Pregnancy and Childbirth Care Following Conflict and Displacement: Care for Refugee Women in Low‐Resource Settings

Women in developing countries experience the same problems during pregnancy and childbirth and die of the same complications, regardless of whether they live in stable situations or in situations of conflict and displacement. They need services and/or care during pregnancy and childbirth wherever they are and in whatever circumstances prevail. This article provides an overview of the Safe Motherhood Initiative, including the recent directions taken to prevent maternal and neonatal mortality and morbidity. In addition, pregnancy and childbirth care in complex humanitarian emergencies is examined, highlighting the experiences in refugee settings. In some of these settings, pregnancy outcomes have been better than in host or home countries. The challenge remains to ensure that good‐quality pregnancy and childbirth care, in line with the global standards set for achieving safe motherhood, is consistently available and accessible to women affected by complex humanitarian emergencies.     

The Professionalization of International Disaster Response: It Is Time for Midwives to Get Ready

Disasters and humanitarian emergencies due to natural or human origins result in severe and often prolonged suffering of the affected population. Midwives have a role to play in providing assistance because women and their infants experiencing such crises have unique vulnerabilities and needs. This article introduces midwives and other women's health care practitioners to international humanitarian emergency response efforts and describes preparation and training activities they can undertake to get ready to volunteer with an international health aid agency. Various clinical realities and challenges are discussed, including recommended priorities for providing reproductive health care in disaster zones. Common ethical dilemmas in crisis health care settings are also reviewed. By arriving in the field well prepared to participate and collaborate, midwives can make substantial contributions to the safety, health, and comfort of women and their families who have experienced a natural disaster, armed conflict, or disease epidemic.     

Responding to Humanitarian Crises: Midwifery Care in Bangladesh

Sexual and reproductive health and rights (SRHR) is often a neglected topic of intervention in humanitarian crises despite its wide-ranging impact on women and girls’ well-being. Increasing frequency of climate-induced natural disasters calls for an urgent need to identify innovative practices for sustainable and effective humanitarian preparedness and response to ensure SRHR of affected populations. One such innovation is the empowerment of midwives in disaster response program planning and implementation. This article describes how midwives deployed to rural primary health centers provided quality SRHR services, particularly for labor and birth assistance and initial management of perinatal emergencies and referral in the aftermath of the 2022 flooding in northern and northeastern Bangladesh. Supportive supervision from physicians, adequate health care logistics and supplies, and administrative support from local health authorities created an enabling environment for the midwives. Community engagement through volunteers helped build rapport with residents and allowed patients to navigate health services. Deploying midwives as a response to climate-induced natural disaster was successful in establishing quality SRHR services. Future recommendations include systematically deploying midwives in health centers closest to the communities in locations vulnerable to climate change as part of routine health service delivery. This innovative approach clearly demonstrated that utilization of midwives during and after natural disasters could build community and health system resilience to climate change.     

The need for priority reproductive health services for displaced Iraqi women and girls

Disregarding reproductive health in situations of conflict or natural disaster has serious consequences, particularly for women and girls affected by the emergency. In an effort to protect the health and save the lives of women and girls in crises, international standards for five priority reproductive health activities that must be implemented at the onset of an emergency have been established for humanitarian actors: humanitarian coordination, prevention of and response to sexual violence, minimisation of HIV transmission, reduction of maternal and neonatal death and disability, and planning for comprehensive reproductive health services. The extent of implementation of these essential activities is explored in this paper in the context of refugees in Jordan fleeing the war in Iraq. Significant gaps in each area exist, particularly coordination and prevention of sexual violence and care for survivors. Recommendations for those responding to this crisis include designating a focal point to coordinate implementation of priority reproductive health services, preventing sexual exploitation and providing clinical care for survivors of sexual violence, providing emergency obstetric care for all refugees, including a 24-hour referral system, ensuring adherence to standards to prevent HIV transmission, making condoms free and available, and planning for comprehensive reproductive health services.     

