INTRODUCTION:Waterbirth is a pain relief option and a comfort measure not widely available in US hospitals. This study presents a secondary analysis of a randomized control trial of waterbirth examining participants' entry into the tub and final location of birth (water or non-water) to determine characteristics associated with successful waterbirth. METHODS:We analyzed data from a hospital-based waterbirth study that was conducted at a large, urban, midwestern medical center. Among those planning a waterbirth who presented in labor at term, we compared participant and labor characteristics by tub entry during labor and completion of birth in water using Fisher's exact and Kruskal-Wallis tests. RESULTS:Of 124 participants randomized to waterbirth, 96 were eligible for inclusion in this analysis, with 68 (71%) entering the tub during labor and 41 (43%) giving birth in water. Common reasons for not entering the tub included hypertension (n = 10) and desire for epidural analgesia (n = 10). Of those who entered and subsequently left the tub, 14 desired epidural analgesia and 4 required cesarean or operative vaginal birth. Participants who enterefd the tub had greater cervical dilatation at admission (4.3 vs 2.6 cm, P < .001). Those who entered the tub and gave birth in water were older (31.2 vs 27.5 y, P = .012), had greater dilatation at hospital admission (4.8 vs 3.6 cm, P = .023), and were more likely to be multiparous (56% vs 27%, P = .023). Participants who gave birth in water were also more likely to be married and have higher educational attainment. DISCUSSION:Medical contraindications emerging after admission highlight labor unpredictability and the importance of ongoing assessment for waterbirth eligibility. Although characteristic differences related to tub entry were primarily physiologic, those related to giving birth in the tub also included sociodemographic differences. Future work should evaluate how labor support, clinical decision‑making, and structural factors shape equitable access to waterbirth.
INTRODUCTION:This systematic review and meta-analysis aimed to evaluate the effects of nutritional interventions during pregnancy on maternal and neonatal outcomes. METHODS:The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in PROSPERO (CRD42024528918). Randomized controlled trials published between 2014 and 2024 were identified through systematic searches conducted between May and July 2024. Methodological quality was assessed using the Revised Cochrane Risk of Bias tool, version 2, and the certainty of evidence was rated with Grading of Recommendations Assessment, Development and Evaluation. Pooled estimates were calculated using a random-effects model. RESULTS:Twenty-three trials involving 9389 participants were included. Nutritional interventions significantly increased birth weight within healthy limits and reduced the risks of low birth weight, small for gestational age, preterm birth, and gestational diabetes mellitus. No significant effects were observed for macrosomia, large for gestational age, birth length, head circumference, gestational hypertension, preeclampsia, maternal anemia, cesarean birth, or neonatal intensive care unit admission. Subgroup analyses showed stronger effects for personalized counseling, interventions with 4 or more sessions, and programs including food supply. DISCUSSION:Nutritional interventions during pregnancy are crucial for reducing major adverse outcomes such as gestational diabetes mellitus and preterm birth. Integrating structured nutritional counseling into antenatal care may contribute to improved population-level maternal and child health.
Inflammatory breast cancer (IBC) is a rare but aggressive form of cancer; hence, early diagnosis is essential. Although predominantly occurring in older women, it can occur during pregnancy and lactation, making the diagnosis especially challenging. IBC is characterized by erythema and edema of the breast skin, with or without an underlying palpable mass. In pregnant and postpartum women, it can be easily confused with lactational mastitis. Awareness of the history and clinical signs of IBC, and how it differs from lactational mastitis, increases the likelihood that women will receive due care and have a chance at survival. Midwives play a key role in early recognition of breast abnormalities, given the multiple opportunities during pregnancy, birth, and the postpartum period to observe women's breasts. This Clinical Rounds article presents a real case of IBC in a postpartum woman. Discussion of the clinical presentation, diagnostic tips, and appropriate management options are included and compared with the diagnosis and management of lactational mastitis.
INTRODUCTION:A growing body of literature suggests that patient-provider communication in perinatal care is a key factor in addressing inequities in pregnancy outcomes. The purpose of this study was to explore how a sample of midwives who provide perinatal care perceive their communication practices about racism-related risks with Black women who are pregnant during clinical encounters. METHODS:Fourteen midwives from a national mixed-methods study completed semistructured interviews about communication practices regarding pregnancy risks during prenatal care. Interviews were analyzed using thematic analysis. RESULTS:Three themes developed. Evolving Communication describes the multitude of ways participants engaged in patient-centered communication over time, tailored to the needs of individual patients and circumstances. Tension describes the internal conflict midwives experience when they want to address racism in conversations but fear causing offense, harm, or misunderstanding. Room for Growth was defined as the lack of formal training and the desire to learn more about incorporating discussions about structural racism into communication with Black women when discussing risks or complications during pregnancy. DISCUSSION:Midwives in this study deployed adaptive communication strategies while experiencing tension between wanting to convey accurate information effectively and being considerate of how their communication might be received. Education and training in best practices for communicating with patients who are diverse may help reduce clinicians' reticence to raise potentially charged topics and support open, frank dialogue. Midwives have a clear commitment to ensuring Black patients are seen, heard, and receive excellent care, and there is a need for midwifery education to include training on communicating about how structural racism and contextual factors drive health care.
