Comment

New WHO antenatal care model—quality worth paying for?

The 2016 WHO guidelines on antenatal care1 were evidence for its benefit, they do not discard it
published earlier this month and are widely but recommend that clinicians continue whatever
welcomed because they are not only academically is their current practice.
robust, but also relevant to end-users and patients.
Some of the recommendations might come as
The guidelines cover antenatal care for normal
a surprise to clinicians, for example, the use of
pregnancies and have adopted a woman-centred,
acupuncture as an option for early pregnancy
holistic approach to care. They cover nutritional
nausea or low back pain during pregnancy, or
interventions, maternal and fetal assessment,
magnesium or calcium supplements for the
preventive measures, interventions for common
treatment of leg cramps. Other recommendations
physiological pregnancy symptoms, and health
represent a shift from the traditional model of
systems interventions to improve the use and
antenatal care, such as the recommendations for
quality of antenatal care. The guidelines address
caseload/team midwifery or group antenatal care in
antenatal evidence-based practices that improve
settings with well developed midwifery systems.
outcomes and detail how these practices should be
Others represent a matter of judgment, including
delivered. In addition to standard antenatal medical
the recommendation for one routine ultrasound
advice, the 49 recommendations include guidance
scan performed before 24 weeks of gestation to
on psychological support, nutrition, and
estimate gestational age, improve detection of
domestic violence screening. Each
fetal anomalies and multiple pregnancies, reduce
recommendation is backed up with an evidence
induction of labour for post-term pregnancy, and
review, generally based upon systematic reviews
improve a woman’s pregnancy experience. The
conducted by the Cochrane Collaboration. But
choice of timing of this single scan has little
even with the most rigorous analyses of the
evidence behind it, but a late second trimester scan
evidence, there are conflicting opinions as to how to
is too late for accurate dating and too early for
deal with some of the results, and what to
accurate placental site localisation or for detection of
recommend when there is very limited evidence to
fetal growth restriction. The GDG has partly justified
support or reject common practice. The WHO
this timing so as to detect congenital
antenatal care Guideline Development Group (GDG)
abnormalities, even though there are few
is to be congratulated for putting into practice the
interventions available for this to change fetal
old adage that “no evidence of benefit is not the
outcome other than pregnancy termination. As
same as evidence of no benefit”. So in symphysis-
such, the detection of fetal abnormalities is rarely a
fundal height measurement, for example, where
priority in resource constrained settings and, by 24
there is limited
weeks, termination of pregnancy is illegal in many
settings. It might have made more sense to
recommend an earlier, more accurate dating scan,
ideally performed before 16 weeks of gestation,
which would also detect multiple pregnancies and the
most serious of abnormalities like anencephaly. A
further optional scan could then be offered at 20
weeks of gestation according to culture, a woman’s
wishes, and availability of resources to detect and
treat fetal abnormalities.
Perhaps the most striking of the
Sven Torfinn/Panos

recommendations in the new guidelines is that

for antenatal care contacts. The new guidelines
recommend a minimum of eight routine antenatal
visits (now renamed contacts) for both primigravid
257D4 ownloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim
Indoneswiawfwro.tmheClalninceicta.cloKmey.Vcoolm38b8y ENlsoevveimerboenr M26a,r2c0h1267, 2021. For personal use only. No other uses
without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 and parous women with the initial contact in the first trimester,
two contacts in the second trimester, and five contacts scheduled

257D4 ownloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim
Indoneswiawfwro.tmheClalninceicta.cloKmey.Vcoolm38b8y ENlsoevveimerboenr M26a,r2c0h1267, 2021. For personal use only. No other uses
without permission. Copyright ©2021. Elsevier Inc. All rights reserved.

in the third trimester. WHO studies undertaken in
the 1990s had suggested that a four-contact schedule
was adequate,2 and WHO had implemented this
approach.3 However, updated systematic reviews
now suggest that this is less acceptable to
women and results in a 15% excess of perinatal
deaths compared with eight or more visits, with
no difference in maternal outcomes.4 The GDG
estimates that this equates to about four extra
perinatal deaths per 1000 births in a typical low-
resource setting with a perinatal mortality rate of
25 per 1000 births. Although the aspiration for
additional care is to be welcomed, some will
question the huge investment required to achieve
this upscaling of antenatal visits for all women.
Indeed, even the latest UK National Institute for
Health and Care Excellence antenatal care guidelines
recommend only seven antenatal contacts for healthy
multiparous women, although ten for nulliparous
women.5 The GDG correctly points out that
implementing these guidelines globally will result in
an increased financial burden for both the health
system and the healthy women who are advised
to have fortnightly contacts in the last 6 weeks of
pregnancy, often travelling long distances to
reach the health facility. Over half of all perinatal
deaths result from deficiencies in intrapartum
care,6 and care providers in settings with severely
constrained budgets will need to consider carefully
the relative benefits of investing in these
additional antenatal care contacts for low risk
women or improving the quality of intrapartum
care.
And that takes us to the problem with most
guidelines, especially for low-resource settings.
Although they provide aspirations for optimal
clinical care, they rarely address the relative cost-
effectiveness of the various aspects of care,
especially against other health interventions
outside of that guideline. There is often intense
competition for health budgets, and governments
and health-care providers are frequently
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
Comment
left without robust evidence-based guidance on
the critical issue of cost-effectiveness. This can
often lead to the choice of the headline action—like
eight antenatal care contacts—rather than the less
tangible issue of quality improvement. Future
guidelines would benefit from a list of the most
cost-effective actions for implementation. For in
places with highly constrained budgets, this can
make the difference between life and death for
many women and their babies.
Andrew Weeks, *Marleen Temmerman
Sanyu Research Unit, Department of Women’s and Children’s
Health, University of Liverpool, Liverpool, UK (AW); Maternity
Division, Liverpool Women’s Hospital, Liverpool, UK (AW);
Department of Obstetrics and Gynaecology, Aga Khan
University, East Africa, Nairobi, Kenya (MT); and Faculty of
Medicine and Health Sciences, Ghent University, 9000 Ghent,
Belgium (MT) marleen.temmerman@aku.edu
AW is Director of the WHO Collaborating Centre for Research and Research
Synthesis in Reproductive Health at the University of Liverpool; has co-
authored papers with James Neilson, the Chair of the WHO antenatal
care Guidelines Development Group; and is a grant holder with Gill Gyte,
another member of WHO antenatal care Guidelines Development Group.
MT has a consultancy contract with WHO Headquarters, Cluster of Families,
Women, Children for support of reproductive, maternal, newborn, and
child health in Africa; all consultancy fees are paid to Aga Khan
University. We declare no other competing interests.
1 WHO. WHO recommendations on antenatal care for a positive
pregnancy experience. Geneva: World Health Organization, 2016.
http://www.who.
int/reproductivehealth/publications/maternal_perinatal_health/anc-
positive-pregnancy-experience/en/ (accessed Nov 11, 2016).
2 Villar J, Ba’aqeel H, Piaggio G, et al, for the WHO Antenatal Care
Trial Research Group. WHO antenatal care randomised trial for the
evaluation of a new model of routine antenatal care. Lancet 2001;
357: 1551–64.
3 WHO. WHO antenatal care randomized trial: manual for the
implementation of the new model. Geneva: World Health
Organization, 2001.
www.who.int/entity/reproductivehealth/publications/maternal_
perinatal_health/RHR_01_30/en/ (accessed Nov 11, 2016).
4 Dowswell T, Carroli G, Duley L, et al. Alternative versus standard
packages of antenatal care for low-risk pregnancy. Cochrane Database
Syst Rev 2015; 7: CD000934.
5 NICE. Antenatal care for uncomplicated pregnancies. Clinical
guideline CG62. London: National Institute for Health and Care
Excellence, 2008 (updated 2016). 2016.
https://www.nice.org.uk/guidance/cg62 (accessed Nov 14,
2016).
6 Lawn JE, Blencowe H, Waiswa P, et al, for The Lancet Ending
Preventable Stillbirths Series study group with The Lancet Stillbirth
Epidemiology investigator group. Stillbirths: rates, risk factors, and
acceleration towards 2030. Lancet 2016; 387: 587–603.
wDwoww.nthloealadnecdetf.ocromFakVuoltla3s8K8edNookvteermanbeUrn2i6ve, r2s0it1a6s Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 22577, 5

2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.

Adapting workforce
density threshold to
WHO’s new antenatal
care recommendations
A morning scene at the
maternity outpatient waiting room
of Chamawa First-Level Hospital in
Lusaka, Zambia, struck me because of
how overcrowded it was, with
almost 100 pregnant women
waiting to see one of the few
doctors on duty. Anxiously, I
imagined how the scene would
change after the revision of the
national antenatal care guidelines;
how much busier will the doctors
be? How much more congested will
the waiting room be? And how well
will the hospital keep functioning?
WHO recommends, in its antenatal
care guidelines, a minimum of eight
antenatal care contacts as an
interven- tion necessary to reduce
perinatal mortality.1 In response to
the launch of WHO’s guidelines
in 2016, an increasing number of
countries raised the minimum
number of antenatal care
contacts from four to eight.
Zambia is in the process of
preparing to pilot a new national
policy enforcing a minimum of
eight antenatal care contacts as
one of 25 early adopting countries
of the 2016 WHO guidelines. In
subdistrict five of Lusaka province
where Chawama First-Level Hospital
and eight health centres or posts
are located, a total of 188
physicians, nurses, and midwives
work to serve 403 000 people in
the local catchment area.2 Thus, the
density of health workers, a health-
system-related moni- toring indicator
for UN Sustainable Development
Goal (SDG) 3, for the sub- district
was estimated at 0∙47 health
workers (ie, physicians, nurses, and
midwives) per 1000 population. This
number is far below both the
national average in Zambia of
1∙81 health workers per 1000
population,3 and WHO’s global
threshold of 4∙45 health workers per
1000 population. Although the
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
Correspondence
In 2006, WHO initially set the 3 WHO. Global Health Observatory data
threshold for density of health repository. Geneva: World Health
Organization, 2018.
workers at 2∙28 per 1000
population as the benchmark to
http://apps.who.int/gho/data/node.
main.HWF (accessed Oct 17, 2019).
ensure cove- rage of skilled birth
4 WHO. The World Health Report 2006-working
together for health. Geneva: World
attendance of 80% or more.4 In Health Organization, 2006.
2016, WHO revised the threshold to https://www.who.int/ whr/2006/en/
(accessed Oct 17, 2019).
4∙45 per 1000 popu- lation as the 5 WHO. Global strategy on human resources
benchmark to ensure 50th for health: Workforce 2030. Geneva: World
percentile of composite index of Health Organization, 2016.
https://www.who.int/hrh/
skilled birth attendance coverage resources/globstrathrh-2030/en/ (accessed
and 11 additional SDG monitoring Oct 17, 2019).
indicators.5 As a result, two of 12 SDG
monitoring indicators embedded
into the composite index are Cigarette prices,
those related to maternal
health—ie, coverage of skilled smuggling, and
birth attendance and at least four deaths in France and
antenatal care visits. A change in
the minimum number of antenatal
Canada Submissions should be
made via our electronic
care contacts from four to eight submission system at
http://ees.elsevier.com/
will demand an increase in the Tripling real cigarette prices would
thelancet/
number of health workers. approximately halve cigarette con-
WHO should further revise the sumption worldwide. Although high
1
current threshold for density of excise taxes could increase smug-
gling, weakper
health workers in response to the A Cigarettes customs
adult per enforcement
day, relative price: France
increase in the minimum number
Sales, legal and contraband
of antenatal care contacts. The Sales, contraband
Price index Re
Cigarettes per adult per day
two international norms (ie,
6 al
5
minimum number of ante- natal 4
400 pri
ce
care contacts and threshold for 3 ind
2 300
density of health workers) 1
ex
(19
published by WHO in 2016 are 0
200 80
likely to be neither coordinated nor =1
00)
consistent. Generally WHO’s 100
recommendations are highly
influential to the health policies 0
of a country. Thus, WHO must B Cigarettes per adult per day, relative price: Canada
ensure consistency in the 12
Effects of organised smuggling
10
international norms and standards 8
400
across its guidelines to avoid 6
4 300
disseminating conflicting 2
Re
Cigarettes per adult per day
0
messages, or their reliability will be 200 al
questioned and ultimately damaged.
1950
pri
ce
100 ind
I declare no competing interests.
ex
0
Hirotsugu Aiga 19601970198019902000 20102020 (19
aiga.hirotsugu@jica.go.jp Year 80
=1
Human Development Department, Japan 00)
International Cooperation Agency, Tokyo 102-8012,
Japan; and Department of Global Health, Milken
Institute School of Public Health, The George
Washington University, Washington, DC, USA
question remains, has the global
1 WHO. WHO recommendations on antenatal care for a positive pregnancy
threshold set by WHO been experience. Geneva: World Health Organization, 2016.
designed to ensure eight antenatal https://www.who.int/reproductivehealth/
publications/maternal_perinatal_health/anc- positive-pregnancy-experience/en/
care contacts? (accessed Oct 17, 2019).
2 Ministry of Health. National health facility census analytical report. Lusaka:
Ministry of Health, 2019.
Figure: Real price of cigarettes and
consumption per adult per day in France
and Canada since 1950
The real price index represents prices, adjusted
for inflation, as a percentage of 1980 prices.3,4
For France, consumption includes only
manufactured cigarettes until 1989, then
manufactured and grams of fine-cut tobacco
from 1990 to 2018, and smuggled tobacco
from 2004. For Canada, consumption includes
manufactured and hand-rolled cigarettes
(estimated as grams of fine-cut or pipe tobacco until 1973, then grams of fine-
cut tobacco from 1974 to 2015) and estimated smuggled cigarettes (about
34 billion sticks from 1990 to 1994).5 Smuggled cigarettes between 1995 and 2002
were estimated using the average ratio of legal to smuggled cigarettes for 1994
and 2003.

wDwoww.nthloealadnecdetf.ocromFakVuoltla3s9K5edJaonkutearrayn4U, 2n0iv2e0rsitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from

ClinicalKey.com by Elsevier on March 272, 7

2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 SOGC REAFFIRMED GUIDELINES
No. 282, Reaffirmed December 2017 (Replaces No. 72, April 1998)
No. 282-Rural Maternity Care
This joint position paper has been prepared by the Joint
Position Paper Working Group, approved by the Executive
and Council of the Society of Obstetricians and
Gynaecologists of Canada and approved by the Councils
and/or Executives of the Canadian Association of Midwives,
the Canadian Association of Perinatal and Women’s Health
Nurses,* the College of Family Physicians of Canada, and
the Society of Rural Physicians of Canada.
Katherine J. Miller, MD, Almonte, ON
Carol Couchie, RM, Nippising First Nation, Garden Village, ON
William Ehman, MD, Nanaimo, BC
Lisa Graves, MD, Sudbury, ON
Stefan Grzybowski, MD, Vancouver, BC
Jennifer Medves, RN, PhD, Kingston, ON
*Joint Position Paper Working Group: Kaitlin Dupuis, MD,
Nanaimo, BC; Lynn Dunikowski, MLS, London, ON; Patricia
Marturano, Mississauga, ON; Vyta Senikas, MD, Ottawa, ON;
Ruth Wilson, MD, Kingston, ON; John Wootton, MD, Shawville,
QC.
Key Words: Maternity care, pregnancy, rural communities, remote
communities
J Obstet Gynaecol Can 2017;39(12):e558–e565
https://doi.org/10.1016/j.jogc.2017.10.019
Copyright © 2017 Published by Elsevier Inc. on behalf of The Society
of Obstetricians and Gynaecologists of Canada/La Société des
obstétriciens et gynécologues du Canada
This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be construed a
Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate in
Deow55nl8oad• edDfEorCFEakMuBltaEsRKeJdOokGteCranDUÉniCveErsMitaBsRMEus2l0im17Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
Abstract
Objective: To provide an overview of current information on issues
in maternity care relevant to rural populations .
Evidence: Medline was searched for articles published in English
from 1995 to 2012 about rural maternity care . Relevant
publications and position papers from appropriate organizations
were also reviewed .
Outcomes: This information will help obstetrical care providers in
rural areas to continue providing quality care for women in their
communities .
Recommendations:
1. Women who reside in rural and remote communities in Canada
should receive high-quality maternity care as close to home as
possible.
2. The provision of rural maternity care must be collaborative, woman-
and family-centred, culturally sensitive, and respectful.
3. Rural maternity care services should be supported through active
policies aligned with these recommendations.
4. While local access to surgical and anaesthetic services is desir-
able, there is evidence that good outcomes can be sustained
within an integrated perinatal care system without local access to
opera- tive delivery. There is evidence that the outcomes are
better when women do not have to travel far from their
communities. Access to an integrated perinatal care system
should be provided for all women.
5. The social and emotional needs of rural women must be consid-
ered in service planning. Women who are required to leave their
communities to give birth should be supported both financially
and emotionally.
6. Innovative interprofessional models should be implemented as
part of the solution for high-quality, collaborative, and integrated
care for rural and remote women.
7. Registered nurses are essential to the provision of high-quality rural
maternity care throughout pregnancy, birth, and the postpartum
period. Maternity nursing skills should be recognized as a funda-
mental part of generalist rural nursing skills.
8. Remuneration for maternity care providers should reflect the unique
challenges and increased professional responsibility faced by
pro- viders in rural settings. Remuneration models should
facilitate interprofessional collaboration.
from ClinicalKey.com by Elsevier on March 27,

2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.

9. Practitioners skilled in neonatal resuscitation and newborn care
are essential to rural maternity care.
10. Training of rural maternity health care providers should include
col- laborative practice as well as the necessary clinical skills and
competencies. Sites must be developed and supported to train
mid- wives, nurses, and physicians and provide them with the
skills necessary for rural maternity care. Training in rural and
northern settings must be supported.
11. Generalist skills in maternity care, surgery, and anaesthesia are
valued and should be supported in training programs in family
medi- cine, surgery, and anaesthesia as well as nursing and
midwifery.
12. All physicians and nurses should be exposed to maternity care in
their training, and basic competencies should be met.
13. Quality improvement and outcome monitoring should be integral
to all maternity care systems.
14. Support must be provided for ongoing, collaborative,
interprofessional, and locally provided continuing education and
patient safety programs.
INTRODUCTION AND BACKGROUND
C anadian women deserve quality maternity care
regard- less of whether they live in urban, rural, or
remote communities. Individual health care providers
must work to develop and maintain models of maternity
care adapted to the communities in which women
reside and to the re- sources available. Building on the
1998 Joint Position Statement on Rural Maternity
Care,1 this enhanced docu- ment includes new
evidence. Acknowledging that interprofessional care
of women through the continuum of prenatal,
intrapartum, and postnatal periods is the norm, this paper
represents the collaboration between not only phy-
sician organizations but also nursing and midwifery
organizations. The authors of this paper and their
respec- tive organizations have agreed that rural
maternity care must include agreement on the
following overarching
recommendations.
Recommendations
1. Women who reside in rural and remote
communities in Canada should receive high-
quality maternity care as close to home as
possible.
2. The provision of rural maternity care must be col-
laborative, woman- and family-centred,
culturally sensitive, and respectful.
3. Rural maternity care services should be supported
through active policies aligned with these
recommendations.
Defining “rural” in Canada remains challenging.
Rurality indices attempt to capture the essence of rural
with vari- ables such as the distance between the site
and advanced care, between the site and basic care, as
well as the popu- lation number and density of the site. 2
This definition attempts to cover the variety of rural
centres from those
No. 282-Rural Maternity Care
that are geographically isolated to centres that, while
close to basic and advanced care, are in regions with
low popu- lation density. Rural maternity care is often
characterized by maternity care teams led by family
physicians, nurses, and midwives. In some
communities, they are the only ones providing
maternity care, and in other cases backup is provided
by general surgeons, GP-anaesthetists, obstetrician-
gynaecologists, and/or family physicians with surgical
training.
Recent years have seen the closure of rural maternity
pro- grams as part of regionalization of care and cost
cutting.3 In addition to administrative pressures, lack of
skilled per- sonnel in maternity care has resulted in
service decreases and program closures.4 Maternity
programs are dependent not only on clinical personnel
but also on support person- nel, services such as
diagnostic imaging, laboratory testing, and blood banks,
appropriate and functional equipment, and effective
transport systems across large distances in all types of
weather.
DISCUSSION
Levels of Service
The safety of rural maternity services has been the
subject of a number of studies over the past 20 years, and
the weight of evidence supports the provision of local
services even in communities without access to local
surgical services.5,6 Several recent studies have examined
the importance of dis- tance to services as it relates to
outcomes and have shown that perinatal mortality,
morbidity, and intervention rates in- crease the farther
women live from birthing services.7,8 While low-volume
units face unique challenges, there is no evi- dence that
a minimum number of deliveries is required to
maintain competence. 9 The question is not whether to
provide birthing services but what level of services is
fea- sible and sustainable.
When a community is unable to sustain local services,
almost all women will travel to access services
elsewhere and, de- pending on the distance to the
nearest referral centre, they may be away from their
homes and communities from 36 weeks’ gestation until
they give birth. This separation can cause substantial
stress for women and their families, and when
socioeconomic vulnerability is a complicating factor, rates
of adverse outcomes increase.7,10
Other rural communities are able to provide medically
sup- ported maternity services. If surgical services are
unavailable, the proportion of women delivering locally is
lower because of both risk-management decisions and
patient choice. Factors that influence patient choice
 are not always those that motivate care providers.11 Rural maternity care

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of

MuslimDInEdConEeMsiaBfEroRm JCOlinGicCalKDeyÉ.cCoEmMbyBERlEsev2i0e1r 7on•Mear5c5h 927,
 SOGC REAFFIRMED GUIDELINES

providers have identified many challenges including deter- what should be a joyful period in their lives.5 They may be
mining and accepting risk, obtaining and maintaining overwhelmed by the need to navi-
competencies in low-volume environments, and balancing
women’s needs against the realities of rural practice. 12
Evolving models of non-hospital-based maternity care will
likely share similar challenges.
In communities with a surgical service the needs of
women are more effectively met locally. In these
communities, the
majority (>75% depending on provider model) of
women
give birth locally and the outcomes are good. 7,13
Models such as the Rural Birth Index have been devel-
oped to aid hospitals and health care planners to
measure and quantify the need for and feasibility of
local maternity services. 14 This model was developed
and works well in British Columbia and identifies
both catchment populations that are underserved and
overserved.14

Recommendation
stem without local access to operative delivery. There is evidence that the outcomes are better when women do not have to travel far fro

Impact of the Loss of Maternity Services

When rural maternity services are lost, women are re-
quired to travel to ensure adequate access to maternity
care providers and services. These women, who may
need to leave their communities for a month or more,
report financial, social, and psychological
5
consequences. Financial costs almost always include
accommodation and food in the re- ferral community,
often for a month or more in the period before and after
the birth of the child.5 Additional finan- cial costs
include loss of income and travel costs if the partner
wishes to be present at the birth of the baby, ar-
rangements for other children who may need to remain
at home, and the cost of phone calls to distant support
networks.5 Studies in British Columbia have shown that
women from some remote communities without mater-
nity services spent an average of 29 days in the referral
community at a cost of almost $4000 per person.10,15
Perhaps even more striking than the financial
implications of having to travel to give birth are the
social and psycho- logical costs. Women report feelings
of isolation, separation, and social disruption during
 gate resources unfamiliar to them, the pain of missing
friends and family members who could not be with
them in the re- ferral community, and worries about
how the newborn will integrate with other children
left at home5 or the commu- nity in general.15 These
social costs may be particularly acute for Aboriginal
women because of their strong cultural ties to the
land and their close-knit community values.15–17
Collaborative Care and the Rural Maternity Team
The long-term sustainability of a low-volume
maternity unit depends on interprofessional respect,
continuing educa- tion opportunities, and collaborative
models of practice that include all providers.18 Models
based on multidisciplinary collaboration have been
suggested as one solution to the declining number and
changing nature of maternity care pro- viders in
Canada.19 Key elements of successful collaborative
maternity programs have been described by the
Multidis- ciplinary Collaborative Primary Maternity
Care Project.20 All rural maternity teams are unique, but
they may include nurses, nurse-practitioners, midwives,
family physicians, and spe- cialist physicians and they
may be supported by health and social programs.
Registered nurses have been described as multi-
specialists18 when they practise in rural and remote
settings. They care for women during labour and birth,
Deow56nl0oad• edDfEorCFEakMuBltaEsRKeJdOokGteCranDUÉniCveErsMitaBsRMEus2l0im17Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia
from ClinicalKey.com by Elsevier on March 27,
which demands complex knowledge and skills and a
high degree of responsibility.21 If these skills are not
used often, maintaining proficiency may be
challenging,22 and programs and continuing educa- tion
are important to ensure competence. The skill sets of
maternity nursing are no different from other multi-
specialist roles but also include the task of safeguarding
women giving birth.23 In low-volume units, a nurse may
Recommendation
5. The social and emotional needs of rural women
must be considered in service planning. Women
who are re- quired to leave their communities to
give birth should be supported both financially and
emotionally.
be the only person in the hospital with a labouring
woman who has the expertise to evaluate normal
progression with physicians and other nurses on call. 24
This requires the nurse to have the confidence to make
decisions about what is normal in labour and to call for
backup as required.
Regulated midwifery has expanded greatly across Canada.
Rural midwives face the same challenges of professional
iso- lation, unsustainable workload, and difficulties in
obtaining locum coverage that other practitioners face. 25
Issues of transport and surgical backup are amplified in
home deliv- eries, an important component of many
midwifery practices.

Funding and health care system design solutions have
been proposed,25 and there is an increasing recognition of
the need for collaboration between other provider
groups and midwives.26
Greater awareness of the needs of Aboriginal women
living in rural and remote areas, particularly the North,
have brought a demand for low-risk maternity services,
often based on care by registered midwives, registered
Aboriginal mid- wives, and traditional midwives. These
programs have resulted in the return of birth to several
Aboriginal communities across the country. Of great
community importance, these programs have excellent
medical and social outcomes.27,28 These programs strive
to help communities “retain and restore” what is
important from their own birth traditions without losing
the benefits of modern obstetrical practice.27 Although
in areas of extremely low population density it is
unrealistic to believe that all women can deliver in their
home communities, it is important that Aboriginal,
rural, and remote women can access low-risk maternity
care that reflects their experiences, expectations, and
culture.27,29 The importance of returning birth to the North
and to Aborigi- nal communities has been
acknowledged by several national organizations.30,31
In the past decade, many medical communities have re-
sponded to the declining number of care providers by
creating collaborative practice models. The most
common model is a group of family physicians working
in a shared prenatal clinic with a defined period of
on- call responsibility.32–34 Both physicians and patients
report a high level of satisfaction with these
models,11,32–34 and outcomes are good.32,34 At least one
community notes that group practice has led to the
creation of a more support- ive environment and the
development of best practice protocols.33
Communities that are unable to support sustainable
surgi- cal or obstetrical specialist care but that are large
enough to justify local surgical services can effectively
be sup- ported by GP-surgeons who provide only
Caesarean sections or broader surgical services. The
evidence suggests that they make a significant
contribution to equitable access to care for rural
populations, and their patients have out- comes
comparable to those of specialist surgeons and
obstetricians.35–37 GP-surgeons face many challenges
includ- ing accessing initial training, the lack of an
accepted regulatory framework, and limited continuing
professional development opportunities. Support from
the dominant surgical specialist professions is varied,
and GP-surgery has at times faced active resistance
from the discipline of general surgery.38
No. 282-Rural Maternity Care
While only a small percentage of Canadian specialists
prac- tice in rural and remote communities, many rural
maternity programs are reliant on specialist obstetricians
and/or general surgeons who are often practising solo or
in very small groups. Rural specialists report a high
level of satisfaction with the support they receive
locally, but very few feel supported by national
organizations such as the Royal College of Physicians
and Surgeons of Canada or the Canadian Medical
Association.39 Respondents to a survey expressed an
overwhelming desire for relevant and acces- sible
ongoing professional development and noted a lack of
training opportunities.39 Rural maternity care teams need
to be supported by consulting urban specialists who are
responsive and respectful, and who understand the rural
reality.
Obstetrical anaesthesia services, delivered largely by
GP- anaesthetists, form a key component of rural
maternity systems and include not only epidurals
administered during labour and anaesthesia at Caesarean
section but also support for neonatal resuscitation.
Provision of a full- time elec- tive epidural service is
difficult for practitioners who wear many hats and work
solo or in small groups.40 Greater train- ing and
continuing professional development opportunities, as
well as novel funding mechanisms, have been proposed
as part of the solution.41
Health and social supports from early pregnancy
through the postpartum and newborn periods are
essential to the provision of quality care.42,43 Doula care
has been shown to improve maternal and newborn
outcomes.44 Innovative models of community-based
doula training have shown success, and engaging the
human resources of rural com- munities has deep roots
in Canada. It is essential that all rural women have
access to supports such as prenatal educa- tional,
postpartum care, and lactation support even when local
intrapartum services are not offered.
While differences in scope and remuneration models
create barriers to true collaboration between different
care pro- vider groups, many communities have found
ways to overcome them. Group practice models often
include en- hanced roles for nurses and nurse-
practitioners,32,33 thus reducing demands on family
physicians who are also pro- viding primary care,
emergency room coverage, and/or hospital care. The
integration of midwifery care in rural com- munities
provides new opportunities and new challenges. 25
Remuneration models that recognize the level of
respon- sibility and challenges faced by the rural
accoucheur should be considered. It is also important to
remove financial dis- incentives and regulatory barriers
to shared care between the medical and midwifery
 professions such that collabora- tive practice can be encouraged.

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of

MuslimDInEdConEeMsiaBfEroRm JCOlinGicCalKDeyÉ.cCoEmMbyBERlEsev2i0e1r 7on•Mear5c6h 127,
 SOGC REAFFIRMED GUIDELINES

experiences, but without them the strong base of

Recommenda
generalism that rural health care is built on will be lost.
Innovative interprofessional models should be imple- mented as part of the solution for high-quality, collaborative, and in
The last decade has seen the opening of numerous new
Registered nurses are essential to the provision of high- quality rural maternity care throughout pregnancy, birth, and the postpa
Remuneration for maternity care providers should reflect the rural and northern
unique challengestraining sites that
and increased bring
profes- increased
sional responsibility f
opportunities to learn maternity care in a rural
environment. Rural training sites face unique
challenges, including increased cost52; funding that
accommodates these additional costs must be available
to all professional programs.
All learners should have appropriate competencies for
rural maternity care such as interprofessional work,
collabora- tive practice and a commitment to ongoing
learning. Management of uncomplicated vaginal birth
must remain a key competency for nursing, midwifery,
and family phy- sician training. In some jurisdictions
outside Canada, this has been designated an added or
Newborn Care optional skill for family medicine residents.53 To date,
Newborn care is an important part of any maternity the Canadian family medi- cine residency curriculum
care system. Approximately 10% of newborns will has resisted similar streaming, instead insisting that all
require re- suscitation, and 1% will require extensive residents should be competent in normal vaginal
resuscitation, with at least one half of these cases being deliveries.54
unexpected.45 Cana- dian guidelines recommend that Access to additional training in advanced skills,
“all health care facilities providing care for newborn including Caesarean section and obstetrical anaesthesia,
infants must be able to resus- citate and stabilize such is essential. Rural track maternity programs and
infants until transfer to another appropriate facility” and fellowships in mater- nity care have been shown to
that such care should be multidis- ciplinary and provided increase the number of new physician graduates
by trained staff with access to ongoing education and offering maternity care.55,56 Currently training in
training.46 In rural and remote settings, however, performing Caesarean section is provided for family
specialized pediatric and neonatal staff are rare. There physicians at several residency sites in Canada. Train- ing
is limited evidence regarding providers and out- in broader general surgical skills is more difficult to
comes of neonatal resuscitation in rural Canada, but access. Those wishing to train as GP-anaesthetists have
some research suggests that levels of training and skill access at many sites to third year programs accredited
levels are lower than in larger centres.47,48 This gap, by the College of Family Physicians of Canada; the
along with lower birth volumes and less access to standards for these pro- grams are set by the Canadian
specialized practitioners (e.g., respiratory therapy), Anesthesiologists’ Society and the Society of Rural
highlights the increased need for local access to quality Physicians of Canada. Enhanced skills training for
training and quality assurance programs in rural family physicians remains critical for rural ma- ternity
communities. care. Recommendations
practice as well as the necessary clinical skills and competencies. Sites must be developed and supported to train midwives, nurses, and
Recommendation
should be supported in training programs in family medicine, surgery, and an- aesthesia as well as nursing and midwifery.
9. Practitioners
ng, and basic competenciesskilled
shouldinbeneonatal
met. resuscitation and newborn care are essential to rural maternity care.

