Comment
New WHO antenatal care model—quality worth paying for?
The 2016 WHO guidelines on antenatal care1 were
published earlier this month and are widely welcomed
because they are not only academically robust, but
also relevant to end-users and patients. The guidelines
cover antenatal care for normal pregnancies and have
adopted a woman-centred, holistic approach to care.
They cover nutritional interventions, maternal and
fetal assessment, preventive measures, interventions
for common physiological pregnancy symptoms,
and health systems interventions to improve the use
and quality of antenatal care. The guidelines address
antenatal evidence-based practices that improve
outcomes and detail how these practices should be
delivered. In addition to standard antenatal medical
advice, the 49 recommendations include guidance
on psychological support, nutrition, and domestic
violence screening. Each recommendation is backed
up with an evidence review, generally based upon
systematic reviews conducted by the Cochrane
Collaboration. But even with the most rigorous
analyses of the evidence, there are conflicting opinions
as to how to deal with some of the results, and what
to recommend when there is very limited evidence
to support or reject common practice. The WHO
antenatal care Guideline Development Group (GDG) is
to be congratulated for putting into practice the old
adage that “no evidence of benefit is not the same as
evidence of no benefit”. So in symphysis-fundal height
measurement, for example, where there is limited
Sven Torfinn/Panos
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evidence for its benefit, they do not discard it but
recommend that clinicians continue whatever is their
current practice.
Some of the recommendations might come as
a surprise to clinicians, for example, the use of
acupuncture as an option for early pregnancy nausea
or low back pain during pregnancy, or magnesium
or calcium supplements for the treatment of leg
cramps. Other recommendations represent a shift
from the traditional model of antenatal care, such as
the recommendations for caseload/team midwifery or
group antenatal care in settings with well developed
midwifery systems. Others represent a matter of
judgment, including the recommendation for one
routine ultrasound scan performed before 24 weeks
of gestation to estimate gestational age, improve
detection of fetal anomalies and multiple pregnancies,
reduce induction of labour for post-term pregnancy,
and improve a woman’s pregnancy experience. The
choice of timing of this single scan has little evidence
behind it, but a late second trimester scan is too late for
accurate dating and too early for accurate placental site
localisation or for detection of fetal growth restriction.
The GDG has partly justified this timing so as to detect
congenital abnormalities, even though there are
few interventions available for this to change fetal
outcome other than pregnancy termination. As such,
the detection of fetal abnormalities is rarely a priority
in resource constrained settings and, by 24 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 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 and parous women with
the initial contact in the first trimester, two contacts
in the second trimester, and five contacts scheduled
from ClinicalKey.com
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Vol 388 Novemberon March 27,
26, 2016

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
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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.
27,
 Correspondence

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.
In 2006, WHO initially set the
threshold for density of health
workers at 2∙28 per 1000 population
as the benchmark to ensure cov­e­
rage of skilled birth attendance of
80% or more.4 In 2016, WHO revised
the threshold to 4∙45 per 1000 popu­
lation as the benchmark to ensure
50th percentile of composite index
of skilled birth attendance coverage
and 11 additional SDG monitoring
indicators.5 As a result, two of 12 SDG
monitoring indicators embedded
into the composite index are those
related to maternal health—ie,
coverage of skilled birth attendance
and at least four antenatal care visits.
A change in the minimum number of
antenatal care contacts from four to
eight will demand an increase in the
number of health workers.
WHO should further revise the
current threshold for density of health
workers in response to the increase in
the minimum number of antenatal
care contacts. The two international
norms (ie, minimum number of ante­
natal care contacts and threshold for
3 WHO. Global Health Observatory data
repository. Geneva: World Health Organization,
2018. http://apps.who.int/gho/data/node.
main.HWF (accessed Oct 17, 2019).
4 WHO. The World Health Report 2006-working
together for health. Geneva: World Health
Organization, 2006. https://www.who.int/
whr/2006/en/ (accessed Oct 17, 2019).
5 WHO. Global strategy on human resources for
health: Workforce 2030. Geneva: World Health
Organization, 2016. https://www.who.int/hrh/
resources/globstrathrh-2030/en/ (accessed
Oct 17, 2019).
Cigarette prices,
smuggling, and deaths
in France and Canada
Tripling real cigarette prices would
approximately halve cigarette con­ Submissions should be
made via our electronic
sumption worldwide.1 Although high
submission system at
excise taxes could increase smug­ http://ees.elsevier.com/
gling, weak customs enforcement thelancet/
A Cigarettes per adult per day, relative price: France
Sales, legal and contraband
Sales, contraband
Price index
6
400