Understanding and Meeting the Needs of Women in the Postpartum Period: The Perinatal Maternal Health Promotion Model

A new model for the care of women in the postpartum focuses on the development of life skills that promote complete well‐being. The year following childbirth is a time of significant transition for women. In addition to the physiologic changes associated with the postpartum period, a woman undergoes marked psychosocial changes as she transitions into a motherhood role, reestablishes relationships, and works to meet the physical and emotional needs of her infant and other family members. It is a time when women are vulnerable to health problems directly related to childbirth and to compromised self‐care, which can manifest in the development or reestablishment of unhealthy behaviors such as smoking and a sedentary lifestyle. In addition to long‐term implications for women, compromised maternal health in the postpartum period is associated with suboptimal health and developmental outcomes for infants. Maternal health experts have called for a change in how care is provided for women in the postpartum period. This article presents the rationale for a health promotion approach to meeting the needs of women in the postpartum period and introduces the Perinatal Maternal Health Promotion Model. This conceptual framework is built around a definition of maternal well‐being that asserts that health goes beyond merely the absence of medical complications. In the model, the core elements of a healthy postpartum are identified and include not only physical recovery but also the ability to meet individual needs and successfully transition into motherhood. These goals can best be achieved by helping women develop or strengthen 4 key individual health‐promoting skills: the ability to mobilize social support, self‐efficacy, positive coping strategies, and realistic expectations. While the model focuses on the woman, the health promotion approach takes into account that maternal health in this critical period affects and is affected by her family, social network, and community. Clinical implications of the model are addressed, including specific health promotion strategies that clinicians can readily incorporate into antepartum and postpartum care.     

Introduction of CenteringPregnancy in a Public Health Clinic

CenteringPregnancy is a promising group visit prenatal care innovation that provides substantial health promotion content. Elements unique to group care include peer support and self‐management training and activities. CenteringPregnancy was introduced at a large public health clinic serving predominantly low‐income African American pregnant women. All prenatal care at this clinic was provided by certified nurse‐midwives, and all providers were trained in the CenteringPregnancy model. One hundred and ten women received prenatal care in CenteringPregnancy groups. Focus groups of pregnant women, providers, and health center staff reported that the program benefited women despite implementation challenges such as scheduling changes. Compared to women in individual care, women in CenteringPregnancy had significantly more prenatal visits, increased weight gain, increased breast feeding rates, and higher overall satisfaction. This pilot project demonstrated that CenteringPregnancy can be implemented in a busy public health clinic serving predominantly low‐income pregnant women and is associated with positive health outcomes.     

Pregnancy Planning and Diabetes: A Qualitative Exploration of Women's Attitudes Toward Preconception Care

Introduction: Seeking preconception care is recognized as an important health behavior for women with preexisting diabetes. Yet many women with diabetes do not seek care or advice until after they are pregnant, and many enter pregnancy with suboptimal glycemic control. This study explored the attitudes about pregnancy and preconception care seeking in a group of nonpregnant women with type 1 diabetes mellitus. Methods: In‐depth semistructured interviews were completed with 14 nonpregnant women with type 1 diabetes. Results: Analysis of the interview data revealed 4 main themes: 1) the emotional complexity of childbearing decisions, 2) preferences for information related to pregnancy, 3) the importance of being known by your health professional, and 4) frustrations with the medical model of care. Discussion: These findings raise questions about how preconception care should be provided to women with diabetes and highlight the pivotal importance of supportive, familiar relationships between health professionals and women with diabetes in the provision of individualized care and advice. By improving the quality of relationships and communication between health care providers and patients, we will be better able to provide care and advice that is perceived as relevant to the individual, whatever her stage of family planning.     