INTRODUCTION:Out-of-hospital community births account for 1.6% to 2% of births in the United States and are associated with fewer obstetric interventions but increased neonatal risk. Little is known about how maternity care providers' characteristics, values, and prior exposure to community birth influence attitudes toward community birth. METHODS:We conducted an observational cross-sectional survey using a 40 to 43 item Research Electronic Data Capture questionnaire distributed October 2 to 30, 2024. Eligible participants ("providers") included in-hospital physicians, midwives, community birth providers, and registered nurses. The survey assessed demographics, practice characteristics, provider values, prior community birth experience, and attitudes toward community birth. Descriptive statistics were used to summarize characteristics. Group comparisons between in-hospital and community birth providers were conducted using analysis of variance and χ2 or Fisher exact tests. Associations between attitudes and provider values were evaluated using linear models with Bonferroni correction. RESULTS:Sixty-seven providers completed the survey (51 in hospital, 16 community based). Most respondents were female (89.6%) and White (77.6%), with a median of 7 years in practice (IQR, 3-14.5). Attitudes significantly differed by role (P = .007) and credentials (P = .002). In-hospital providers reported safety concerns about community birth and perceived antenatal counseling to be inadequate. Perceived patient distrust during transfer was common among both in-hospital and community-based providers (69% and 81%, respectively). After adjustment for provider role and multiple comparisons, no significant differences in personal values were noted by attitude group; however, providers with positive attitudes toward community birth were more likely to believe that patients value compassion (β = 2.3, P = .004). DISCUSSION:Provider attitudes toward community birth appear to be shaped more by professional role and clinical experience than by differences in underlying value systems. High levels of perceived patient distrust during transfer highlight the need for interventions that strengthen compassion across maternity care settings.
Kratom is an emerging substance in the United States that is commonly used to manage chronic pain and withdrawal symptoms from opioids. Kratom products are federally unregulated and legal in many states, and prolonged use can lead to the development of a substance use disorder. For pregnant persons, there are additional risks of maternal and infant withdrawal symptoms. Treatment of kratom use disorder (KUD) is complicated by misperception of the substance's harmful effects as well as limited screening options to identify and track use. There are few reports on the management of perinatal KUD and outcomes following childbirth. Buprenorphine has limited evidence for the treatment of KUD in the general population. This medication is supported for the treatment of opioid use disorder in pregnancy, but only 3 cases describe its application for pregnant persons with KUD. Key considerations for this treatment approach include identifying an effective buprenorphine dose and using collaborative care to address patient concerns. This case study illustrates strategies for the diagnosis and management of KUD in pregnancy.
INTRODUCTION:The United States faces persistent perinatal health care inequities, and there is growing recognition that midwifery care, including community-based care offered outside of hospital settings, could address these challenges. Medicaid finances half of the births in the United States, but state policies notably limit access to community midwifery care for people insured through Medicaid. METHODS:To understand barriers to Medicaid participation and how community midwives navigate these barriers in practice, we conducted a qualitative, interview-based study with midwives (n = 62) and nonmidwife birth center administrators (n = 2) in independent home birth practices and freestanding birth centers in California; data were collected between 2022 and 2025. RESULTS:The main barriers community midwives face to becoming Medicaid providers in California include: (1) extremely low reimbursement rates for the extensive continuity of care community midwives provide; (2) liability insurance and birth center licensing requirements that are unaffordable and not reflective of community birth settings; and (3) complex administrative bureaucracy that places undue burden on these independent clinicians. Midwives expressed a commitment to being accessible within their communities and striving to provide care to people across the socioeconomic spectrum. Because of the numerous barriers to being Medicaid providers, midwives employed various workarounds to increase access to midwifery care. DISCUSSION:The expansion of midwifery care is a critical intervention to improve perinatal health care in the United States, although access to the midwifery model of care remains suppressed by a fragmented approach to insurance and long-standing marginalization of US midwives. In California, structural barriers make Medicaid participation administratively inaccessible and financially unsustainable for most community midwives. These findings have national implications for improving state Medicaid policies, such as by reducing administrative burdens, improving reimbursement rates, and restructuring the payment model; doing so could increase access to community midwifery care and improve perinatal health care outcomes.