Real price index (1980=100)

Cigarettes per adult per day

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
5
density of health workers) published 4 300
by WHO in 2016 are likely to be neither
3
coordinated nor consistent. Generally 200
WHO’s recommendations are highly 2
100
influential to the health policies of 1
a country. Thus, WHO must ensure 0 0
consistency in the international norms
and standards across its guidelines B Cigarettes per adult per day, relative price: Canada
to avoid disseminating conflicting 12
Effects of organised
400
messages, or their reliability will be smuggling
Real price index (1980=100)
Cigarettes per adult per day

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 question remains, has the global
threshold set by WHO been designed to
ensure eight antenatal care contacts?
10
questioned and ultimately damaged. 8 300
I declare no competing interests.
6
200
Hirotsugu Aiga
aiga.hirotsugu@jica.go.jp
4
100
2
Human Development Department, Japan
International Cooperation Agency, Tokyo 102-8012, 0 0
Japan; and Department of Global Health, Milken 1950 1960 1970 1980 1990 2000 2010 2020
Year
Institute School of Public Health, The George
Washington University, Washington, DC, USA
Figure: Real price of cigarettes and consumption per adult per day in France and
1 WHO. WHO recommendations on antenatal
care for a positive pregnancy experience.
Canada since 1950
The real price index represents prices, adjusted for inflation, as a percentage of 1980
Geneva: World Health Organization, 2016.
prices.3,4 For France, consumption includes only manufactured cigarettes until 1989,
https://www.who.int/reproductivehealth/
publications/maternal_perinatal_health/anc- then manufactured and grams of fine-cut tobacco from 1990 to 2018, and smuggled
positive-pregnancy-experience/en/ (accessed 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
Oct 17, 2019).
2 Ministry of Health. National health facility fine-cut tobacco from 1974 to 2015) and estimated smuggled cigarettes (about
census analytical report. Lusaka: Ministry of 34 billion sticks from 1990 to 1994).5 Smuggled cigarettes between 1995 and 2002 were
Health, 2019. estimated using the average ratio of legal to smuggled cigarettes for 1994 and 2003.

www.thelancet.com Vol 395

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 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
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.

This document reflects emerging clinical and scientific advances on 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 opin-
ions. 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.
Women 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 tai-
lored to their needs. The values, beliefs and individual needs of each woman and her family should be sought and the final decision about the
care and treatment options chosen by the woman should be respected.

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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
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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
Indonesia fromJOGCClinicalKey.com by Elsevier
DÉCEMBRE 2017on•March
e55927,
 SOGC REAFFIRMED GUIDELINES
providers have identified many challenges including deter-
mining and accepting risk, obtaining and maintaining
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
4. While local access to surgical and anaesthetic ser-
vices is desirable, there is evidence that good outcomes
can be sustained within an integrated perinatal care
system without local access to operative 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.
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 consequences.5 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 what should be a joyful period
in their lives.5 They may be overwhelmed by the need to navi-
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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
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.
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, 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
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
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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.
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DÉCEMBRE 2017on•March
e56127,
 SOGC REAFFIRMED GUIDELINES
Recommendations
6. Innovative interprofessional models should be imple-
mented 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 fundamental part of gen-
eralist rural nursing skills.
8. Remuneration for maternity care providers should
reflect the unique challenges and increased profes-
sional responsibility faced by providers in rural settings.
Remuneration models should facilitate interprofessional
collaboration.
Newborn Care
Newborn care is an important part of any maternity care
system. Approximately 10% of newborns will require re-
suscitation, and 1% will require extensive resuscitation, with
at least one half of these cases being unexpected.45 Cana-
dian guidelines recommend that “all health care facilities
providing care for newborn infants must be able to resus-
citate and stabilize such infants until transfer to another
appropriate facility” and that such care should be multidis-
ciplinary and provided by trained staff with access to ongoing
education and training.46 In rural and remote settings,
however, specialized pediatric and neonatal staff are rare.
There is limited evidence regarding providers and out-
comes of neonatal resuscitation in rural Canada, but some
research suggests that levels of training and skill levels are
lower than in larger centres.47,48 This gap, along with lower
birth volumes and less access to specialized practitioners (e.g.,
respiratory therapy), highlights the increased need for local
access to quality training and quality assurance programs in
rural communities.
Recommendation
9. Practitioners skilled in neonatal 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
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experiences, but without them the strong base of generalism
that rural health care is built on will be lost. The last
decade has seen the opening of numerous new rural and
northern training sites that bring increased 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 optional skill for family
medicine residents.53 To date, the Canadian family medi-
cine residency curriculum has resisted similar streaming,
instead insisting that all residents should be competent in
normal vaginal deliveries.54
Access to additional training in advanced skills, including
Caesarean section and obstetrical anaesthesia, is essential.
Rural track maternity programs and fellowships in mater-
nity care have been shown to increase the number of new
physician graduates offering maternity care.55,56 Currently
training in performing Caesarean section is provided for
family physicians at several residency sites in Canada. Train-
ing in broader general surgical skills is more difficult to access.
Those wishing to train as GP-anaesthetists have access at
many sites to third year programs accredited by the College
of Family Physicians of Canada; the standards for these pro-
grams are set by the Canadian Anesthesiologists’ Society and
the Society of Rural Physicians of Canada. Enhanced skills
training for family physicians remains critical for rural ma-
ternity care.
Recommendations
10. Training of rural maternity health care providers
should include collaborative practice as well as the
necessary clinical skills and competencies. Sites must
be developed and supported to train midwives, nurses,
and physicians and provide them with the skills nec-
essary for rural maternity care. Training in rural and
northern settings must be supported.
11. Generalist skills in maternity care, surgery, and an-
aesthesia are valued and should be supported in
training programs in family medicine, surgery, and an-
aesthesia as well as nursing and midwifery.
12. All physicians and nurses should be exposed to ma-
ternity care in their training, and basic competencies
should be met.