Training for Rural Maternity Care

A decision to practise in a rural region has been linked
to a number of factors, including being from a rural
area and having the opportunity to train in a rural
area.49,50 Practi- tioners are most comfortable in
environments that are similar to those in which they
have trained. Early expo- sure to both rural
environments and maternity care plays a key role in
decision making about practice scope and location. 51
Many programs struggle to provide these
Deow56nl2oad• edDfEorCFEakMuBltaEsRKeJdOokGteCranDUÉniCveErsMitaBsRMEus2l0im17Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia
from ClinicalKey.com by Elsevier on March 27,

Patient Safety and Continuing Professional
Education
Comprehensive patient safety programs should be an
inte- gral part of rural maternity care. The characteristics
of these safety programs have been well described: they
should be comprehensive, patient focused, and applied
within a culture of safety.57,58 They should identify
system failures, analyze the factors that contribute to the
failures, and redesign the care process to prevent errors
in the future.57 A key com- ponent is the review of
events based on “a culture of openness to all relevant
perspectives in which those in- volved in adverse events
are treated as partners in learning”59; these reviews
should be carried out with an understanding of the rural
environment.
To promote consistent and evidenced-based practice,
con- tinuing professional development programs must be
available for rural caregivers. Although historically
these programs have been delivered off-site and to each
discipline sepa- rately, newer models involve locally
delivered collaborative learning. Rural communities are
ideally suited to this improved model because the
health care professional teams are small, and strong
collaboration is essential. Education that supports all
members of the team to provide high-quality rural
maternity care is optimal so that the whole team has the
same knowledge base. Locally delivered continuing
professional development contrib- utes to the culture of
safety while building collaborative teams and ensuring
that the content is relevant to the rural reality.
One example of a collaborative and locally provided
patient safety program is Managing Obstetrical Risk
Efficiently (MOREOB).60 This interdisciplinary program
builds a culture of safety through the development of
knowledge, skills, at- titudes, behaviours, and practices
that make patient safety the priority for all caregivers. It
promotes quality obstetri- cal care and quality of life
for caregivers, integrating high reliability organization
principles and using a foundation of current, evidence-
based core clinical content. It adapts to local
circumstances and all levels of care and caregivers, both
urban and rural. Teamwork, respect, and communication
are improved by the team reviewing the core clinical
content and sharing knowledge through audit, case
review, emer- gency drills, and other activities.
Ultimately, a culture of patient safety is established.
Research shows that maternal and newborn outcomes
as well as health care use im- proved at hospitals
adopting the 3-year program.61 Rural centres (including
sites with as few as 10 deliveries per year) that have
adopted the program have demonstrated improve- ment
in knowledge, communication, teamwork, and patient
safety.
No. 282-Rural Maternity Care
Re
Quality improvement and outcome monitoring should be integral
Support must be provided for ongoing, collabora- tive, interpro
CONCLUSIONS
Rural maternity care services are under stress, and many
rural and remote communities across Canada have seen
local ma- ternity services diminish and close. Rural
women and families who have to travel to access
maternity care experience in- creased levels of stress,
increased personal costs, and increased rates of
adverse outcomes. Current health care policy does not
adequately support rural nurses, doctors, and midwives to
meet the needs of rural women, and new ap- proaches
are needed to support collaborative, integrated, and safe
care for mothers and newborns in rural Canada.
REFERENCES
1. Iglesias S, Grzybowski S, Klein MC, Gagné GP, Lalonde A. Rural
obstet- rics. Joint position paper on rural maternity care. Joint Working
Group of the Society of Rural Physicians of Canada (SRPC), The
Maternity Care Committee of the College of Family Physicians of
Canada (CFPC), and the Society of Obstetricians and Gynaecologists
of Canada (SOGC). Can Fam Physician 1998;44:831–43.
2. Kralj B. Measuring rurality—RI02008 BASIC: methodology and results.
Toronto ON: Ontario Medical Association Economics Department;
2008 [cited 2012 May 8]. Available at: http://www.health.gov.on.ca/
english/providers/program/uap/docs/up_rio_methodology.pdf.
Accessed August 10, 2012.
3. Kornelsen J, Grzybowski S, Iglesias S. Is rural maternity care
sustainable without general practitioner surgeons? Can J Rural Med
2006;11:218–20.
4. Sutherns R, Bourgeault IL. Accessing maternity care in rural Canada:
there’s more to the story than distance to a doctor. Health Care Women Int
2008;29:863–83.
5. Kornelsen J, Grzybowski S. Safety and community: the maternity
care needs of rural parturient women. J Obstet Gynaecol Can
2005;27:554– 61.
6. Leeman L, Leeman R. Do all hospitals need cesarean delivery
capability? An outcomes study of maternity care in a rural hospital
without on-site cesarean capability. J Fam Pract 2002;51:129–34.
7. Grzybowski S, Stoll K, Kornelsen J. Distance matters: a
population based study examining access to maternity services for
rural women. BMC Health Serv Res 2011;11:147.
8. Lisonkova S, Sheps SB, Janssen PA, Lee SK, Dahlgren L, Macnab YC.
Birth outcomes among older mothers in rural versus urban areas: a
residence-based approach. J Rural Health 2011;27:211–9.
9. Society of Obstetricians and Gynaecologists of Canada, College
of Family Physicians of Canada; Society of Rural Physicians of
Canada. Number of births to maintain competence. Can Fam
Physician 2002;48:751–8.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of
MuslimDInEdConEeMsiaBfEroRm JCOlinGicCalKDeyÉ.cCoEmMbyBERlEsev2i0e1r 7on•Mear5c6h 327,
SOGC REAFFIRMED GUIDELINES
10. Kornelsen J, Stoll K, Grzybowski S. Stress and anxiety associated
with lack of access to maternity services for rural parturient women. Aust J
Rural Health 2011;19:9–14.
11. Zelek B, Orrantia E, Poole H, Strike J. Home or away? Factors
affecting where women choose to give birth. Can Fam Physician
2007;53.
12. Grzybowski S, Kornelsen J, Cooper E. Rural maternity care services
under stress: the experiences of providers. Can J Rural Med
2007;12:89– 94.
13. Iglesias A, Iglesias S, Arnold D. Birth in Bella Bella: emergence
and demise of a rural family medicine birthing service. Can Fam
Physician 2010;56:e233–40.
14. Grzybowski S, Kornelsen J, Schuurmans N. Planning the optimal level of
local maternity service for small rural communities: a systems study in
British Columbia. Health Policy (New York) 2009;92:149–57.
15. Kornelsen J, Moola S, Grzybowski S. Geographic induction of rural par-
turient women: is it time for a protocol? J Obstet Gynaecol Can
2007;29:583–5.
16. Kornelsen J, Kotaska A, Waterfall P, Willie L, Wilson D. The
geography of belonging: the experience of birthing at home for First
Nations women. Health Place 2010;16:638–45.
17. Kornelsen J, Kotaska A, Waterfall P, Willie L, Wilson D. Alienation and
resilience: the dynamics of birth outside their community for rural
First Nations women. J Aborig Health 2011;7:55–64.
18. Medves JM, Davies BL. Sustaining rural maternity care—don’t forget the
RNs. Can J Rural Med 2005;10:29–35.
19. Peterson WE, Medves JM, Davies BL, Graham ID.
Multidisciplinary collaborative maternity care in Canada: easier said
than done. J Obstet Gynaecol Can 2007;29:880–6.
20. Society of Obstetricians and Gynaecologists of Canada. A national birth-
ing initiative for Canada. Ottawa ON: SOGC; 2008 [cited 2012 May
14]. Available at: http://www.sogc.org/projects/pdf/BirthingStrategy
VersioncJan2008.pdf. Accessed on August 10, 2012.
21. MacKinnon KA. Labouring to nurse: the work of rural nurses who
provide maternity care. Rural Remote Health 2008;8:1047.
22. MacKinnon K. Learning maternity: the experiences of rural nurses. Can J
Nurs Res 2010;42:38–55.
23. MacKinnon K. Rural nurses’ safeguarding work: reembodying
patient safety. ANS Adv Nurs Sci 2011;34:119–29.
24. Deaton BJ, Essenpreis H, Simpson KR. Assessing competence.
Meeting the unique needs of nurses in small rural hospitals.
AWHONN Lifelines 1998;2:33–7.
25. Kornelsen J. Rural midwifery: overcoming barriers to practice. Can J
Midwifery Res Pract 2009;8:6–11.
26. Canadian Nurses Association, Canadian Association of Midwives,
Canadian Association of Perinatal and Women’s Health Nurses.
Joint Position Statement. Nurses and midwives collaborate on
client-centred care; 2011 [cited 2012 May 14]. Available at:
http://www
.canadianmidwives.org/DATA/DOCUMENT/Joint%20Position
%20Statement_Nurses%20and%20Midwives_march_07_2012.pdf. Ac-
cessed on August 10, 2012.
27. Couchie C, Sanderson S, Society of Obstetricians and Gynaecologists of
Canada. A report on best practices for returning birth to rural and
remote aboriginal communities. J Obstet Gynaecol Can 2007;29:250–
60. SOGC Policy Statement no. 188, December 2007.
28.
Van Wagner V, Epoo B, Nastapoka J, Harney E. Reclaiming birth, health,
and community: midwifery in the Inuit villages of Nunavik, Canada. J
Midwifery Womens Health 2007;52:384–91.
29. Dooley J, Kelly L, St Pierre-Hansen N, Antone I, Guilfoyle J, O’Driscoll
T. Rural and remote obstetric care close to home: program description,
evaluation and discussion of Sioux Lookout Meno Ya Win Health Centre
obstetrics. Can J Rural Med 2009;14:75–9.
30. Society of Obstetricians and Gynaecologists of Canada. Returning birth
to Aboriginal, rural, and remote communities. J Obstet Gynaecol Can
2010;32:1186–8. SOGC Policy Statement no. 251, December 2010.
31. National Aboriginal Council of Midwives. 2012 statement. Montreal:
NACM; 2012. Available at: http://d7.nacm-dev.site.koumbit.net/about.
Accessed on September 17, 2012.
32. Stretch NC. Community obstetrics: a new look at group obstetrical care
in rural communities. Can J Rural Med 2002;7:183–90.
33. Osmun WE, Poenn D, Buie M. Dilemma of rural obstetrics. One com-
munity’s solution. Can Fam Physician 1997;43:1115–9.
34. Orrantia E, Poole H, Strike J, Zelek B. Evaluation of a novel model for
rural obstetric care. Can J Rural Med 2010;15:14–8.
35. Aubrey-Bassler K, Newbery S, Kelly L, Weaver B, Wilson S.
Maternal outcomes of cesarean sections: do generalists’ patients have
different outcomes than specialists’ patients? Can Fam Physician
2007;53:2132–8.
36. Deutchman ME, Sills D, Connor PD. Perinatal outcomes: a
comparison between family physicians and obstetricians. J Am Board
Fam Pract 1995;8:440–7.
37. Iglesias S, Bott N, Ellehoj E, et al. Outcomes of maternity care
services in Alberta, 1999 and 2000: a population-based analysis. J
Obstet Gynaecol Can 2005;27:855–63.
38. Pollett WG. The future of surgery—Santayana or Ford. Can J Surg
2000;43:347–52.
39. Toguri C, Jong M, Roger J. Needs of specialists in rural and remote
Canada. Can J Rural Med 2012;17:56–62.
40. Angle P, Kurtz Landy C, Murthy Y, Cino P. Key issues and barriers
to obstetrical anesthesia care in Ontario community hospitals with
fewer than 2,000 deliveries annually. Can J Anaesth 2009;56:667–
77.
41. Douglas J, Preston R. Provision of obstetric anesthesia: throwing down
the gauntlet! Can J Anaesth 2009;56:631–5.
42. Health Canada. Family-centred maternity and newborn care: national
guidelines. [Internet]. Ottawa ON: Health Canada; 2000 [cited 2012 May
18]. Available at: http://www.phac-aspc.gc.ca/hp-ps/dca-dea/
publications/fcm-smp/index-eng.php. Accessed on August 10, 2012.
43. World Health Organization. World Health Report 2005. Make every
mother and child count. Geneva: WHO; 2005 [cited 2012 May 25]. Avail-
able at: http://www.who.int/whr/2005/en/index.html. Accessed on
August 10, 2012.
44. McGrath SK, Kennell JH. A randomized controlled trial of
continuous labor support for middle-class couples: effect on cesarean
delivery rates. Birth 2008;35:92–7.
45. Zaichkin J, Kattwinkel J, McGowan J, American Heart Association,
American Academy of Pediatrics. Textbook of neonatal
resuscitation. 6th ed. Elk Grove Village IL: American Academy of
Pediatrics; 2011.
46. Fetus and Newborn Committee, Canadian Paediatric Society. Position
statement. Levels of neonatal care. Paediatr Child Health
2006;11:303–6.
Deow56nl4oad• edDfEorCFEakMuBltaEsRKeJdOokGteCranDUÉniCveErsMitaBsRMEus2l0im17Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia
from ClinicalKey.com by Elsevier on March 27,

47. Mitchell A, Niday P, Boulton J, Chance G, Dulberg C. A prospective
clinical audit of neonatal resuscitation practices in Canada. Adv
Neonatal Care 2002;2:316–26.
48. Foster K, Craven P, Reid S. Neonatal resuscitation educational experi-
ence of staff in New South Wales and Australian Capital Territory
hospitals. J Paediatr Child Health 2006;42:16–9.
49. Henry JA, Edwards BJ, Crotty B. Why do medical graduates choose
rural careers? Rural Remote Health 2009;9:1083.
50. Rourke JT, Incitti F, Rourke LL, Kennard M. Relationship between prac-
tice location of Ontario family physicians and their rural background
or amount of rural medical education experience. Can J Rural Med
2005;10:231–40.
51. Stretch N, Voisin A, Dunlop S. Survey of rural family physician- obste-
tricians in Southwestern Ontario. Can J Rural Med 2007;12:16–21.
52. Maudlin RK, Newkirk GR. Family medicine spokane rural training track:
24 years of rural-based graduate medical education. Fam Med
2010;42:723–8.
53. Coonrod RA, Kelly BF, Ellert W, Loeliger SF, Rodney WM,
Deutchman
M. Tiered maternity care training in family medicine. Fam Med
2011;42:631–7.
54. Graves L, Hutten-Czapski P. An approach to maternity care education
for Canadian family medicine residents. A discussion paper of the Mater-
No. 282-Rural Maternity Care
nity and Newborn Care Committee. Mississauga ON: College of Family
Physicians of Canada; 2006.
55. Ratcliffe SD, Newman SR, Stone MB, Sakornbut E, Wolkomir M,
Thiese SM. Obstetric care in family practice residencies: a 5-year
follow-up survey. J Am Board Fam Pract 2002;15:20–4.
56. Delzell JE Jr, Ringdahl EN. The University of Missouri rural obstetric
network: creating rural obstetric training sites for a university-based resi-
dency program. Fam Med 2003;35:243–5.
57. Committee on Data Standards for Patient Safety. Aspden P, Corrigan JM,
Wolcott J, Erickson SM, editors. Patient safety: achieving a new
standard for care. Washington DC: National Academies Press; 2004.
58. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer
health system. Washington DC: National Academy Press; 2000.
59. Emanuel L, Berwick D, Conway J, et al. What exactly is patient
safety? In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors.
Advances in patient safety: new directions and alternative approaches,
Vol. 1. Assess- ment. Rockville MD: Agency for Healthcare Research
and Quality; 2008.
60. Salus Global Corporation. MOREOB Managing Obstetrical Risk
Effi- ciently. [Internet]. London ON: Salus; 2012 [cited 2012 May
15]. Available at: http://www.moreob.com. Accessed on August 10,
2012.
61. Thanh NX, Jacobs P, Wanke MI, Hense A, Sauve R. Outcomes of the
introduction of the MOREOB continuing education program in
Alberta. J Obstet Gynaecol Can 2010;32:749–55.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of
MuslimDInEdConEeMsiaBfEroRm JCOlinGicCalKDeyÉ.cCoEmMbyBERlEsev2i0e1r 7on•Mear5c6h 527,
 SOGC CONSENSUS STATEMENT

It is SOGC policy to review the content 5 years after publication, at which time the document may be re-affirmed or revised to
reflect emergent new evidence and changes in practice.

No 379, May 2019 (Replaces No. 89, May

2000) This Consensus Statement is the first in a 4-part series on labour
and delivery.

No. 379-Attendance at and Resources

for Delivery of Optimal Maternity Care
This Consensus Statement was revised by a Consensus of the Disclosure statements have been provided by all authors.
Society of Obstetricians and Gynaecologists of Canada
Key Words: Attendance, resources, delivery, maternity care
(SOGC)’s committees and approved by:
The Board of the SOGC
The Society of Rural Physicians of Canada (SRPC)
The Canadian Association of Perinatal and Women’s
Health
Nurses (CAPWHN)
CHANGES IN PRACTICE
The College of Family Physicians of Canada (CFPC) 1. Clearer definition of levels of care across Canada
The Canadian Association of Midwives (CAM) 2. Need for Enhanced skills for surgery for remote areas of
The Canadian Anesthesiologists’ Society (CAS) has reviewed the country
the 3. Update on documentation and risk areas
Consensus Statement involving anaesthesiologists. 4. More appropriate cases kept at various levels of care
The section related to paediatricians in this Consensus
Statement was reviewed by members of the Canadian
Paediatric Society’s Fetus and Newborn Committee.
This Consensus Statement supersedes the original
version (No. 89) that was published in May 2000. OBJECTIVE
Linda Stirk, MDCM, PhD, Toronto, ON
Jude Kornelsen, PhD, Vancouver, BC
T he objective of this document is to improve
obstetri- cal and neonatal care by ensuring all
pregnant women
are aligned with appropriate resources, personnel, and
facilities to encourage safe normal physiological birth
J Obstet Gynaecol Can 2019;41(5):688−696
in a family-centred environment as close to home as
https://doi.org/10.1016/j.jogc.2018.12.003 possible for both rural and urban communities.
© 2019 The Society of Obstetricians and Gynaecologists of
Canada/La Société des obstétriciens et gynécologues du Canada.
Published by Elsevier Inc. All rights reserved. 1. It outlines minimum standards of care for various
types of birthing facilities and situations involving
assisted births.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not
be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these
opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior
written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In
order to facilitate informed choice women should be provided with information and support that is evidence based, culturally appropriate, and
tailored to their needs. The values, beliefs, and individual needs of each individual and their family should be sought and the final decision
about the care and treatment options chosen by the individual should be respected.
This guideline was written using language that places women at the centre of care. The SOGC is committed to respecting the rights of all
people
− including transgender, gender non-binary, and intersex people − for whom the guideline may apply. We encourage health care providers to
engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be used as a critical
part of providing safe and appropriate care. The values, beliefs, and individual needs of each patient and their family should be sought and
the final decision about the care and treatment options chosen by the patient should be respected.
D6ow88nlo●adMedAfoYr JFOakGultCas KMeAdoIk2te0r1a9n Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
 No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care
2. It introduces classifications of levels of care that
have been developed by some provinces and
territories.
3. The Society of Obstetricians and Gynaecologists of
Canada (SOGC) recommends the adoption of one
national standardized set of definitions to encompass
all facilities providing maternity care for different
levels of anticipated risk.
4. The SOGC recognizes that removing individuals
from their community may have a variety of adverse
social, economic, and health outcomes. The SOGC
supports an informed decision made by the pregnant
woman after she has a clear understanding of local
services available and their limitations. Health and
psychosocial risks of leaving the community should
be included when selecting the appropriate location
of birth. Infor- mation should be culturally sensitive
and tailored to the needs, values, and beliefs of
individual women.
5. Women’s autonomy in making informed decisions
about their care must be respected1 and their choice
dis- cussed in detail and fully supported by the
available resources, even in difficult situations when
health care providers disagree with the choice.2
The goal is a normal physiological birth with the best
out- come possible for mother and baby. An effective
and effi- cient communication and transport system
should be in place to transfer pregnant women and
newborn infants from low-acuity environments to
centres that offer the level of care required for an
optimal delivery and maternal and neonatal security. It
is recognized that there are geo- graphic and weather
restrictions that affect transport from some areas in
Canada and that these realities must be con- sidered in
the decision-making process.
Facility standards are regulated by individual provincial
perinatal care program and health authorities and thus
present a challenge for the production and acceptance
of a single national document. Although models and
descrip- tions of resource levels vary somewhat among
provinces and territories, there are enough similarities
in the organi- zation of these levels of care across
Canada to present a generalized minimum standard.
PREAMBLE
In Canada, the choice of birthing location can include
home, free-standing birth centre, and hospital. The
volume and complexity of maternity care that can be
supported vary in each of these settings. British
Columbia and Ontario have published care definitions
grading hospitals from level I to level III, with
increasing capabilities as the level increases. These
definitions provide expectations for
capabilities in maternity and/or neonatal care facility
levels and the appropriate staffing needed for each
service. The Perinatal Tiers of Service model grades
hospitals on the acuity and complexity of maternal-fetal
and neonatal con- ditions. There is considerable overlap
between these mod- els, and they are included in online
Appendix A and B of this document.3,4 They are similar
to the American College of Obstetricians and
Gynecologists (ACOG) national set of definitions that
are consensus based to ensure equity of access to
maternity care. Hospitals with local access to Cae- sarean
delivery can become the referral centre for births
planned at home, in birthing centres, or in sites with no
local surgical access. The qualifications of the staff and
the requirements to stay in hospital at all times may be
adapted or modified for each individual setting.
One fifth (20%) of the Canadian population lives in
rural communities and is experiencing declining access
to local maternity care services due to the closure of
small level I programs.5,6 Despite published data
showing favourable outcomes in low-intervention
settings and a national con- sensus on the benefits of
childbirth close to home, rural Canada has seen
continued attrition of these programs. This is in part due
to the attrition of rural surgical services and a growing
concentration of specialists in urban centres.7 With the
increased use of technology and the increasing trend
towards sub-specialization, less than 4% of obstetricians
and gynaecologists practice in communities of fewer than
25 000 individuals. The recommendations in the Joint
Position Paper on Rural Surgery and Operative
Delivery from 2015 are to establish formal networks of
care integrating rural and regional hospitals through
collab- oration among specialist surgeons, midwives,
and rural Family Physicians trained in Enhanced
Surgical Skills (FPESS).8 In western and northern
Canada, these net- works of surgical and maternity care
exist with FPESS co- workers. However, in eastern
Canada, Quebec, and Ontario, many of the Caesarean
deliveries are performed by general surgeons. The
SOGC recommends strengthen- ing the training
programs that give family physicians and general
surgeons Caesarean section surgical skills. For FPESS,
SOGC recommends the development of formal, robust,
and collegial relationships to enhance general surgi- cal
skills, as well as the implementation of a rigorous
evalu- ation system implemented by all key
stakeholders in all jurisdictions. Fostering a renewed
interest in providing sur- gical and operative delivery
training to staff in rural hospi- tals would improve
collaboration among specialist surgeons, midwives, and
rural family physicians.8 In order to make any informed
decision on delivery location, preg- nant women should
be supported in understanding the health and
psychosocial risks of either a planned local birth
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from CliniMcalAKYeyJ.cOomGbCy
EMlsAevI i2er01o9n M● a6rc8h927,
SOGC CONSENSUS STATEMENT

or a birth outside the community should transfer regional network of referral and support. This system
become necessary.

It is important to recognize the duality that while most

physiological births occur without incident, it may not
be possible to predict all emergencies. The presence of
a birth attendant will not always guarantee a positive
outcome. In large urban settings, when problems are
identified by nurses, midwives, and family physicians
during labour and birth, the responder may very well be
an in-house specialist member of the team. However, in
rural Canada this response may occur via technology-
enabled conferencing. This newer technology requires that
patient confidentiality be maintained at all times over
secure lines. If transfer is not possible, extended
consultation or guidance may occur over this
technology to provide support to the rural care
provider. There are wide variations in staffing of
maternity care teams across disparate geographies and
varying levels of service in Canada. In many Canadian
jurisdictions, mid- wives and family physicians may
attend labouring women at birth centres without on-site
surgical backup, and these births almost always occur
without incident.

Maternity care in rural and remote settings may be pro-

vided only by midwives or family physicians or may
have fluctuating interprofessional care teams. Some rural
physi- cians may have enhanced surgical skills, or the
team could include a rural obstetrician or general
surgeon. All settings strive towards the goal of a
normal physiological birth for a healthy infant and
mother. It is recommended that in all facilities
providing maternity care, the most responsible care
provider review the risk profile and communicate any
changes in maternal or fetal status to the entire medical
team as they arise. The progress of each woman in
labour should include maternal comorbidities and fetal
conditions that would help guide the optimal care
setting for each woman and her baby (local or at a more
resourced centre), and assist providers in deciding
whether to remain in house or to remain immediately
available.

For those facilities with local access to surgically

trained care providers, timely performance of Caesarean
delivery is dependent on the complex interplay of
surgical team and infrastructure availability. For
communities without local access to Caesarean delivery,
plans for efficient and timely transport to the
appropriate level of care must be in place should that
become necessary. Safe rural maternity care requires a
collaborative approach among all team mem- bers. This
requires that providers supporting home birth, attending
births in birth centres, and level I hospitals with- out
Caesarean section capability are all integrated into a
 requires prompt response by or acceptance of transfer
by consulting specialists. Each province has devised a
referral pattern to support northern or other remote
facilities.
Whenever the most responsible care provider
covering obstetrics is called from labour and delivery
by a primary midwife, nurse, or physician, he or she
should respond to these calls within 30 minutes to
review the situation and make a decision to take
further action.9−11 This defines the “30-minute
response-to-arrival time.” If a Caesarean sec- tion is
needed, additional time may be necessary to call in
the surgical, anaesthetic, pediatric, and nursing teams
where resources are available. The response could
include consul- tation remotely with providers at sites
with higher level of care and the timely initiation of
transfer if indicated.
The 30-minute decision-to-incision time was introduced
in 1989 by ACOG9 and subsequently endorsed by the
Ameri- can Academy of Pediatrics and quoted in the
National Insti- tute for Health and Care Excellence
(NICE) guidelines in the United Kingdom.10,11 Both
30-minute guidelines have become the commonly
cited standards for clinical care and for medicolegal
matters, despite the minimal evidence.12 To meet these
standards, all members of the interdisciplinary team
should clearly communicate their availability to the
D6ow90nlo●adMedAfoYr JFOakGultCas KMeAdoIk2te0r1a9n Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
entire staff to ensure appropriate coverage.
RISK ASSESSMENT AND RESOURCE NEEDS
The Society for Maternal-Fetal Medicine in the United
States has a detailed coding list of all low-risk
situations13 and describes some situations that would
require initiation of transfer.14 In addition, current
antenatal records in most provinces and territories
include detailed lists of complica- tions that require
screening. Low-risk pregnancies include primigravida and
multigravida individuals without any sig- nificant medical
or surgical (no previous Caesarean section) complications,
term pregnancy (>37 weeks gestation), and singleton
vertex pregnancy with no fetal anomalies that may be
cared for appropriately with local resources. Repeat
assessment and risk evaluation need to occur at each
visit. If the clinical situation changes, the care provider
should re-evaluate the birth location in the context of
the resour- ces available, and if the anticipated
consequences outweigh the available local resources, the
recommended birth loca- tion may need to change.
Clinical risk is multifactorial and many attempts have
been published using different predictive algorithms.15−17
How- ever, a comprehensive assessment of risk must
take into consideration social risk to the woman and her
family, including emotional and cultural isolation,
financial stress,
 No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care
and personal safety.18 Emerging evidence in Canada
and internationally has demonstrated that the absence
of local maternity care in rural settings leads to
increased adverse outcomes and that distance to
services is positively corre- lated with the severity of
such outcomes.19
Supporting patients who plan their births at home, birth
centres, or level I facilities without local access to
Caesar- ean section respects the autonomy of the
woman giving birth and her family. Place-of-birth
informed-choice deci- sions require clinical skills
unique to the care providers working in these
environments. This discussion should include risks,
benefits, and alternatives as well as indica- tions for
and timing of transport to a surgical setting as needed.
Level I hospitals without local Caesarean section
availability may have no more resources than birth
centres but histori- cally have supported one third of
the catchment area for local births.20 Sustainability of
these centres requires main- taining competency among
local midwives, physicians, and nursing teams, with
support from specialists in reviewing cases and
accepting referrals. These competency require- ments
will differ in different geographic locations, and it is
recognized that some remote level I hospitals cannot
meet the 30-minute rules with the available staff in the
region. The majority of low-risk women will have a
safe, normal physiological birth with minimal
intervention, but mothers need to understand risks of
remaining in certain birth locations.
QUALITY IMPROVEMENT
Mechanisms for quality and safety improvement must be
in place at all levels of birthing facilities. Ongoing skills
drills and quality improvement programs that quantify
metrics of safety are an integral element of care across
Canada. Quality programs such as Fundamentals of
Fetal Health Surveillance Course (online and classroom
components), MOREOB (Managing Obstetrical Risk
Efficiently), ALARM (Advances in Labour and Risk
Management), and other maternity emergency skills
programs can assist in the quality assessment of clinical
risk management. In all settings, reviewing intrapartum
fetal surveillance and prac- tising emergency skills
through simulated scenarios with the interprofessional
team of health care providers creates a culture that
supports improved communications leading to quicker
responses for abnormal surveillance. Ongoing quality
improvement programs and team building are essential
in each institution to evaluate their response-to- arrival
time and decision-to-incision time protocols and their
capacity to effectively respond to emergencies.
DEFINITIONS OF BIRTH FACILITIES IN CANADA
In all community birthing settings (home, birth centres,
and level I hospitals), the following conditions should
be met:
● Informed choice discussions should be conducted
with women and families in the prenatal period,
including rea- sons for transport, risks of transport,
and possible delays and emergency measures
applicable in community set- ting.
● Transport mechanisms should be available, and trans-
port processes should be rehearsed jointly with the
maternity care and transport teams.
● Consultation with an obstetrician should be available
by telephone or technology-enabled conferencing.
● Medications to manage obstetrical emergencies, such
as magnesium sulfate, antenatal corticosteroids, and
toco- lytics, ideally should be available to initiate
management prior to a potential transfer.21
● Medications to treat postpartum hemorrhage ideally
should be available in all community birth settings.
Home
Pregnant women may choose to deliver at home under
the care of a regulated midwife. Risk assessment is
performed using established criteria to evaluate if the
woman is an appropriate candidate. The number of
women choosing this option has increased over the last
few years due to the general increased awareness and
availability of midwives in some provinces. Midwifery
clients benefit from less inter- vention and from more
one-to-one care and have good outcomes.22,23
Birth Centres
Birth centres care for low-risk individuals and are
attended by regulated midwives or family physicians.
These centres offer a home-like environment and
promote minimal inter- vention. They have less
equipment and fewer resources than a hospital.
Hospitals
Level I without local Caesarean section skills
Some rural community hospitals provide maternity care
for low-risk women without local access to Caesarean
section. These hospitals are resourced similarly to birth
centres and supported by combinations of midwives,
family physicians, and registered nurses. There is
evidence of good maternal- newborn outcomes, which
allow women and their families to stay in their
communities.5 Level I nonsurgical facilities should be
linked to regional sites for clinical support and
specialist consultation.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from CliniMcalAKYeyJ.cOomGbCy
EMlsAevI i2er01o9n M● a6rc9h127,
SOGC CONSENSUS STATEMENT

Level I with local Caesarean section skills do support

There is a second cohort of level I hospitals that offers
local Caesarean section services, often staffed by
midwives and rural family physicians, some of whom
have advanced training in surgery (FPESS) along with
anaesthesia and general surgeons with Caesarean
section skills. They also require support staff and
resources for newborn care. They offer planned local
births for women with low to moderate degrees of risk
when births are anticipated to be uncomplicated and
neither mother nor newborn is likely to require
resources beyond the local capacity. Such services may
meet the needs of up to 80% of the local catchment
population.24−26 These programs are vulnerable due to
low procedural volume, which can create acute staffing
challenges and can lead to instability/fluctuation in the
availability of local access to Caesarean section. Thus
some sites fluctuate between “have” and “have-not”
status in terms of local access to Caesarean section.

