BACKGROUND:Cesarean section (CS) rates are increasing rapidly worldwide, and the CS rate in South Korea reached 67.4% in 2024. Although many studies have examined these trends, few have assessed whether they reflect differences across maternal birth cohorts. We examined variation in the CS rate by maternal age, calendar period, and maternal birth cohort. METHODS:Using nationwide National Health Insurance claims data, we identified 6,635,390 deliveries among women aged 15-44 years in 2007-2024. The outcome was mode of delivery, classified as CS or vaginal delivery. We fitted hierarchical age-period-cohort cross-classified random-effects models, with maternal age entered as fixed linear and quadratic terms and calendar period and birth cohort as random effects. The models were adjusted for parity, insurance type, and hospital type and fitted separately by parity. RESULTS:The crude CS rate increased from 36.4% in 2007 to 67.4% in 2024. Maternal age was strongly associated with CS, but period and cohort variation persisted after adjustment (period τ2 = 0.117; cohort τ2 = 0.020). Estimated period random effects increased from 2015 onward, and estimated cohort random effects were positive among women born between 1992 and 2002. Age, period, and cohort patterns were more pronounced among primiparous women. DISCUSSION:Korea's increasing CS rate appears to reflect not only maternal aging but also period patterns after 2015 and elevated CS rates among recent birth cohorts, especially among primiparous women. These findings suggest that changes in the obstetric care environment and cohort-specific delivery practices should be considered when interpreting recent national trends.
BACKGROUND:Women of refugee background in high income countries experience inequitable perinatal health outcomes, prompting the development of Group Pregnancy Care (GPC). GPC was implemented at two sites in Melbourne, Australia and this study aimed to describe (1) sociodemographic and obstetric characteristics of Australian-born, migrant and refugee background women; (2) the quality of antenatal care for refugee background women attending GPC (i.e., number of antenatal visits, gestation of first visit, interpreter when required); and (3) the economic costs of providing GPC. METHODS:A cross-sectional study of routinely collected perinatal data provided by the two participating hospitals. Statistical analyses included Chi-squared tests, linear and logistic regression. RESULTS:Of the 28,898 women giving birth at the two sites, 39.0% were born in Australia, 51.9% overseas, and 9.1% were of refugee background. Australian Pregnancy Care Guidelines were met for the majority of the 225 GPC participants: first visit < 14 weeks gestation (81.3%), attending recommended number of antenatal visits (84.4%); and having an interpreter > 80% of antenatal visits (83.7%). Refugee background women attending GPC had odds between 2 and 4 times higher of meeting guidelines compared to refugee background women in usual care. CONCLUSION:GPC has the potential to facilitate earlier and increased engagement with antenatal attendance, coupled with access to an interpreter when required. Future expansion of GPC for women of refugee background should be conducted within a rigorous evaluation framework that includes the extension of the program to diverse population groups with appropriate cultural guidance and adaptation.
OBJECTIVE:Since 2021, a Dutch guideline recommends offering induction of labor (IOL) from 41 + 0 weeks, alongside the option of expectant management (EM), through shared decision-making (SDM). We examined care providers' opinions and use of the guidelines' SDM tools, self-reported adherence to SDM content recommendations, perspectives on SDM conversations, and its association with birth beliefs. METHODS:For this cross-sectional survey, including 575 maternity care providers, an online questionnaire was developed. Most questions used a 5-point Likert scale. Birth beliefs (medical vs. natural) were assessed using the Birth Beliefs Scale. Uni- and multivariable regression analyses were used to assess the association between a medical and natural view and SDM content and perspectives. RESULTS:Among participants aware of the tools, usage rates were 63% for Tool 1 (steps of SDM), 72% for Tool 2 (choice card IOL/EM), and 51% for Tool 3 (choice card alternatives). Helpfulness scores exceeded the neutral midpoint (3.7, 3.8, and 3.7). The majority of participants reported addressing most of the items of SDM that were recommended in the guideline, though lower rates were seen for addressing outcome percentages (37%), parity differences (33%), and EM beyond 42 weeks (37%). Birth beliefs influenced SDM content, emphasis on advantages of options, and perspectives; those with stronger natural views paid more attention to women's preferences and alternatives. CONCLUSION:Care providers are generally positive about the tools in the late-term management guideline, though not all use them. Key elements for SDM are often omitted, and birth beliefs influence how SDM is conducted.