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.
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No. 282-Rural Maternity Care
Recommendations
13. Quality improvement and outcome monitoring should
be integral to all maternity care services.
14. Support must be provided for ongoing, collabora-
tive, interprofessional, and locally provided continuing
education and patient safety programs.
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.
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No. 282-Rural Maternity Care
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e56527,
 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 (SOGC)’s
Key Words: Attendance, resources, delivery, maternity care
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)
The College of Family Physicians of Canada (CFPC)
CHANGES IN PRACTICE
The Canadian Association of Midwives (CAM) 1. Clearer definition of levels of care across Canada
The Canadian Anesthesiologists’ Society (CAS) has reviewed the 2. Need for Enhanced skills for surgery for remote areas of the
Consensus Statement involving anaesthesiologists. country
The section related to paediatricians in this Consensus Statement 3. Update on documentation and risk areas
was reviewed by members of the Canadian Paediatric Society’s 4. More appropriate cases kept at various levels of care
Fetus and Newborn Committee.
This Consensus Statement supersedes the original version
(No. 89) that was published in May 2000.
Linda Stirk, MDCM, PhD, Toronto, ON
Jude Kornelsen, PhD, Vancouver, BC OBJECTIVE

he objective of this document is to improve obstetri-

T cal and neonatal care by ensuring all pregnant women
are aligned with appropriate resources, personnel, and
facilities to encourage safe normal physiological birth in a
family-centred environment as close to home as possible
J Obstet Gynaecol Can 2019;41(5):688−696
for both rural and urban communities.
https://doi.org/10.1016/j.jogc.2018.12.003
© 2019 The Society of Obstetricians and Gynaecologists of Canada/La
Société des obstétriciens et gynécologues du Canada. Published by 1. It outlines minimum standards of care for various types of
Elsevier Inc. All rights reserved. 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.