Level II
Level II hospitals provide family-centred care, and women
benefit from less intervention and good outcomes for
nor- mal physiological birth in a higher security level
of care. These hospitals care for pregnant women with
low- and moderate-risk pregnancies and in some
provinces are cate- gorized by the level of their
neonatal care facilities. Level II hospitals in rural areas
offer some combination of obstetri- cal, anaesthesia,
pediatric, and neonatal support (in person or via
technology-enabled telemedicine support systems). In
larger urban centres, obstetrical, anaesthesia, and pediat-
ric teams are usually in house. Many urban level II
hospi- tals include a neonatal intensive care unit
(NICU) and may have an adult intensive care unit
(ICU) on site or nearby. A family physician or
obstetrician may decide to stay in house, depending on
the volume and complexity of cases. This will change
the capacity to proceed with an immediate Caesarean
section or call for additional team members.

Level III
Tertiary hospitals have, as their mission, a low
intervention rate for low-risk populations with safe normal
physiological births. They can also provide care for both
low- and high- risk pregnancies and have on-site
perinatal, neonatal, and anaesthetic services. An
obstetrician is always in house, and an adult ICU is on
site or nearby to handle maternal comor- bidities. NICU
facilities are available, and a maternal-fetal medicine
specialist is frequently available for consultation.

Hospitals Without Planned Intrapartum Care

There are both rural and urban hospitals that are not
desig- nated sites for maternity care. Some rural sites
 a consistent volume of deliveries for individuals who
are unable to or have chosen not to leave the
community, and some urban sites strategically focus on
other non-maternity care priorities. When labouring
women arrive at these centres the births are
considered “emergencies” even if they occur without
incident in a low-risk population. In rural settings,
individuals from communities without maternity care
have poorer outcomes than those from communities
with local access to maternity care, regardless of where
they deliver. Hospitals without maternity services need
to be prepared for precipitous local deliveries and
have emergency transfer protocols in place. The level
of preparedness and skills drills practices should be
equivalent to those that are practised for other
emergencies such as cardiovascular events and
stroke.
TIME TO CAESAREAN BIRTH
It is important that the entire health care team work
as quickly as possible to arrange a Caesarean birth
when indicated, recognizing that even 30 minutes is
too long for some fetal situations. Research
evaluating adherence to the 30-minute decision-to-
incision time in Europe, the United Kingdom, and
Australia has shown varying suc- cess rates from
40% to 98%.27−29 After a review of insti- tutional
D6ow92nlo●adMedAfoYr JFOakGultCas KMeAdoIk2te0r1a9n Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
policies, centres were able to improve their adherence
rates to 61% of cases initiated within 30 minutes.30−32 The
2012 Guidelines for Perinatal Care recom- mend that
timing must consider maternal and fetal risks and
benefits.33 It is estimated that 0.67% of cases in a large
centre will require an emergency Caesarean section,
and this often occurs unexpectedly in low-risk
women.34 In smaller rural centres, with preselected
women of low risk, this emergency number is closer to
0.4%.35 A recent prospective study showed that
compliance with the 30- minute decision-to-incision
time was routinely achieved (98%) in a tertiary care
hospital, while obese women require an additional 4.5
minutes.36,37
Endorsing programs that use skills drills (such as fetal
heartrate [FHR] surveillance, MORE OB, and ALARM),
routinely reviewing fetal heart surveillance, classifying the
urgency of the case to inform the incoming team, estab-
lishing a specific overhead code call, and improving
com- munication among all the involved staff have
resulted in a quicker response time and improved
neonatal out- comes.38−41 Performing regular simulation
drills and maintaining a collaborative team approach
improve out- comes and reduce response time for
Caesarean deliver- ies.42−45 Adherence to the 30-minute
decision-to-incision rule is more critical for cases with
high potential for a rap- idly deteriorating fetal status,
as with abnormal FHR
 No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care
pattern, or maternal conditions such as suspicion of
uter- ine rupture or placental abruption. It is estimated
that 0.4% of to 0.67% of all pregnant women will
require an emergency Caesarean section that ideally
should be per- formed within 5 to 10 minutes.27 This
will not be possible in all hospitals, and any potential or
foreseeable delays need to be discussed with the
pregnant woman prior to and clearly documented when
choosing a location for delivery.
It is the responsibility of hospitals with Caesarean
section capability to ensure adequate operating room
time and availability of nursing, anaesthetic, surgical, and
newborn resuscitation personnel to deal effectively with
obstetrical emergencies. Hospitals without local access
to Caesarean section need to have an emergency
referral and transport protocol in place. Indications for
emergency Caesarean births are abnormal fetal
surveillance in labour (71%), abnormal fetal
surveillance antepartum (10%), abruption (6.3%),
suspected uterine rupture (4.8%), and cord pro- lapse
(8%). Urgent Caesarean births include nonprogres- sive
labour (54%) or atypical fetal surveillance (36%).
Where the fetal surveillance is normal or atypical, the
maternal condition is stable, and pain control is
adequate, the Caesarean delivery should be initiated
expeditiously in collaboration with anaesthetic and
other necessary support personnel. The NICE
guidelines suggest that timing can be up to 75 minutes
but would require careful maternal and fetal monitoring
after the discontinuation of oxytocin. Documenting
reasons for delay would allow audits to be carried out
regularly for quality improvement.
Failed trial of labour after Caesarean, breech, or
multiple gestation births are usually urgent and often
occur in level II or III hospitals.34 When there has been
an unsuccessful trial of assisted vaginal delivery, a
Caesarean delivery should be performed depending on
the acuity of the situa- tion, and all adverse events
documented.46
KEY POINTS FOR OPTIMAL CARE IN LABOUR AND
DELIVERY
1. Situational Awareness
a. Timely attendance by the health care team members
and auditing of programs to optimize response-to-
arrival and decision-to-incision time should be
recognized and in place where resources allow.
Respect between consul- tants and low-risk obstetrics
providers is imperative to ensure integrated care for
women in all geographic regions.
b. Recognition that in rural and remote settings where
good outcomes are contingent on appropriate case
selection for delivery in the local community,
thoroughly informed choices need to include a clear
assessment of the risks and be discussed with the
pregnant women and their support persons.
2. Communication Among All Health Care Team
Members
a. Clinical and social risk factors should be reviewed
itera- tively throughout the antepartum, intrapartum,
postpar- tum, and newborn periods. Risk factors
should be known by the entire team and clearly
communicated in a standardized fashion. Any
changes to the risk status should be clearly
communicated to the whole team in a respectful and
timely manner to ensure patient safety. In rural
settings, early discussions with regional referral
centre specialists should be encouraged. Patient
priori- ties and values need to be respected.
b. Transfer of care between health team members is a
rec- ognized risk event and should be performed with
atten- tion to the inclusion of detailed information
regarding progress in labour thus ensuring a
seamless transi- tion.47,48 When the availability of
team members changes, the risk status of the
labouring women needs to be reassessed.
3. Documentation
Progress and details of the labour should be clearly
docu- mented in a contemporaneous fashion and
identifiable in the records that are available to all health
team members. This could be as simple as a
communication board in the labour and delivery unit.
4. Fetal Surveillance, Interpretation, and Response
Monitoring of fetal health surveillance, by auscultation
or electronically, should be performed according to
national SOGC guidelines and interpreted and
documented appro- priately. Newer technology-assisted
conferencing of real- time electronic fetal monitor
tracings may allow both improved flexibility and a more
rapid decision-making pro- cess in response to an
abnormal tracing. It is important that the health care
provider monitoring the uterine activity and FHR be
competent in fetal health surveillance interpreta- tion
and the skills for intrauterine resuscitation. Refresher
courses and review of poor outcomes can improve
reaction time and outcomes when provided to all
members of the health team. The scope of practice of
nurses and midwives differs in their reporting of
problems and seeking interven- tion, but primary health
care providers need to be aware of
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from CliniMcalAKYeyJ.cOomGbCy
EMlsAevI i2er01o9n M● a6rc9h327,
SOGC CONSENSUS STATEMENT

their responsibility to report problems to the appropriate blood gas val- ues.58,59 Both umbilical artery and
team members in a timely manner. umbilical vein

5. Key Core Requirements for All Births

a. The indication(s) for any intervention should be

evidence based and documented at the time of the
event(s).
b. When a forceps or vacuum delivery is required, the
SOGC recommends adherence to acceptable applica-
tion of low or mid-forceps, as outlined in the SOGC
guidelines.49,50 Assisted vaginal births, such as
delivery from the mid-pelvic cavity with forceps or
vacuum, breech, or twin vaginal birth, may be
carried out in the birthing room or in the operating
room, depending on the clinical judgement of the
physician and the policy of the unit. The risks of
proceeding in the absence of immediate access to a
Caesarean section should be care- fully considered in
each individual case.
c. For assisted low station and outlet delivery, the
presence of an anaesthesiologist is not routinely
required, but the choice of analgesia should be
discussed by the attending physician and the woman.
d. For planned vaginal breech or twin birth, birth
location should be appropriate, and personnel for
operating room and newborn care should be
informed upon admission to the unit.
e. In the event of an unsuccessful assisted delivery, the
backup plan should be known to the entire health
care team and previously discussed with the woman
as part of the informed consent process.
f. Fetal well-being during labour may be assessed by
scalp pH or scalp lactate depending on the
equipment as well as the technical expertise in each
centre.51
g. Apgar scores provide an assessment of the newborn
at birth. Further observation of the newborn’s
condition is required to determine the need for
resuscitation. The documentation must be clearly
indicated on maternal and newborn charts and
available to all teams involved in the care. The
SOGC recommends measuring umbili- cal arterial
and venous cord blood gases or lactates after all
births in centres where this is financially supported
and the service is provided by the laboratory. These
results can help determine a proper management
plan for the newborn and adequate level of care and
surveil- lance.52−56 The ACOG and the Royal College
of Obste- tricians and Gynecologists recommend
that arterial and venous cord blood samples be
obtained when a Caesar- ean section is performed for
fetal compromise.
h. Delayed cord clamping is now recommended by
pediat- ric societies.57 Any delay should be recorded
as this time delay may cause artefactual changes in
 sampling is recommended.49 Analysis of samples
drawn from a clamped segment of umbilical cord
will be accu- rate for pH for 1 hour and accurate
for base excess for 40 minutes. The cord blood gas
sample can be analyzed with point-of-care
equipment on the unit if there is no 24-hour
dedicated laboratory support, but the equip- ment
must be calibrated regularly and subjected to peri-
odic quality checks. If the facilities exist, the
sample can be sent to the laboratory at room
temperature for analy- sis of pH, PO2, PCO2, and
base deficit, within 1 hour of delivery.
Alternatively, the sample could be collected in a
heparinized syringe, placed on ice, refrigerated, and
ana- lyzed within 24 hours.46,60−64
6. Communication Policy
There must be timely team communication between
deliv- ery and operating room personnel (if these are
different staff within an institution) when individuals
are in active labour. This policy will optimize
appropriate time response to cover emergencies.
Surgical backup for emergency cases needs to be
communicated to the entire health care team. Urban
hospitals with a greater obstetrical volume should
assess the necessity of having in-house physicians
present and a second obstetrical and/or surgical and
anaesthetic team available for emergency cases.
D6ow94nlo●adMedAfoYr JFOakGultCas KMeAdoIk2te0r1a9n Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
CONCLUSION
The goal for all birthing facilities in Canada is the
provision of seamless, continuous high quality of care,
whether for low-risk vaginal deliveries or women who
require a higher level of care. Formal networks of
specialist and generalist care providers who are fully
supported by rigorous quality improvement will
increase achievement of this goal. Care- ful criteria
used for case selection based on local resources must
inform decision making with women, but ultimately the
right of women to make informed decisions must be
respected. When a woman’s choice contravenes best
pro- vider advice, strategies to mitigate provider stress
and offer provider support must be considered. In rural
communi- ties, the risks of providing intrapartum care
locally must be balanced with the risks of travel when
care is provided in a referral centre. Travel that removes
or separates the preg- nant woman from her family can
cause significant stress and deleterious effects, burdens,
and disruption that may be far reaching in the rural
community.
Governments and hospitals should provide adequate
health care personnel, institutional, and financial
resources to achieve standards of maternity care that lead
to optimal out- comes for Canadians and their newborns
while preserving
 No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care
an acceptable work environment and schedule for the
health care providers. Hospitals should provide adequate
infrastruc- ture and operational policies that allow
achievement of this position paper and collaborative
teamwork and interprofes- sional communication.
Refresher courses and continuous quality assessment
programs should be part of this process.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at .
REFERENCES
1. Kotaska A. Informed consent and refusal in obstetrics: a practical
ethical guide. Birth 2017;44:195–9.
2. Smith MK, Levy KS, Yudin MH. Informed consent during labour:
patient and physician perspectives. J Obstet Gynaecol Can
2018;40:614–7.
3. Provincial Council for Maternal and Child Health. Standardized
Maternal and Newborn Levels of Care Definitions. Toronto: Provincial
Council for Maternal and Child Health; 2013. Available at:
http://www.pcmch.on.ca/ wp-content/uploads/2015/07/Level-of-Care-
Guidelines-2011-Updated- August1-20131.pdf. Accessed January 14,
2019.
4. Aitken K, Allen L, Pantazi S, et al. MRI significantly improves
disease staging to direct surgical planning for abnormal invasive
placentation: a single centre experience. J Obstet Gynaecol Can
2016;38:246–51.e1.
5. No-251-Returning birth to aboriginal, rural, and remote
communities. J Obstet Gynaecol Can 2017;39:e395–7.
6. Hernandez-Andrade E, Romero R, Ahn H, et al. Transabdominal
evaluation of uterine cervical length during pregnancy fails to identify
a substantial number of women with a short cervix. J Matern Fetal
Neonatal Med 2012;25:1682–9.
7. Miller KJ, Couchie C, Ehman W, et al. Rural maternity care. J
Obstet Gynaecol Can 2012;34:984–1000.
8. Iglesias S, Kornelsen J, Woollard R, et al. Joint position paper on
rural surgery and operative delivery. Can J Rural Med
2015;20:129–38.
9. American College of Obstetricians and Gynecologists. Standards of
obstetric-gynecologic services. 7th ed Washington, DC: American
College of Obstetricians and Gynecologists; 1989.
10. American Academy of Pediatrics, American College of Obstetrics
and Gynecology. Guidelines for perinatal care. 6th ed Elk Grove
Village, IL: American Academy of Pediatrics and American College of
Obstetrics and Gynecology; 2007.
11. National Institute for Health and Care Excellence. Caesarean section
guideline. London, UK: National Institute for Health and Care Excellence;
2011.
12. Miller LA. Decision to incision and the legal standard of care. J
Perinat Neonatal Nurs 2016;34:288–9.
13. Armstrong J, McDermott P, Saade GR, et al. Coding update of the
SMFM definition of low risk for cesarean delivery from ICD-9-CM to
ICD-10-CM. Am J Obstet Gynecol 2017;217:B2–12.e56.
14. Institute of Medicine, National Research Council. An update on
research issues in the assessment of birth settings: workshop
summary. In: Pray L,
ed. An update on research issues in the assessment of birth settings:
workshop summary, Washington, DC: National Academies Press; 2013.
15. Hobel CJ, Hyvarinen MA, Okada DM, et al. Prenatal and intrapartum
high- risk screening. I. Prediction of the high-rish neonate. Am J Obstet
Gynecol 1973;117:1–9.
16. Daga AS, Daga SR, Patole SK. Risk assessment in birth asphyxia. J
Trop Pediatr 1990;36:34–9.
17. Artal R. Risk factors for complications during pregnancy. Merck Manual.
Kenilworth, NJ: Merck & Co.; 2017. Available at:
http://www.merckmanuals. com/en-ca/professional/gynecology-and-
obstetrics/high-risk-pregnancy/risk- factors-for-complications-during-
pregnancy. Accessed January 14, 2019.
18. Barclay L, Kornelsen J, Longman J, et al. Reconceptualising risk: perceptions
of risk in rural and remote maternity service planning. Midwifery 2016;38:63–
70.
19. Grzybowski S, Stoll K, Kornelsen J. Distance matters: a population
based study examining access to maternity services for rural women. BMC
Health Serv Res 2011;11:147.
20. Grzybowski S, Kornelsen J, Schuurman N. Planning the optimal
level of local maternity service for small rural communities: a
systems study in British Columbia. Health Policy 2009;92:149–57.
21. Rupley DM, Tergas AI, Palmerola KL, et al. Robotically assisted
delayed total laparoscopic hysterectomy for placenta percreta. Gynecol Oncol
Rep 2016;17:53–5.
22. Hutton EK, Cappelletti A, Reitsma AH, et al. Outcomes associated
with planned place of birth among women with low-risk
pregnancies. CMAJ 2016;188:E80–90.
23. Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned
home and planned hospital births in low-risk women attended by
midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth
2009;36:180–9.
24. Grzybowski S, Stoll K, Kornelsen J. The outcomes of perinatal
surgical services in rural British Columbia: a population-based study.
Can J Rural Med 2013;18:123–9.
25. Iglesias S, Bott N, Ellehoj E, et al. Outcomes of maternity care
services in Alberta, 1999 and 2000: a population-based analysis. J
Obstet Gynaecol Can 2005;27:855–63.
26. Homan FF, Olson AL, Johnson DJ. A comparison of cesarean
delivery outcomes for rural family physicians and obstetricians. J
Am Board Fam Med 2013;26:366–72.
27. MacKenzie IZ, Cooke I. What is a reasonable time from decision-to-
delivery by caesarean section? Evidence from 415 deliveries. BJOG
2002;109:498–504.
28. Hillemanns P, Strauss A, Hasbargen U, et al. Crash emergency
cesarean section: decision-to-delivery interval under 30 min and its
effect on Apgar and umbilical artery pH. Arch Gynecol Obstet
2005;273:161–5.
29. Homer CS, Catling-Paull C. Safe timing for an urgent Caesarean
section: what is the evidence to guide policy? Aust Health Rev
2012;36:277–81.
30. Onah HE, Ibeziako N, Umezulike AC, et al. Decision-delivery interval
and perinatal outcome in emergency caesarean sections. J Obstet
Gynaecol 2005;25:342–6.
31. Tashfeen K, Patel M, Hamdi IM, et al. Decision-to-delivery time intervals
in emergency Caesarean section cases: repeated cross-sectional study
from Oman. Sultan Qaboos Univ Med J 2017;17:e38–42.
32. Gupta S, Naithani U, Madhanmohan C, et al. Evaluation of decision-to-
delivery interval in emergency cesarean section: a 1-year prospective audit in a
tertiary care hospital. J Anaesthesiol Clin Pharmacol 2017;33:64–70.
33. American Academy of Pediatrics, American College of Obstetricians and
Gynecologists. Guidelines for perinatal care. 7th ed Elk Grove Village,
 IL:

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from CliniMcalAKYeyJ.cOomGbCy
EMlsAevI i2er01o9n M● a6rc9h527,
SOGC CONSENSUS STATEMENT
American Academy of Pediatrics and American College of Obstetrics and
Gynecology; 2012.
34. Tolcher MC, Johnson RL, El-Nashar SA, et al. Decision-to-incision
time and neonatal outcomes: a systematic review and meta-analysis.
Obstet Gynecol 2014;123:536–48.
35. Rowe RE, Townend J, Brocklehurst P, et al. Duration and urgency of
transfer in births planned at home and in freestanding midwifery
units in England: secondary analysis of the birthplace national prospective
cohort study. BMC Pregnancy Childbirth 2013;13:224.
36. Amankwah Y, Caughey S, Walker M. A prospective study of the
efficiency of the “code 333” process at the Ottawa hospital. J Obstet
Gynaecol Can 2011;33:244–51.
37. Pulman KJ, Tohidi M, Pudwell J, et al. Emergency Caesarean
section in obese parturients: is a 30-minute decision-to-incision
interval feasible? J Obstet Gynaecol Can 2015;37: 988–94.
38. Weiner E, Bar J, Fainstein N, et al. The effect of a program to shorten
the decision-to-delivery interval for emergent cesarean section on
maternal and neonatal outcome. Am J Obstet Gynecol
2014;210:224.e1–6.
39. Lipman SS, Carvalho B, Cohen SE, et al. Response times for
emergency cesarean delivery: use of simulation drills to assess and
improve obstetric team performance. J Perinatol 2013;33:259–63.
40. Tyner JE, Rayburn WF. Emergency cesarean delivery: special
precautions. Obstet Gynecol Clin North Am 2013;40:37–45.
41. Dupuis O, Sayegh I, Decullier E, et al. Red, orange and green
Caesarean sections: a new communication tool for on-call
obstetricians. Eur J Obstet Gynecol Reprod Biol 2008;140:206–11.
42. Balki M, Hoppe D, Monks D, et al. The PETRA (Perinatal
Emergency Team Response Assessment) scale: a high-fidelity
simulation validation study. J Obstet Gynaecol Can 2017;39:523–
33.e12.
43. Mooney SE, Ogrinc G, Steadman W. Improving emergency caesarean
delivery response times at a rural community hospital. Qual Saf Health
Care 2007;16:60–6.
44. de Regt RH, Marks K, Joseph DL, et al. Time from decision to
incision for cesarean deliveries at a community hospital. Obstet
Gynecol 2009;113:625–9.
45. Salmeen K, Brincat C. Time from consent to cesarean delivery during
labor. Am J Obstet Gynecol 2013;209:212.e1−6.
46. Strickland DM, 3rd Gilstrap LC, Hauth JC, et al. Umbilical cord pH
and PCO2: effect of interval from delivery to determination. Am J
Obstet Gynecol 1984;148:191–4.
47. Khalifeh A, Berghella V. Not transabdominal!. Am J Obstet
Gynecol 2016;215:739–44.e1.
48. Canadian Medical Protective Association. Good practices
guideline. Ottawa: Canadian Medical Protective Association.
Available at: https:// www.cmpa-
acpm.ca/serve/docs/ela/goodpracticesguide/pages/index/ index-
e.html. Accessed January14, 2019.
49.
Society of Obstetricians and Gynaecologists of Canada. Advances in labour and
risk management (ALARM). 24th ed. Ottawa: Society of Obstetricians and
Gynaecologists of Canada; 2017.
50. Cargill YM, MacKinnon CJ, Arsenault MY, et al. Guidelines for
operative vaginal birth. J Obstet Gynaecol Can 2004;26:747–61.
51. Bowler T, Beckmann M. Comparing fetal scalp lactate and
umbilical cord arterial blood gas values. Aust N Z J Obstet
Gynaecol 2014;54:79–83.
52. ACOG Committee on Obstetric Practice. ACOG committee opinion
no. 348, November 2006: umbilical cord blood gas and acid-base
analysis. Obstet Gynecol 2006;108:1319–22.
53. Dani C, Bresci C, Berti E, et al. Short term outcome of term newborns
with unexpected umbilical cord arterial pH between 7.000 and 7.100.
Early Hum Dev 2013;89:1037–40.
54. Georgieva A, Moulden M, Redman CW. Umbilical cord gases in
relation to the neonatal condition: the EveREst plot. Eur J Obstet
Gynecol Reprod Biol 2013;168:155–60.
55. Cantu J, Szychowski JM, Li X, et al. Predicting fetal acidemia
using umbilical venous cord gas parameters. Obstet Gynecol
2014;124: 926–32.
56. White CR, Doherty DA, Newnham JP, et al. The impact of
introducing universal umbilical cord blood gas analysis and lactate
measurement at delivery. Aust N Z J Obstet Gynaecol 2014;54:71–
8.
57. Lemyre B, Sample M, Lacaze-Masmonteil T, et al. Minimizing blood
loss and the need for transfusions in very premature infants. Paediatr
Child Health 2015;20:451–62.
58. Lievaart M, de Jong PA. Acid-base equilibrium in umbilical cord blood
and time of cord clamping. Obstet Gynecol 1984;63:44–7.
59. Wiberg N, Kallen K, Olofsson P. Delayed umbilical cord clamping at
birth has effects on arterial and venous blood gases and lactate
concentrations. BJOG 2008;115:697–703.
60. Chauhan SP, Meydrech EF, Morrison JC, et al. Remote umbilical
arterial blood pH analysis: accuracy, utility, and limitations. Am J
Perinatol 1997;14:39–43.
61. ACOG technical bulletin. Umbilical artery blood acid-base
analysis. Number 216−November 1995. (Replaces no. 127, April
1989). Int J Gynaecol Obstet 1996;52:305–10.
62. Chauhan SP, Cowan BD, Meydrech EF, et al. Determination of fetal
acidemia at birth from a remote umbilical arterial blood gas analysis.
Am J Obstet Gynecol 1994;170:1705–9; discussion 9−12.
63. Peipert JF, Sweeney PJ. Diagnostic testing in obstetrics and gynecology:
a clinician's guide. Obstet Gynecol 1993;82:619–23.
64. Simhan HN, Umbilical cord blood acid-base analysis at delivery Up
To Date; 2017. https://www.uptodate.com/contents/umbilical-cord-
blood- acid-base-analysis-at-delivery. Accessed January14, 2019.
D6ow96nlo●adMedAfoYr JFOakGultCas KMeAdoIk2te0r1a9n Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
 No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care

APPENDIX A

Table 1. Maternal and newborn level of care definitions

Gestational age Maternal care Newborn care

Level I Level Ia and Level Ib Level I
≥36+0 weeks Risk Expected skill level
● Low maternal and neonatal risk including no significant ● Evaluation and postnatal care of
medical diseases or risk factors likely to affect healthy newborn infants who are
pregnancy and not anticipated to experience any predominantly cared for in a mother-
significant complications baby dyad model (rooming-in)
● Between 36+6 days and 36+0 days only if spontaneous ●● Phototherapy
preterm labour in absence of any other maternal-fetal ● ● Management, for a limited duration, of
complications; in particular APH, hypertension, diabetes, any term newborn complications such as
maternal infection or fever in labour greater than 38°C transient tachypnea of the newborn,
● For all other cases <37 weeks consultation or transfer is antibiotic prophylaxis, hypoglycemia,
recommended. and feeding difficulties
● Operative vaginal deliveries should be undertaken ● Resuscitation and stabilization of ill
only when there is a reasonable chance of success infants before transfer to an appropriate
and a backup plan is in place (SOGC/MOREOB). care facility
Support
● The goal, where possible, should be to provide human
resources and supports needed for 24/7 anaesthesia
coverage.
● Labour analgesia should be available. This includes use of
systemic narcotics (e.g. IM, IV, PCA), nitrous oxide with
appropriate monitoring, and safety protocols and labour
epidural pain relief based on the availability of anaesthesia
staff at the centre.
● Epidural services, where available, should follow established
CAS/ASA guidelines for obstetrical anaesthesia.
● When a Caesarean delivery is determined to be
necessary and within scope of service, there must be
timely access to anaesthetic and surgical services for
the operative procedure. (Refer to SOGC guidelines).
Level Ia Level Ib
Does not provide Caesarean Provides Caesarean
delivery service 24/7/365 delivery service
● Singleton pregnancies only 24/7/365
● VBAC deliveries should ● May care for uncomplicated
not be offered. dichorionic twin pregnancies
● Informed consent should be ≥36+0 weeks
documented regarding the ● Capability for
availability of resources and electronic fetal
procedures i.e. capacity to provide monitoring
on-site Caesarean birth. ● Suspected SGA infants would
not be delivered without
consultation.
● Assessment and care by an
anaesthesiologist or FP/GP
anaesthetist for operative
deliveries
Level II Level IIa Level IIa
≥34+0 weeks Care as above Care as above PLUS:
PLUS: Risk Risk
● Women carrying a fetus with anomalies (minor) not ● Planned/anticipated care for infants
likely with a gestational age ≥34+0 weeks
to need immediate interventions and a birth weight >1800 g
● Low to moderate maternal risk experiencing low- Illness and intervention
risk medical/obstetrical complications where SGA ● Mild illness expected to
is not suspected resolve quickly
● May care for uncomplicated dichorionic twin ● Care of stable infants who are convalescing
pregnancies. after intensive care
If less than 36+0 weeks consider consultation ● Nasal oxygen with oxygen
and transfer. saturation monitoring (acute and
convalescing)
(continued )
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
CMlinAicYalJKOeyG.coCmMbyAEIl2se0v1i9er o● n6M9a6r.ceh127,
SOGC CONSENSUS STATEMENT
Table 1. (Continued)
Gestational age Maternal care
Support
● 24/7 induction and augmentation of labour
● 24/7 availability of continuous EFM
● Available assessment within 30 minutes by
obstetrics, anaesthesia, and pediatrics for
emergencies and potential Caesarean sections
Level IIb Level IIb
≥32+0 weeks Care as above PLUS:
● May care for uncomplicated dichorionic
twin pregnancies. If less than 34+0 weeks
consider consultation and transfer.
Level IIc Level IIc
≥30+0 weeks Care as above
PLUS: Risk
● Moderate maternal and/or neonatal risk
● Delivery of infants with antenatally diagnosed
non−life-threatening fetal anomalies
(following consultation with an MFM
specialist and pediatrician) not requiring
immediate intervention
● May care for uncomplicated dichorionic or
monochorionic twin pregnancies. If <32 weeks+0
gestation consider consultation and transfer.
● May care for uncomplicated triplets as
expertise and capacity allow
Newborn care
● Ability to initiate and maintain a
peripheral IV line
● Gavage feeding
Retro-transfers
● Stable neonatal retro-transfers with a
corrected age over 32+0 weeks and
a weight >1500?g and not requiring
invasive or non-invasive ventilation
or advanced treatments or
investigations
Level IIb
Care as above PLUS:
Risk
● Planned/anticipated care of infants with
a gestational age ≥32+0 weeks and a
birth weight >1500 g
Illness and interventions
● Moderately ill with problems expected
to resolve quickly or who are
convalescing after intensive care
● CPAP, either transitional or extended
stable CPAP
● May have mechanical ventilation for
brief durations (<24 hours)
● Insert and maintain umbilical lines.
● Maintenance of PICC lines
● Peripheral IV infusions and total
parenteral nutrition
Retro-transfers
● Stable neonatal retro-transfers with a
corrected >30+0 weeks and >1200?g
and not requiring invasive ventilation,
subspecialty support, surgical support,
advanced treatments, and investigations
Care as above PLUS:
Risk
● Planned/anticipated care of infants with
a gestational age ≥30+0 weeks and a
birth weight >1200?g. See note below.
Illness and interventions
● Moderately ill newborns with problems
expected to resolve within a week or
who are convalescing after intensive
care
● Mechanical ventilation for conditions
expected to resolve within a week or
extended CPAP
● IV infusion
● Total parenteral nutrition
● The ability to insert and maintain
umbilical central lines
● Maintenance of percutaneous IV central lines,
access to PICC line insertion
● Support of babies with extended
mechanical ventilation and lower
gestational age may be required as a
result of temporary inability to transport
(e.g., geography, weather, capacity).
(continued )
D6ow96nl.oea2ded● fMor AFYakuJlOtasGKCedMokAteIra2n0U19niversitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
 No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care

Table 1. (Continued)
Gestational age Maternal care Newborn care
Retro-transfers
● Retro-transfers should be reviewed on
a case-by-case basis between the
tertiary and receiving sites.
Note:
The gestational age and birth weight
criteria of 30+0 weeks and >1200?g will
be a change from usual practice for some
IIc units and should be implemented only
following a clinical trial to make sure
that the outcomes are comparable to
Level III care for the 30- to 32-week
population. Until this evaluation has
been completed the admission criteria
for those IIc units currently functioning
with 32+0 week as their admission
criteria should remain at status quo.
Not having ROP screening service (on-
site or remote) is a confining feature and
a major obstacle to retro-transfer.
Centres with limited coverage are
encouraged to explore local or regional
cross-coverage. At this point ROP
screening as a “must have” for Level IIb
has been removed.
Level III Level III Level IIIa Level IIIb
Any Care as above PLUS: Care as above PLUS: As in IIIa PLUS:
gestational ● High-risk maternal and/or neonatal ● Any gestational ● On site surgical capability
age or (newborn care requirements age or weight
weight must be within the scope of the ● Mechanical ventilation
newborn program services and support including high-
resources) frequency, and possibly
● High maternal risk and/or complex inhaled nitric oxide, for
medical, surgical and/or obstetrical as long as required
complications requiring complex ● Timely access
multidisciplinary and subspecialty to a comprehensive
critical care at any gestational age range of subspecialty
● High fetal risk complications such as consultants
diagnosis of congenital malformations
that require access to: special
fetal diagnostic or therapeutic
procedures,
pediatric subspecialty consultation or care,
neonatal surgical services
● Neonatal intensive care services as per
Neonatal Scopes of Services
document
● On-site adult intensive care unit
services available to accept transfer
and care of unstable
parturients
APH: antepartum hemorrhage; ASA: American Society of Anesthesiologists; CAS: Anesthesiologists Society; CPAP: continuous positive airway pressure; EFM:
elec- tronic fetal monitoring; FP/GP: family practitioner/general practitioner; IM: intramuscular; IV: intravenous; MFM: maternal-fetal medicine; MOREOB: Managing
Obstetrical Risk Efficiently; PCA: patient-controlled analgesia; PICC: peripherally inserted central catheter; ROP: retinopathy of prematurity; SGA: small for
gestational age; SOGC: Society of Obstetricians and Gynaecologists of Canada; VBAC: vaginal birth after Caesarean section.
Modified from Provincial Council for Maternal and Child Health. Standardized Maternal and Newborn Levels of Care Definitions. Toronto: Provincial Council for Maternal
and Child Health; 2013. Available at: http://www.pcmch.on.ca/wp-content/uploads/2015/07/Level-of-Care-Guidelines-2011-Updated-August1-20131.pdf. Accessed
on January 14, 2019.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
CMlinAicYalJKOeyG.coCmMbyAEIl2se0v1i9er o● n6M9a6r.ceh327,
 SOGC CONSENSUS STATEMENT

APPENDIX B

Table 1. Levels of acuity and complexity

Level Risk assessment Acuity
Low Low risk Condition not anticipated to
affect well-being; if a condition
is present requiring increased
observation, it is transient.
Medium Medium risk Condition affecting well-being but
not life-threatening; requires
increased observation and care.
High High risk Condition life-threatening;
requires intensive care.
Modified from 2Perinatal Tiers of Service Module, Chapter 6. 2016.
Complexity
Maternal-fetal or neonatal conditions that are
common, have a mild systemic impact, and can be managed
using standard
resources and treatment protocols by a midwife or general
practitioner.
Maternal-fetal or neonatal medical, surgical, or obstetrical
conditions that may have
a systemic impact and require access to a range of specialty
care providers and resources.
Maternal-fetal or neonatal medical, surgical or obstetrical
conditions with
severe systemic impact and requiring access to multispecialty
and/or sub- specialty care
providers and resources.

