and percentages, and continuous variables were expressed as means along with their standard deviations. For the univariate analyses, we compared demographic variables with adherence scores. A multivariate linear regression model was used to identify predictors of adherence. Results Average adherence was similar for control and probiotic group participants (P = .86) Univariate analysis showed that average adherence increased directly with age, education, and income. Participants who were partnered or living with others had higher average adherence compared with those who were single and living alone. Asian and White participants had the highest and Black participants had the lowest average, and there was no difference based on Hispanic ethnicity. Adjusting for all the variables in the regression, participants who identified as Black were significantly less likely to adhere to capsules than White participants, and those who were married or living with partners were more likely to adhere than the single participants. Discussion Diverse participants are critically important to RCTs. This secondary analysis provides evidence that participant characteristics and the social determinants of health play an important role in adherence to self‐administered interventions in RCTs, although more research is needed. Our findings suggest that intentional consideration of RCT participant characteristics may allow for the development and tailoring of strategies to enhance intervention adherence. The study was registered on ClinicalTrials.gov (NCT03696953) on January 10, 2018.

Introduction Existing data is often used for reproductive research and quality improvement. Electronic health records (EHRs) with a single data field for sex and gender conflate sex assigned at birth, genotype, gender identity, and the presence of anatomic tissue and organs. This is problematic for inclusion of transgender and gender‐diverse populations in research. This article discusses considerations with a single‐item sex and gender variable drawn from EHR records and describes an audit to determine variable validity as a criterion for inclusion or exclusion in perinatal research. Methods Individuals with a live birth at a large academic medical center from 2010 to 2022 were identified via electronic query, and records with male demographic information were reviewed to validate (1) the patient's date of birth and delivery date in the EHR matched the medical record number, (2) male sex and gender demographic information, and (3) male gender terms in EHR notes. Results All health records of male birthing individuals (n = 8) had EHR evidence of giving birth within the health system during the timeframe, and the date of birth matched the medical record number of the EHR. All had male gender in the EHR demographic information. Six patients did not have any male gender terms in available EHR notes, only female gender terms. Two records had recent notes using male gender terms. Discussion Current EHRs may not have reliable data on the gender and sex of gender‐diverse individuals. A single sex and gender variable drawn from EHRs should not be used as inclusion or exclusion criteria for health research or quality improvement without additional record review. EHRs can be updated to collect more data on sex, gender identity, and other relevant variables to improve research and quality improvement.