Health Care and Social Service Providers' Descriptions of Pacific Islander Mothers' Breastfeeding Patterns

Introduction: Despite recommendations and numerous health benefits attributed to breastfeeding, rates in the United States are below desired levels, particularly within vulnerable populations. In Hawaí, breastfeeding rates are higher than national averages except in Native Hawaiian and other Pacific Islander populations. Health care and social service providers are integral to successful breastfeeding promotion efforts. They are in an ideal position to reflect on the context in which their clients live and on its relationship to breastfeeding activities. The aim of this study was to describe health care and social service providers' perceptions of the influences on the breastfeeding patterns of Pacific Islander women. Methods: Focus ethnographic methods were used to collect interview data from health care and social service providers (N = 20) serving Native Hawaiian and Pacific Islander women in one rural community. An iterative analysis process of coding and categorizing, followed by conceptual abstraction into patterns, was completed. Results: Four patterns emerged: shaped by connections, lived unfamiliarity, stressed by circumstance, and missed opportunities. Participants' insights concerning the needs of this population yielded population‐specific issues and health care system issues affecting breastfeeding promotion. A number of gaps in breastfeeding services were identified. Discussion: Sociocultural, maternal knowledge, and workload barriers to successful breastfeeding predominated providers' perspectives. Broader system and community level issues were implied, but not directly addressed. The nature of successful breastfeeding support and promotion requires inclusion of this broader level perspective. J Midwifery Womens Health 2010;55:162–170 c̊ 2010 by the American College of Nurse‐Midwives.     

Utilizing Task Shifting to Increase Access to Maternal and Infant Health Interventions: A Case Study of Midwives for Haiti

The shortage of health workers worldwide has been identified as a barrier to achieving targeted health goals. Task shifting has been recommended by the World Health Organization to increase access to trained and skilled birth attendants. One example of task shifting is the use of cadres of health care workers, such as nurses and auxiliary nurse‐midwives, who can successfully deliver skilled care to women and infants in low‐resource areas where women would otherwise lack access to critical health interventions during the childbearing years. Midwives for Haiti is an organization demonstrating the use of task shifting in its education program for auxiliary midwives. Graduates of the Midwives for Haiti education program are employed and working with women in hospitals, birth centers, and clinics across Haiti. This article reviews the Midwives for Haiti education program and presents successes and challenges in task shifting as a strategy to increase access to skilled maternal and newborn care and to meet international health goals to reduce maternal and infant mortality in a low‐resource country.     

Exploring Dental Care Misconceptions and Barriers in Pregnancy

Abstract: Background: Poor oral health is increasingly linked to adverse pregnancy outcomes, including preterm birth and low‐birthweight infants. Little is known about childbearing women’s experiences in obtaining dental care. The objective of this study was to explore Florida women’s experience of barriers in obtaining dental care before and during their pregnancies. Methods: Study data were derived from a larger data set of a study that examined barriers to prenatal care. One month after giving birth face‐to‐face interviews were conducted with 253 African American women, 18 to 35 years old, who were residents of one of three Florida counties. Interview questions about women’s experiences on obtaining oral health care before and during pregnancy, and recall of guidance about oral health care during prenatal visits were transcribed and analyzed qualitatively. Through subject‐level content analysis, key themes were assessed about the participants’ perspectives on obtaining oral health care before and during pregnancy. Results: Most participants did not obtain dental care and did not recall receiving dental information during prenatal visits. Barriers to dental care included lack of insurance, difficulty in finding a dentist, low priority given to dental care, misconceptions about the safety and appropriateness of dental care during pregnancy, and sporadic anticipatory guidance during prenatal care. Conclusions: Misconceptions about the appropriateness of oral health care during pregnancy may affect women’s access to and use of this care. Given the implications of poor oral health on possible adverse birth outcomes and its larger connection with the general health of mothers and babies, attention to oral health misconceptions and barriers is warranted. (BIRTH 37:4 December 2010)     

Lost in translation: reproductive health care experiences of Somali Bantu women in Hartford, Connecticut