Table 2. Levels of acuity and complexity according to tier

T1a Low-acuity and low-complexity acute care perinatal services and home births
Low-risk women with healthy term pregnancies anticipating SVD of healthy singleton infants
Healthy singleton infants ≥37 weeks and ≥2500 g and those requiring care for minor transient conditions
T1b Some increased-acuity but low-complexity acute care perinatal services
● Women with some pregnancy risk and/or conditions requiring increased observation and care, not
anticipated to affect well-being; planned and emergency Caesarean section available
● Infants ≥35 weeks and ≥1800 g and those with some risks requiring increased observation and transient care
T2a Medium-acuity and medium-complexity acute care perinatal services
Women with moderate risk pregnancies and/or with conditions that could affect the well-being of the mother or fetus
Infants ≥32 weeks and ≥1500 g and those with moderate risks requiring increased observation and care
T2b More increased-acuity but medium-complexity
● Women with moderate-risk pregnancies and/or with conditions that are affecting the well-being of the mother or fetus
but are not life-threatening
● Infants ≥30 weeks and ≥1200 g and those with conditions requiring more acute and/or complex management and care
T3 Medium- to high-acuity (not life-threatening) and medium-complexity conditions
Women with high-risk pregnancies and/or with conditions that are seriously affecting the well-being of the mother or fetus but are not
anticipated to be life-threatening
Infants <30 weeks and <1200 g and those with conditions of high acuity and/or requiring complex management and care that are
beyond the scope of the referring service
T4 High-acuity (may be life-threatening) and high-complexity acute care perinatal services
● Women with very high-risk pregnancies and/or with conditions that are life-threatening to the mother or fetus
● Infants with conditions of high acuity requiring multispecialty and subspecialty neonatal care
Modified from 2Perinatal Tiers of Service Module, Chapter 6. 2016.

D6ow96nl.oea4ded● fMor AFYakuJlOtasGKCedMokAteIra2n0U19niversitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27,
 Sexual & Reproductive Healthcare 7 (2016) 52–57

Contents lists available at ScienceDirect

Sexual & Reproductive

Healthcare

Quality of intra-partum care at a university hospital in

Nepal: A prospective cross-sectional survey
Johanna Cederfeldt a*, Jenny Carlsson a, Cecily Begley a,b
, Marie Berg a,c

a
Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, P.O. BOX 457, SE 405 30 Gothenburg, Sweden
b
School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
c
Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden

A R T I C L E I N F O ABSTRAC T

Article history:
Objective: To investigate the quality of intra-partum care provided to women with an expected
Received 8 July 2015
normal birth at a university hospital in Nepal.
Revised 19 October 2015
Accepted 15 November 2015
Methods: A prospective cross-sectional study was conducted during three weeks in November 2013.
Nurses at the labor ward collected data from 292 consecutive births. Of these, 164 women of low
risk were ex- pected to have a normal birth and were included in the study; 107 (65%) were
Keywords:
Intra-partum care nulliparous. The self- administered questionnaire covered maternal characteristics, previous
Quality of health care pregnancies and births, current pregnancy, labor and birth. Nine items assessed care management,
Bologna score five of which comprised the Bologna score with a total possible score of 5: presence of a
Nepal companion, use of partograph, non-use of augmen- tation, non-supine position, and skin-to-skin
Survey contact.
Results: The women were assisted by physicians (56%), nurses (42%) or students under supervision
(2%). All were in good health after birth. Two had a postpartum hemorrhage exceeding 500 ml and
49% had an episiotomy. Apgar score in all neonates was ≥ 7 at five minutes. Mean Bologna score
was 1.43 (vari- ance 0-3).
Conclusions: The management of care in normal birth could be improved in the studied setting, and
there is a need for more research to support such improvement.
© 2015 Elsevier B.V. All rights reserved.

1877-5756/© 2015 Elsevier B.V. All rights reserved.

Introduction

The overall objective of intra-partum care is for a healthy

mother to give birth to a healthy child, with the minimum of
intervention compatible with medical safety [1]. Although
childbirth is a normal physiological process, complications in
pregnancy and birth con- stitute the majority of causes of death
and disability among women of reproductive age in low-
income settings [2], and they are some of the leading causes
of neonatal mortality [3]. Optimal maternity care providing
the best outcomes for mother and child must be based on
scientific evidence to allow the physiological process of birth to
be as undisturbed as possible. Although medical or technical
intra- partum care interventions are indispensable when needed,
they will cause negative effects when overused [4–6]. The World
Health Or- ganization (WHO) advocates that normal birth
should be de- medicalized, since a medicalization of childbirth
may induce a wide range of negative effects, some of which
have serious conse- quences. Unnecessary intervention may
harm mother and child [1],

* Corresponding author. Bissmarksgatan 10, 30296 Halmstad, Sweden. Tel.:

+0046709588721.
E-mail address: johanna.cederfeldt@gmail.com (J. Cederfeldt).

http://dx.doi.org/10.1016/j.srhc.2015.11.004

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
and there is an increase in operative birth with each
intervention introduced in labor, particularly in
primiparous women [7].
The most critical time for maternal and neonatal survival is
labor, birth and the immediate post-partum period, yet
most women and newborns in low- and middle-income
settings do not receive the care required during this
period [8].
In Nepal the maternity care available is limited by
inequality, and location and economic status are important
barriers to improving maternal health. Only 36% of
women are assisted by a so called skilled birth attendant
[9], which in Nepal is an auxiliary nurse- midwife, a nurse
or a physician with an additional two months training in
selected midwifery skills. Thus there are no profession- al
midwives fulfilling international standards [10]. The maternal
and child health situation is however improving, and between
1990 and 2013 the national maternal mortality ratio [MMR]
was reduced by 76%, from 790 to 190 in 100,000 live
births [11]. Infant mortality
ratio (per 1000 live births) was reduced from 97.79 in
1990 to 29.4 in 2015 [12]. This development is at least
partially contributed to strategies introduced by the
government of Nepal to increase the availability of family
planning, safe abortion, antenatal care, and skilled
attendance as well as medical care in childbirth [13]. Al-
though the government has issued a clinical protocol for
safe motherhood, including care in normal labor and
birth [14], no

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57
initiative has been found that focuses on improving the normal,
phys- iological process of childbirth: Since this is an important
measure to reduce the risk of complications, it is of
importance to study the care provided in normal birth in
Nepal.
The aim of this study was to investigate the quality of
intra- partum care provided to women with an expected
normal birth at a university hospital in Nepal.
53
A self-administered questionnaire, previously developed and vali-
dated [16,17], was further developed for this study. The
authors tested the questionnaire on a group of registered
nurses and reg- istered nurse-midwives at a Masters seminar
at the University of

Materials and methods

The study was conducted at the labor ward of a university

hos- pital in Nepal, with approximately 4800 births per
year. A prospective, cross-sectional design was chosen as it is
considered a suitable method to describe a situation as it
appears at a fixed point in time [15].

Sample size

The sample size was calculated using the formula: n = (Z2

× P(1
– P))/e2, where Z is the value of the normal distribution
correspond- ing to 85% CI, P is the expected true proportion
and e is desired precision (+ or – 0.5). The proportions used
were those expected for no skin-to-skin contact (80%), use of a
partograph (80%), and rates of augmentation of labor (70%),
based on anecdotal evidence of ex- isting hospital figures. The
estimated sample size required was 130, 130 and 169 for those
three conditions, respectively. With an es- timated birth rate
of between 90 and 100 births per week, a three week study
period was deemed adequate to reach an appropriate sample
size.

Setting

The labor ward consisted of one labor room with five beds
that could be separated with curtains, one delivery room with
three gy- necology chairs placed next to each other in an
open area, and one operation theatre. Caregivers, i.e. auxiliary
nurse-midwives, nurses or physicians were based in the
different rooms and women moved between the rooms and
got new caregivers as their labor pro- gressed. Thus one-on-
one care was not practiced. Fifteen nurses worked
exclusively at the ward; three in the day shift, and two in the
evenings and nights. Of these about one third had completed
a two month “Skilled Birth Attendance” course. There was a
team of 16 physicians employed at the clinic, and their shifts
were evenly distributed over the 24 hours. The nurses were
responsible for intra- partum care, which was provided by
themselves, physicians, or medical or nursing students under
supervision. Fetal status was evaluated by a nurse or a
physician, listening to the fetal heart rate with a Doppler every
half-hour and observing amniotic fluid passed for meconium.
Maternal well-being was initially assessed by a phy- sician,
measuring temperature, pulse and blood pressure. Palpations of
contractions were performed regularly by a physician, and a nurse
or a physician examined the women vaginally every fourth
hour or more often when needed. One cardiotocograph machine
was avail- able at the ward, but it was not routinely used.
Nurses, physicians, and medical and nursing students under
supervision, all assisted the women in vaginal births. Only
physicians performed vacuum extractions (VE) and cesarean
sections (CS). This intra-partum care was based on the national
clinical protocol issued by the Ministry of Health and
Population in Nepal [14].

Measurements

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 second author visited the ward daily, to collect the com- pleted
Gothenburg. The questionnaire was further reviewed by an questionnaires and answer questions regarding the study. All
asso- ciate professor at the university connected to the questionnaires were collected in a closed envelope and kept
hospital where the study took place. To minimize the risk of safe by the first and second author.
misinterpretations, and to achieve a chronological order of
questions, the questionnaire was re-designed to consist of four
different sections. Section one; ma- ternal characteristics,
included maternal age, gestational age and level of education.
Section two described the outcome of previous pregnancies
and births, and section three described the current preg- nancy,
including obstetric risk factors and use of maternity health
care. The information collected in these sections was used
to dis- tinguish the women included in further analysis.
The fourth section described current labor and birth. It
in-
cluded nine items describing intra-partum care, and four
items measuring the outcome of expected normal birth. Five of
the intra- partum care variables were part of the Bologna score,
an instrument developed by WHO to evaluate the
management of care in normal birth [18]. The score, which
has been tested and validated in both high- and low-income
settings [16,17], consisted of five variables: presence of a
companion during labor and birth; use of partograph; absence
of labor augmentation (i.e. no medical augmentation,
amniotomy, fundal pressure, forceps, VE, or emergency CS);
use of non-supine position for birth; and skin-to-skin contact
of mother and child for at least 30 minutes within the first
hour after birth. Each affirmative answer was assigned one
point, and a total score of five was assessed as representing
effective management of care in normal birth [18]. The other
four items assessing intra-partum care were: use of
pharmacological and/or non-pharmacological pain management,
episiotomy, and prevention of post-partum hemor- rhage. The
four outcome measures were; rupture of anal sphincter
(yes/no), post-partum hemorrhage (no/500–1000 ml/>1000
ml), Apgar score at five minutes, and mother in health after birth
(yes/no).

Inclusion and exclusion criteria

The inclusion criterion was: an expected normal birth, i.e.

women assessed to be of low risk, who received skilled
attendance in child- birth. Low risk was defined as: no obstetric
risk factors in previous pregnancies, childbirths or current
pregnancy; no maternal chronic illness that may affect the
outcome of the birth; singleton full- term pregnancy, i.e.
gestational age 37 weeks and 0 days – 41 weeks and 6 days;
cephalic position; spontaneous start of labor; in active labor;
and fetal heart rate of 110–150 beats per minute on arrival
to the ward. Both adolescent pregnancy [19] and pregnancy late
in life [20] have been found to correlate with higher risk, and
mater- nal age <20 years and >35 years were therefore
exclusion criteria from the low risk category.

Conduct of the study

Data were collected by the 15 nurses employed at the

labor ward. Before the study commenced explanation sessions
were held with all the nurses, after which they all opted to
participate and gave in- formed written consent. A pilot
study was conducted over three consecutive day and
evening shifts, to test the questionnaire and the design of
data collection. The nurses who worked during any of those
shifts also took part in the pilot study. Subsequently, two
questions were modified to avoid misunderstandings; a
question regarding active labor on admission was simplified
to a yes/no vari- able to avoid misconceptions, and a question
regarding amniotic fluid was modified to request the status of
amniotic fluids in general, and not only if the membranes
ruptured spontaneously. During the study period, the nurses
filled in questionnaires for all consecutive births. The first and
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 54 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57

Table 1
Maternal characteristics. Table 2
Outcomes on the Bologna score items.
All Primipara Multipara p-value
n = 164 %
n = 164 (%) n = 107 n = 57 (%)
<Primary school 7 (4.3) 1 (0.9)
(%) 6 (10.5) Presence of a companion during 3 1.8
Primary school 19 (11.6) 12 (11.2) 7 (12.3) labor and birth
Mean age (SD) 26 (3.7) 24 (3.2) 28 (3.4) 0.049† Use of a partograph 156 95.1
Secondary school 90 (54.9) 59 (55.1) 31 (54.4) 0.14‡
Educational level Absence of labor augmentation 48 29.3
University 48 (29.3) 35 (32.7) 13 (22.8)
Non-supine position 0 0.0
Maternity healthcare 164 (100.0) 107 (100.0) 57 (100.0)
Skin-to-skin contact of mother and child ≥ 30 minutes 27 16.5
†
Independent-sample t-test ‡ Chi-square = 3.914, d.f. = 2, p = 0.14 (NB: >20% of the
cells have expected frequencies of <5). Bologna score

No woman received care rated with the full 5 point score.

Statistics
Data were processed using SPSS version 21.0. Level of
signifi- cance was defined as 0.05. Differences in age between
primi- and multipara were analyzed with Independent-sample t-
tests. Their educational level and frequency of episiotomy was
analyzed with a Pearson Chi-square test.
Author contributions
The first and second authors modified the questionnaire
used in the study and were responsible for obtaining the
ethical approv- al, the acquisition, processing, analysis, and
interpretation of the data, and manuscript writing. The third
author developed the analysis and assisted in interpretation of
data and manuscript writing. The fourth author developed the
research design and protocol, and con- tributed to the analysis
and manuscript writing. All authors agreed the final version of
the paper.
Ethical approval
For this study ethical approval was granted by the
Institutional Review Board at the Institute of Medicine at
Tribhuvan University, Nepal (ID no 87/070/071 and ID no
88/070/071).
Results
The mean score was 1.43, with a minimum of 0 (n = 5/3.0%)
and a maximum of 3 (n = 9/5.5%) (Table 2). At least one of the
six types of augmentation defined in the Bologna score (see
above) was used in 116 births (70.7%). Two types of
augmentation were used to augment the process of labor;
medical augmentation (n = 87/ 53.0%), and amniotomy (n =
47/28.7%). Either one or both of these were administered to 94
women (57.3%), and the most common reasons were: poor
contractions (n = 71/75.5%), to progress labor (n = 45/47.9%),
and fetal distress (n = 8/8.5%), with some women re- quiring
augmentation for more than one reason. The types of
augmentation to complete the birth included: fundal pressure
(n = 8/ 4.9%), and instrumental births (Table 3). The main
reason for emergency CS was fetal distress (n = 23/71.9%).
Pain management
Pharmacological analgesia was administered to 85
women (51.8%), the most common being local anesthesia for
episiotomy or repair after episiotomy or lacerations (n =
54/32.9%). Other types of analgesia were; spinal anesthesia (n =
25/15.2%), anti-spasmodic (n = 6/3.7%), and general anesthesia (n
= 1/0.6%). Non-pharmacological pain management was given to
55 women (33.5%), the most common being massage (n =
32/19.5%), and support (n = 22/ 13.4%). Both
pharmacological and non-pharmacological pain management
were administered to 37 women (22.6%), whereas n = 61
(37.2%) received neither.

A total of 292 women gave birth at the hospital during the

time of the study. Of them, 44 (15.1%) were excluded from Episiotomy
further anal- ysis due to elective CS, and 19 (6.5%) due to
induced labor. The remaining 229 women (78.4%) were Episiotomy was performed on 80 women (48.8%), the
admitted in spontaneous labor. Among them, 65 women main reasons being; tight perineum (n = 64/80.0%), fetal
(28.4%) were excluded from the low-risk category due to; distress (n = 7/ 8.8%), primipara (n = 4/5.0%), for vacuum
pre-term delivery (n = 24), not in active labor (n = 19), extraction (n = 7/8.8%), and to hasten delivery (n = 4/5.0%). A
maternal age <20 years (n = 7), previous CS (n = 4), pre- significant difference was found between primiparas (n =
mature rupture of membranes (n = 2), maternal age >35 years 73/86.9%) and multiparas (n = 7/14.58%), with a p-value of
(n = 2), oligohydramnios (n = 2), meconium stained liquor on <0.001 (chi-square = 66.92, d.f. = 1).
arrival (n = 2), placenta previa (n = 1), obstetric cholestasis (n
= 1) and post-term delivery (n = 1).
All women and infants included in the study survived labor,
birth and the immediate post-partum period. They received Table 3
skilled at- tendance in childbirth from a physician (n = Delivery outcomes in women with expected normal childbirth.
92/56.1%), a nurse (n = 68/41.5%), or a medical or nursing
All Primipara Multipara
student under supervision (n = 4/2.4%).
n = 164 (%) n = 107 n = 57
(%) (%)
Maternal characteristics Spontaneous vaginal birth 124 (75.6) 76 (71.0) 48 (84.2)
Vacuum extraction 8 (4.9) 8 (7.5) 0 (0.0)
Of the 164 women included in the study, 107 (65.2%) Emergency cesarean section 32 (19.5) 23 (21.5) 9 (15.8)
Rupture of anal sphincter 2 (1.5)§ 2 (2.4)§ 0 (0.0)
were pri- miparas and 57 (34.8%) were multiparas. The
Post-partum hemorrhage 2 (1.2) 0 (0.0) 2 (3.5)
median number of previous births among multiparous women 500–1000 ml
was 1 (range 1–3). The median level of education in both Apgar score ≥7 at 5 min 164 (100.0)
groups was secondary school. Ma- ternal characteristics are §
Percentage computed from vaginal births only.
further described in Table 1.
 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57 55
them during labor and birth. In combination with the lack of
Prevention of post-partum hemorrhage one-on- one professional care, this suggests that continuous
support was not a part of the intra-partum care at the labor
Interventions to prevent post-partum hemorrhage were ward. This may be due
imple- mented in 143 births (87.2%). “As per national protocol”
or “active management of third stage” were cited in n = 67 cases
(40.9%). Other specified interventions were; oxytocin intra-
muscular injections or oxytocin in Ringers Lactate given
intravenously (n = 83/50.6%), uterine massage (n = 60/36.6%),
controlled cord traction (n = 43/26.2%), emp- tying of bladder or
catheterization (n = 16/9.8%), rectal misoprostol tablets (n =
13/7.9%), and methylergometrine injections (n = 3/ 1.8%).
Two women (1.2%) had a post-partum hemorrhage greater than
500 ml but less than 1000 ml.

Delivery outcome

All women were assessed to be in good health after

childbirth. This was a yes/no question, and further
explanation of this assess- ment was only provided in two
cases; one mother was described as looking cheerful, and
another one as feeding her baby. No women included in the
study were treated in the intensive care unit after birth. The
mean Apgar score at five minutes was 8 (min 7 – max 9).
Delivery outcome is further presented in Table 3. There were no
missing data in this section.

Discussion

In this prospective study at a university hospital in Nepal,

164 (56%) of the 292 women were assessed to have an
expected normal birth. The results revealed that intra-partum
care at the labor ward, for these low-risk women, achieved the
overall objective of a healthy mother giving birth to a healthy
child. However, there were higher rates of medico-technical
interventions than expected and low levels of measures promoting
normal birth. The low Bologna score (mean 1.43) may indicate
that the intra-partum care in normal labor and birth, based
on the criteria of WHO, is not well managed, or that the
labors of the women included in the study deviated from
their expected normal progress [18].

Labor augmentation

This study revealed high levels of amniotomy and medical

aug- mentation of labor. Considering the potential risks of
amniotomy, WHO suggests that there should be a valid reason
to interfere with the spontaneous rupture of membranes in
normal labor [1]. A Co- chrane review found that early
amniotomy and medical augmentation did not affect
maternal or neonatal outcome, al- though there was a slight
reduction in CS rates [21]. The present study, however,
revealed a high rate of emergency CS in expected normal birth
(19.5%) despite the high levels of amniotomy and medical
augmentation of labor. A Cochrane Review of maternal po-
sitions and mobility in the first stage of labor found that, in 25
studies involving over 5000 women, upright and ambulant
positions re- sulted in a first stage that was on average one
hour and 22 minutes shorter [22]. This is a similar degree of
shortening of labor to that found in the review of early
amniotomy and medical augmenta- tion of labor [21]. Upright
positions were also shown to reduce CS rates and use of
analgesia [22]. The need for interventions to augment labor could
thus be reduced if women were allowed and encour- aged to
labor and give birth in non-supine positions.

Presence of a companion during labor and birth

The vast majority of women (98.2%) had no companion with

 the WHO recommendations [1] and the scientific evidence
to the setup of care at the ward, with the women moving [29], which stip- ulate that the procedure should be used
between different caregivers throughout labor and birth, as restrictively. Multiparous women also had a very high rate
well as to the re- strictive setting with several women birthing (14.6%), far above accepted norms. Liberal or routine use of
simultaneously in the same rooms. The result differs from a episiotomy has been shown to be ineffi-
similar study using the Bologna score in Sweden [16], where
98.7% of the women had a compan- ion present as part of the
routine care. Previous research has found continuous support,
especially by non-clinicians, to shorten labor, reduce CS and
instrumental birth rates as well as improve mater- nal
satisfaction and neonatal Apgar scores [23]. Continuous
support in labor is also recommended by a number of key
authors [24,25]. Allowing birthing women the presence of a
companion through- out labor and birth could therefore be
beneficial to the outcome of the intra-partum care provided at
the ward. Simple measures, such as separating the
gynecology chairs with screens or curtains to protect the
privacy of the women, could be a cost effective way to make
this possible, granting women continuous support in a situ-
ation where the staffing of the ward does not allow the staff
to provide such care.

Position in labor and birth

All women in this study gave birth in supine positions,

which is similar to the findings both in Cambodia [17] and
Sweden [16]. It is, however, contrary to the scientific
evidence that demon- strates that women should be freely
allowed to choose positions in childbirth [1,25,26] and that
they should be discouraged from spending long periods lying
on their backs [1,22]. Several positive effects of upright
positions in labor and birth have been found for both
mother and child [1,22,26], and women who give birth in
upright positions tend to experience fewer interventions and
report greater satisfaction with their birthing experience
[26].

Pain management

The results of this study indicate that the focus of pain

man- agement at the ward was not to relieve labor pain, as
it mainly consisted of preventive analgesia prior to
interventions such as episiotomy or CS. The women were
routinely left to handle labor pain alone, contrary to evidence-
based practice and international recommendations [1,23,27].
Anxiety and fear may increase the negative experience of
labor pain. Aside from the psychological aspects, pain may
also cause complications both for the mother and the
unborn child [27]. WHO rank helping women to cope with
labor pain as one of the most central aspects of intra-
partum care, and non-pharmacological strategies are
considered the most important measures to do so [1].
Freedom to move around in labor may help to alleviate pain
[1,22,26], and women who receive continuous one-on-one
support in childbirth tend to use less analgesia and
anesthesia [23]. An overview of systematic reviews on pain
relief in labor concluded that epidurals and inhaled
analgesia were effective in reducing pain, and that
immersion in water, relaxation, acupuncture, and massage
may also help [28]. Although not all of these may be
available at the study site, massage and educating women
in relaxation techniques should be possible, and should be
used.

Episiotomy

Of the primiparas having a vaginal birth, a majority (86.9%)

was subject to an episiotomy; this is contrary to the national
clinical pro- tocols for reproductive health in Nepal [14],
56 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57

cient and possibly harmful [25] and a more restrictive use is birth. Previous research has also found pos- itive effects of
recommended [29]. midwifery-led care in Nepal [35]. It may therefore be suggested
that the introduction of midwife-led care at the labor ward would be
Mode of delivery cost-effective and would optimize the intra-partum care provided
to women with an expected normal birth. However,
Only three-quarters of the women had a spontaneous
vaginal birth and almost one fifth (19.5%) had an emergency
CS. No infants had an Apgar score <7 at five minutes, which
may suggest that the labors were terminated in time to
ensure the well-being of the infants. On the other hand, such
a high rate of CS may be due to the limited means available
to assess the fetal status, and the fact that all infants had an
Apgar score of ≥7 may indicate that at least some of them
would have benefited from a vaginal birth. Adding the
emergency CS to the elective CS at the labor ward reveals a total
CS rate of 26% during the time of the study, from the total
popu- lation of 292 women. This can be compared to a
national rate of 4.6% in Nepal in 2011 [12]. There is no
evidence of any benefits for mother or child when CS rates
exceed 15% [30], and therefore mea- sures to decrease the rate
would be appropriate. Continuous support in labor and birth
[23], introducing and implementing evidence- based
guidelines, insisting on a mandatory second opinion before CS,
peer review of all CSs on a monthly basis by the multidisci-
plinary team, and nurse-led relaxation and birth preparation
classes
[31] may all help to reduce the rate of emergency CS.

Skin-to-skin contact of mother and child

Although skin-to-skin contact is stipulated in national

recom- mendations in Nepal [14], 83.5% (n = 134) of the
women in this study had no skin-to-skin contact with their
child after birth. This result differs from previous studies using
the Bologna score in Cambodia
[17] and in Sweden [16], where skin-to-skin care was used in
74.3% and 92.3% of births, respectively. A Cochrane review found
early skin- to-skin contact between mother and child to have a
positive impact on infant blood glucose levels and
maintenance of infant temper- ature, as well as on breast
feeding and interaction between mother and child. There were
no adverse effects found, nor was there ev- idence of any
positive effects of separating mother and child [32].

Summary

De-medicalization of intra-partum care is an important

measure to reduce the risk of complications [1,4–7]. A simple
and cost- effective means to promote the normal,
physiological process of childbirth at the ward may be to
adjust the routines to include con- tinuous support in labor and
birth, preferably from non-clinicians, non-pharmacological pain
management such as massage, relax- ation and use of baths
if feasible, upright laboring and birthing positions, and skin-to-
skin contact between mother and child after birth. This would
contribute to safe-guarding maternal and neo- natal well-
being and achieving an optimal normal outcome. The results
of this study suggest that a medicalized perspective on child-
birth is prevalent at the study site. The personnel responsible
for the intra-partum care were nurses rather than registered
mid- wives (RM), and the majority of the women in the study
were assisted by physicians in childbirth. It is possible that
the lack of RMs could be a contributing factor to the
medicalization of intra- partum care at the ward. WHO deem
midwifery to be the profession best suited to care for women
in normal pregnancy and birth [1], and midwife-led care has
been shown to reduce both interven- tions [24,33] and costs
[24,34] compared with routine obstetric involvement in normal
midwifery is not authorized as an autonomous profession in partum care over time [18], the results of this study could be
Nepal as yet [10]. used for comparison in a follow-up study. The results also
provide practical clinical implications which could be useful to
Strengths and limitations improve intra-partum care at this specific labor ward.

The questionnaire incorporated an instrument developed by Conclusion

prom- inent experts in the field [18], which had been evaluated
and validated in different settings [16,17]. This In 2008 the government of Nepal issued a clinical protocol
strengthened the validity of the study. Further expert for safe motherhood [14], which included care in normal labor
review of the questionnaire before the study was conducted and birth.
enhanced both the validity and the reliability of the survey
tool. The questionnaire was written in English, which is not
an official language in Nepal. However, the English skills
among the data collectors were high, as they had completed
their nursing ed- ucation in English and the patient
records were documented in English. Furthermore, the
risk of inaccurate responses was mini- mized by using short
and simple sentences with precise questions, and avoiding
negatives. The pilot study revealed no linguistic mis-
understandings and the data collectors expressed that the
questions were easy to understand, which indicates a high
reliability.
One weakness of the questionnaire was that it did not
allow re-
spondents to specify whether the membranes had ruptured
before or after admission to the labor ward. As a result, it
was not possi- ble to exclude women who were admitted
with meconium-stained liquor from the low-risk category,
unless the respondents had added this information by their
own accord. However, with an average of 14 births a day
at the ward during the time of the study, the nurses had a
heavy work-load. It was therefore considered a priority to
keep the questionnaire short and simple, to ensure that
they were able to complete them. There was no drop-out
and very few missing data in the study, which suggests
that this may have been a reasonable trade-off. The
question regarding medical pain management was a yes/no
variable asking whether the women had received
pharma- cological pain relief during labor and birth, and a
request to specify what type of medication had been
administered. The medication specified was given in
connection with episiotomy, suturing and CS, and there
were no missing data. It may be considered a weakness
of the questionnaire that it did not ask if the women had
received any medication specifically aimed to alleviate labor
pain. However, in this setting, the only such medication
available was epidural an- esthesia, which was provided
only to women with a heart condition. Since they were not
included in the study, it may be assumed that the findings
would have been the same even if this question had been
formulated differently. Questionnaires were collected for all
births during time of the study. The missing data thus
concerned a few questions in selected questionnaires,
which may be seen as a strength of the study. The high
attendance of the first and second author at the ward
during the study period contributed positively to the
success of data collection. If the study were to be
repeated, the same results may not be achieved without
such presence.
The study was conducted at a university hospital in a major
city
where the women had the privilege of expert care and
facilities. This was not representative for most women in
Nepal [9], which made it difficult to generalize conclusions
to different settings. The ward received referred
complicated cases, which may have affected the intra-
partum care as well as the view of childbirth in this
specific group of personnel. This may be seen as a weakness
of the study. Since the Bologna score was designed to
measure the improvement of dif- ferent aspects of intra-
 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57 57
[Internet]. World Health Organization, <http://www.who.int/maternal_child
_adolescent/topics/newborn/care_at_birth/en/>; 2015 [accessed 25.5.15].
However, none of their measures initiated to combat maternal
and neonatal mortality has focused specifically on improving the
intra- partum care provided in births with an expected normal
progress, and until this study no research had investigated this
subject. In order to safe-guard the normal, physiological process
of childbirth for the health of both mother and child, it is
important to continuously assess and reflect on how care is
provided to women with a high probability of having a
normal childbirth. It was satisfying that all women and infants
in this study survived. However, routines in place at the labor
ward indicate a medicalized perspective on childbirth and an
over-use of medical technical intervention.
There is a need for more research as a basis to support
positive
changes in the provision of care, such as qualitative interview
studies with health care professionals to gain understanding
of their thoughts on how to perform intra-partum care. An
action re- search project may also be fruitful to achieve
sustainable improved care routines. The women’s perception of
their intra-partum care is another area of interest, which
could offer important perspec- tives on the care provided at the
ward. Finally, research into the need for education to provide
staff with midwifery competencies is also recommended.
The clinical implications of this study are that there are
simple and cost-effective measures to optimize the intra-partum
care pro- vided to women with an expected normal birth. A
reduction of harmful interventions such as episiotomy, and
established rou- tines for continuous one-on-one support,
upright positions in labor and birth, non-pharmacological pain
management, and early skin- to-skin contact between mother
and child, would improve the care for these women and infants
in order to achieve a normal outcome.