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 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
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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
MAY JOGC
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 SOGC CONSENSUS STATEMENT
or a birth outside the community should transfer 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
regional network of referral and support. This system
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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
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.
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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.
MAY JOGC
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 SOGC CONSENSUS STATEMENT
Level I with local Caesarean section skills
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 do support
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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 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, MOREOB, 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.
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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
MAY JOGC
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 SOGC CONSENSUS STATEMENT
their responsibility to report problems to the appropriate
team members in a timely manner.
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 blood gas val-
ues.58,59 Both umbilical artery and umbilical vein
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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.
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
https://doi.org/10.1016/j.jogc.2018.12.003.
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 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 healthy
medical diseases or risk factors likely to affect pregnancy newborn infants who are predominantly
and not anticipated to experience any significant cared for in a mother-baby dyad
complications model (rooming-in)
 Between 36+6 days and 36+0 days only if spontaneous   Phototherapy
preterm labour in absence of any other maternal-fetal complications;   Management, for a limited duration, of
in particular APH, hypertension, diabetes, any maternal infection term newborn complications such as transient
or fever in labour greater than 38°C tachypnea of the newborn, antibiotic
 For all other cases <37 weeks consultation or transfer is prophylaxis, hypoglycemia, and
recommended. feeding difficulties
 Operative vaginal deliveries should be undertaken only  Resuscitation and stabilization of ill
when there is a reasonable chance of success and a infants before transfer to an appropriate
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 24/7/365
 Singleton pregnancies only  May care for uncomplicated
 VBAC deliveries should not dichorionic twin pregnancies
be offered. ≥36+0 weeks
 Informed consent should be  Capability for electronic
documented regarding the availability fetal monitoring
of resources and procedures i.e.  Suspected SGA infants would
capacity to provide on-site not be delivered without
Caesarean birth. 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 PLUS: Care as above PLUS:
Risk Risk
 Women carrying a fetus with anomalies (minor) not likely  Planned/anticipated care for infants with
to need immediate interventions a gestational age ≥34+0 weeks and a
 Low to moderate maternal risk experiencing low-risk birth weight >1800 g
medical/obstetrical complications where SGA is not Illness and intervention
suspected  Mild illness expected to resolve
 May care for uncomplicated dichorionic twin pregnancies. quickly
If less than 36+0 weeks consider consultation  Care of stable infants who are convalescing
and transfer. after intensive care
 Nasal oxygen with oxygen saturation
monitoring (acute and convalescing)
(continued)

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 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
≥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
Level IIc
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)

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 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 age  On site surgical capability
age or (newborn care requirements or weight
weight must be within the scope of the newborn  Mechanical ventilation
program services and resources) support including high-
 High maternal risk and/or complex frequency, and possibly
medical, surgical and/or obstetrical inhaled nitric oxide, for
complications requiring complex as long as required
multidisciplinary and subspecialty  Timely access
critical care at any gestational age to a comprehensive
 High fetal risk complications such as range of subspecialty
diagnosis of congenital malformations that consultants
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.

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 SOGC CONSENSUS STATEMENT

APPENDIX B

Table 1. Levels of acuity and complexity

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

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.

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 Sexual & Reproductive Healthcare 7 (2016) 52–57

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare

j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g

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 A B S T R A C T

Article history: Objective: To investigate the quality of intra-partum care provided to women with an expected normal
Received 8 July 2015 birth at a university hospital in Nepal.
Revised 19 October 2015 Methods: A prospective cross-sectional study was conducted during three weeks in November 2013. Nurses
Accepted 15 November 2015
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 nulliparous. The self-
Keywords:
administered questionnaire covered maternal characteristics, previous pregnancies and births, current
Intra-partum care
pregnancy, labor and birth. Nine items assessed care management, five of which comprised the Bologna
Quality of health care
Bologna score score with a total possible score of 5: presence of a companion, use of partograph, non-use of augmen-
Nepal tation, non-supine position, and skin-to-skin contact.
Survey 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.

Introduction and there is an increase in operative birth with each intervention

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).
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

http://dx.doi.org/10.1016/j.srhc.2015.11.004
1877-5756/© 2015 Elsevier B.V. All rights reserved.

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 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.
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
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
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53
Gothenburg. The questionnaire was further reviewed by an asso-
ciate professor at the university connected to the hospital where
the study took place. To minimize the risk of 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 second author visited the ward daily, to collect the com-
pleted questionnaires and answer questions regarding the study. All
questionnaires were collected in a closed envelope and kept safe
by the first and second author.
54 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57

Table 1 Table 2
Maternal characteristics. Outcomes on the Bologna score items.

All Primipara Multipara p-value n = 164 %

n = 164 (%) n = 107 (%) n = 57 (%) Presence of a companion during labor and birth 3 1.8
†
Use of a partograph 156 95.1
Mean age (SD) 26 (3.7) 24 (3.2) 28 (3.4) 0.049
Absence of labor augmentation 48 29.3
Educational level 0.14‡
Non-supine position 0 0.0
<Primary school 7 (4.3) 1 (0.9) 6 (10.5)
Skin-to-skin contact of mother and child ≥ 30 minutes 27 16.5
Primary school 19 (11.6) 12 (11.2) 7 (12.3)
Secondary school 90 (54.9) 59 (55.1) 31 (54.4)
University 48 (29.3) 35 (32.7) 13 (22.8)
Maternity healthcare 164 (100.0) 107 (100.0) 57 (100.0)
† 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