The 2025 revision of Ireland's midwifery education standards marks the first comprehensive update since 2012 and includes an important step forward in acknowledging trans and gender diverse (TGD) people as recipients of midwifery care. However, despite this progress, the standards remain constrained by gender-exclusive language and a lack of substantive integration of TGD perspectives across curricula. Drawing on international literature and recent evidence on TGD pregnancy experiences, this commentary argues that recognition without structural embedding risks tokenism and perpetuates inequity. Situating the discussion within a human rights framework, it highlights the relevance of the International Confederation of Midwives' Philosophy and Bill of Rights, which centers on self-determination, bodily autonomy, justice and equity, principles that align directly with trans inclusion. The commentary calls for consistent inclusive terminology, explicit competencies in TGD health, and leadership education that equips midwives to advocate for equity and human rights. It also underscores the need to foster safe, affirming environments for trans and non-binary midwives, ensuring that the profession itself embodies the inclusivity it promotes in care.
INTRODUCTION:Women from minoritized backgrounds experience disproportionately higher perinatal mortality than white women, with stillbirth rates highest among Black women and elevated among some Asian ethnic groups. Despite this, women from the global majority remain underrepresented in National Health Service Perinatal and Maternal Mental Health Services, United Kingdom (UK). This scoping review aims to: (i) examine the use of creative health approaches to support mental wellbeing following baby loss among minoritized women, and (ii) identify priorities for future research into culturally informed creative mental health interventions. METHOD AND DESIGN:This scoping review employed a structured methodology to identify qualitative, quantitative, and gray literature exploring creative health approaches for women from minoritized backgrounds following baby loss. RESULTS:A total of 1808 records were identified. Following deduplication, 507 records were screened and 22 full-text articles assessed for eligibility and eight included in the scoping review. A content analysis identified three overarching themes: (i) navigating the unseen-meaning, identity, and silence in perinatal loss; (ii) healing through creative expression; and (iii) holding on and moving forward-creative connection after baby loss. CONCLUSION:Creative approaches supported women in making sense of baby loss by fostering continuing bonds with their baby and facilitating reflection on identity and future direction. Group-based creative methods promoted belonging and helped counter silence surrounding baby loss within communities. However, there remains a significant lack of research in this area, particularly involving global majority women.
INTRODUCTION:Respectful maternity care (RMC) is a critical component of high-quality maternal care, yet its relationship with postpartum emotional distress remains underexplored. This study examined the mediating role of Baby-Friendly Hospital Initiative practices and moderating effects of support in the association between RMC and postpartum emotional distress. METHODS:We analyzed cross-sectional postpartum survey data from 207 women at a US based academic medical center. RMC was measured using the Mothers on Respect Index (MORi), and postpartum emotional distress was modeled as a latent construct comprising nervousness, sadness, anhedonia, and worry. We used Structural Equation Modeling with bootstrapped confidence intervals (n = 5000) to test for mediation and simple slope analysis to explore moderation by emotional and practical support. RESULTS:The median (SD) MORi score was 77 (12.0). RMC was associated with lower postpartum emotional distress [β = -0.224; 95% CI [-0.390, -0.059]], and was moderated by emotional support (β = 0.152, p = 0.014). Specifically, higher RMC was associated with lower distress among women with low emotional support (p = 0.002), but not among those with high emotional support (p = 0.968). However, practical support did not moderate the association. The indirect effect through Baby-Friendly Hospital Initiative practices was significant [β = -0.044; 95% CI [-0.102, -0.003]]. CONCLUSIONS:RMC may reduce postpartum emotional distress in part through the implementation of Baby-Friendly Hospital Initiative practices. The protective effect of RMC was strongest among women with lower emotional support. Our preliminary findings call for the need for longitudinal studies and replication in more diverse populations.