Acknowledgements

This study was financially supported by the Swedish

Interna- tional Development Cooperation Agency (Sida) through a
Minor Field Study scholarship. We want to thank all the
nurses working at the labor ward, Dr Agrawal, and Assoc. Prof.
Bajracharya at TU, Kath- mandu, Nepal.

Conflict of interest

None of the authors have any conflict of interest of

financial dis- closures pertaining to this manuscript to report.

References

[1] WHO. Care in normal birth: a practical guide. [Internet] Geneva: World
Health Organization,
<http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.24.pdf>; 1996
[accessed 14.4.14].
[2] WHO. Health statistics and health information systems. [Internet] World
Health Organization,
<http://www.who.int/healthinfo/statistics/indmaternalmortality/ en/>; 2015
[accessed 25.5.15].
[3] You D, Bastian P, Wu J, Wardlaw T. Levels and trends in child mortality
[Internet] United Nations Children’s Fund,
<http://www.childinfo.org/files/Child_Mortality
_Report_2013.pdf>; 2013 [accessed 25.5.15].
[4] Berg M, Asta Ólafsdóttir Ó, Lundgren I. A midwifery model of woman-
centred childbirth care – in Swedish and Icelandic settings. Sex
Reprod Healthc 2012;3(2):79–87.
[5] Campbell OMR, Graham WJ. Strategies for reducing maternal mortality:
getting on with what works. Lancet 2006;368(9543):1284–99.
[6] Lain SJ, Hadfield RM, Raynes-Greenow CH, et al. Quality of data in perinatal
population health databases: a systematic review. Med Care 2012;50(4):7–
20.
[7] Tracy S, Sullivan E, Wang YA, Black D, Tracy M. Birth outcomes associated
with interventions in labor amongst low risk women: a population-based
study. Women Birth 2007;20(2):41–8.
[8] WHO. Maternal, newborn, child and adolescent health: newborn care at birth
 [9] WHO. Success factors for women’s and children’s health: Nepal. [Internet]
World Health Organization,
<http://www.who.int/pmnch/knowledge/publications/
nepal_country_report.pdf>; 2015 [accessed 17.10.15].
[10] Bogren MU, van Teijlingen E, Berg M. Where midwives are not yet
recognized: a feasibility study of professional midwives in Nepal.
Midwifery 2013;29(10):1103–9.
[11] WHO. Maternal mortality in 1990–2013 [Internet] World Health
Organization,
<http://www.who.int/gho/maternal_health/countries/npl.pdf?ua=1>; 2014
[accessed 16.6.14].
[12] WHO. Global health observatory data repository [Internet] World Health
Organization,
<http://apps.who.int/gho/data/view.main.CMDRREG7-CH0?lang=en>; 2013
[accessed 16.6.14].
[13] Ministry of Health and Population. Nepal Health Sector Programme
Implementation Plan II (NHSP -IP 2) 2010 – 2015. Kathmandu:
Government of Nepal, Ministry of Health and Population; 2010.
[14] Family Health Division. Reproductive health clinical protocols for
SN/ANM. Ministry of Health and Population Government of Nepal;. Report
nr.:2065; 2008.
[15] Polit DF, Beck CT. Nursing research: generating and assessing evidence
for nursing practice. Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins; 2012.
[16] Sandin-Bojö A-K, Kvist LJ. Care in labor: a Swedish survey using the
Bologna Score. Birth 2008;35(4):321–8.
[17] Sandin-Bojö AK, Hashimoto M, Kanal K, Sugiura Y. Intrapartum care at a
tertiary hospital in Cambodia: a survey using the Bologna Score.
Midwifery 2012;28(6):880–5.
[18] Chalmers B, Porter R. Assessing effective care in normal labor: the Bologna
score. Birth 2001;28(2):79–83.
[19] WHO. Maternal, newborn, child and adolescent health: adolescent
pregnancy [Internet] World Health Organization,
<http://www.who.int/maternal_child
_adolescent/topics/maternal/adolescent_pregnancy/en/>; 2015 [accessed
13.10.15].
[20] Christian P, Katz J, Wu L, Kimborough-Pradhan E, Khatry SK, LeClerq SC,
et al. Risk factors for pregnancy-related mortality: a prospective study in
rural Nepal. Public Health 2008;122(2):161–72.
[21] Wei S, Wo BL, Xu H, Luo ZC, Roy C, Fraser WD. Early amniotomy and
early oxytocin for prevention of, or therapy for, delay in first stage
spontaneous labor compared with routine care. Cochrane Database Syst
Rev 2013;(8):CD006794. doi:10.1002/14651858.CD006794.pub4.
[22] Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and
mobility during first stage labor. Cochrane Database Syst Rev 2013;
(10):CD003934. doi:10.1002/14651858.CD003934.pub4.
[23] Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for
women during childbirth. Cochrane Database Syst Rev 2013;(7):CD003766.
doi:10.1002/ 14651858.CD003766.pub5.
[24] Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity
models versus other models of care for childbearing women. Cochrane
Database Syst Rev 2015;(9):CD004667.
doi:10.1002/14651858.CD004667.pub4.
[25] Enkin M, Keirse MJNC, Neilson J, et al. Effective care in pregnancy and
childbirth: a synopsis. Oxford: Oxford University; 2001. p. 485–509.
[26] Priddis H, Dahlen H, Schmied V. What are the facilitators, inhibitors,
and implications of birth positioning? A review of the literature. Women
Birth 2012;25(3):100–6.
[27] Berghäll M. Behandling av förlossningssmärta. Finska
Läkaresällskapets Handlingar 2012;172(1):20–8.
[28] Jones L, Othman M, Dowswell T, et al. Pain management for women in
labor: an overview of systematic reviews. Cochrane Database Syst Rev
2012;(3):CD009234. doi:10.1002/14651858.CD009234.pub2.
[29] Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst
Rev 2009;(1):CD000081. doi:10.1002/14651858.CD000081.pub2.
[30] Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. The
global numbers and costs of additionally needed and unnecessary
caesarean sections performed per year: overuse as a barrier to universal
coverage [Internet]. World Health Organization,
<http://www.who.int/healthsystems/topics/financing/ healthreport/30C-
sectioncosts.pdf>; 2010 [accessed 10.6.15].
[31] Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M, Wasia KJ, Gruen
RL. Non-clinical interventions for reducing unnecessary caesarean section.
Cochrane Database Syst Rev 2011;(6):CD005528.
doi:10.1002/14651858.CD005528.pub2.
[32] Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin
contact for mothers and their healthy newborn infants. Cochrane Database
Syst Rev 2012;(5):CD003519. doi:10.1002/14651858.CD003519.pub3.
[33] Begley C, Devane D, Clarke M, McCann C, Hughes P, Reilly M, et al.
Comparison of midwife-led and consultant-led care of healthy women at
low risk of childbirth complications in the Republic of Ireland: a
randomised trial. BMC Pregnancy Childbirth 2011;11:85.
doi:10.1186/1471-2393-11-85.
[34] Kenny C, Devane D, Normand C, Clarke M, Howard A, Begley C. A cost-
comparison of midwife-led compared with consultant-led maternity care in
Ireland (the MidU study). Midwifery 2015;31(11):1032–8. doi:10.1016/
j.midw.2015.06.012.
[35] Rana TG, Rajopadhyaya R, Bajracharya B, Karmacharya M, Osrin D.
Comparison of midwifery-led and consultant-led maternity care for low risk
deliveries in Nepal. Health Policy Plan 2003;18(3):330–7.
 Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

10

Transforming intrapartum care: Respectful

maternity care
Meghan A. Bohren a, *, O€ zge Tunçalp b, Suellen Miller c
a
Gender and Women's Health Unit, Centre for Health Equity, University of Melbourne School of Population
and Global Health, 207 Bouverie Street, Carlton, VIC 3053, Australia
b
UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research
Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World
Health Organization, Avenue Appia 20 1202 Geneva, Switzerland
c
Bixby Center, Safe Motherhood Program, Department of Obstetrics, Gynecology and Reproductive Sciences,
School of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158, USA

abstract
Keywords:
Maternal health services [MeSH] Respectful maternity care is recommended by the World Health
Culturally competent care [MeSH] Organization and refers to care that maintains dignity, privacy,
Patient-centred care [MeSH] confidentiality, ensures freedom from harm and mistreatment,
Delivery and enables informed choice and continuous support during
Obstetric [MeSH]
labour and childbirth. In this paper, we review the evidence of
Respectful care
respectful maternity care and discuss considerations for
professional practice for health care providers. While there is
limited evidence on what type of interventions can improve
respectful maternity care, promising skills development for
providers has included training on values, transforming attitudes,
and interpersonal communica- tion. Within a health facility,
enabling environments may be created by setting up quality
improvement teams, monitoring experiences of poor treatment,
mentorship, and improved working conditions for staff. In order to
provide respectful care, health fa- cilities and health systems must
be structured in a way that sup- ports and respects providers, and
ensures adequate infrastructure and organisation of the maternity
ward.
© 2020 Published by Elsevier Ltd.

* Corresponding author.
E-mail addresses: meghan.bohren@unimelb.edu.au (M.A. Bohren), tuncalpo@who.int (O€ . Tunçalp), suellenmiller@gmail.com
(S. Miller).

https://doi.org/10.1016/j.bpobgyn.2020.02.005
1521-6934/© 2020 Published by Elsevier Ltd.

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from
ClinicalKey.com by Elsevier on March 27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All
rights
114 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

Introduction

Over the past several decades, women across the world have been encouraged to give birth in health
facilities in order to ensure timely access to skilled care and referral if additional care needs arise [ 1].
Despite an increasing proportion of women giving birth in health facilities globally, expected re-
ductions of maternal and newborn mortality and morbidity have not necessarily been met [ 2]. High
rates of avoidable maternal and newborn mortality and morbidity are often due to poor quality of care
[3], and increasing evidence suggests that disrespectful and undignified care is commonplace in many
settings [4,5].
JCLP_press_logoThe World Health Organization (WHO) defines quality of care for women and
newborns as “the extent to which health care services … improve desired health outcomes. In
order to achieve this, health care needs to be safe, effective, timely, efficient, equitable and people-
centred” [6,7]. The WHO Framework for improving quality of care for women during childbirth
highlights that women's experiences of care are equally important to clinical care provision [ 7].
Further, in a systematic review of high-quality clinical guidelines for maternity practice, Miller and
colleagues (2016) noted that even the provision of evidence-based clinical care cannot be
considered quality care unless the care is provided respectfully [8]. However, non-clinical intra-
partum care practices, such as emotional support through labour companionship [9,10], continuity
of carer [11], effective communication [12], and respectful care [13,14] are often not prioritised in
many settings. These non-clinical practices are often inexpensive to implement and should com-
plement any necessary clinical interventions to optimise quality of care for women and their
families [15]. In this paper, we review the evidence of respectful maternity care and discuss con-
siderations for professional practice for health care providers including obstetricians, midwives,
nurses and trainees.

What is respectful maternity care?

The emphasis on quality care in nursing, midwifery, and medicine began formally in the 1960s and
1970s [16,17], and has used a variety of terms, such as quality care, humanized care, rights-based care,
family-centred care, patient-centred care, woman-centred care, and respectful care. In maternity care,
these concepts appeared in the 1970s along with the women's rights movement, which included
women's health and rights, and impacted provider-thinking about provision of care. At the same time,
nursing and midwifery journals published research on what we now label “evidence-based respectful
care,” such as evidence supporting birthing positions other than supine [18,19]. By the early 2000s,
respectful maternity care began to appear in textbooks and training courses for midwives [20,21]. This
included the American College of Nurse Midwives (ACNM) training on greeting and listening to the
woman and her family, providing privacy and comfort measures, and explaining what will happen and
answering questions.
Today, respectful maternity care has evolved to refer to “care organized for and provided to all
women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from
harm and mistreatment, and enables informed choice and continuous support during labour and
childbirth,” and is recommended by WHO for all women [15]. WHO's recommendations on intra-
partum care for a positive childbirth experience (2018) highlight that respectful maternity care is in
accordance with human rights based approaches to maternity care, could improve women's experi-
ences of labour and childbirth and address health inequalities [15]. Shakibazadeh and colleagues
conducted a qualitative evidence synthesis (systematic review of qualitative research) and developed
twelve domains of respectful maternity care from the perspectives of women and healthcare providers
(Box 1) [14].
 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126 115

Box 1
Twelve domains of respectful maternity care [14].

1. Being free from harm and mistreatment

2. Maintaining privacy and confidentiality
3. Preserving women's dignity
4. Prospective provision of information and seeking informed consent
5. Ensuring continuous access to family and community support
6. Enhancing quality of physical environment and resources
7. Providing equitable maternity care
8. Engaging with effective communication
9. Respecting women's choices that strengthens their capabilities to give birth
10. Availability of competent and motivated human resources
11. Provision of efficient and effective care
12. Continuity of care

At the same time, mistreatment of women during childbirth is widely prevalent globally [5,13], and
includes practices that may make a woman feel dehumanised, disempowered, or not in control of her
birth [13]. Such practices may include physical or verbal abuse, discrimination, non-consented vaginal
exams and/or procedures (e.g. caesarean section, episiotomy, induction of labour), lack of privacy, lack
of supportive care, and neglect [4]. These mistreatment experiences may occur at the interpersonal
level between the woman and the healthcare provider, or at the health facility or health system level
[12]. It is important to note that certain components of respectful care can occur in the presence of
mistreatment, and women may therefore experience elements of both respectful care and mistreat-
ment throughout labour and childbirth.

Why is respectful maternity care important?

Respectful maternity care is an important component of quality of care [7]. When women feel
supported, respected, safe, and able to participate in shared decision-making with their providers, they
may be more likely to have positive childbirth experiences. However, when women experience
disrespectful care, they may be less likely to use facility-based maternity care services in the future [ 22]
and may be more likely to have negative birth experiences.
The value that women and their families place on different aspects of respectful care may vary
across both settings and individuals. Therefore, it is important for healthcare providers to ask women
about their values, needs, and fears, and support women in order to have positive childbirth experi-
ences. For example, women in high-income countries may value shared decision-making more highly
than women in lower-income countries [14], although this may also be impacted by health literacy,
empowerment, and gender equality within a society.
Furthermore, providing respectful maternity care is a human rights issue [23,24]. All women have
the right to freedom from harm and ill treatment, the right to provide informed consent and refusal to
consent, and respect for choices and preferences, including companionship during maternity care [25].

Measurement

There is currently no core outcome set related to respectful care or mistreatment. The implications
of no core outcome set are that researchers have used different methods, de finitions, approaches, and
tools for measurement, which complicates comparison across sites.

Measurement approaches

Attempts to measure respectful maternity care and mistreatment during childbirth to date have
used the following quantitative approaches:
116 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

● Direct observations of labour: data collector either conducts 1:1 observation of woman
throughout labour and childbirth, or conducts an observation of the maternity ward, labour room,
or delivery room
● Facility-based exit interviews: surveys conducted with women after discharge from the health
facility for childbirth
● Community-based interviews: surveys conducted with women during the postpartum period
(ranging from several weeks to several years)

Qualitative research (including in-depth interviews, focus group discussions, open-ended survey
questions) has also been conducted with many stakeholders including women, community members,
obstetricians, junior doctors, midwives, nurses, and facility administrators to better understand the
perceptions and experiences of respectful care and mistreatment [26e31].

Key measurement studies

There are a number of measurement studies conducted globally using labour observations and
interviews with women [32e38]. In this section, we will focus on three recent tool development
and measurement studies supported by formative and multi-country measurement phases.

WHO “How women are treated during facility-based childbirth” study

WHO led the development of two tools to measure the mistreatment of women during childbirth:
(1) labour observation for one-to-one observations of women from admission to 2 h postpartum, and
(2) community-based survey with women at up to eight weeks postpartum. The tools are openly
available in eight languages [39]. WHO developed these tools in four countries (Ghana, Guinea,
Myanmar, and Nigeria) and assessed the prevalence of different types of mistreatment in these
settings.
In the labour observation component (n¼2016 women), over 40% of women had observed ex-
periences of physical abuse, verbal abuse, or discrimination, 59% of women did not consent to their
first vaginal examination, and 4.5% of women gave birth in a health facility without a provider present
[5]. In the community-based survey ¼ (n 2672 women), over 35% of women reported experiencing
physical abuse, verbal abuse, or discrimination, and many women had unconsented procedures
including caesarean section (11%), episiotomy (56%), and induction of labour (27%) [5].
The key strengths of this study are the use of an evidence-informed typology of speci fic acts that
constitute mistreatment, an iterative tool design process, 24-h per day/7 days per week data
collection for the labour observation, and the use of non-clinical data collectors which may reduce
the risk of under-reporting [5]. However, one-to-one labour observations are resource intensive,
and more work is needed to explore how observations of mistreatment and respectful care may be
integrated into routine quality improvement or service assessment.

Person-centred maternity care in low-income and middle-income countries

Similarly, Afulani and colleagues developed a scale to measure person-centred maternity care,
and explored the prevalence of person-centred maternity care in Ghana, India, and Kenya [40].
The scale includes 30-items across three domains: dignity and respect, communication and
autonomy, and supportive care [40]. They found that the lowest scores were in communication
and autonomy, including that over 60% of women in Ghana and India reported that providers did
not explain the purpose of examinations or procedures [40]. The key strengths of this study
centred on the use of a validated tool across three countries, and the use of both objective and
subjective questions to better understand the both contextual- and individual-level factors that
affect women's experiences of care [40]. Owing to the inherent differences in interpretation of
both the questions and responses, more work is needed to develop public health and maternity
care responses that can action the more sub- jective measures into better care for individual
women.
 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126 117

The giving voice to mothers study

In the United States, Vedam and colleagues (2019) measured lived experiences of maternity
care across diverse populations in the United States [41]. They found that women of colour and
poorer women were more likely to experience mistreatment compared to white or richer women,
including loss of autonomy, being shouted at or threatened, or being ignored [41]. These findings
demonstrate that the mistreatment of women during childbirth is not just a phenomenon in
lower-income coun- tries and much work remains to be done in high-income settings, particularly
for women of colour. The key strengths of this study are the participatory approach to
measurement, as the researchers and study population (women) co-designed and validated
quantitative indicators, as well as the over- sampling from under-represented communities [41].
Applying the tools from this study at a population-level may help to provide additional insights
into discrimination and racism faced in maternity care.
Other measurement studies have contributed to understanding the conceptualisation and mani-
festations of elements of respectful maternity care and/or mistreatment during childbirth. However,
validated measures have typically not been used, thus complicating comparability across study
contexts.

Assessing women's experiences of care

Indicators measuring quality of maternity care have typically focused on assessing the coverage of
life-saving interventions (e.g. proportion of births with skilled attendance, proportion of births by
caesarean section) and health outcomes (e.g. maternal death, postpartum haemorrhage, pre-
eclampsia/eclampsia). However, increasing attention is now being given to quality of care indicators
related to the woman's experience [3]. Measuring and reporting on women's experiences of intra-
partum care are important to better understand quality and their interactions with health services.
However, much remains to be done to ensure that women's experiences of maternity care are inte-
grated into research, monitoring, and audit and feedback mechanisms. For example, a Cochrane review
of continuous support for women during childbirth found that only 41% of randomised controlled trials
(11 out of 27 trials) reported on women's experiences of continuous support, which was one of the
primary outcomes of the review [9,10]. The other 59% of randomised controlled trials measured clinical
outcomes only (such as mode of birth and use of interventions) but did not report on women's ex-
periences [9,10].
Larson and colleagues provide guidance on measuring person-centred care as part of quality
improvement or research initiatives [42]:

● Defining the purpose of measurement is important to ensure that appropriate indicators are
used. For example, patient experience measures can be used to evaluate quality of care, while
satisfaction measures can track patients' responses to care. Both measures are important for
accountability and quality, but serve different purposes: patient experience relates to providing
high quality of care, while patient satisfaction refers to the responsiveness of care to the ex-
pectations of the population.
● Addressing subjectivity is important to understand how the phrasing of questions, response
choices, and whether the questions account for expectations may influence the results.
● Validated tools should be used to standardise measurement to ensure that the approach used is
measuring what it is intended to measure.

The Quality, Equity, and Dignity Network, supported by WHO, United Nations Children's Fund
(UNICEF), and United Nations Population Fund (UNFPA) is leading efforts to standardise indicators
for measuring respectful maternity care and mistreatment during childbirth across Ministries of Health
currently in eleven low- and middle-income countries [43]. Shared learning resources and access to
country data is available via the Network website [https://worldhealthorg-my.sharepoint.com/Users/
millers/Desktop/www.qualityofcarenetwork.org].
118 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

Considerations for practice

There is limited evidence on what type of interventions can improve respectful maternity care. A
systematic review of interventions to promote respectful maternity care [44] was conducted for the
WHO recommendation on respectful maternity care [15] and identified five interventional studies (all
conducted in Africa and none conducted in high income countries). Most of the interventions were
multi-component and included both community engagement and quality improvement for providers.
Types of components included [15,44]:

● Training in values and transforming attitudes

● Training in interpersonal communication skills
● Setting up quality improvement teams
● Monitoring experiences of mistreatment
● Mentorship for healthcare providers
● Improving privacy in maternity wards (e.g. with curtains or partitions between beds)
● Improving working conditions for staff
● Hosting maternity open days (for women and their families to visit the maternity unit and interact
with providers)
● Mediation/alternative dispute resolution
● Counselling of community members who experienced mistreatment during childbirth
● Improving accountability by setting up complaint mechanisms
● Educating women and girls about their rights

Women in the respectful care intervention groups were more likely to report experiencing
respectful care and not report experiencing mistreatment, compared to women without the inter-
vention [44].
Depending on the characteristics of the woman and/or her community, there may be additional
considerations for improving respectful care and inclusive services. For example, evidence from
Indigenous Australian communities demonstrates that “Birthing on Country,” (Indigenous women
giving birth on ancestral land) reduced the risk of preterm birth [45], improved cultural safety [46],
and was highly valued [46]. Similarly, refugee and migrant women in high-income countries who had
labour and childbirth support from a community-based doula (someone from their ethnic or cultural
background) reported improved experiences of culturally responsive care [10,47]

Health policy and systems considerations

In order to provide respectful care, health facilities, and health systems must be structured in a
way that supports and respects providers, and provides adequate infrastructure and organisation
of the maternity ward space. Table 1 depicts some of the ways that maternity care can be
structured to provide a more supportive environment for both healthcare providers and women
[15].
The International Childbirth Initiative (ICI) is a consortium of professional associations
(including the International Confederation of Midwives (ICM), International Federation of Gyne-
cology and Obstetrics (FIGO), the International Childbirth Education Association (ICEA)) univer-
sities, and other international organizations). ICI has developed a process for facilities to improve
and ensure respectful care in childbirth, provide a healthy and positive birth environment, pro-
mote wellness, support women's choices and autonomy, and to use evidence-based maternity
services ("ICI Principles and 12 Steps") [48]. Their unique, underlying foundation is to approach
childbearing, birth, immediate postpartum, and care of the newborn as applied to a triad: the mother-
baby-family. The ICI Principles and 12 Steps Initiative includes guidance for policy makers and
providers, and gives specific details for how to achieve the steps and indicators for demonstrating
adherence (https://www.internationalchildbirth.com).
 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126 119

Table 1
Structuring health policies and environments to provide respectful maternity care. Adapted from the WHO recommendations
for intrapartum care for a positive childbirth experience [15].

Resource Description

Policies ● Developing and implementing policies to provide respectful care to all

women including (but not limited to):
— Allowing all women to have at least one person of their choice present as
a labour companion (spouse/partner, family member, friend, or doula)
— Promoting midwifery continuity-of care models
● Establishing policies and governance to ensure that training, staffing, super-
vision and monitoring, supplies, equipment, and infrastructure are
adequately addressed to support the provision of respectful care.
Training ● Healthcare facility administrators: sensitised and orientated to respectful
care and how to develop and apply respectful care in their setting
● Healthcare providers: regular practice-based training on providing
respectful maternity care that meets the needs (social, cultural, linguistic) of
the women accessing services, supported by pre-service training and
orientation of new staff
● Outreach staff: training for effective community engagement, focusing on
including women's voices and providing opportunities for community
interaction with healthcare providers (for example, through maternity open
days)
● Users: orientation sessions for women, their families, and potential com-
panions so that users know what to expect from their maternity care
Staff ● Adequate numbers of competent, trained, and supervised healthcare pro-
viders with appropriate skills mixes
● Appropriate and reliable remuneration for providers
Supervision and monitoring ● Regular supportive supervision by labour ward or facility lead
● Staff meetings to review respectful maternity care processes
● Easily accessible mechanisms for service users and providers to submit
complaints (e.g. complaints box)
● Establishment of accountability mechanisms for redress in the event of
mistreatment or violations
● Establishment of standardised informed consent procedures
Supplies ● Written, up-to-date standards and benchmarks outlining clear goals, and
operational and monitoring plans for respectful maternity care
● Adequate provisions for staff in the maternity wards, such as refreshments
● Health education materials in an accessible format (written or pictorial) and
in the languages of the communities served
● Standard informed consent forms and consent processes including commu-
nicating results of any procedures or examinations to the woman and/or her
family
● Information on what to expect for the woman and her supporters
● Essential medicines for labour and childbirth available in sufficient
quantities at all times in the labour and childbirth areas
Equipment ● Basic and adequate equipment for labour and childbirth available in sufficient
quantities at all times in the labour and childbirth areas
Infrastructure ● Adequate physical environment to support respectful care including:
— Rooming-in to allow women and their babies to stay together
— Clean, appropriately lit, well-ventilated labour, childbirth, and neonatal
areas that are adequately equipped and maintained
— Privacy measures such as private rooms, or consistent use of curtains or
partitions in shared areas
— Continuous energy supply
— Clean and accessible bathrooms for women to access during labour and
after birth
— Safe drinking water for women and hand hygiene station with soap/
alcohol-based hand sanitizer
— Sufficient bed capacity for the patient load
— Facilities for labour companions or family support people to use,
including physical private space for the woman and her companions
● On-site pharmacy and medicine/supplies stock management that is
managed by a trained pharmacist or dispenser
120 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

Box 2
The International Childbirth Initiative (ICI) 12 Steps to safe and respectful mother-baby-family ma-
ternity care [48]. Reprinted with permission.

1. Provide respect, dignity and informed choice

2. Provide free or affordable care with cost transparencies
3. Routinely provide Mother-Baby-Family maternity care
4. Offer continuous support
5. Provide pain relief measures
6. Provide evidence-based practices
7. Avoid harmful practices
8. Enhance wellness and prevent illness
9. Provide emergency care and transport
10. Have a supportive human resource policy
11. Provide a care continuum
12. Promote breastfeeding and skin-to-skin contact

Health provider considerations

Currently there are a few systematic reviews of respectful care clinical practices and how to
make evidence-based clinical care respectful [8,49]. A systematic review for the Lancet's
Midwifery Series
[49] reported that women valued clinical interventions as well as timely and pertinent information and
support, which help them to maintain control and dignity. The series resulted in the development of a
Quality, Maternal and Newborn Care framework centred on needs of mothers and newborns.
Table 1 mainly focuses on what the facility and health systems can do to provide an enabling
environment for health providers themselves to be treated respectfully and for health providers to
deliver respectful care. The ICI 12 Steps (Box 2) contain broad and specific recommendations for
policy- makers and providers. There are also some considerations for individual providers to self-
check if they are providing quality, respectful care. Some research has also been conducted on
“what matters to women”. The White Ribbon Alliance's “What Women Want” campaign reached
out to 1.2 million women across 114 countries to discover what women wanted in reproductive
health care [50], with considerations for health care providers. Further, some national clinical
guidelines and recommen- dations for best practices for providers have been published which
emphasise respectful care [51e54]. In Lancet's Maternal Health Series, Miller and colleagues
(2016), used a systematic review approach to report recommended and not recommended clinical
practices in a framework of respectful care [8]. In their review of 51 high quality, evidence-based
guidelines, they identified interventions for respectful care across all phases of maternity care
services. The advice for clinical providers for intra-
and post-partum included:
Intrapartum.

— offer women the possibility of being cared for by a midwife; provide one-to-one continuous sup-
portive care
— allow and encourage women to have their choice of a birth companion
— treat every woman with respect, provide her with information, ask her about her expectations, and
involve her in decisions about her care
— consider women's psychological and emotional needs
— assess labouring women's pain level and desire for pain relief (nonpharmacological and
pharmacological)
— allow and encourage women to drink and eat lightly
— encourage and help women to move and adopt any position, except supine
— inform women that they should push when they feel the urge to push
— inform women that active management of the third stage prevents PPH
 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126 121

— encourage women to have skin-to-skin contact as soon as possible after birth

— avoid separating women and newborns in the first hour after birth
— encourage and support breastfeeding in the first hours after birth

Postpartum.

— provide individualized, culturally and contextually appropriate care that is responsive to changing
needs and based on individual care
— facilitate rooming-in, and promote parent participation in educational activities on newborn health
— promote exclusive breastfeeding

In 2018, WHO published recommendations on intrapartum care for a positive childbirth experience
with a priority question focusing on what matters to women [15,44]. This question was cross-cutting, a
required criterion for inclusion of clinical practices in their recommendations. Table 2 outlines the
WHO recommendations focused on a positive childbirth experience for the woman, her family, and the
newborn.
The companionship during labour and childbirth recommendation was primarily based on a
Cochrane intervention review of continuous support during childbirth and a Cochrane qualitative
evidence synthesis on labour companionship [9,10]. The findings from the Cochrane intervention re-
view of 26 published randomised controlled studies with nearly 16,000 women demonstrated that
women with continuous support are more likely to have a) spontaneous vaginal births, b) positive
feelings about their childbirth, and c) shorter labours [9]. Women with continuous support were less
likely to have a) baby with low 5-min Apgar, b) use intrapartum analgesia, c) have a caesarean birth, d)
use regional analgesia, and e) have an instrumental birth [9].
Recognising that there is no standardized definition of “effective communication,” WHO made
recommendations on how to achieve effective communication between maternity care providers and
women/families, which included the following [12,15]: Providers should introduce themselves to the
woman and her companions, call the woman by her name, offer the woman/her companions infor-
mation in clear, short messages in their language, communicate positively, support her needs empa-
thetically and compassionately, support her to understand that she has choices, explain all procedures
and receive consent (verbal or written), encourage her to express her needs/preferences, keep the
woman/companions updated on the process of labour, ensure con fidentiality, make sure the woman/
companions are aware of how to address complaints (suggestion boxes, formal complaint mecha-
nisms), and to interact with the companions with clear explanations on how to better support the
woman during the childbirth experience.
Furthermore, WHO outlined key areas where providers should counsel women about what to
expect from the process of labour and childbirth, as well as any interventions, including [15]:

1. Discuss with women how there are no definitive answers to the length of the latent stage of labour
and inform them of the usual parameters of first and second stages of labour. This discussion will
aid women and their families to make decisions about any suggested interventions and care.
2. Discuss with women how routine cardiotocography is not recommended for assessment of foetal
health in healthy women in spontaneous labour, and that intermittent auscultation is
recommended.
3. Discuss with and provide women with their choice of non-pharmacologic and pharmacologic pain
relief.
4. Discuss with and help women assume their choice(s) of labouring positions.
5. During the second stage, discuss with women that they only need to push when they feel the
urge to push.
6. Discuss with women how routine or liberal use of episiotomy is not recommended for women
with spontaneous vaginal births.
7. Discuss with women the importance of skin-to-skin contact and provide them and their newborns
with skin-to-skin contact in the first hour after birth.
122 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

Table 2
WHO recommendations for intrapartum care for a positive childbirth experience [15].