Introduction: Reproductive health problems are the leading cause of women's morbidity and mortality worldwide. In the United States, officially sponsored refugee women continue to face challenges in accessing reproductive health programs despite having access to health insurance. Methods: The objective of this study was to explore the reproductive health experiences of 1 such population—Somali Bantu women in Connecticut—to identify potential barriers to care experienced by marginalized populations. The study was qualitative, consisting of key informant interviews, a focus group session, and a semistructured survey. Results: Although all the women in the study reported having access to reproductive health care services, they also reported having unmet health needs resulting from barriers to care that included ethnic distinction/language barriers, passive acceptance of incorrect care, cultural discordance in family planning services, patient‐provider sex discordance, and desire but limited scope for ownership in health care outcomes. The root cause of the various types of patient‐provider discordance was the lack of recognition that the Somali Bantu are distinct in culture, language, and solidarity from ethnic Somalis, resulting in Language Line translation services being conducted in a Somali language that the Somali Bantu women did not understand. Discussion: The results of the study primarily highlight the larger issue of information asymmetry within the health care system that, if left unaddressed, will persist as new vulnerable populations of refugees arrive in the United States.     

Improving Access to Maternity Care for Women with Opioid Use Disorders: Colocation of Midwifery Services at an Addiction Treatment Program

Perinatal drug and alcohol use is associated with serious medical and psychiatric morbidity for pregnant and postpartum women and their newborns. Participation in prenatal care has been shown to improve outcomes, even in the absence of treatment for substance use disorders. Unfortunately, women with substance use disorders often do not receive adequate prenatal care. Barriers to accessing care for pregnant women with substance use disorders include medical and psychiatric comorbidities, transportation, caring for existing children, housing and food insecurity, and overall lack of resources. In a health care system where care is delivered by each discipline separately, lack of communication between providers causes poorly coordinated services and missed opportunities. The integration of mental health and substance use treatment services in medical settings is a goal of health care reform. However, this approach has not been widely promoted in the context of maternity care. The Dartmouth‐Hitchcock Medical Center Perinatal Addiction Treatment Program provides an integrated model of care for pregnant and postpartum women with substance use disorders, including the colocation of midwifery services in the context of a dedicated addiction treatment program. A structured approach to screening and intervention for drug and alcohol use in the outpatient prenatal clinic facilitates referral to treatment at the appropriate level. Providing midwifery care within the context of a substance use treatment program improves access to prenatal care, continuity of care throughout pregnancy and the postpartum, and availability of family planning services. The evolution of this innovative approach is described. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

“I Wasn't Alone”—A Study of Group Prenatal Care in the Military

The military has recognized that health and quality of life for service members are closely tied to the resources for their families, including how they are cared for during pregnancy and childbirth. However, there has been little examination of women's experience with different models of prenatal care (PNC) in military settings. The purpose of this article is to describe the results of a qualitative study of women's experiences with the CenteringPregnancy model of group PNC compared to individual PNC in two military health care settings. This clinical trial enrolled 322 women who were randomized into group or individual PNC at two military treatment facilities. Qualitative interviews were completed with 234 women during the postpartum period. Interpretative narrative and thematic analysis was used to identify three themes: 1) “I wasn't alone”—the experience with group PNC; 2) “I liked it but…”—recommendations to improve group PNC; and 3) “They really need to listen”—general concerns across the sample about PNC. Greatest concerns of women in individual PNC included lack of continuity and time with the provider. Our military families must be assured that their health care system meets their needs through personal and family‐centered care. Group PNC offers the potential for continuity of provider while also offering community with other women. In the process, women gain knowledge and power as a health care consumer.     

Changing Concepts of Women’s Health—What does this mean for Obstetrics and Gynaecology?

Over the past decade, increased attention has focused on the topic of women’s health. Traditionally, women’s health was considered to encompass only reproductive health and health care. Currently, however, women’s health is defined as involving women’s social, cultural, spiritual, emotional and physical well-being, and is influenced by social, political and economic factors, as well as by a woman’s biology. Therefore, in providing health care to women, one must address not only their biology and their reproductive functions but also the broader determinants of health and in particular the critical role of gender as a determinant of health. The health priorities women themselves identify, their own perceptions of their health and well-being and the diversity of women are all key components of optimal care for women. While obstetricians and gynaecologists have played a leading role in improving reproductive and gynaecologic care and outcomes, they must identify, acknowledge and address the multiple factors which influence the health and illness of their patients. Together with other physicians and health professionals, obstetricians and gynaecologists through their clinical work, their educational activities and their research must integrate and apply this broader understanding of women’s health if they are to provide appropriate holistic care to their women patients.     