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
No woman received care rated with the full 5 point score. 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 further anal- Episiotomy
ysis due to elective CS, and 19 (6.5%) due to induced labor. The
remaining 229 women (78.4%) were admitted in spontaneous labor. Episiotomy was performed on 80 women (48.8%), the main
Among them, 65 women (28.4%) were excluded from the low-risk reasons being; tight perineum (n = 64/80.0%), fetal distress (n = 7/
category due to; pre-term delivery (n = 24), not in active labor 8.8%), primipara (n = 4/5.0%), for vacuum extraction (n = 7/8.8%), and
(n = 19), maternal age <20 years (n = 7), previous CS (n = 4), pre- to hasten delivery (n = 4/5.0%). A significant difference was found
mature rupture of membranes (n = 2), maternal age >35 years (n = 2), between primiparas (n = 73/86.9%) and multiparas (n = 7/14.58%),
oligohydramnios (n = 2), meconium stained liquor on arrival (n = 2), with a p-value of <0.001 (chi-square = 66.92, d.f. = 1).
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 skilled at- Table 3
tendance in childbirth from a physician (n = 92/56.1%), a nurse Delivery outcomes in women with expected normal childbirth.
(n = 68/41.5%), or a medical or nursing student under supervision
All Primipara Multipara
(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)
Emergency cesarean section 32 (19.5) 23 (21.5) 9 (15.8)
Of the 164 women included in the study, 107 (65.2%) were pri- Rupture of anal sphincter 2 (1.5)§ 2 (2.4)§ 0 (0.0)
miparas and 57 (34.8%) were multiparas. The median number of Post-partum hemorrhage 2 (1.2) 0 (0.0) 2 (3.5)
previous births among multiparous women was 1 (range 1–3). The 500–1000 ml
median level of education in both groups was secondary school. Ma- Apgar score ≥7 at 5 min 164 (100.0)

ternal characteristics are further described in Table 1. § Percentage computed from vaginal births only.

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 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57
Prevention of post-partum hemorrhage
Interventions to prevent post-partum hemorrhage were 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 them
during labor and birth. In combination with the lack of one-on-
one professional care, this suggests that continuous support was not
a part of the intra-partum care at the labor ward. This may be due
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55
to the setup of care at the ward, with the women moving between
different caregivers throughout labor and birth, as well as to the re-
strictive setting with several women birthing simultaneously in the
same rooms. The result differs from a 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], the WHO
recommendations [1] and the scientific evidence [29], which stip-
ulate that the procedure should be used restrictively. Multiparous
women also had a very high rate (14.6%), far above accepted norms.
Liberal or routine use of episiotomy has been shown to be ineffi-
56 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57
cient and possibly harmful [25] and a more restrictive use is
recommended [29].
Mode of delivery
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 birth. Previous research has also found pos-
itive effects of midwifery-led care in Nepal [35]. It may therefore
be suggested that the introduction of midwife-led care at the labor
ward would be cost-effective and would optimize the intra-partum
care provided to women with an expected normal birth. However,
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midwifery is not authorized as an autonomous profession in Nepal
as yet [10].
Strengths and limitations
The questionnaire incorporated an instrument developed by prom-
inent experts in the field [18], which had been evaluated and validated
in different settings [16,17]. This strengthened the validity of the
study. Further expert review of the questionnaire before the study
was conducted 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-partum care over time [18], the results of this
study could be used for comparison in a follow-up study. The results
also provide practical clinical implications which could be useful to
improve intra-partum care at this specific labor ward.
Conclusion
In 2008 the government of Nepal issued a clinical protocol for
safe motherhood [14], which included care in normal labor and birth.
 J. Cederfeldt et al./Sexual & Reproductive Healthcare 7 (2016) 52–57
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.
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 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, *, Ozge 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

a b s t r a c t
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, and
Delivery enables informed choice and continuous support during labour
Obstetric [MeSH] and childbirth. In this paper, we review the evidence of respectful
Respectful care
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.
€ Tunçalp), suellenmiller@gmail.com
E-mail addresses: meghan.bohren@unimelb.edu.au (M.A. Bohren), tuncalpo@who.int (O.
(S. Miller).

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

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 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].

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 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, definitions, 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:

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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 (n ¼ 2016 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 (n ¼ 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 specific 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.

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 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].

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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).

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 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

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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

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 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 confidentiality, 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.

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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

Effective communication
Companionship during labour
and childbirth
Continuity of care
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 between maternity Recommended
care providers and women in labour, using
simple and culturally acceptable methods, is
recommended.
A companion of choice is recommended for all Recommended
women throughout labour and childbirth.
Midwife-led continuity-of-care models, in Context-specific
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.