Care option Recommendation Category of recommendation

Care throughout labour and birth

Respectful maternity care Respectful maternity care e which refers to Recommended

care organized for and provided to all women
in
a manner that maintains their dignity, privacy
and confidentiality, ensures freedom from harm
and mistreatment, and enables informed choice
and continuous support during labour and
childbirth e is recommended.
Effective communication Effective communication between maternity Recommended
care providers and women in labour, using
simple and culturally acceptable methods, is
recommended.
Companionship during labour A companion of choice is recommended for all Recommended
and childbirth women throughout labour and childbirth.
Continuity of Midwife-led continuity-of-care models, in Context-specific
care
which a known midwife or small group of recommendation
known midwives supports a woman
throughout the antenatal, intrapartum and
postnatal continuum, are recommended for
pregnant women in settings with well-
functioning midwifery programmes.

First stage of labour

Maternal mobility and position
Oral fluid and food
Perineal/pubic shaving
Enema on admission
Epidural analgesia for pain
relief
Opioid analgesia for pain relief
Relaxation techniques for pain
management
Manual techniques for pain
management
Encouraging the adoption of mobility and an Recommended
upright position during labour in women at low
risk is recommended.
For women at low risk, oral fluid and food Recommended
intake during labour is recommended.
Routine perineal/pubic shaving prior to giving Not recommended
vaginal birth is not recommended.
Administration of enema for reducing the use of Not recommended
labour augmentation is not recommended.
Epidural analgesia is recommended for healthy Recommended
pregnant women requesting pain relief during
labour, depending on a woman's preferences.
Parenteral opioids, such as fentanyl, Recommended
diamorphine and pethidine, are recommended
options for healthy pregnant women requesting
pain relief during labour, depending on a
woman's preferences.
Relaxation techniques, including progressive Recommended
muscle relaxation, breathing, music,
mindfulness and other techniques, are
recommended for healthy pregnant women
requesting pain relief during labour, depending
on a woman's preferences.
Manual techniques, such as massage or Recommended
application of warm packs, are recommended
for healthy pregnant women requesting pain
relief during labour, depending on a woman's
preferences.

Second stage of labour

Fundal pressure Application of manual fundal pressure to Not recommended

facilitate childbirth during the second stage of
labour is not recommended.
Episiotomy policy Routine or liberal use of episiotomy is not Not recommended
recommended for women undergoing
spontaneous vaginal birth.
 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126 123

Table 2 (continued )

Care option Recommendation Category of recommendation

Birth position (for women with For women with and without epidural Recommended
and without epidural analgesia, encouraging the adoption of a birth
analgesia) position of the individual woman's choice,
including upright positions, is recommended.

Care of the newborn

Skin-to-skin contact Newborns without complications should be Recommended

Breastfeeding
Bathing and other immediate
postnatal care of the newborn
kept in skin-to-skin contact with their mothers
during the first hour after birth to prevent
hypothermia and promote breastfeeding.
All newborns, including low-birth-weight Recommended
babies who are able to breastfeed, should be
put to the breast as soon as possible after birth
when they are clinically stable, and the mother
and baby are ready.
Bathing should be delayed until 24 h after birth. Recommended
If this is not possible due to cultural reasons,
bathing should be delayed for at least 6 h.
Appropriate clothing of the baby for ambient
temperature is recommended. This means one
to two layers of clothes more than adults, and
use of hats/caps. The mother and baby should
not be separated and should stay in the same
room 24 h a day.

8. All newborns, including low-birth-weight babies who are able to breastfeed, should be put to
the breast as soon as possible after birth when they are clinically stable, and the mother and
baby are ready.

Adherence to clinical guidelines, including not performing interventions and procedures which are
“not-recommended,” such as applying fundal pressure, routine episiotomy, and enema on admission,
can help providers to deliver evidence-based, respectful care.
Besides clinical evidence-based guidelines resources, there are organizations and initiatives
that are devoted to helping mothers and families understand their rights in childbearing. Further,
they also help health care providers to understand what constitutes respectful maternity care and
how providers can implement respectful maternity care in their practices [50].

Summary

Respectful maternity care is recommended for all women throughout labour, childbirth, and
postpartum periods, and refers to care organized for and provided to all women “in a manner that
maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and
enables informed choice and continuous support during labour and childbirth, ” [15]. Despite clear
guidance about what constitutes respectful care, global evidence suggests that not all women receive
this type of care. Furthermore, the provision of respectful care may not be prioritised in the same way
as the provision of clinical care. More work is needed to understand how respectful care can be pro-
vided, particularly in lower-resource contexts, and how non-recommended practices can be removed
from clinical settings.
124 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

Practice points
Key practice points are listed below, and (*) indicates points recommended by WHO [13].
Respectful maternity care should be provided to all women*

— Treat all women and their families with dignity, respect, and confidentiality, regardless of
their low, average, or high maternal risk status, abilities, differences, ethnicity, age, marital
status, or if they have co-morbidities, such as infectious diseases.
— Be culturally humble: encourage women to engage in culturally appropriate birthing prac-
tices, and address women in a culturally appropriate manner. For example, in some
cultures it is considered rude to look directly into the eyes of the person you are speaking
to, particularly if the care provider is male; in other cultures, it is a sign of honesty and
sincerity to look directly at the woman and her family members.

Effective communication between maternity care providers and women in labour should be
provided*

— Inform women and their families about: evidence, risk, and benefits of procedures, pro-
cesses, and use/non-use of technologies and strategies during maternity care.
— Use effective, respectful, two-way communication techniques; speak respectfully, but also
listen respectfully to women and their families.
— Partner with women and families on decision-making, respecting their individual/family/
cultural preferences.

A companion of choice is recommended for all women throughout labour, childbirth, and post-
partum*
Midwife-led continuity of care should be for pregnant women in settings with well-functioning
midwifery programmes*
Encourage women to mobilise, use upright or preferred positions, and have access to oral
fluids and food (low-risk women)*
Depending on women's preferences, facilitate use of appropriate pain relief measures
including epidural analgesia, opioid analgesia, relaxation measures, and manual techniques*
Provide evidence-based, recommended care and avoid non-recommended practices such as
routine enemas, episiotomy, fundal pressure, perineal/pubic shaving, or separating mother
and baby*
Do no harm: Do not harm women physically or emotionally and do not engage in harmful
practices, unnecessary practices, or practices not recommended based on evidence. Do not
coerce women or force them or their families to pay bribes to receive care.

Research agenda

— Behavioural change interventions to de-implement clinical practices that are commonly

practiced but not recommended (e.g. manual fundal pressure, routine perineal shaving)
— Multi-component strategies to ensure implementation and sustainability of respectful ma-
ternity care within well-functioning health systems.
— Measurement methods for respectful maternity care for routine use in audit and feedback or
quality improvement initiatives.
 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126 125

Declaration of Competing Interest

None.

Acknowledgements

We acknowledge our institutional support for our time: University of Melbourne (MAB), World
Health Organization (O€ T), and University of California San Francisco (SM). We appreciate
helpful feedback from Mercedes Bonet (World Health Organization), Stine Bernitz (Oslo
Metropolitan Uni-
versity), and Andrew Weeks (University of Liverpool) on earlier drafts of this manuscript.
The contents of this article are the sole responsibility of the authors and do not necessarily reflect
the views of their individual institutions.

References

[1] World Health Organization. The World Health Report 2005: make every mother and child count. Geneva, Switzerland:
World Health Organization; 2005. https://www.who.int/whr/2005/whr2005_en.pdf?ua 1.¼ [Accessed 14 January 2020].
[2] World Health Organization. Maternal mortality: levels and trends 2000 to 2017. Geneva, Switzerland: World Health
Organization; 2019. https://www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/.
[Accessed 14 January 2020].
[3] Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the
Sustainable Development Goals era: time for a revolution. The Lancet Global Health 2018;6(11):e1196e252.
*[4] Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in
health facilities globally: a mixed-methods systematic review. PLoS Med 2015;12(6):e1001847. discussion e1001847.
*[5] Bohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, et al. How women are treated during facility-based
childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet
2019;394(10210):P1750e63.
[6] World Health Organization. Quality of care: a process for making strategic choices in health systems. Geneva,
Switzerland: World Health Organization; 2006. http://www.who.int/management/quality/assurance/QualityCare_B.Def.
pdf. [Accessed 14 January 2020].
*[7] Tuncalp O, Were WM, Maclennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al. Quality of care for pregnant women and
newborns - the WHO vision. BJOG An Int J Obstet Gynaecol 2015;122(8):1045e9.
*[8] Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comande D, et al. Beyond too little, too late and too much, too
soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016;388(10056):2176e92.
[9] Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane
Database Syst Rev 2017;7:CD003766.
[10] Bo h ren M A, B erger B O, Mu n the- Kaa s H, T un ç a lp O€ . Perceptions and experiences of labour companionship: a
qualitative
evidence synthesis. Cochrane Database Syst Rev 2019;(3):CD012449.
[11] Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for
childbearing women. Cochrane Database Syst Rev 2016;(4):CD004667.
[12] Chang YS, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between
maternity care staff and women in labour: a mixed-methods systematic review. Midwifery 2018;59:4e16.
[13] Bohren MA, Oladapo OT, Tuncalp O, Wendland M, Vogel JP, Tikkanen M, et al. Formative research and development of
innovative tools for "Better Outcomes in Labour Difficulty" (BOLD): study protocol. Reprod Health 2015;12:50.
*[14] Shakibazadeh E, Namadian M, Bohren MA, Vogel JP, Rashidian A, Pileggi VN, et al. Respectful care during childbirth in
health facilities globally: a qualitative evidence synthesis. BJOG 2017;125(8):932e42.
*[15] World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva,
Switzerland. https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/. [Accessed 14
January 2020].
[16] Williamson, J. W. Evaluating quality of patient care. A strategy relating outcome and process assessment. (0098-7484
(Print)).
[17] Donabedian A. The evaluation of medical care programs. Bull N Y Acad Med 1968;44(2):117e24.
[18] Hugo M. A look at maternal position during labor. J Nurse Midwifery 1977;22(26).
[19] Liu YC. Effects of an upright position during labor. Image - J Nurs Scholarsh 1989;21(1):14e8.
[20] American College of Nurse Midwives (ACNM). Life-saving skills: manual for midwives. Washington, DC, USA: ACNM;
1989.
[21] Klein S MS, Thompson F. A book for midwives. Berkeley, California, USA: Hesperian Foundation; 1995.
[22] Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gulmezoglu AM. Facilitators and barriers to facility-based
delivery in low- and middle-income countries: a qualitative evidence synthesis. BMC Reprod Health 2014;11(71).
[23] Council of Europe. Council of Europe, Strasbourg, France. Resolution 2306 (2019) Obstetrical and gynaecological violence.
2019. http://assembly.coe.int/nw/xml/XRef/Xref-XML2HTML-EN.asp?fileid¼28236&lang ¼en. [Accessed 14 January
2020].
[24] United Nation Human Rights Council. Special Rapporteur on Violence against Women. A human rights-based approach to
mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric
violence. New York, USA: United Nations; 2019. https://digitallibrary.un.org/record/3823698?ln ¼en. [Accessed 14
January 2020].
126 M.A. Bohren et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 67 (2020) 113e126

[25] Khosla R, Zampas C, Vogel JP, Bohren MA, Roseman M, Erdman JN. International human rights and the mistreatment of
women during childbirth. Health Hum Rights 2016;18(2):131e43.
[26] Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Re flections from South African obstetric services. Soc Sci
Med 1998;47(11):1781e95 (1982).
[27] Bohren MA, Vogel JP, Tuncalp O, Fawole B, Titiloye MA, Olutayo AO, et al. “By slapping their laps, the patient will
know that you truly care for her”: a qualitative study on social norms and acceptability of the mistreatment of women
during childbirth in Abuja, Nigeria. Soc Sci Med: Popul Health 2016;2:640e55.
[28] Balde MD, Bangoura A, Diallo BA, Sall O, Balde H, Niakate AS, et al. A qualitative study of women's and health
providers' attitudes and acceptability of mistreatment during childbirth in health facilities in Guinea. Reprod Health
2017;14(1):4.
[29] Balde MD, Diallo BA, Bangoura A, Sall O, Soumah AM, Vogel JP, et al. Perceptions and experiences of the mistreatment of
women during childbirth in health facilities in Guinea: a qualitative study with women and service providers. Reprod
Health 2017;14(1):3.
[30] Bohren MA, Vogel JP, Tuncalp O, Fawole B, Titiloye MA, Olutayo AO, et al. Mistreatment of women during childbirth
in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers. Reprod
Health 2017;14(1):9.
[31] Maya ET, Adu-Bonsaffoh K, Dako-Gyeke P, Badzi C, Vogel J, Bohren M, et al. Women's perspectives of mistreatment during
childbirth at health facilities in Ghana: findings from a qualitative study. Reprod Health Matters 2018.
[32] Abuya T, Ndwiga C, Ritter J, Kanya L, Bellows B, Binkin N, et al. The effect of a multi-component intervention on disrespect
and abuse during childbirth in Kenya. BMC Pregnancy Childbirth 2015;15:224.
[33] Rosen HE, Lynam PF, Carr C, Reis V, Ricca J, Bazant ES, et al. Direct observation of respectful maternity care in five
countries: a cross-sectional study of health facilities in East and Southern Africa. BMC Pregnancy Childbirth 2015;15:306.
[34] Sando D, Ratcliffe H, McDonald K, Spiegelman D, Lyatuu G, Mwanyika-Sando M, et al. The prevalence of disrespect
and abuse during facility-based childbirth in urban Tanzania. BMC Pregnancy Childbirth 2016;16:236.
[35] Dey A, Shakya HB, Chandurkar D, Kumar S, Das AK, Anthony J, et al. Discordance in self-report and observation data on
mistreatment of women by providers during childbirth in Uttar Pradesh, India. Reprod Health 2017;14(1):149.
[36] Sethi R, Gupta S, Oseni L, Mtimuni A, Rashidi T, Kachale F. The prevalence of disrespect and abuse during facility-
based maternity care in Malawi: evidence from direct observations of labor and delivery. Reprod Health 2017;14(1):111.
[37] Sheferaw ED, Bazant E, Gibson H, Fenta HB, Ayalew F, Belay TB, et al. Respectful maternity care in Ethiopian public health
facilities. Reprod Health 2017;14(1):60.
[38] Banks KP, Karim AM, Ratcliffe HL, Betemariam W, Langer A. Jeopardizing quality at the frontline of healthcare: prevalence
and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia. Health Pol Plann 2018;33(3):317e27.
[39] Bohren MA, Vogel JP, Fawole B, Maya ET, Maung TM, Balde MD, et al. Methodological development of tools to
measure how women are treated during facility-based childbirth in four countries: labor observation and community
survey. BMC Med Res Methodol 2018;18(1):132.
*[40] Afulani PA, Phillips B, Aborigo RA, Moyer CA. Person-centred maternity care in low-income and middle-income coun-
tries: analysis of data from Kenya, Ghana, and India. The Lancet Global Health 2019;7(1):e96 e109.
[41] Vedam S, Stoll K, Taiwo TK, Rubashkin N, Cheyney M, Strauss N, et al. The Giving Voice to Mothers study: inequity
and mistreatment during pregnancy and childbirth in the United States. Reprod Health 2019;16(1):77.
[42] Larson E, Sharma J, Bohren MA, Tuncalp O. When the patient is the expert: measuring patient experience and satisfaction
with care. Bull World Health Organ 2019;97(8):563e9.
[43] Adeniran A, Likaka A, Knutsson A, Costello A, Daelmans B, Maliqi B, et al. Leadership, action, learning and
accountability to deliver quality care for women, newborns and children. Bull World Health Organ 2018;96(3):222e4.
[44] Downe S, Lawrie TA, Finlayson K, Oladapo OT. Effectiveness of respectful care policies for women using routine intra-
partum services: a systematic review. Reprod Health 2018;15(1):23.
[45] Kildea S, Gao Y, Hickey S, Kruske S, Nelson C, Blackman R, et al. Reducing preterm birth amongst Aboriginal and Torres
Strait Islander babies: a prospective cohort study, Brisbane, Australia. Clin Med 2019;12:43e51.
[46] Hartz DL, Blain J, Caplice S, Allende T, Anderson S, Hall B, et al. Evaluation of an Australian aboriginal model of maternity
care: the malabar community midwifery link service. Women Birth: j Aust Coll Midwives 2019;32(5):427e36.
[47] Akhavan S, Edge D. Foreign-born women's experiences of community-based doulas in Swedenda qualitative study.
Health Care Women Int 2012;33(9):833e48.
*[48] Lalonde AB, Miller S. Mother-baby friendly birthing facilities initiative. Int J Gynaecol Obstet 2015;128(2):93e4.
[49] Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings
from a new evidence-informed framework for maternal and newborn care. Lancet 2014;384(9948):1129e45.
[50] White Ribbon. Alliance. What women want! Demands for quality reproductive and maternal healthcare from women
and girls. White Ribbon alliance, Washington DC, United States of America. Available from:
https://www.whatwomenwant. org/globalfindings. [Accessed 7 February 2020].
[51] The Royal College of Midwives. The RCM Evidence based guidelines for midwifery-led care in labour United Kingdom.
https://www.rcm.org.uk/media/2271/evidence-based-guidelines-introduction.pdf. [Accessed 14 January 2020].
[52] Butler MM, Fullerton JT, Aman C. Competence for basic midwifery practice: updating the ICM essential competencies.
Midwifery 2018;66:168e75.
[53] International Confederation of Midwives (ICM). Competence for basic midwifery pratice: updating the ICM essential
competencies. In: Internacional confederation of midwives, the hague, The Netherlands; 2018. . [Accessed 14 January
2020].
[54] Royal College of Obstetricians and Gynaecologists. Checklist for Respectful Care in Women's Health: 6 tips for health
care professionals. London, United Kingdom: Royal College of Obstetricians and Gynaecologists; 2019. Available from:
https:// www.rcog.org.uk/en/global-network/centre-womens-global-health/our-resources/. [Accessed 14 January
2020].
 Contraception 98 (2018) 228–231

Contents lists available at ScienceDirect

Contraception

jo u rn al ho me p ag e : www. e l s e v i e r . c o m / l o c a t e / c o n

Original research article

Predictors for follow-up among postpartum patients enrolled in a

☆ ☆☆,☆☆☆,★
clinical trial ,
Maureen K. Baldwin ⁎, Kyle D. Hart, Maria I. Rodriguez
Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode UHN 50, Portland, OR 97239

a r t i c l e in f o
abstract
Article history:
Received 8 November 2017 Objective: To identify risk factors for failure to attend postpartum follow-up within 3 months of delivery,
Received in revised form 24 April includ- ing social support, intrinsic motivation, insurance type and prenatal care attendance.
2018 Study design: This planned secondary analysis is derived from a randomized controlled trial of patients
Accepted 27 April 2018 intending intrauterine device (IUD) use following their delivery (n=197). Subjects were postpartum from a
vaginal or ce- sarean birth at ≥32 weeks’ gestation. We obtained baseline demographics and certainty about
Keywords: their plan to re- ceive a postpartum IUD. We administered validated scales for social support and intrinsic
Maternity care
motivation at enrollment. We then reviewed health records for prenatal visits and any postpartum visit by 3
Postpartum visit
months and performed logistic regression to assess for predictors of follow-up.
Contraception
Results: A total of 38/197 subjects (19.3%) failed to attend any postpartum visit by 3 months. Subjects who
Intrauterine device
Insertion timing failed to follow up were more likely to have Medicaid versus private insurance (92% versus 8%, p b.01).
Immediate postpartum Income b$50,000, no car, younger age, unplanned pregnancy, unemployment, multiple children, missed
prenatal visits and late initiation of prenatal care were also associated with failure to follow up. Higher scores
for social support and goal-directed motivation were not significantly associated with follow-up.
Conclusions: In our cohort, we found that one in five participants did not attend a postpartum visit by 3
months. Several socioeconomic indicators are associated with loss to follow-up, most notably Medicaid
insurance. Having high motivation and social support is not sufficient to predict successful follow-up.
Implications: The main predictors for not attending a postpartum visit are Medicaid insurance or limited
prenatal care, and not social support or intrinsic motivation. Interventions to improve postpartum
contraception uptake should focus efforts on provision of immediate postpartum contraception for this
population.
© 2018 Elsevier Inc. All rights reserved.

1. Introduction
The postpartum period is a busy time. For some families, this
includes increased economic stresses, infant feeding difficulties and
challenges with care for older children. These competing demands
may cause women to neglect their own healthcare and miss their post-
partum visit [1]. Failure to attend a postpartum visit can have important
implications for a woman's health: evaluation for postpartum depres-
sion, blood pressure, breast health, and wound healing are typically
☆ Funding: This work was supported by the Society of Family Planning Research
Fund. Additional support for data management was provided through Oregon Clinical
and Translational Research Institute grant support (1 UL1 RR024140 01).
☆☆ Clinical Trial Registration: clinicaltrials.gov (NCT01594476).
☆☆☆ Interim data from this study were presented at the Family Planning Fellowship
meeting, San Francisco, CA, May 2013, as an oral presentation and at the North
American Forum on Family Planning Conference, Miami FL, October 2014, as a
poster.
★ Dr. Rodriguez is a Women's Reproductive Health Research fellow; grant
1K12HD085809.
⁎ Corresponding author. Tel.: +1 503 494 9762.
E-mail address: schaum@ohsu.edu (M.K. Baldwin).
addressed at this time. Often, this visit is the only opportunity for
interconception care, which includes glycemic control, weight
manage- ment, contraception management and discussion of birth
spacing rec- ommendations [2]. The American College of
Obstetricians and Gynecologists emphasizes the importance of a
full physical, social and psychological assessment within 6 weeks of
giving birth to protect and promote women's health [3].
A clear understanding of the barriers and facilitators of postpartum
care attendance can help guide innovations to improve the obstetric
care model. A prior study at our institution identified that 55% of postpar-
tum subjects with Medicaid insurance who did not return for a scheduled
postpartum contraception visit had limited prenatal care (b10 visits) [4].
In addition to prenatal care attendance and insurance type, we hypothe-
sized that having limited social support and lower motivation to pursue
contraception would be significant predictors of follow-up.
The objective of this secondary analysis was to determine
whether poor attendance to prenatal care and validated measures of
motivation and social support are lower among patients not
returning for postpar- tum care. Our sample consisted of patients
planning a postpartum

https://doi.org/10.1016/j.contraception.2018.04.016
0010-7824/© 2018 Elsevier Inc. All rights reserved.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March 27,
2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 M.K. Baldwin et al. / Contraception 98 (2018) 228–231 229
Our planned sample size for the original RCT had sufficient power
intrauterine device (IUD) who were enrolled in a randomized to compare prenatal care attendance between those who had follow-
controlled trial (RCT). up

2. Material and methods

This is a planned secondary analysis of data obtained from the

Early Postpartum Intrauterine Device Study, an RCT to examine
outcomes as- sociated with a scheduled 3- versus 6-week postpartum
visit to place an IUD [5]. The study was conducted from February
2012 through Decem- ber 2013 at Oregon Health & Science
University (OHSU), an academic tertiary care hospital in Portland,
Oregon, with approximately 2400 de- liveries per year.
The primary objective of this analysis is to identify predictors of
fail- ure to follow up for postpartum care within 3 months after
delivery, re- gardless of whether an IUD was ultimately received.
We compared prenatal attendance between participants who did
and did not follow up. Secondary analyses included a comparison
by follow-up status of validated test score measurements for
perceived social support and in- trinsic motivation. The OHSU
Institutional Review Board approved the study (IRB#8120).
Subjects included inpatient postpartum patients participating in an
RCT comparing timing of IUD insertion at 3 versus 6 weeks
postpartum, intending to use an IUD for contraception, with no
contraindications to IUD use, and either public or private insurance
coverage that included IUD insertion. Participants were ≥18 years old,
English- or Spanish- speaking, and within 5 days of vaginal or cesarean
delivery of a live singleton infant at ≥32 weeks’ gestation. Potential
subjects were excluded if they were unable to return for postpartum
care, including incarceration, upcoming travel or living far away.
Most data on covariates were collected at the time of trial enrollment
following informed consent. Data were collected and managed using
REDCap electronic data capture tools hosted at OHSU [6]. Missing
data were handled with case-wise deletion. We asked participants to
respond to the question “How sure are you about your plan to receive an
IUD?” using a 100-mm visual analog scale (VAS) at the time of
enrollment.
Participants also completed two validated 12-question psychologi-
cal survey instruments at enrollment. The Snyder Hope Scale (Future
Scale) includes four questions that reflect agency, four that reflect path-
ways and four that are distracters. The total possible score for the
Future Scale ranges from 8 to 64 [7]. Responses to this scale correlate
well with other psychological tests designed to assess optimism,
expectancy for attaining goals and self-esteem. We planned to interpret
this score as a measure of intrinsic motivation. We administered the
Multidimensional Scale of Perceived Social Support (MDSS) to assess
perceived social sup- port, another possible indicator for the ability to
carry out a plan [8]. There are three subscales for the MDSS: family,
friends and significant other, with a possible score ranging from 4 to 28
for each subscale. We also assessed reported intendedness of the recent
pregnancy [9].
Following enrollment, we scheduled a single postpartum visit at
the allocated timing of 3 or 6 weeks (±3 days) with an Ob/Gyn
faculty or midwife study provider in either the patient's primary
clinic or the Family Planning clinic if her primary clinic did not
perform IUD inser- tion. We did not aid with rescheduling or
reminders.
One study investigator reviewed the electronic medical record
charts for prenatal and postpartum care attendance. We defined the
pri- mary outcome as no record of a postpartum visit with a
clinician prior to 3 months after delivery in the electronic medical
record. The majority of subjects attended prenatal care at an
outpatient clinic within our hospi- tal system (93%). Other subjects
were referred from nearby clinics, the majority of which have an
electronic medical record that can be viewed within our system. In
addition to chart review for this secondary study, the parent trial
included phone/email follow-up at 3, 4 and 6 months postpartum.
For participants outside our medical system, we also ac- cepted self-
report of postpartum follow-up.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March
27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 The median value for the VAS for intention to receive an IUD
and those who did not, though fewer were needed for this outcome was similar among those who did or did not follow up (97.0 versus
than for the primary outcome. The primary outcome was IUD
insertion by 3 months and had goal enrollment of 240, though slow
enrollment resulted in study closure after 197 enrolled. In this cohort
of both privately and publicly insured patients, we originally
estimated that 48 (20%) subjects might not return for follow-up and
that 22/48 (45%) of subjects would have had limited prenatal care.
For this planned secondary analysis, a total of 62 participants were
needed to have 90% power and alpha b0.025 to detect a 40%
difference in prenatal care attendance among those who did (90%)
versus did not attend (50%) a postpartum visit within 3 months.
We used descriptive statistics to characterize the sample
population and tested for differences between those who followed
up and those who did not using Student's t test, Wilcoxon's rank-
sum test, Pearson's chi-squared test or Fisher's Exact Test, as
appropriate. To evaluate the ability of the VAS to discriminate
between those who did and those who did not follow-up, we
constructed a receiver operating characteris- tic curve and
calculated the c-statistic and Youden's criterion. To iden- tify the
best predictors of failure to follow-up for postpartum care, we
constructed a logistic regression model, with model selection based
on variable importance measures from a random forest.

3. Results

Of the 197 subjects who participated in the Early Postpartum

IUD Study, 38 (19.3%) did not return for any postpartum care.
The most dra- matic difference between those who followed up
and those who did not was insurance type: only 3 (3%) of patients
using private insurance for delivery failed to follow-up, while 35
(37%) of those on Medicaid failed to follow up (pb.01) (Table 1). As
we hypothesized, participants who had missed a prenatal visit and
had initiated prenatal care after 14 weeks were more likely to
fail to follow up (14/41, 34% versus 23/ 155, 15%, pb.01 for any
“no show” versus perfect attendance; 20/48, 42% versus 17/148,
12%, pb.01 for late prenatal care versus early). We performed a
sensitivity analysis to assess whether randomization allocation to
3- or 6-week IUD insertion could have influenced subject return
for follow-up and found no difference.
Interestingly, the validated scales of social support and intrinsic
mo- tivation were not associated with follow-up. Median values for
all social support subscales were similar among participants
regardless of follow- up. Because the family subscale was an
important variable in the ran- dom forest analysis, we
dichotomized it at 17 (based on the optimal cut-point identified in
a classification tree) to adjust the multivariable regression model,
but this variable was not a significant independent predictor. The
mean score for the Future Scale was 46.5 (range 23– 56), which
did not vary significantly by follow-up status and also was not
significantly different between those receiving Medicaid versus pri-
vate insurance. However, among Medicaid recipients, the total
score for the Future Scale was slightly higher among those who did
not follow-up (48.3 versus 45.9, p=.04).
A number of other variables that may be related to
socioeconomic indicators differed between those who followed up
for a postpartum visit compared to those who did not. Not
returning for a postpartum visit occurred more frequently among
those with lower income, with lower educational attainment, not
owning a car, having had an un- planned pregnancy, planning to
quit work or school, and having more than one child at home
(Table 1, pb.01 for all). Participants under age 24 had high loss to
follow-up (17/45, 38%) compared to those age 24 and older
(21/152, 14%, pb.01).
Among Medicaid recipients, socioeconomic indicators did not
predict follow-up. Having fewer than 10 prenatal visits was more
common among those with loss to follow-up than in those who
returned (68% versus 45%, p=.06). A majority of participants younger
than age 24 were Medicaid recipients (84%), of whom 16/38 (42%)
did not return for follow-up.
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March
27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
230 M.K. Baldwin et al. / Contraception 98 (2018) 228–231

Table 1
Demographic and clinical characteristics of all enrolled postpartum patients and Medicaid recipients only by follow-up status (attended any postpartum visit within 3 months)

Characteristicsa All subjects Medicaid recipients

Follow-up n=159 No follow-up n=38 p Follow-up n=60 No follow-up n=35 p

Age 29.7±5.8 25.6±4.3 b.01b 26.6±5.8 25.3±4.0 .22b
Ethnicity Hispanic (vs. non-Hispanic) 20 (13) 7 (18) .50c 15 (25) 6 (17) .53c
Primary language Spanish (vs. English) 4 (3) 2 (5) .33d 2 (3) 2 (6) .62d
Education less than college (vs. more) 32 (20) 22 (58) b.01c 25 (42) 21 (60) .13c
Income b50 k (vs. ≥50 k) 63 (45) 31 (91) b.01c 46 (92) 30 (94) 1.00d
Pregnancy was not planned (vs. planned) 71 (45) 26 (68) .01c 45 (75) 25 (71) .89c
Preterm birth (b37 vs. ≥37 weeks) 8 (5) 8 (21) b.01d 5 (8) 8 (23) .06d
Two or more children (vs. only infant) 66 (42) 25 (66) 0.01c 29 (48) 23 (66) .15c
Early randomization timing (3 vs. 6 weeks) 77 (48) 23 (61) .25c 26 (43) 22 (63) .11c
Any missed prenatal visits (vs. none) 27 (17) 14 (38) .01c 17 (28) 13 (38) .45c
Limited prenatal care (vs. ≥10 visits) 48 (30) 24 (65) b.01c 27 (45) 23 (68) .06c
Late prenatal care (≥14 vs. b14 weeks) 28 (18) 20 (54) b.01c 21 (35) 19 (56) .08c
VAS b80 mm (vs. ≥80 mm) 19 (12) 11 (29) .02c 7 (12) 10 (29) .07c
MDSS total 69.0 (61.0–72.0) 67.0 (59.0–72.0) .61e 69.0 (61.8–72.0) 67.0 (59.2–72.0) .53e
Future Scale total 46.2±6.3 48.0±5.2 .07b 45.9±5.7 48.3±5.2 .04b

Data are n (%) or median and interquartile range, x.x (x.x–x.x); x ± x indicates mean ± standard deviation.
a
Missing data handled case-wise. All variables with 0–1 missing case except income with n=175 for all subjects and n=82 for Medicaid recipients.
b
Student's t test (two-sided).
c
Pearson's chi-squared test.
d
Fisher's Exact Test.
e
Wilcoxon rank-sum test with continuity correction.