Contraception Care for Transmasculine Individuals on Testosterone Therapy

Contraception and fertility‐associated advisement is needed for any individual with a uterus who is engaging in sexual activity with reproductive potential. As greater awareness spreads regarding the health care needs of transgender, nonbinary, and gender‐nonconforming individuals, the research on evidence‐based care for these populations lags behind. Many clinicians may not be well versed in the best practices to support the sexual and reproductive well‐being of individuals who are taking gender‐affirming hormone therapy. This article reviews the use of contraception for individuals who are on testosterone gender‐affirming hormone therapy. Each contraceptive method is individually considered for the risks and benefits that are unique to this population.     

Why Do Women Seek Antenatal Care Late? Perspectives From Rural South Africa

Despite the widespread availability of free antenatal care services, most women in rural South Africa attend their first antenatal clinic late in pregnancy and fail to return for any followup care, potentially leading to avoidable perinatal and maternal complications. Using interviews with pregnant women from the rural Hlabisa district of South Africa, we documented perceptions of health and health care during pregnancy and investigated factors shaping the utilization of antenatal care. Our findings indicate that most women in this setting do not perceive significant health threats during pregnancy, and in turn view more than one antenatal care visit as unnecessary. In contrast, women perceive labour and delivery as a time of significant health risks that require biomedical attention, and most women prefer to give birth in a health facility. This paradox, in which health care is important for childbirth but not during pregnancy, is embodied in most women's primary reason for seeking antenatal care in this setting: to receive an antenatal attendance card that is required to deliver at a health facility. Health education programs promoting antenatal care are required to explain the importance of effective antenatal care toward maternal and child health.     

Pelvic Floor Physical Therapy and Women's Health Promotion

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic‐floor‐related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy‐related pelvic floor dysfunction. PFPT is an evidence‐based, low‐risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction.     

Perceived Discrimination and Depressive Symptoms,Smoking, and Recent Alcohol Use in Pregnancy

Abstract: Background: Perceived discrimination is associated with poor mental health and health‐compromising behaviors in a range of vulnerable populations, but this link has not been assessed among pregnant women. We aimed to determine whether perceived discrimination was associated with these important targets of maternal health care among low‐income pregnant women. Methods: Face‐to‐face interviews were conducted in English or Spanish with 4,454 multiethnic, low‐income, inner‐city women at their first prenatal visit at public health centers in Philadelphia, Penn, USA, from 1999 to 2004. Perceived chronic everyday discrimination (moderate and high levels) in addition to experiences of major discrimination, depressive symptomatology (CES‐D ≥ 23), smoking in pregnancy (current), and recent alcohol use (12 months before pregnancy) were assessed by patients’ self‐report. Results: Moderate everyday discrimination was reported by 873 (20%) women, high everyday discrimination by 238 (5%) women, and an experience of major discrimination by 789 (18%) women. Everyday discrimination was independently associated with depressive symptomatology (moderate = prevalence ratio [PR] of 1.58, 95% CI: 1.38–1.79; high = PR of 1.82, 95% CI: 1.49–2.21); smoking (moderate = PR of 1.19, 95% CI: 1.05–1.36; high = PR of 1.41, 95% CI: 1.15–1.74); and recent alcohol use (moderate = PR of 1.23, 95% CI: 1.12–1.36). However, major discrimination was not independently associated with these outcomes. Conclusions: This study demonstrated that perceived chronic everyday discrimination, but not major discrimination, was associated with depressive symptoms and health‐compromising behaviors independent of potential confounders, including race and ethnicity, among pregnant low‐income women. (BIRTH 37:2 June 2010)