BACKGROUND:Postpartum health-related problems are diverse, and some may extend beyond the first postpartum year. The purpose of this study was to describe women's postpartum health problems in the first and second postpartum years. METHODS:We analyzed data from an online survey (N = 427) conducted in 2024. Respondents gave birth within the past 2 to 22 months. Open-ended questions elicited women's health problems; physical and mental health ratings were also gathered. Data were analyzed by qualitative content analysis and non-parametric statistics. RESULTS:The three most frequently reported problems were depression/anxiety, musculoskeletal issues, and genitourinary disorders. The number of physical health problems did not differ between women 2-12 months and 13-22 months postpartum, p = 0.958. Similarly, mental health problems showed no difference between the time frames, p = 0.087. The number of physical and mental health problems was correlated with each other (r = 0.156, p < 0.01). The number of physical health problems was correlated with body mass index (r = 0.136, p < 0.01) and negatively correlated with physical (r = -0.218, p < 0.01) and mental health ratings (r = -0.175, p < 0.01). The number of mental health problems was negatively correlated with physical (r = -0.202, p < 0.01) and mental health ratings (r = -0.310, p < 0.01). DISCUSSION:Women reported a broad range of postpartum health problems, with no significant differences between the first and second years. Findings underscore postpartum care should be extended into the second year.
BACKGROUND:The psychological impact of stillbirth on parents is profound, increasing the need for respectful care. Despite the existence of international guidelines, there has been no clinical confirmation of their efficacy in improving parental mental health outcomes. METHODS:This study is a web-based cross-sectional study and part of the OPALE (Observatory on PerinatAL hEalth) project. Participants were selected if they suffered a pregnancy loss after 20 weeks (including termination of pregnancy for medical reasons) in the last 10 years. The survey includes: the CiaoLapo Stillbirth Support (CLASS) checklist, the Perinatal Grief Scale (PGS), the National Stressful Events Survey PTSD Short Scale (NSESSS), and questions on satisfaction with care. RESULTS:261 participants completed the survey. In a multivariate analysis, higher CLASS scores were correlated with lower PGS and NSESSS scores, suggesting a direct relationship between guideline adherence and better psychological outcomes. Specifically, satisfying over 40 of the 60 checklist items independently predicted greater care satisfaction (OR 2.0, CI 1.1-3.8), higher experiences of respectful care (OR 3.6, CI 1.9-7.0), lower grief (OR 0.08, CI 0.1-0.2), and reduced PTSD symptoms (OR 0.21, CI 0.1-0.5). CONCLUSIONS:This is the first study which identifies a correlation between adherence to stillbirth care guidelines and better psychological outcomes, indicating their importance in enhancing parents' mental health.
BACKGROUND:Little is known about the negative impacts of the COVID-19 pandemic on health behaviors among postpartum women. We aimed to assess self-reported changes in physical activity, sitting time, and sleep among postpartum women early in the pandemic. METHODS:We conducted an online survey of postpartum women in the United States (n = 809) during May and June of 2020. Multiple logistic regression models were used to examine associations between socio-demographic, medical, and COVID-19-related factors (e.g., COVID-related worries and stressors) and self-reported changes in health behaviors. RESULTS:The prevalence of being less physically active, sitting for longer times, and sleeping less since the pandemic started were 57.4%, 64.9%, and 26.3%, respectively. Medicaid-insured recipients reported more reduced physical activity and longer sitting time than privately insured women. Breastfeeding was associated with higher odds of being less physically active. Worse health status was strongly associated with adverse changes in the three behaviors (All Ptrend < 0.05). A higher score on social connection with family members was associated with reduced physical activity and longer sitting time, while those with a higher social connection score with community/neighbors/friends were more physically active. COVID-19-related worries were associated with lower odds of being less physically active but greater likelihood of sitting longer and sleeping less. COVID-19-related stressors were associated with higher odds of sleeping less. CONCLUSIONS:Early in the COVID-19 pandemic, adverse changes in health behaviors were prevalent among US postpartum women. Intervention programs optimizing multiple health behaviors among postpartum women and high-risk groups are needed during pandemic situations.