96.5 mm; p=.68). Nevertheless, very high scores appear to be initiation, MDSS family subscale and VAS for IUD intention ≥80 mm.
predic- tive of follow-up (sensitivity=87%, specificity=29%).
In multivariable analysis, private insurance (versus Medicaid) was
the strongest predictor of follow-up [odds ratio (OR): 10.4, 95% confi-
dence interval (CI): 3.1–48.1], followed by a VAS score for intention to
receive an IUD of greater than or equal to 80 mm (OR: 1.9, 95% CI:
1.0–9.2) and receipt of prenatal care prior to 14 weeks’ gestational age
(OR: 2.3, 95% CI: 1.0–5.7) (Table 2). There were no significant indepen-
dent predictors for Medicaid recipients.

4. Discussion

Even among motivated research subjects, one in five patients do

not follow up with recommended postpartum care. All
socioeconomic indi- cators, including financial instability and lower
educational achieve- ment, are associated with not returning, but
the strongest predictor is Medicaid insurance. Initiation of prenatal
care after the first trimester, missed prenatal visits and fewer than
10 prenatal visits are associated with failure to follow up.
Psychological assessments for self-reported motivation and
perceived social support are not significant predictors.
We expected the validated “Future Scale” to be able to identify
those who have both agency and pathway, or “will and ways,” to
follow through with a plan. However, the best behavioral predictor
of future visit attendance is past attendance. There are likely forces
stronger

Table 2
Multivariable logistic regression of factors related to postpartum follow-up within
3 months among postpartum patients seeking IUD for contraception

Covariates: OR (95% CI)a All subjects Medicaid recipients

n=197 n=95

Age (per year increase) 1.0 (0.9–1.1) 1.02 (0.9–1.1)

Preterm birth (b37 weeks) 0.4 (0.1–1.6) 0.4 (0.1–1.5)
3-week follow-up group 0.7 (0.3–1.6) 0.5 (0.2–1.3)
(vs. 6-week group)
Private insurance (vs. Medicaid) 10.4 (3.1–48.1) --
Prenatal care prior to 14 weeks 2.3 (1.0–5.7) 2.1 (0.8–5.4)
Score N17 on MDSS family subscale 1.9 (0.7–5.5) 2.3 (0.8–7.3)
VAS for IUD intention ≥80 mm 3.1 (1.0–9.2) 2.7 (0.8–8.8)

All subjects: null deviance=189.1; deviance=137.8; AIC=149.8; BIC=169.4.

Medicaid only: null deviance=123.0; deviance=108.9; AIC=122.9;
BIC=140.7.
a
Model includes age, preterm birth, randomization group, insurance, prenatal care
than motivation that impact utilization of healthcare services for
this population.
Throughout this study period, nearly all pregnant patients in
Oregon who did not have private insurance were eligible for
Medicaid insur- ance, with coverage extending to 185% of the
Federal Poverty Level through 2 months postpartum. These
data are reassuring that nearly all privately insured and college-
educated patients will follow up. How- ever, it is concerning that
those who are probably at the highest need for postpartum
support were less likely to return.
The predictors for loss to follow-up here are consistent with
those in the much larger retrospective cohort in New York (n=4049)
[10]. They found that nonattendance at a postpartum visit was more
likely for pa- tients using Medicaid or who were uninsured [relative
risk 1.4, 95% CI 1.2–1.6]. While a much smaller study, our
prospective design allowed more precise classification of patient-
level characteristics and the follow-up outcome and showed a more
robust relationship. Our find- ings provide additional evidence that
insurance type is the most impor- tant predictor to identify patients
at risk for health disparities due to inadequate access and utilization
of postpartum health care services.
The main study limitation is a potential misclassification of
whether subjects returned for follow-up. We reviewed the electronic
medical re- cord, which shares health visit information state-wide
for most health systems, to locate subjects referred to our hospital
who may have returned to their primary provider for follow-up. In
all, 6.6% of subjects had prenatal care outside our health system.
After phone/email contact, only 5/13 (38%) subjects outside our
health system had no confirmation of follow-up. Differential follow-
up measures could have resulted in an overestimation of loss to
follow-up, but this would not be expected to be a differential bias
with respect to demographic characteristics.
Another limitation of this study is generalizability. This study
likely overestimates the proportion of postpartum patients who will
return for follow-up because it only included research participants
motivated to return for postpartum contraception who agreed to
enroll and who were going to be compensated for returning
regardless of whether they changed their mind about using an IUD.
This is a best-case scenario and provides estimates for postpartum
follow-up under the most ideal condi- tions. We tried to mimic real-life
clinic scheduling as much as possible for this cohort to avoid the
potential impact of a clinical trial on return rates. For example, we did
not provide additional help with rescheduling ap- pointments, we
did not provide extra appointment reminders, and we did not
provide directed counseling about IUD insertion or side effects be-
yond what was discussed with their primary provider.
 M.K. Baldwin et al. / Contraception 98 (2018) 228–231
Attendance for participants enrolled in postpartum
contraceptive studies who are actively seeking contraception seems
no better than with patients not involved in research [10,11].
However, short interpregnancy intervals can negatively impact a
subsequent preg- nancy, so contraception is a particularly
important service for postpar- tum patients to receive early [1,12,13].
Our research and clinical efforts should work toward provision
of high-quality postpartum care. We recommend that options for
contra- ceptive initiation be available during the maternity care
hospitalization for all patients. Providers and health systems should
facilitate easier ac- cess to postpartum services that might improve
utilization among high- risk groups. Services such as home visits,
telephone assessments or mother–baby dyad visits could be
conducted for those who have diffi- culty attending clinic
appointments [14].
Healthcare innovations should focus efforts for postpartum care to-
ward those with prior difficulty attending appointments. Research stud-
ies with postpartum outcomes should consider excluding potential
subjects with a history of limited prenatal care. Health systems should
focus efforts and resources for immediate initiation of contraception
during the maternity care hospitalization.
Acknowledgments
Subject enrollment and data collection were performed by study
coordinators through the OHSU Women's Health Research Unit. In
particular, we would like to acknowledge the lead coordinator for this
study, Jacqueline Sequin.
References
[1] D'Angelo D, Williams L, Morrow B, Cox S, Harris N, Harrison L, et al.
Preconception and interconception health status of women who recently gave
birth to a live-
231
born infant — pregnancy Risk Assessment Monitoring System (PRAMS), United
States, 26 reporting areas, 2004. MMWR Surveill Summ 2007;56(10):1–35.
[2] Verbiest S, Bonzon E, Handler A. Postpartum health and wellness: a call for quality
woman-centered care. Matern Child Health J 2016;20(Suppl. 1):1–7.
[3] Committee Opinion No 666: Optimizing Postpartum Care, Obstet Gynecol
2016;127
(6):e187–92.
[4] Simmons KB, Edelman AB, Li H, Yanit KE, Jensen JT. Personalized contraceptive
assis- tance and uptake of long-acting, reversible contraceptives by postpartum
women: a randomized, controlled trial. Contraception 2013;88(1):45–51.
[5] Baldwin MK, Edelman AB, Lim JY, Nichols MD, Bednarek PH, Jensen JT. Intrauterine
device placement at 3 versus 6 weeks postpartum: a randomized trial. Contracep-
tion 2016;93(4):356–63.
[6] Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic
data capture (REDCap) — a metadata-driven methodology and workflow process
for providing translational research informatics support. J Biomed Inform 2009;42
(2):377–81.
[7] Snyder CR, Harris C, Anderson JR, Holleran SA, Irving LM, Sigmon ST, et al. The
will and the ways: development and validation of an individual-differences measure
of hope. J Pers Soc Psychol 1991;60(4):570–85.
[8] Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteris-
tics of the multidimensional scale of perceived social support. J Pers Assess 1990;
55(3–4):610–7.
[9] Shulman HB, Gilbert BC, Msphbrenda CG, Lansky A. The Pregnancy Risk Assessment
Monitoring System (PRAMS): current methods and evaluation of 2001 response
rates. Public Health Rep 2006;121(1):74–83.
[10] Wilcox A, Levi EE, Garrett JM. Predictors of non-attendance to the postpartum fol-
low-up visit. Matern Child Health J 2016;20(Suppl. 1):22–7.
[11] Chen BA, Reeves MF, Creinin MD, Schwarz EB. Postplacental or delayed
levonorges- trel intrauterine device insertion and breast-feeding duration.
Contraception 2011; 84(5):499–504.
[12] Zhu BP. Effect of interpregnancy interval on birth outcomes: findings from three
re-
cent US studies. Int J Gynaecol Obstet 2005;89(Suppl. 1):S25–33.
[13] Zhu BP, Rolfs RT, Nangle BE, Horan JM. Effect of the interval between pregnancies
on perinatal outcomes. N Engl J Med 1999;340(8):589–94.
[14] Uhm S, Pope R, Schmidt A, Bazella C, Perriera L. Home or office etonogestrel
implant insertion after pregnancy: a randomized trial. Contraception 2016;94
(5):567–71.
 Women's Health Issues 30-6 (2020) 426–435

www.whijournal.com

Policy matters

Postpartum
Medicaid
Coverage
and
Contraceptiv
e Use Before

and After
Ohio’s
Medicaid
Expansion
Under the
Affordable
Care Act
Anne L. Dunlop,
MD, MPH a, Peter
Joski, MSPH b,
Andrea E. Strahan,
PhD b,
Erica Sierra, PhD c,
E. Kathleen Adams,
PhD b,*
a

E
m
o
r
y

U
n
i
v
e
r
s
i
t
y

N
e
l
l

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March
27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 Hodgson Woodruff School of Nursing, Emory
University School of Medicine, Atlanta, Georgia (Amer trimest
b
Department of Health Policy and ican er,”
Management, Emory University Rollins School Colleg women
of Public Health, Atlanta, Georgia c Medical
e of need a
Mutual of Ohio, Cleveland, Ohio
Obstet compr
Article history: Received 13 June 2019; Received in revised form 10 August 2020; Accepted 19 August ricians ehensi
2020
and ve
Gynec assess
abstract ologist ment
s, of their
Background: Ensuring that women with Medicaid-covered 2018) physic
births retain coverage beyond 60 days postpartum can help
as al
women to receive care that will improve their health
they recover
outcomes. Little is known about the extent to which the
Affordable Care Act (ACA) Medicaid expansion has allowed strugg y from
for longer postpartum coverage as more women entering le with birth,
Medicaid under a pregnancy eligibility category could now a reprod
become income eligible. This study investigates whether range uctive
Ohio’s Medicaid expansion increased continuous enrollment of health
and use of covered services postpartum, including health care
postpartum visit attendance, receipt of contraceptive proble needs,
counseling, and use of contraceptive methods. ms and
Methods: We used Ohio’s linked Medicaid claims and vital
that emotio
records data to derive a study cohort whose prepregnancy
can nal
and 6-month postpartum period occurred fully in either
before (January 2011 to June 2013) or after (November 2014
seriou well-
to December 2015) the ACA Medicaid expansion sly being
implementation period (N ¼ 170,787 after exclusions). We impac (Ranji,
categorized women in this cohort according to whether they t their Gomez
were pregnancy eligible (the treatment group) or income health , &
eligible (the comparison group) as they entered Medicaid and and Salgani
used multivariate logistic regression to test for differences in ability coff,
the association of the ACA expansion with their postpartum to care 2019).
enrollment in Medicaid and use of services. for Wome
Results: Women who entered Ohio Medicaid in the
thems n are
pregnancy eligible category had a 7.7 percentage point
elves more
increase in the probability of remaining continuously
enrolled 6 months postpartum relative to those entering as and likely
income eligible. Income eligible women had approximately a their to die
5.0 percentage point increased likelihood of both a famili from
postpartum visit and use of long-acting reversible es, pregna
contraceptives. Pregnancy-eligible women had a significant includ ncy-
but smaller (approximately 2 percentage point) increase in ing related
the likelihood of long-acting reversible contraceptive use. anemi conditi
Conclusions: Ohio’s ACA Medicaid expansion was associated a, ons in
with a significant increase in the probability of women’s
physic the
continuous enrollment in Medicaid and use of long-acting
al postpa
reversible contraceptives through 6 months postpartum.
Together, these changes translate into decreased risks of
exhau rtum
unintended pregnancy and short interpregnancy intervals. stion, period
© 2020 Jacobs Institute of Women's Health. and than

Published by Elsevier Inc. postpa during

rtum pregna
depres ncy or
sion. deliver
There is increased recognition of PhD, 1518 Clifton Road NE, Atlanta, GA 30322.
Phone: 404-727-9370; fax: 404-727-9969. Durin y
the importance of the postpartum
E-mail address: eadam01@emory.edu (E.K. g this (Crean
period for the health and well-being of Adams).
period ga,
women
, Syvers
someti on,
Supported in part by the Ohio Department mes Seed,
of Medicaid and through the Medicaid referr &
Technical Assistance and Policy Program ed to Callag
(MEDTAPP) via federal financial participation
as the han,
funds, Contract # (G-1617-05-003). Views
stated here are those of the researchers only “fourt 2017),
and are not attributed to the study sponsors, h and
the Ohio Department of Medicaid or to the the
Federal Medicaid Program. No financial
disclosures were reported by the authors of this
10
paper.
4
* Correspondence to: E. Kathleen Adams,
Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March
27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
9-3867/$ - see front matter © 2020 Jacobs Institute of Women's Health.
Published by Elsevier Inc. https://doi.org/10.1016/j.whi.2020.08.006

Downloaded for Fakultas Kedokteran Universitas Muslim Indonesia (eucrasia2018part6@gmail.com) at University of Muslim Indonesia from ClinicalKey.com by Elsevier on March
27, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435
expansion of Medicaid coverage postpartum is recognized as an
important strategy for decreasing U.S. maternal mortality
(Stuebe, Moore, Mittal, Reddy, Low, & Brown, 2019; Zephyrin,
Coleman, Nuzum, & Getachew, 2019). Pregnancy-related
Medicaid coverage for many women lasts only 60 days post-
partum. There is considerable variability across states as to
whether and how Medicaid coverage is continued postpartum
largely owing to states’ choices regarding the optional Medicaid
expansion under the Affordable Care Act (ACA). In states
without a Medicaid expansion, many women continue to become
unin- sured beyond 60 days postpartum because they do not
meet the state’s Medicaid income eligibility requirements for
parents (Ranji et al., 2019).
Before the ACA, Medicaid income eligibility varied widely by
state and women often qualified only if their incomes were very
low and/or if they belonged to one of Medicaid’s historical cat-
egories of eligibility (pregnant, parent, child, senior, or disabled).
Low-income women who were parents qualified for Medicaid
prepregnancy with household incomes ranging from 17% of the
federal poverty level (FPL) to 212% FPL in 2012 (Henry J. Kaiser
Family Foundation, 2020a). Other low-income women came
into Medicaid coverage only under a pregnancy eligibility cate-
gory for which eligibility varied from 133% FPL to 300% FPL in
2012 (Henry J. Kaiser Family Foundation, 2020b). Because
Medicaid eligibility resulting from pregnancy is temporary, many
women are vulnerable to becoming uninsured postpartum. This
situation results in coverage gaps before, between, and after
pregnancies (Adams & Johnston, 2016; Daw, Hatfield, Swartz, &
Sommers, 2017); one study of women who had Medicaid coverage
at delivery in 2005–2013 found that as many as 55% lacked
insurance at 6 months postpartum (Wherry, 2018).
As of January 2014, the ACA allowed for the expansion of
Medicaid eligibility for individuals with incomes at or below
138% of the FPL; in 2014 this equaled $27,310 for a family of
three (Patient Protection and Affordable Care Act, Public Law 111–
148, 2010). Although the ACA Medicaid expansion was intended
to be national, a June 2012 Supreme Court ruling made it
optional for states (U.S. Supreme Court, 2012). As of January
2020, 37 states (including the District of Columbia) had
expanded Medicaid and 14 states had not (Henry J. Kaiser
Family Foundation, 2020c). Improvement in prepregnancy
insurance coverage was found in states expanding Medicaid
under the ACA (Adams, Dunlop, Strahan, Joski, Applegate, &
Sierra, 2019; Clapp, James, Kaimal, & Daw, 2018), whereas the
uninsurance rate among post- partum women was found to
decrease by 56.0% in expansion states compared with a decrease
of 29.0% in nonexpansion states (McMorrow & Kenney, 2018).
Such decreases in postpartum uninsurance may increase
women’s access to and use of a postpartum visit and other
important health care, including contraceptive services.
Access to and use of contraception in the postpartum period
is recognized as important for the prevention of unintended
pregnancies and short interpregnancy intervals (Ranji et al.,
2019), both of which are linked with adverse health outcomes
for the woman and child (Gemmill & Lindberg, 2013) particularly
among low-income families (Appareddy, Pryor, & Bailey, 2017).
Data from the National Survey of Family Growth (2006–2010)
demonstrate that more than one-half of the unintended preg-
nancies experienced by U.S. parous women occur within 2 years
after a birth, with 70% occurring within the first year. The use of
less effective methods of contraception increases the risk for
unintended pregnancy postpartum, as does younger maternal
age, lower maternal education, and Medicaid versus private
427
health insurance (White, Teal, & Potter, 2015). Increasing
women’s access to health insurance, including during the post-
partum period, has the potential to decrease unintended preg-
nancy by decreasing financial barriers to contraceptive use
(Culwell & Feinglass, 2007; Guttmacher Institute, 2018; Johnston
& Adams, 2017; Kost, Finer, & Singh, 2012).
Coverage of family planning and contraceptive methods
was also affected by the ACA. Before the ACA, federal law
required Medicaid programs to offer family planning benefits
to in- dividuals of reproductive age free of cost sharing, but
states had considerable latitude in designating services and
contraceptive methods covered (Ranji et al., 2016). Under the
ACA, qualified health plans and Medicaid expansion states
were required to cover 18 contraceptive methods approved by
the U.S. Food and Drug Administration, counseling on the
prevention of sexually transmitted infections and human
immunodeficiency virus, and screening for breast and cervical
cancers for the newly Medicaid eligible (Patient Protection
and Affordable Care Act, Public Law 111–148, 2010; Ranji et
al., 2016; Centers for Medicare and Medicaid Services, 2015).
Expansion states seem to have covered these services across
all eligibility groups, not just the Medicaid expansion group
(Walls, Gifford, Ranji, Salganicoff, & Gomez, 2016). Research
that examined ACA im- pacts on privately insured women
found that out-of-pocket costs for contraception decreased
sharply and the use of long- term methods of contraception
(including both long-acting reversible contraceptives [LARC]
methods and sterilization) increased more than other
methods (Becker, 2018; Carlin, Fertig, & Dowd, 2016). An
analysis found that the use of state plan amendments for
expanded family planning was associated with increased
contraceptive use postpartum in two study states (Redd &
Hall, 2019). A very recent study found both postpartum
Medicaid enrollment and outpatient visits were higher with
expansion, but the authors did not analyze family planning
and contraceptive use (Gordon, Sommers, Wilson, & Travedi,
2020).
This study investigates whether women with a Medicaid
birth after ACA expansion are more likely to remain enrolled in
Medicaid and attend postpartum visits, receive contraceptive
counseling, and use contraceptive methods compared with
women in the pre-ACA period. This study focuses on Ohio, where
Medicaid eligibility expanded in January 2014 and where linkage
between Medicaid claims and vital records before and after that
expansion is facilitated by collaboration between the state’s
Department of Medicaid and Department of Health. The
Medicaid expansion in Ohio changed postpartum Medicaid
eligibility for a large group of women.
Ohio Medicaid Policies
Table 1 details Ohio’s prepregnancy and postpartum
Medicaid eligibility criteria in both the pre-ACA and post-ACA
periods for women based on the eligibility category under
which they entered Medicaid: income eligible or pregnancy
eligible. Women (with dependent children) were eligible
before pregnancy in Ohio only if their income was less than
90% of the FPL before the ACA and less than 138% after the
ACA; if they entered Medicaid at these income levels, they
remained eligible postpartum as long as they continued to
meet the eligibility criteria in subsequent recertification cycles.
In contrast, those entering Medicaid in the pregnancy eligible
group were not eligible until they became pregnant and if
their income was less than 200% of the FPL in both the pre-
and post-ACA periods (205% FPL owing to the use of
428 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435

Table 1
Prepregnancy and Postpartum Medicaid Eligibility Criteria in Ohio Before and After the ACA Medicaid Expansion for Women Entering Medicaid as Income or
Pregnancy Eligible

Period of Coverage Medicaid Eligibility Category

Income Eligible Pregnancy Eligible*

Before the ACA y

After the ACA Before the ACA After the ACA
Prepregnancy <90% FPL <138% FPL Not eligible Not eligible
Postpartum <90% FPL <138% FPL <90% FPL; eligible 60 days if >90% FPL <138% FPL; eligible
60 days if >138% FPL

Abbreviations: ACA, Affordable Care Act; FPL, federal poverty level.

* Eligible if income <200% the FPL (205% FPL owing to use of modified adjusted gross income post ACA) before and after the ACA Medicaid expansion.
y
Only women with dependent children and meeting income criteria were eligible before the ACA.

modified adjusted gross income measure under ACA rules).

Medicaid women with a delivery claim to an Ohio Birth Certifi-
However, this pregnancy-eligible group of women lost
cate was 88.9% across study years. Indicators of health system
eligibility 60 days postpartum if their income was more than
use (postpartum visit attendance, receipt of contraceptive
90% of the FPL in the pre-ACA period but at the more
counseling, and use of contraceptive methods) were generated
generous cutoff of greater than 138% of the FPL in the post-
from procedure, diagnosis, and National Drug Codes recorded on
ACA period.
inpatient and outpatient encounter claims for deliveries with any
Ohio’s eligibility levels were higher than the median state’s
amount of Medicaid payment (Appendix Table 1). To capture
level both for parents (64% FPL) and for pregnant women (185%
prepregnancy and postpregnancy information and prior
FPL) before the ACA. States with lower income eligibility levels
Medicaid paid births, encounters with a date of service from
before the ACA saw greater increases in insurance for women of
January 2008 through 6 months postpartum (June 2016) were
reproductive age and, as expected, the increases were larger for
included for each Medicaid birth January 2011 through
those without dependent children (Johnston, Strahan, Joski,
December 2015. The source of last menstrual period (LMP) was
Dunlop, & Adams, 2018). It is helpful to note that a woman’s
income can change from before to after delivery for a number of
reasons (e.g., job loss, marriage) but also her income eligibility
Medicaid Deliveries, 2011 - 2015
can change owing to the change in household size, most
commonly owing to the addition of the baby to the family. We
306,737
note that there were no specific changes in the coverage of
contraceptives in Ohio’s Medicaid program before versus after
the ACA and that female Ohio Medicaid beneficiaries are eligible Deliveries to Mothers < 20 and > 44 years Excluded
for the same pregnancy services, which include education, care
265,772
coordination, counseling, high-risk monitoring, nurse midwife
services, preconception care, prenatal care, ultrasound exami-
nations, prenatal risk assessment, delivery, and transportation, Deliveries to Mothers whose eligibility is based on disability
regardless of their eligibility group (Ohio Department of Medicaid, Family Planning, Strong Start Enrollees Excluded
2020). All states are required to assess pregnancy eligible
237,091
women’s eligibility for other Medicaid coverage (e.g., coverage
based on income) as the 60-day mark approaches (Chen &
Hayes, 2020). If deemed income eligible, they will remain Deliveries from July 1, 2013, to Dec. 31, 2013, Excluded
eligible until the next recertification; in Ohio, this is 12
213,672
months. In the analysis that follows, we categorized women in
Ohio Medicaid according to whether they entered Medicaid
based on pregnancy or income eligibility, thus defining treat- Deliveries from January 1, 2014, to October 31, 2014,
and 2014 Deliveries with LMP prior to February 1, 2014, Excluded
ment and comparison groups, respectively.
172,862
Methods
Deliveries with Missing Values for Model Variables Excluded
Data
170,787 for Analysis of Enrollment
Postpartum
The Ohio Department of Medicaid and the Ohio Department
of Health granted permission for access to its electronic
Limited to Deliveries Continuously Enrolled in Medicaid Six Months Postpartum;
Medicaid enrollment and encounter records and birth certificate Women Receiving a Hysterectomy during Delivery Hospitalization Excluded
records, respectively. The study was reviewed and approved by
Institu- tional Review Boards of the Ohio Department of 138,426 for Analysis of Postpartum Service
Medicaid and Emory University (#IRB00084905). Personal Use

identifiers were used to perform a well-documented iterative Service use includes postpartum visit
matching process between Medicaid administrative records and attendance, receipt of contraceptive
yearly Ohio Birth Certificates that involved both deterministic counseling, and use of contraceptive methods.
and probabilistic matching (Baldwin, Johnson, Berthoud, & Dublin, Figure 1. Derivation of study cohort of births, January 2011 to December 2015.
2015; Campbell, Deck, & Krupski, 2008). The average match
rate of
 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435
the Ohio Birth Certificate. If the LMP date was missing on the
woman’s record, the infant’s gestational age at delivery was used
to determine LMP (9.0%). If both LMP and gestational age at
delivery were missing on birth records, the LMP was calculated
by subtracting 9 months from the infant’s date of birth (<1%).
Medicaid enrollment status was obtained from monthly
administrative eligibility records. Record matching and data
processing was completed in SAS 9.4 (SAS Institute, Cary, NC).
Study Cohort
From the files on Ohio Medicaid births January 2011 through
December 2015 we defined our cohort for studying Medicaid
enrollment postpartum, making multiple exclusions (Figure 1) to
allow for a focus on the group whose postpartum eligibility
changed under the ACA Medicaid expansion (Table 1). From the
initial count of 306,737 Medicaid paid births, we excluded
women who could have been 18 years old before pregnancy
because their eligibility was through the Medicaid/Children’s
Health Insurance Program and, thus, not affected by the ACA
Medicaid expansion. We excluded women whose Medicaid
eligibility was based on disability for the same reason. After also
excluding women in Ohio’s family planning state plan amend-
LogitDit [ b0 D b1PREGi D b2MedACA D b3ðPREGi 3 MedACAÞ D b4Xit D b5Cit D b6 D Mt D εit
ment or other programs (e.g., Strong Start) that could extend
some postpartum coverage, our cohort equaled 237,091. We then
omitted women with births that occurred in the last two quar-
ters of 2013 through October 31, 2014, and those with a date of
birth in 2014 but a LMP month before February 2014. This pro-
cess left us with a study cohort whose prepregnancy and
6 months postpartum remained fully in our study period before
(January 2011 to June 2013) or after (November 2014 to
December 2015) the enactment of the ACA’s Medicaid expansion
(N 172,862).
¼ is a vector of individual covariates including age, mother’s edu-
For these births, we identified whether women entered
Medicaid as income or pregnancy eligible, thus defining a
treatment and a comparison group. To identify the comparison
group of women who already had children and, hence, could
meet Ohio’s parental threshold for income eligibility before
pregnancy, we subset women with parity equal to one or higher
and enrolled in Medicaid the month before LMP. We identified
the remaining women as the treatment group of pregnancy-
eligible women. After excluding those with missing values for
covariates included in our models, our study cohort included
170,787 Ohio Medicaid births. For studying contraceptive plan-
ning and contraception use postpartum among this initial
cohort, we omitted those women with a hysterectomy during the
delivery admission and not continuously enrolled in Medicaid for
6 months after delivery (N ¼ 138,426).
Dependent Variables
We first examine enrollment trends for each woman by
month through 6 months (180 days) postpartum with a focus on
the change 60 days postpartum. Among those continuously
enrolled 6 months and not having a hysterectomy during the
delivery admission (N ¼ 138,426), we used procedure and
429
diagnosis codes for postpartum visits and contraceptive coun-
seling and National Drug Codes for contraceptive methods that
require prescriptions, found in the inpatient and/or outpatient
encounter claims. These codes are detailed in Appendix Table 1. We
categorized the contraceptive methods according to the World
Health Organization tiers of contraceptive effectiveness (World
Health Organization & Johns Hopkins Bloomberg School of
Public Health, 2011).
Analysis
We estimated logistic regression models using a treatment/
comparison and pre/post analysis to estimate the association of
the Medicaid ACA expansion (MedACA) with changes in the
probability of 1) being enrolled 6 months postpartum and 2) use
of services postpartum. We used multivariable logistic regression
models and a difference-in-differences approach that provides
marginal effects (Imbens, 2014). These can be interpreted as the
change in the probability of the outcome for women entering as
pregnancy eligible versus women entering as income eligible
related to the implementation of the ACA Medicaid expansion,
controlling for other important covariates. The model is shown
below.
Where D ¼ 1 if enrolled through 6 months postpartum and D
¼ 0 otherwise; PREG ¼ 1 if entered Medicaid as pregnancy
eligible and 0 if entered Medicaid as income eligible; MedACA
¼ 1 if after
the ACA and 0 otherwise; and (PREGi × MedACA) represents the
interaction term. We focus on b3 for the interaction term as the
estimated association of the ACA expansion with the change in
the probability of being enrolled continuously postpartum for
the pregnancy compared with the income-eligible group. The Xi
cation, father’s education, race/ethnicity, marital status, poor
prior outcome (includes perinatal death, small for gestational
age/intrauterine growth restricted birth), prior preterm birth,
previous Medicaid birth (Table 2), Cit¼ a vector including the
number of obstetricians/gynecologists per 10,000 women 15–
44 years and the Ohio regional code (derived from the Rural-
Urban Continuum Codes; designated as Appalachian, metropol-
itan, rural, or suburban) and season for their birth months, and
Mt ¼monthly time trend to control for secular trends affecting
both groups (e.g., employment levels). These covariates were
selected based on previous research supporting that these vari-
ables are associated with health care use and/or birth outcomes
that affect health care use postpartum (Bryant, Blake-Lamb,
Hatoum, & Kotelchuck, 2016; Lee, Steer, & Filippi, 2006; Lu &
Prentice, 2002). For the dependent variable of disenrollment in
the first 6 months postpartum, we estimate a parametric survival
analysis model with Weibull distribution; here we estimate the
odds of disenrollment. We again use the logistic model when
analyzing use of services (use of postpartum care visit, contra-
ceptive counseling, and contraceptive methods) and analyze use
separately for the pregnancy and income eligible groups.
Although we expected a differential change in disenrollment
patterns for these two groups we did not a priori expect a dif-
ferential change in the use of services while enrolled
430 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435

Table 2
Characteristics of Women with Medicaid Deliveries and Continuously Enrolled in Medicaid 180 Days Postpartum for Women Entering Medicaid as Income or Pregnancy
Eligible in Ohio Before and After the ACA Medicaid Expansion

Women With a Medicaid Birth* Continuously Enrolled in Medicaid to 180 Days Continuously Enrolled in Medicaid to 180 Days
Post Delivery, Income Eligible Post Delivery, Pregnancy Eligible

Before (2011–2013) After (2014–2015) Before (2011–2013) After (2014–2015)

N 46,428 36,603 37,521 17,874

Age (y)
20–24 42.15% 40.02%y 50.48% 45.35%y
25–34 50.83 51.94 43.21 47.17
35–44 7.02 8.04 6.31 7.49
Education of mother
Unknown 1.02 0.97y 0.71 0.88y
College graduate 2.74 3.83 6.39 8.90
Some college 37.11 37.21 42.14 41.22
High school graduate 36.23 39.69 37.53 37.67
Less than high school graduate 22.91 18.30 13.24 11.32
Education of father
Unknown 32.94 33.50y 28.24 25.98y
College graduate 2.61 3.43 4.81 7.01
Some college 17.35 18.06 22.62 23.46
High school graduate 31.45 31.88 32.55 33.45
Less than high school graduate 15.64 13.13 11.79 10.10
Race/Ethnicity
Non-Hispanic White 59.43 61.00y 68.99 67.35y
Non-Hispanic Black 34.82 32.39 24.58 22.76
Non-Hispanic other 1.59 2.41 2.26 3.82
Hispanic 4.17 4.20 4.16 6.08
Marital status
Not married 71.53 74.41y 73.13 69.93y
Married 28.47 25.59 26.87 30.07
Prior poor outcome 7.96 6.88y 6.08 4.56y
Prior preterm birth 9.21 9.30 4.08 4.19
Medicaid birth in past 3 years 51.03 43.37y 14.22 11.98y
Ohio region
Missing 1.70 1.32y 1.71 1.16y
Appalachian 12.89 12.99 13.23 12.94
Metro 64.81 63.59 61.55 55.98
Rural 10.39 10.61 11.72 13.08
Suburban 10.21 11.49 11.79 12.85
Season
Winter 26.21 27.76y 26.35 29.95y
Spring 29.44 20.54 29.57 21.56
Summer 24.36 23.28 23.97 21.67
Autumn 19.99 28.42 20.11 26.82
Obstetricians/gynecologists per women 6.44 (3.73) 6.52 (3.55) 6.20 (3.34) 6.29 (3.47)
15–44, mean (SD)

Abbreviations: ACA, Affordable Care Act; SD, standard deviation.