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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.

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 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.

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 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 (OT), 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.

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reserved.
 Contraception 98 (2018) 228–231

Contents lists available at ScienceDirect

Contraception

journal homepage: www.elsevier.com/locate/con

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 i n f o a b s t r a c t

Article history: Objective: To identify risk factors for failure to attend postpartum follow-up within 3 months of delivery, includ-
Received 8 November 2017 ing social support, intrinsic motivation, insurance type and prenatal care attendance.
Received in revised form 24 April 2018 Study design: This planned secondary analysis is derived from a randomized controlled trial of patients intending
Accepted 27 April 2018 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 their plan to re-
Keywords:
ceive a postpartum IUD. We administered validated scales for social support and intrinsic motivation at
Maternity care
Postpartum visit
enrollment. We then reviewed health records for prenatal visits and any postpartum visit by 3 months and
Contraception performed logistic regression to assess for predictors of follow-up.
Intrauterine device Results: A total of 38/197 subjects (19.3%) failed to attend any postpartum visit by 3 months. Subjects who failed
Insertion timing to follow up were more likely to have Medicaid versus private insurance (92% versus 8%, pb.01). Income
Immediate postpartum 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.

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 M.K. Baldwin et al. / Contraception 98 (2018) 228–231
intrauterine device (IUD) who were enrolled in a randomized
controlled trial (RCT).
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.
Our planned sample size for the original RCT had sufficient power to
compare prenatal care attendance between those who had follow-up
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229
and those who did not, though fewer were needed for this outcome
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.
The median value for the VAS for intention to receive an IUD was
similar among those who did or did not follow up (97.0 versus
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 predic- than motivation that impact utilization of healthcare services for
tive of follow-up (sensitivity=87%, specificity=29%). this population.
In multivariable analysis, private insurance (versus Medicaid) was Throughout this study period, nearly all pregnant patients in Oregon
the strongest predictor of follow-up [odds ratio (OR): 10.4, 95% confi- who did not have private insurance were eligible for Medicaid insur-
dence interval (CI): 3.1–48.1], followed by a VAS score for intention to ance, with coverage extending to 185% of the Federal Poverty Level
receive an IUD of greater than or equal to 80 mm (OR: 1.9, 95% CI: through 2 months postpartum. These data are reassuring that nearly
1.0–9.2) and receipt of prenatal care prior to 14 weeks’ gestational age all privately insured and college-educated patients will follow up. How-
(OR: 2.3, 95% CI: 1.0–5.7) (Table 2). There were no significant indepen- ever, it is concerning that those who are probably at the highest need for
dent predictors for Medicaid recipients. 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
4. Discussion 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
Even among motivated research subjects, one in five patients do not 1.2–1.6]. While a much smaller study, our prospective design allowed
follow up with recommended postpartum care. All socioeconomic indi- more precise classification of patient-level characteristics and the
cators, including financial instability and lower educational achieve- follow-up outcome and showed a more robust relationship. Our find-
ment, are associated with not returning, but the strongest predictor is ings provide additional evidence that insurance type is the most impor-
Medicaid insurance. Initiation of prenatal care after the first trimester, tant predictor to identify patients at risk for health disparities due to
missed prenatal visits and fewer than 10 prenatal visits are associated inadequate access and utilization of postpartum health care services.
with failure to follow up. Psychological assessments for self-reported The main study limitation is a potential misclassification of whether
motivation and perceived social support are not significant predictors. subjects returned for follow-up. We reviewed the electronic medical re-
We expected the validated “Future Scale” to be able to identify those cord, which shares health visit information state-wide for most health
who have both agency and pathway, or “will and ways,” to follow systems, to locate subjects referred to our hospital who may have
through with a plan. However, the best behavioral predictor of future returned to their primary provider for follow-up. In all, 6.6% of subjects
visit attendance is past attendance. There are likely forces stronger 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
Table 2
Multivariable logistic regression of factors related to postpartum follow-up within overestimation of loss to follow-up, but this would not be expected to be
3 months among postpartum patients seeking IUD for contraception a differential bias with respect to demographic characteristics.
Another limitation of this study is generalizability. This study likely
Covariates: OR (95% CI)a All subjects Medicaid recipients
n=197 n=95
overestimates the proportion of postpartum patients who will return
for follow-up because it only included research participants motivated
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)
to return for postpartum contraception who agreed to enroll and who
3-week follow-up group 0.7 (0.3–1.6) 0.5 (0.2–1.3) were going to be compensated for returning regardless of whether they
(vs. 6-week group) changed their mind about using an IUD. This is a best-case scenario and
Private insurance (vs. Medicaid) 10.4 (3.1–48.1) -- provides estimates for postpartum follow-up under the most ideal condi-
Prenatal care prior to 14 weeks 2.3 (1.0–5.7) 2.1 (0.8–5.4)
tions. We tried to mimic real-life clinic scheduling as much as possible for
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) 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-
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.
pointments, we did not provide extra appointment reminders, and we
a
Model includes age, preterm birth, randomization group, insurance, prenatal care did not provide directed counseling about IUD insertion or side effects be-
initiation, MDSS family subscale and VAS for IUD intention ≥80 mm. yond what was discussed with their primary provider.