INTRODUCTION:Introduced in 2021, the Dutch national guideline on late-term pregnancy management aims to standardize care, reduce regional variation, and optimize maternal and perinatal outcomes. This study aimed to evaluate the extent to which regional protocols adhere to this Dutch national guideline and assess variation in the content of protocols for late-term pregnancy management. METHODS:In this cross-sectional study, content analysis of 60 Dutch regional late-term pregnancy protocols was performed to assess alignment with the Dutch national guideline. Key variables included protocol characteristics, integration of guideline recommendations, use of shared decision-making tools, and regional policy choices. RESULTS:The integration of guideline recommendations varied largely among regional protocols. Induction of labor at 41 weeks alongside the option of expectant management was incorporated into 72% of the protocols, while the recommendation to facilitate shared decision-making was adopted in only 45%. The two recommendations regarding fetal monitoring and the recommendation on increased risk for nulliparous women were infrequently implemented (43%, 37%, and 30%). The implementation of late-term choices varied considerably in terms of shared decision-making conversation timing, additional monitoring, and available alternatives. CONCLUSION:Substantial variation was found in protocol content and the integration of guideline recommendations. Although the guideline highlights the importance of shared decision-making, a lack of clarity remains regarding the content, purpose, and scope of regional protocols. Restructuring the current system of protocol development from regional working groups to a centralized organization may help reduce practice variation and improve the quality of care.
BACKGROUND:Maternal satisfaction with childbirth is a key indicator of intrapartum care quality and is linked to improved maternal and neonatal outcomes, continued use of maternity services, and psychological well-being. Despite growing research attention, a consistent and comprehensive synthesis of global evidence on childbirth satisfaction and its determinants is still lacking. METHODS:A systematic review and meta-analysis of observational studies published in English between 2015 and 2025 was conducted. Eligible studies assessed maternal satisfaction using validated instruments. Searches were performed in PubMed, Scopus, and Google Scholar. Two reviewers independently screened, extracted data, and assessed study quality using the JBI Critical Appraisal Checklist. RESULTS:Thirty-two studies comprising 16,967 women met the inclusion criteria. The pooled prevalence of childbirth satisfaction was 71.0% (95% CI: 65%-77%), with substantial heterogeneity (I2 = 99.17%, p < 0.001). Satisfaction was 64.0% following vaginal birth and 63.0% after cesarean delivery. Regionally, satisfaction was highest among the five European countries (83.0%), moderate among the four Asian countries (74.0%), and lowest among the four African countries (62.0%). Substantial heterogeneity was observed across all analyses. The most commonly reported associated factors included maternal age, education, parity, respectful care, and mode of delivery. DISCUSSION:Differences in birth satisfaction may reflect variations in the quality of delivery services, women's expectations and experiences, socio-demographic characteristics, and cultural factors shaping perceptions of maternity care. LIMITATIONS:Significant heterogeneity across studies-arising from variations in methodological rigor, measurement approaches, and contextual conditions-limits the precision and generalizability of pooled estimates. The exclusion of non-English studies may have introduced language bias, and potential publication bias cannot be excluded, as suggested by observed funnel plot asymmetry. CONCLUSIONS:Approximately seven in ten women report satisfaction with childbirth, though estimates vary by region and study design. Standardized, culturally sensitive tools and high-quality research are needed to enhance understanding and improve women's childbirth experiences. REGISTRATION AND PROTOCOL:The systematic review protocol was registered in PROSPERO.
BACKGROUND:Weight stigma is pervasive in maternity care, contributing to negative health outcomes and disengagement among larger-bodied women. To reduce weight stigma and promote respectful, individualized care, a weight-inclusive approach prioritizes overall well-being rather than focusing on weight as a key health indicator. How maternity care providers adopt weight-inclusive approaches remains underexplored. This study aimed to investigate the perspectives and practices of weight-inclusive maternity care providers. METHODS:Semi-structured interviews were conducted online with medical, midwifery, and allied health maternity care providers, nominated by consumers or peers for their weight-inclusive practice. Interviews were audio recorded, transcribed, and analyzed thematically. RESULTS:Twenty-four professionals were interviewed, with three themes generated to describe their weight-inclusive approaches: (1) Time and space for reflection-participants described a gradual shift from weight-centric to weight-inclusive care, often prompted by personal or professional experiences of weight stigma; (2) Questioning weight science-participants questioned the value of body mass index or weight as indicators of individual health, favoring holistic assessments; and (3) Taking action to make change-participants had made specific changes to their practice, including to clinical environments, communication, and in responding to weight-centric systems. DISCUSSION:Our findings map how some maternity care providers describe enacting weight-inclusive maternity care. Despite systemic barriers such as weight-centric education and clinical guidelines, maternity care providers made meaningful change through deliberate reflection and compassionate practice. Reform in education and clinical guidelines is needed. Extending existing frameworks, our study describes maternity-specific enactments to address weight stigma and support broader adoption of weight-inclusive approaches.