* Women with a Medicaid-paid delivery from January 2011 to December 2015 (quarters 3 and 4 of 2013 and January 1 to October 31 of 2014 excluded),
enrolled in Medicaid entire 180-day after the delivery period, and no hysterectomy
¼ (N 138,426).
y
p < .01, c2 test.
Authors’ analysis of 2008–2016 electronic Medicaid enrollment and encounter records and 2011–2015 birth certificate records from the Ohio Department of Medicaid
and the Ohio Department of Health.

postpartum. In these models, b3 is the estimate of the change in
the probability after versus before the ACA of using specific
services while enrolled postpartum. All analyses were conducted
using Stata 16 Statistical Software (StataCorp, 2019).
Results
Descriptive Analysis
For the pregnancy-eligible group, a total of 37,521 women
met criteria for inclusion in the analysis of service use in the pre-
ACA period and 17,874 met criteria for inclusion in the analysis in
the post-ACA period (Table 2). For the income-eligible compar-
ison group, a total of 46,428 women met criteria for inclusion in
the analysis in the pre-ACA period and 36,603 met criteria for
inclusion in the analysis in the post-ACA period.
As the data in Table 2 show, there were significant changes
in some of their characteristics from the pre-versus post-ACA
pe- riods. Women in both eligibility groups continuously
enrolled through 6 months postpartum tended to be older and
more educated after the ACA. Although the percentage of the
income eligible group that are single increased, this
percentage decreased for the pregnancy-eligible group. There
was no sig- nificant difference in the percent of women with a
prior preterm birth in the pre- and post-ACA periods for
either group, although for both groups there was a
significantly smaller percentage with a prior poor pregnancy
outcome in the post-ACA period.
Figure 2 details the percentage of women in the
pregnancy- and income-eligible groups before versus after the
ACA who remain continuously enrolled through each month
of the 180 days after delivery. As expected, for the pregnancy-
eligible women in the pre-ACA period (solid blue line), the
percentage
 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435
who were continuously enrolled decreased sharply after the
second month and decreased steadily each month thereafter,
with only 66% still enrolled at 6 months postpartum. The asso-
ciation of ACA implementation with the continuous enrollment
of the pregnancy eligible group through 6 months after delivery
is seen in the increase from 66% before the ACA to 83% after the
ACA (dashed versus solid blue line). The association of ACA
implementation with the continuous enrollment of the income-
eligible group was significant but smaller, moving from 88%
before the ACA to 93% after the ACA (seen in the dashed versus
solid green line), as expected, given that women entering
Medicaid in this eligibility group were eligible postpartum in
both the pre-ACA and post-ACA periods.
For women who remained enrolled in Medicaid after a
Medicaid birth and did not have a hysterectomy after delivery,
Table 3 shows the differences in postpartum use. A
significantly greater percentage of women in the income
eligible group had a postpartum care visit and contraceptive
counseling after the ACA but there was a significant decrease
in the use of these services among women in the pregnancy
eligible group. This pattern also held for the two groups in
their use of any contraceptive method in the post- versus pre-
ACA periods. Among those using any method there was a
significantly greater percentage of income eligible women in
the post-ACA period who used tier 1 methods (and in
particular LARC rather than sterilization methods), whereas
there was no significant change in the use of tier 1 methods for
pregnancy-eligible women after the ACA.
Multivariate Analysis
In Table 4, we present the results from the logistic and hazard
rate multivariate models, which provide different, but consistent,
Percent Continuously Enrolled in Medicaid in Months aGer Delivery
100.0%
95.0%
90.0%
85.0%
80.0%
75.0%
70.0%
65.0%
1 Month
Pregnancy Elig.: Pre-ACA 93.2%
Pregnancy Elig.: Post-ACA 94.6%
Income Elig.: Pre-ACA 99.3%
Income Elig.: Post-ACA 98.6%
Figure 2. Percent of women continuously enrolled in Medicaid through 6 months postpartum for women entering as pregnancy and income eligible, before and after the
ACA Medicaid Expansion in Ohio. Source: Authors’ analysis of 2011–2016 electronic Medicaid enrollment and encounter records and birth certificate records from the Ohio
Department of Medicaid and the Ohio Department of Health. Data shown are for births in the periods pre (January 2011–June 2013) and post (November 2014–December
431
measures of the association of the ACA expansion with contin-
uous enrollment 6 months postpartum for the pregnancy versus
the income eligible group. Each model controls for the set of
characteristics of women noted in Table 2. A complete set of
parameter estimates for both enrollment models is presented in
Appendix Table 2. Results from the logistic regression indicate a
7.70 percentage point increase in the probability of
continuous enrollment postpartum for the pregnancy-eligible
group compared with the income-eligible group. Parallel
results are seen in the adjusted hazard ratio, which shows a
29% decrease in the risk of disenrollment within 6 months
postpartum for the pregnancy eligible compared with the
income-eligible group from the pre-ACA to the post-ACA
periods.
In Table 5, we present the marginal effects from the
logistic regressions comparing service use after versus before
the ACA of women during the delivery hospitalization and
within 6 months (180 days) postpartum. For the pregnancy
eligible group, there was a significant 1.27 percentage point
decrease in the receipt of contraceptive counseling and no
change in the percentage receiving a postpartum visit. In
contrast, there was a significant 2.04 percentage point
increase in their use of LARC methods. This increase was seen
despite there being no sig- nificant change in the use of tier 1
methods overall among the pregnancy-eligible group owing to
a decrease in sterilization among these women.
For the income-eligible group, those enrolled through
6 months postpartum had statistically significant increases in
the likelihood of a postpartum visit (of 5.09 percentage
points) and in the likelihood of use of tier 1 methods (4.25
percentage points). The latter was primarily driven by a
significant increase in the likelihood of use of LARC methods
of 4.91 percentage points for the income eligible women in
the post- vs pre-ACA
2 Months 3 Months 4 Months 5 Months 6 Months
91.9% 81.0% 72.9% 69.1% 65.8%
93.0% 90.5% 88.1% 85.3% 82.7%
98.5% 95.4% 92.4% 90.2% 88.2%
97.8% 96.6% 95.4% 94.2% 93.0%
2015) ACA Medicaid expansion implementation.
432 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435

Table 3
Enrollment and Postpartum Care and Contraception Use among Women Entering Medicaid as Income or Pregnancy Eligible in Ohio Before and After the ACA Medicaid
Expansion

Women with a Medicaid Birth* Delivery to 180 Days, Income Eligible Delivery to 180 Days, Pregnancy Eligible

Before (2011–2013) After (Nov 2014–2015) Before (2011–2013) After (Nov 2014–2015)

Continuous enrollment in Medicaid

N 46,428 36,603 37,521 17,874
Percent 88.17 92.97y 65.79 82.71y
Use of care
Postpartum care visit 31.54% 37.12%y 32.22% 30.53%y
Contraceptive counseling 6.11 6.87y 5.69 5.70
Use of contraceptive methods z
15.02 16.74y 12.33 11.78
Tier 1
22.25 22.40 24.68 23.36y
Tier 2
0.32 0.21y 0.27 0.16x
Tier 3/4 2.84 3.82y 2.70 2.88
Tier unspecified 40.43 43.17y 39.98 38.17y
Any method
Subsets of tier 1 7.14 9.74y 7.72 7.85
LARC 7.98 7.09y 4.67 3.98x
Sterilization
Abbreviation: ACA, Affordable Care Act; LARC, long-acting reversible contraception.
* Women with a Medicaid-paid delivery ending in live birth from January 2011 to December 2015 (quarters 3 and 4 of 2013 and January 1 to October 31 of
2014 excluded), enrolled in Medicaid entire 180 day post delivery period, and no hysterectomy.
y
p < .01, c2 test.
z
World Health Organization (WHO) tiers of Contraceptive Effectiveness (from Johns Hopkins Bloomberg School of Public Health/Center for Communication
Programs and World Health Organization. Family planning: a global handbook for providers 2011 Update. 2011): tier 1 (high effectiveness) includes sterilization
(permanent), implants (long-acting reversible), and intrauterine devices (long-acting reversible); tier 2 (medium effectiveness) includes injectable methods, vaginal
ring, patch, and oral contraceptive pills; tiers 3 and tier 4 (low effectiveness) include condoms, diaphragms, fertility awareness methods, and spermicide.
x
p < .05, c2 test.
Authors’ analysis of 2008–2016 electronic Medicaid enrollment and encounter records and 2011–2015 birth certificate records from the Ohio Department of
Medicaid and the Ohio Department of Health.

periods, whereas there was no significant change in their use of

income eligibility criteria for Medicaid. Thus, these women were
sterilization methods.
less likely to experience disruptions in coverage.
Coverage disruption, known as churning, is frequent among
Discussion
Medicaid enrollees (Klein, Glied & Ferry, 2005) as individuals
and families experience changes in their lives that affect both
This study demonstrates that in Ohio, a state that expanded
their income and other eligibility criteria. Such coverage
Medicaid under the ACA, there was a higher retention of women
disruptions are linked with decreased or delayed health care use
with a Medicaid paid birth continuously through 6 months
(Banerjee, Ziegenfuss, & Shah, 2010). Importantly, the extension
postpartum in the post- versus pre-ACA period, with a greater
of Medicaid coverage following delivery allows women to access
impact on women entering as pregnancy eligible compared with
postpartum care recommended by the American College of Ob-
income eligible. These findings demonstrate that in the post-
stetricians and Gynecologists and other groups (American College
compared with pre-ACA period, a greater proportion of the
of Obstetricians and Gynecologists, 2018) and is recog- nized as
women who entered Medicaid as pregnancy eligible were able to
essential to ensuring access to screening and treatment for
retain their Medicaid coverage beyond the 60 days postpartum
postpartum depression and chronic health conditions. Whereas
because, upon recertification, they satisfied the more generous
Goldman and Sommers (2019) found a decrease in

Table 4
Adjusted Marginal Effect for Enrollment and Hazard Ratio for Disenrollment 6 Months Postpartum Among Women 20 to 44 With Medicaid Paid Delivery Who
Entered Medicaid as Pregnancy Eligible Versus Income Eligible in Ohio Before and After the ACA Medicaid Expansion

DV ¼ Enrolled 6 Months DV ¼ Dise nrollment

N ¼ 170,787* N ¼ 170,7 87*

Adjusted Marginal Effectsy Adjusted Hazard Ratiosz

Interaction
Preg Elig × Post MedACA 7.70x 0.71x

Abbreviation: ACA, Affordable Care Act; DV, dependent variable.

Note: Logistic and hazard rate regressions are adjusted for mother’s age, mother’s education, father’s education, race/ethnicity, marital status, poor prior outcome,
prior preterm birth, previous Medicaid birth, obstetricians/gynecologists per women 15–44, Ohio regional code, seasonality, and monthly time trend.
* Women with a Medicaid-paid delivery from January 2011 to December 2015 (quarters 3 and 4 of 2013 and January 1 to October 31 of 2014 excluded).
y
Logit regression with STATA margins command. Marginal effect indicates the percent point change in the probability of the outcome.
z
Parametric survival analysis model with Weibull distribution. Cox proportional hazards assumption failed. A ratio of <1 indicates a lower odds of the outcome
(disenrollment).
x
p < .01.
Authors’ analysis of 2008–2016 electronic Medicaid enrollment and encounter records and 2011–2015 birth certificate records from the Ohio Department of Medicaid
and the Ohio Department of Health.
 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435 433

Table 5
Adjusted Marginal Effects for Postpartum Service and Contraception Use Among Women 20–44 With Medicaid Paid Delivery by Eligibility Group in Ohio Before and
After the ACA Medicaid Expansion

Income EligiblePregnancy Eligible

During Delivery Hospitalization or 1–180 Days after DeliveryDuring Delivery Hospitalization or 1–180 Days after Delivery
N ¼ 83,031*N ¼ 55,395*
Post 2014–2015Post 2014–2015

Preventive care
Postpartum visit 5.09y –0.16
Contraceptive counseling –0.52 –1.27z
Contraceptives
Tier 1 4.25y 1.28
Tier 2 –3.97y 0.83
Tier 3/4 0.05 0.02
Any method 0.25 0.70
Subsets of tier 1
LARC 4.91y 2.04y
Sterilization –0.50 –0.61

Abbreviation: ACA, Affordable Care Act; LARC, long-acting reversible contraception.

Note: Logistic regressions are adjusted for mother’s age, mother’s education, father’s education, race/ethnicity, marital status, poor prior outcome, prior preterm
birth, previous Medicaid birth, obstetricians/gynecologists per women 15–44, Ohio regional code, seasonality, and monthly time trend.
* Women with a Medicaid-paid delivery ending in live birth from January 2011 to December 2015 (quarters 3 and 4 of 2013 and January 1 to October 31 of
2014), enrolled in Medicaid entire 180-day postdelivery period, and no hysterectomy.
y
p < .01.
z
p <.05.
Authors’ analysis of 2008–2016 electronic Medicaid enrollment and encounter records and 2011–2015 birth certificate records from the Ohio Department of Medicaid
and the Ohio Department of Health.

coverage disruptions for nonpregnant low-income adults after insurance

ACA implementation, the present research suggests the ACA also
helped to decrease churn among postpartum women.
We also found that higher retention of women in Medicaid
following delivery was associated with greater use of post-
partum services. This finding held, however, only among
women eligible based on income. Income-eligible women may
develop and keep a usual source of care from their
prepregnancy and prenatal periods that women entering as
pregnancy eligible cannot achieve. It may also be that
pregnancy-eligible women seek care but encounter barriers to
accessing services if Medicaid provider capacity is insufficient
to meet the growing demand. Earlier findings on the ACA
and women’s access to and use of services are mixed
(Johnston et al., 2018; Simon, Soni, & Cawley, 2017). More data
on the extent to which Medicaid expansions may have
resulted in overcrowded provider networks, especially those
for pregnant women, is warranted (Miller & Wherry, 2017).
This study also demonstrates that the ACA Medicaid expan-
sion in Ohio was associated with an increased use of tier 1
LARC methods by women in the 6 months postpartum for
those entering as pregnancy eligible and income eligible,
albeit with a greater increase for those in the latter group.
Although the estimated percentage increase in use of LARCs
was small, the increased probability of remaining enrolled
and the large num- ber of women affected means the
increased use of LARCs trans- lates into many more women
with better protection against unintended pregnancies. The
postpartum period is an important window of opportunity for
initiating contraception because women are motivated to
prevent unintended pregnancy and short interpregnancy
intervals (Teal, 2014; Zapata et al., 2015), both of which
increase the risk for adverse maternal and infant health
outcomes (Gemmill & Lindberg, 2013) and are much more
likely to occur among women who do not initiate
contraception (Rigsby, Macones, & Driscoll, 1998; Rodriguez,
Evans, & Espey, 2014). Extending the period of public health
coverage postpartum is important, considering that health
in- surance coverage is an important antecedent of
consistent use of contraception (Secura, Allsworth, Madden,
Mullersman, & Peipert, 2010). Improving the postpartum
initiation of effective methods, including tier 1 LARC
methods, is recognized as a key strategy for reducing
unintended pregnancy, short interpreg- nancy intervals, and
adverse maternal and infant health out- comes (Moniz,
Chang, Heisler, & Dalton, 2017).

Limitations

As with any research that uses claims data, this study was
only able to evaluate contraceptive methods, procedures, and
health services that were coded by the health care provider and
reimbursed by health care insurance (Medicaid); contraceptive
methods and other services that were used but not covered at
all, or obtained outside of the insurance plan, are not
represented in the data. Some contraceptive methods,
especially those in World Health Organization tiers 3 and 4
(including condoms), might be obtained by women from
outside the clinical setting and thus not be identified in the
administrative claims data. Findings from this study cannot
necessarily be extrapolated to other states that have expanded
Medicaid under the ACA or later because Ohio had higher than
average eligibility levels before the ACA.

Implications for Practice and/or Policy

In Ohio, the ACA Medicaid expansion and the mandates of

coverage of contraceptive services and methods appear to work
together to improve access to these and other needed services
in the critical postpartum period. Future research on the
Medicaid expansion population in Ohio should examine the
possible as- sociation between the expansion and outcomes
such as preg- nancy intendedness, birth spacing, birth
outcomes (including preterm and low birth weight births), and
maternal and infant
434 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435
mortality. However, to investigate these outcomes, additional
years after implementation are necessary to follow women over
a longer postpartum period and achieve sufficient sample sizes.
Our findings indicate that greater retention of women in
Medicaid postpartum increases insurance coverage and serves to
increase use of needed health care. One way to further maximize
insurance coverage for low-income women in Ohio is for pro-
viders, social workers, and navigators to ensure that women who
lose pregnancy Medicaid eligibility are aware of their options,
which likely include income-based Medicaid eligibility or Ohio’s
federally facilitated Marketplace. In turn, the supply of Medicaid
participating providers willing to serve the increased number of
women enrolled postpartum should be monitored for its
adequacy.
Conclusions
This study shows the expected higher retention of women
with a Medicaid paid birth in the Medicaid program continu-
ously through 6 months postpartum in the post- versus pre-
ACA Medicaid expansion implementation period. The
association of the expansion with continuous enrollment
through 6 months postpartum was significantly greater for
those entering Medicaid as pregnancy eligible compared with
those entering as income eligible. However, those who
entered Medicaid based on preg- nancy and remained
enrolled at 6 months postpartum did not exhibit increased
postpartum visits after the expansion, whereas those who
entered Medicaid based on income eligibility and remained
enrolled at 6 months postpartum did. Both groups
experienced a significant increase in the percentage using tier
1 LARC methods in the 6 months postpartum, with a
substantially greater percentage point increase for the
income-eligible versus the pregnancy-eligible group.
Supplementary Data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.whi.2020.08.006.
References
Adams, E. K., & Johnston, E. M. (2016). Insuring women in the United States
before, during, and after pregnancies. American Journal of Public Health,
106(4), 585–586.
Adams, E. K., Dunlop, A. L., Strahan, A. E., Joski, P., Applegate, M., & Sierra, E.
(2019). Prepregnancy insurance and timely prenatal care for Medicaid
births: Before and after the Affordable Care Act in Ohio. Journal of Women’s Health,
28(5), 654–664.
American College of Obstetricians and Gynecologists (ACOG). (2018). Optimizing
postpartum care. ACOG Committee Opinion. Obstetrics & Gynecology, 131, e140–
e150.
Appareddy, S., Pryor, J., & Bailey, B. (2017). Inter-pregnancy interval and
adverse outcomes: Evidence for an additional risk in health disparate populations.
Journal of Maternal-Fetal & Neonatal Medicine, 30(21), 2640–2644.
Baldwin, E., Johnson, K., Berthoud, H., & Dublin, S. (2015). Linking mothers and
infants within electronic health records: A comparison of deterministic and
probabilistic algorithms. Pharmacoepidemiology and Drug Safety, 24(1), 45–
51.
Banerjee, R., Ziegenfuss, J. Y., & Shah, N. D. (2010). Impact of discontinuity in
health insurance on resource utilization. BMC Health Services Research,
10(1), 195.
Becker, N. (2018). The impact of insurance coverage on utilization of prescription
contraceptives: Evidence from the Affordable Care Act. Journal of Policy
Analysis and Management, 37(3), 571–601.
Bryant, A., Blake-Lamb, T., Hatoum, I., & Kotelchuck, M. (2016). Women ’s use of
health care in the first 2 years postpartum: Occurrence and correlates.
Maternal and Child Health Journal, 20(1), 81–91.
Campbell, K. M., Deck, D., & Krupski, A. (2008). Record linkage software
in the public domain: A comparison of Link Plus, The Link King, and
a basic deterministic algorithm. Health Informatics Journal, 14(1), 5– 15.
Carlin, C. S., Fertig, A. R., & Dowd, B. E. (2016). Affordable Care Act’s mandate
eliminating contraceptive cost sharing influenced choices of women with
employer coverage. Health Affairs, 35(9), 1608–1615.
Centers for Medicare and Medicaid Services. (2015). FAQs About Affordable Care
Act Implementation (Part XXVI). Baltimore, MD: Centers for Medicare and
Medicaid Services.
Chen, A., & Hayes, E. (2020). Q & A on pregnant women’s coverage under
Medicaid and the ACA. Available: https://healthlaw.org/resource/qa-on-
pregnant-womens-coverage-under-medicaid-and-the-aca/. Accessed: July
16, 2020.
Clapp, M. A., James, K. E., Kaimal, A. J., & Daw, J. R. (2018). Preconception coverage
before and after the Affordable Care Act Medicaid expansions. Obstetrics &
Gynecology, 132(6), 1394–1400.
Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-
related mortality in the United States, 2011-2013. Obstetrics & Gynecology,
130(2), 366–373.
Culwell, K. R., & Feinglass, J. (2007). The association of health insurance with use
of prescription contraceptives. Perspectives on Sexual and Reproductive
Health, 39(4), 22–230.
Daw, J. R., Hatfield, L. A., Swartz, K., & Sommers, B. D. (2017). Women in the
United States experience high rates of coverage ‘churn’ in months before and
after childbirth. Health Affairs, 36(4), 598–606.
Gemmill, A., & Lindberg, L. D. (2013). Short interpregnancy intervals in the
United States. Obstetrics and Gynecology, 122(1), 64.
Goldman, A. L., & Sommers, B. D. (2019). Among low-income adults enrolled in
Medicaid, churning decreased after the Affordable Care Act. Health Affairs,
39(1), 85–93.
Guttmacher Institute. (2018). Contraceptive use in the United States.
Available: www.guttmacher.org/fact-sheet/contraceptive-use-united-states.
Accessed: October 29, 2019.
Gordon, S. H., Sommers, B. D., Wilson, I. B., & Trivedi, A. N. (2020). January).
Effects of Medicaid expansion on postpartum coverage and outpatient uti-
lization. Health Affairs, 39(1), 77–84.
Henry J. Kaiser Family Foundation. (2020a). Medicaid Income eligibility limits for
parents, 2002-2020. Available: http://www.kff.org/medicaid/state-indicator/
medicaid-income-eligibility-limits-for-parents/?currentTimeframe 0&sort ¼
Model %7BcolId:Location,sort:asc%7D.
¼ Accessed: June 3, 2020.
Henry J. Kaiser Family Foundation. (2020b). Medicaid and CHIP income eligibility
limits for pregnant women, 2003-2020. Available: http://www.kff.org/
medicaid/state-indicator/medicaid-and-chip-income-eligibility-limits-for-
pregnant-women/?currentTimeframe=0&sortModel=%7B%22colId%22:%22
Location%22,%22sort%22:%22asc%22%7D. Accessed: June 3, 2020.
Henry J. Kaiser Family Foundation. (2020c). Status of states Medicaid expansion
decisions: Interactive map. Available: www.kff.org/medicaid/issue-brief/ status-
of-state-medicaid-expansion-decisions-interactive-map/. Accessed: January 16,
2020.
Imbens, G. (2014). Instrumental variables: An econometrician’s perspective. Na-
tional Bureau of Economic Research. Available: www.nber.org/papers/
w19983. Accessed: September 11, 2020.
Johnston, E. M., & Adams, E. K. (2017). State prescription contraception insurance
mandates: Effects on unintended births. Health Services Research, 52(6 Part
1), 1970–1995.
Johnston, E. M., Strahan, A. E., Joski, P., Dunlop, A. L., & Adams, E. K. (2018).
Impacts of the Affordable Care Act’s Medicaid expansion on women of
reproductive age: Differences by parental status and state policies. Women’s
Health Issues, 28(2), 122–129.
Klein, K., Glied, S., & Ferry, D. (2005). Entrances and exits: Health insurance
churning, 1998–2000. Issue Brief (Commonwealth Fund), 855(1), 12.
Kost, K., Finer, L. B., & Singh, S. (2012). Variation in state unintended pregnancy
rates in the United States. Perspectives on Sexual and Reproductive Health,
44(1), 57–64.
Lee, S. J., Steer, P. J., & Filippi, V. (2006). Seasonal patterns and preterm birth: A
systematic review of the literature and an analysis in a London-based cohort.
BJOG: An International Journal of Obstetrics & Gynaecology, 113(11), 1280–
1288.
Lu, M. C., & Prentice, J. (2002). The postpartum visit: Risk factors for nonuse and
association with breast-feeding. American Journal of Obstetrics and
Gynecol- ogy, 187(5), 1329–1336.
McMorrow, S., & Kenney, G. (2018). Despite progress under the ACA, many new
mothers lack insurance coverage. Health Affairs Blog. Available: https://
www.healthaffairs.org/do/10.1377/hblog20180917.317923/full/. Accessed:
September 11, 2020.
Miller, S., & Wherry, L. R. (2017). Health and access to care during the first 2 years
of the ACA Medicaid expansions. New England Journal of Medicine, 376(10),
947–956.
Moniz, M., Chang, T., Heisler, M., & Dalton, V. K. (2017). Immediate postpartum
long acting reversible contraception: The time is now. Contraception, 95(4),
335.
 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435
Ohio Department of Medicaid. (2020). Ohio Medicaid covered services: Preg-
nancy. Available: https://medicaid.ohio.gov/FOR-OHIOANS/Covered-
Services#1683594-pregnancy. Accessed: July 20, 2020.
Patient Protection and Affordable Care Act. (2010). Public Law, 111(48), 759–762.
Available: http://www.alpinehr.com/news/PPACA.pdf. Accessed: September 11,
2020.
Ranji, U., Bair, Y., & Salganicoff, A. (2016). Medicaid and Family Planning: Back-
ground and Implications of the ACA. February 2016 Issue Brief. Henry J. Kaiser
Family Foundation. Available: www.kff.org/womens-health-policy/issue-
brief/medicaid-and-family-planning-background-and-implications-of-the-
aca/. Accessed: November 11, 2019.
Ranji, U., Gomez, I., & Salganicoff, A.. Expanding postpartum Medicaid coverage.
May 2019 Issue Brief. Henry J. Kaiser Family Foundation. Available: https://
firstfocus.org/wp-content/uploads/2019/11/Issue-Brief-Expanding- Postpartum-
Medicaid-Coverage.pdf. Accessed: January 17, 2020.
Redd, S. K., & Hall, K. S. (2019). Medicaid family planning expansions: The effect
of state plan amendments on postpartum contraceptive use. Journal of
Women’s Health, 28(4), 551–559.
Rigsby, D., Macones, G., & Driscoll, D. (1998). Risk factors for rapid repeat
pregnancy among adolescent mothers: A review of the literature. Journal of
Pediatric and Adolescent Gynecology, 11(3), 115–126.
Rodriguez, M. I., Evans, M., & Espey, E. (2014). Advocating for immediate post-
partum LARC: Increasing access, improving outcomes, and decreasing cost.
Contraception, 90(5), 468–471.
Secura, G. M., Allsworth, J. E., Madden, T., Mullersman, J. L., & Peipert, J. F. (2010).
The Contraceptive CHOICE Project: Reducing barriers to long-acting
reversible contraception. American Journal of Obstetrics & Gynecology, 203(2),
115.e111–115.e117.
Simon, K., Soni, A., & Cawley, J. (2017). The impact of health insurance on pre-
ventive care and health behaviors: Evidence from the first two years of the ACA
Medicaid expansions. Journal of Policy Analysis and Management, 36, 390–417.
StataCorp. (2019). Stata statistical software: Release 16. College Station, TX: Sta-
taCorp LLC.
Stuebe, A., Moore, J. E., Mittal, P., Reddy, L., Low, L. K., & Brown, H. (2019).
Extending Medicaid coverage for postpartum moms. Available: https://
www.healthaffairs.org/do/10.1377/hblog20190501.254675/full/. Accessed:
October 23, 2019.
Teal, S. B. (2014). Postpartum contraception: Optimizing interpregnancy in-
tervals. Contraception, 89(6), 487–488.
U.S. Supreme Court. (2012). 567 U.S. Available: www.supremecourt.gov/
opinions/11pdf/11-393c3a2.pdf. Accessed: June 1, 2019.
Walls, J., Gifford, K., Ranji, U., Salganicoff, A., & Gomez, I. (2016). Medicaid
coverage of family planning benefits: Results From a state survey. Washington,
DC: Kaiser Family Foundation.
435
Wherry, L. R. (2018). State Medicaid expansions for parents led to increased
coverage and prenatal care utilization among pregnant mothers. Health
Services Research, 53(5), 3569–3591.
White, K., Teal, S. B., & Potter, J. E. (2015). Contraception after delivery and short
interpregnancy intervals among women in the United States. Obstetrics and
Gynecology, 125(6), 1471.
World Health Organization (WHO)Johns Hopkins Bloomberg School of Public
Health. (2011). Family planning: A global handbook for providers (2011 up-
date). Baltimore, MD; Geneva, Switzerland: Author.
Zapata, L. B., Murtaza, S., Whiteman, M. K., Jamieson, D. J., Robbins, C. L.,
Marchbanks, P. A., & Curtis, K. M. (2015). Contraceptive counseling and
postpartum contraceptive use. American Journal of Obstetrics & Gynecology,
212(2), 171.e171–171.e178.
Zephyrin, L., Coleman, A., Nuzum, R., & Getachew, Y. (2019). Increasing post-
partum Medicaid coverage could reduce maternal deaths and improve
outcomes. To the Point. Available: www.commonwealthfund.org/blog/2019/
increasing-postpartum-medicaid-coverage. Accessed: January 18, 2020.
Author Descriptions
Anne Lang Dunlop, MD, MPH, is a Professor in the Nell Hodgson School of
Medicine and a board-certified family physician and preventive medicine
physician. Her research focuses on the biological determinants of adverse birth
outcomes and effectiveness of interventions.
Peter Joski, MSPH, is a data analyst in the Department of Health Policy and Man-
agement in the Rollins School of Public Health, with extensive experience creating
analytic files, linking data, and providing statistical programming for health ser-
vices research.
Andrea E. Strahan, PhD, is a recent graduate from the Department of Health
Policy and Management in the Rollins School of Public Health. Her current
research is focused on maternal and child health.
Erica Sierra, PhD, is a lead employer group consultant at Medical Mutual of Ohio.
She is a highly experienced analyst with a demonstrated ability to work with big
data in the public health and health policy field.
E. Kathleen Adams, PhD, is a Professor in the Rollins School of Public Health. Her
research focuses on the application of economic tools and health services research
in the analysis of policies affecting low-income and vulnerable populations.