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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
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.
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 Women's Health Issues 30-6 (2020) 426–435

www.whijournal.com

Policy matters

Postpartum Medicaid Coverage and Contraceptive 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
Emory University Nell Hodgson Woodruff School of Nursing, Emory University School of Medicine, Atlanta, Georgia
b
Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
c
Medical Mutual of Ohio, Cleveland, Ohio

Article history: Received 13 June 2019; Received in revised form 10 August 2020; Accepted 19 August 2020

a b s t r a c t
Background: Ensuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help
women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable
Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid
under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio’s
Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum
visit attendance, receipt of contraceptive counseling, and use of contraceptive methods.
Methods: We used Ohio’s linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy
and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to
December 2015) the ACA Medicaid expansion implementation period (N ¼ 170,787 after exclusions). We categorized
women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the
comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the
association of the ACA expansion with their postpartum enrollment in Medicaid and use of services.
Results: Women who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in
the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible.
Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and
use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2
percentage point) increase in the likelihood of long-acting reversible contraceptive use.
Conclusions: Ohio’s ACA Medicaid expansion was associated with a significant increase in the probability of women’s
continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum.
Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.
Ó 2020 Jacobs Institute of Women's Health. Published by Elsevier Inc.

There is increased recognition of the importance of the
postpartum period for the health and well-being of women
Supported in part by the Ohio Department of Medicaid and through the
Medicaid Technical Assistance and Policy Program (MEDTAPP) via federal
financial participation funds, Contract # (G-1617-05-003). Views stated here are
those of the researchers only and are not attributed to the study sponsors, the
Ohio Department of Medicaid or to the Federal Medicaid Program. No financial
disclosures were reported by the authors of this paper.
* Correspondence to: E. Kathleen Adams, PhD, 1518 Clifton Road NE, Atlanta,
GA 30322. Phone: 404-727-9370; fax: 404-727-9969.
E-mail address: eadam01@emory.edu (E.K. Adams).
(American College of Obstetricians and Gynecologists, 2018) as
they struggle with a range of health problems that can seriously
impact their health and ability to care for themselves and their
families, including anemia, physical exhaustion, and postpartum
depression. During this period, sometimes referred to as the
“fourth trimester,” women need a comprehensive assessment of
their physical recovery from birth, reproductive health care
needs, and emotional well-being (Ranji, Gomez, & Salganicoff,
2019). Women are more likely to die from pregnancy-related
conditions in the postpartum period than during pregnancy or
delivery (Creanga, Syverson, Seed, & Callaghan, 2017), and the

1049-3867/$ - see front matter Ó 2020 Jacobs Institute of Women's Health. Published by Elsevier Inc.
https://doi.org/10.1016/j.whi.2020.08.006

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 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
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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*