BACKGROUND:In recent years, state-level recreational cannabis legalization has bourgeoned throughout the United States, which may explain increasing rates of cannabis use among pregnant women. OBJECTIVE:Our objectives were to: (1) comprehensively explore policies and practices related to screening, testing, and reporting prenatal cannabis use across a multi-state sample, and (2) describe variations in policies and practices by state-level recreational cannabis legalization. METHODS:We conducted an exploratory, multiple-case qualitative case study of perinatal nurses using a combination of convenience and snowball sampling. Interviews were analyzed using content analysis. RESULTS:Of the 22 registered nurses from 15 states of mixed recreational cannabis legalization statuses (legal: n = 6, illegal: n = 9), universal verbal screening was reported in all but one state, which had recreational cannabis legalization. Nurses from nearly one-quarter of states described universal maternal toxicology testing, which is inconsistent with current clinical recommendations. Although discouraged as a standard practice, nurses from most states described policies in which positive toxicology results were reported to social work and/or child protective services. In response to positive toxicology results, changes in clinical practice reported by nurses included discouragement of breastfeeding, which may have concerning health equity implications. CONCLUSION:In contrast to clinical guidelines, nurses in one-third of states reported universal maternal toxicology testing. Nurses reported ethical concerns about testing practices, including biased rationales for testing, failure to conduct informed consent, and threatening with punitive consequences to accomplish testing.
INTRODUCTION:Episiotomy remains a widely performed procedure in many countries, despite international recommendations favoring a restrictive approach. In Mexico, high rates persist in several settings, including public hospitals. Understanding the factors that sustain this practice is key to designing evidence-based respectful birth care strategies. This study aimed to explore healthcare professionals' perspectives on the decision-making process, performance, and perceived consequences of episiotomy, and to engage them in the co-design of behavioral science-informed interventions to promote its restrictive use. METHODS:A two-phase qualitative study was conducted in two public hospitals in Mexico, as part of a broader project aimed at promoting the restrictive use of episiotomy. In Phase 1, we conducted 22 semi-structured interviews with maternal health care workers, selected through purposive sampling. Interviews were analyzed inductively using iterative coding and thematic grouping. In Phase 2, group interviews were conducted to discuss findings and collaboratively design interventions for a future pilot quasi-experimental study. RESULTS:Episiotomy decisions are often guided by clinical and preventive considerations. Non-clinical factors, including productivity burdens and training, also contributed to the high rates of episiotomy. Despite the absence of formal institutional monitoring of episiotomy rates, professionals expressed a strong interest in receiving feedback and training. CONCLUSION:Episiotomy practices in this setting are influenced by clinical, systemic, and educational factors. Addressing potential overuse of episiotomy requires institutional feedback systems, evidence-based training, and strategies to improve dignity in care. Engaging stakeholders through a participatory approach helps ensure that potential interventions are contextually relevant and feasible to implement.
BACKGROUND:Burnout and job satisfaction among midwives have been studied extensively but not in the context of global pandemics. Given the effects of pandemics and similar crises on the experiences and working conditions of midwives, as well as the increasing incidence of such events, it is necessary to evaluate their impact. The dual aims of this study were to analyze whether there were differences in the levels of burnout and job satisfaction experienced during the pandemic between midwives in Spain and the United Kingdom, and to identify risk factors for high levels of burnout during this period. METHODS:We conducted a cross-sectional study using a questionnaire based on validated burnout and job satisfaction scales between October 2020 and March 2021. We recruited a total sample of 599 midwives, 170 in the UK and 429 in Spain. Data were analyzed using logistic regression models in SPSS 20.0. RESULTS:Moderate and high levels of burnout were found in both countries, although UK midwives reported significantly higher levels of burnout than Spanish midwives (p > 0.000). Spanish midwives had higher job satisfaction scores in all variables except benefits received (salary, promotion, and training) (p > 0.000). Age, hospital care units, and rotating work shifts were the main factors related to high levels of burnout (p > 0.000). CONCLUSIONS:During the pandemic, midwives in Spain and the United Kingdom experienced high levels of burnout and job dissatisfaction. Strategies need to be developed to reduce the impact of pandemic-related stressors in order to minimize attrition in the profession without compromising quality of care.
BACKGROUND:This cross-sectional study compared rates of breastfeeding initiation and exclusive breastfeeding among foreign-born mothers who utilized the Women, Infants and Children (WIC) program with foreign-born non-participants and US-born WIC participants. METHODS:Sample children from the nationally representative dataset, the National Survey of Children's Health 2016-2022, ages 6 months to 1 year were included. Descriptive statistics and logistic regressions were executed for analysis. RESULTS:91.8% of foreign-born women who utilized WIC initiated breastfeeding and 34.8% exclusively breastfed for 6 months. By comparison, 68.2% of US-born women who utilized WIC initiated breastfeeding and 10.4% exclusively breastfed for 6 months. Foreign-born women who utilized WIC had 4.04 times the odds [95% CI (1.49, 10.97)] of initiating breastfeeding relative to foreign-born women who did not utilize WIC. Foreign-born women who utilized WIC also had 7.42 times the odds [95% CI (3.22, 17.11)] of initiating breastfeeding and 3.47 times the odds [95% CI (1.52, 7.95)] of exclusive breastfeeding for 6 months relative to US-born women who utilized WIC (adjusted for household federal poverty level, preterm birth, birth order of sample child, sample child's race and mother's age, education, and marital status). CONCLUSION:Foreign-born women who utilized WIC had increased breastfeeding behavior relative to both foreign-born women who did not utilize WIC and US-born women who utilized WIC. This suggests that, rather than WIC contributing to lower breastfeeding rates, there is an unobserved characteristic that is correlated with lower breastfeeding rates among US-born women who utilize WIC that also encourages selection into the program.
INTRODUCTION:This study aimed to evaluate whether and to what extent progesterone use during pregnancy influences offspring's body weight in a large sample, drawn from 1959 to 1976. METHODS:We used the data from the National Collaborative Perinatal Project, which retrospectively collected information on maternal progesterone use and offspring weight from birth to 7 years of age. Multivariable linear regression models were used to evaluate the association between maternal progesterone use and offspring weight, and to verify whether early pregnancy progesterone use, total duration of pregnancy, and duration of pregnancy use affect offspring weight. RESULTS:Among 49,507 mothers, 952 (1.92%) used progesterone during pregnancy. Birth weight of those who used progesterone was significantly lower than that of nonusers after adjusting for potential confounders. We found that the weight gaps were -135 g (95% CI: -163 to -106 g) at birth and -92.6 g (95% CI: -149 to -35.7 g) at 4 months. When progesterone use was first initiated in the second or third trimester, lower weight in offspring of users could persist to 8 months and 1 year, respectively. If the total duration of progesterone use during the entire pregnancy was longer than 20 days, the weight gap between offspring of users and those of nonusers could last for 1 year after birth. CONCLUSIONS:Maternal progesterone use during pregnancy might be associated with lower birth weight of offspring in this population from 1959 to 1976, which suggests that further, updated research to in other populations is warranted.
BACKGROUND:Labor induction, the artificial start of labor using pharmacological or mechanical methods, has been associated with more negative birth experiences, including higher rates of poor maternal mental health, lower rates of breastfeeding self-efficacy, and shorter breastfeeding duration. However, few studies have used qualitative interviews to examine women's experiences with labor induction and why this intervention may lead to more negative birth experiences. METHODS:This study used a descriptive phenomenological approach. We analyzed 15 semi-structured interviews using coding and matrix analysis. Interview questions centered around mothers' birth experiences, the feeling of contractions, and differences between multiple birth experiences when applicable. RESULTS:Mothers with a labor induction stated their contractions were more intense, closer together, or had no break compared to their non-induced births or the coaching they received prenatally from doulas or childbirth educators. A desire for induction and levels of provider support also contributed to mothers' experiences with labor induction. Mothers expressed that this altered contraction patterning increased anxiety and motivated their use of pain medication. DISCUSSION:Our findings suggest that induced labor may lead to more negative birth experiences through altered contraction patterns, not wanting the induction, and lacking trust and support from care providers. Hospital policies should ensure that healthcare providers and clinicians have time to understand mothers' desires for induction and other medical interventions and should provide extra support for mothers who need this intervention. Further research is needed on the possible physiologic effects this altered contraction patterning has on mothers and infants.