y
Before the ACA 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).
However, this pregnancy-eligible group of women lost eligibility
60 days postpartum if their income was more than 90% of the FPL
in the pre-ACA period but at the more generous cutoff of greater
than 138% of the FPL in the post-ACA period.
Ohio’s eligibility levels were higher than the median state’s
level both for parents (64% FPL) and for pregnant women (185%
FPL) before the ACA. States with lower income eligibility levels
before the ACA saw greater increases in insurance for women of
reproductive age and, as expected, the increases were larger for
those without dependent children (Johnston, Strahan, Joski,
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
can change owing to the change in household size, most
commonly owing to the addition of the baby to the family. We
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
for the same pregnancy services, which include education, care
coordination, counseling, high-risk monitoring, nurse midwife
services, preconception care, prenatal care, ultrasound exami-
nations, prenatal risk assessment, delivery, and transportation,
regardless of their eligibility group (Ohio Department of
Medicaid, 2020). All states are required to assess pregnancy
eligible 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 eligible until the next recertification; in Ohio, this is
12 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-
ment and comparison groups, respectively.
Medicaid women with a delivery claim to an Ohio Birth Certifi-
cate was 88.9% across study years. Indicators of health system
use (postpartum visit attendance, receipt of contraceptive
counseling, and use of contraceptive methods) were generated
from procedure, diagnosis, and National Drug Codes recorded on
inpatient and outpatient encounter claims for deliveries with any
amount of Medicaid payment (Appendix Table 1). To capture
prepregnancy and postpregnancy information and prior
Medicaid paid births, encounters with a date of service from
January 2008 through 6 months postpartum (June 2016) were
included for each Medicaid birth January 2011 through
December 2015. The source of last menstrual period (LMP) was
Medicaid Deliveries, 2011 - 2015
306,737
Deliveries to Mothers < 20 and > 44 years Excluded
265,772
Deliveries to Mothers whose eligibility is based on disability
Family Planning, Strong Start Enrollees Excluded
237,091
Deliveries from July 1, 2013, to Dec. 31, 2013, Excluded
213,672
Deliveries from January 1, 2014, to October 31, 2014,
and 2014 Deliveries with LMP prior to February 1, 2014, Excluded

172,862
Methods

Data Deliveries with Missing Values for Model Variables Excluded

The Ohio Department of Medicaid and the Ohio Department 170,787 for Analysis of Enrollment Postpartum

of Health granted permission for access to its electronic Medicaid

enrollment and encounter records and birth certificate records,
respectively. The study was reviewed and approved by Institu-
tional Review Boards of the Ohio Department of Medicaid and
Emory University (#IRB00084905). Personal identifiers were
used to perform a well-documented iterative matching process
between Medicaid administrative records and yearly Ohio Birth
Certificates that involved both deterministic and probabilistic
matching (Baldwin, Johnson, Berthoud, & Dublin, 2015;
Campbell, Deck, & Krupski, 2008). The average match rate of
Limited to Deliveries Con nuously Enrolled in Medicaid Six Months Postpartum;
Women Receiving a Hysterectomy during Delivery Hospitaliza on Excluded
138,426 for Analysis of Postpartum Service Use
Service use includes postpartum visit
a endance, receipt of contracep ve
counseling, and use of contracep ve methods.
Figure 1. Derivation of study cohort of births, January 2011 to December 2015.

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 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 b1 PREGi D b2 MedACA D b3 ðPREGi 3 MedACAÞ D b4 X it D b5 C it D b6 D M t 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 ¼ 172,862).
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
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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
is a vector of individual covariates including age, mother’s edu-
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), Cit ¼ 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 ¼ monthly 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 (N ¼ 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

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 A.L. Dunlop et al. / Women's Health Issues 30-6 (2020) 426–435 431

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,
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

Percent Con nuously Enrolled in Medicaid in Months a er Delivery

100.0%

95.0%

90.0%

85.0%

80.0%

75.0%

70.0%

65.0%
1 Month 2 Months 3 Months 4 Months 5 Months 6 Months
Pregnancy Elig.: Pre-ACA 93.2% 91.9% 81.0% 72.9% 69.1% 65.8%
Pregnancy Elig.: Post-ACA 94.6% 93.0% 90.5% 88.1% 85.3% 82.7%
Income Elig.: Pre-ACA 99.3% 98.5% 95.4% 92.4% 90.2% 88.2%
Income Elig.: Post-ACA 98.6% 97.8% 96.6% 95.4% 94.2% 93.0%

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
2015) ACA Medicaid expansion implementation.

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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 methodsz
Tier 1 15.02 16.74y 12.33 11.78
Tier 2 22.25 22.40 24.68 23.36y
Tier 3/4 0.32 0.21y 0.27 0.16x
Tier unspecified 2.84 3.82y 2.70 2.88
Any method 40.43 43.17y 39.98 38.17y
Subsets of tier 1
LARC 7.14 9.74y 7.72 7.85
Sterilization 7.98 7.09y 4.67 3.98x

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

N ¼ 170,787* N ¼ 170,787*

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.

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 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 Eligible Pregnancy Eligible

During Delivery Hospitalization or 1–180 Days after Delivery During Delivery Hospitalization or 1–180 Days after Delivery

N ¼ 83,031* N ¼ 55,395*

Post 2014–2015 Post 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
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 insurance
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

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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.
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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.