INTRODUCTION:As patient advocates, Black community-based doulas aim to address disparities in perinatal health care within both community and carceral settings. Yet, little is known about how they interpret their work with people who are pregnant and incarcerated. The purpose of this study was to examine Black doulas' perspectives on providing care in carceral systems and the institutional constraints of this work. METHODS:This study draws on interviews with 19 Black doulas who provided services in US jails and prisons. Using a directed content analysis and the reproductive justice framework, their care practices are examined to understand how they provide care in systems structured by punishment, surveillance, and perinatal health care disparities. RESULTS:Participants framed their work as relational and culturally grounded, which countered the punitive logics of incarceration. They described providing one-on-one support and education that people who are pregnant might not have otherwise received, given the precarious state of perinatal health care in carceral facilities. At the same time, they detailed various institutional constraints that influenced their model of care. Despite these constraints, doulas interpreted their work as a transformative intervention within carceral systems. DISCUSSION:By centering Black doulas' perspectives, this study shows how their care work resists state-sanctioned reproductive oppression and affirms alternative visions of perinatal health care that are culturally grounded and rooted in dignity and respect. As such, it demonstrates how Black doulas' insights are critical for informing institutional policies and practices and also for advancing reproductive justice.
The United States is experiencing a high societal burden of pregnancy-related and infant morbidity and mortality during the postnatal year. These trends are inherently linked because the 2 members of the parent-infant dyad are interdependent for their well-being. Several systemic factors contribute to suboptimal health outcomes, including health care siloes under the medical specialization paradigm, multiple care transitions, and lack of care coordination during the postnatal year. Despite the clear positive impact of breastfeeding on parent and child health outcomes, as a dyadic specialty, lactation care does not have an obvious home within the siloed United States health care system. The objective of this article is to propose implementation of a comprehensive dyadic care model for birthing parents and infants during the postnatal year, including a focus on provider-level lactation management. Practical issues, such as clinic workflows, financial sustainability, workforce development solutions, and scope of practice issues are discussed. Midwives are ideally positioned to be leaders in the provision of dyadic perinatal care during the postnatal year, with long-term implications for parent and infant health.
Historically, Massachusetts has lagged behind much of the United States with limited midwifery access and curtailed options for community birth across the state. Over the past 2 decades, significant coalition building and political action culminated in the 2024 passage of the Massachusetts maternal health omnibus law. The purpose of this article is to describe the many events that unfolded to achieve this landmark legislation. This law was enacted through evidence-informed policy and was grounded in reproductive justice. It modernized birth center regulations, established a licensure pathway for certified professional midwives, and improved reimbursement for midwifery services. The passage of this law demonstrates how coalition power can redress long-standing structural barriers to midwifery services and community birth.
Efforts to standardize perinatal care in the early-mid 20th century led to the development of standardized midwifery training manuals produced by the US Children's Bureau and adapted by state health departments. This analysis examines how these manuals facilitated the institutionalization of midwifery education and contributed to the displacement of apprentice-trained Indigenous and Black midwives. Primary-source manuals from the US Children's Bureau and the Alabama and Mississippi departments of public health were examined through direct visual analysis, including a reproduced copy of the Alabama manual. Manuals were selected based on their publication following the Sheppard-Towner Maternity and Infancy Act, their documented use in state-supported programs, and the completeness of available editions. A comparative historical framework, informed by public health history and institutionalization theory, guided interpretation. The manuals codified competencies, literacy and documentation requirements, and supervisory oversight, shifting authority from community midwives to state-approved professionals. Alabama's implementation illustrates how federal guidance was operationalized locally through eligibility standards, record-keeping practices, inspections, and narrowing pathways into practice, measures that selectively advantage nurse-led models. Beyond procedural standardization, the manuals embedded racialized and classed assumptions, framing traditional midwives as problems to be corrected rather than knowledge-holders. These dynamics aligned with broader regulatory campaigns that restricted licensure, increased surveillance, and ultimately diminished traditional midwifery practice. Midwifery training manuals consequently functioned not only as instructional texts but also as tools of institutionalization that reshaped who was permitted to practice, under what authority, and to whose benefit. Understanding this history clarifies contemporary debates surrounding regulation, equity, and authority in midwifery care.
INTRODUCTION:A mental health epidemic exists in women of color who are pregnant, with alarming rates of depression and anxiety. Furthermore, the majority of these women do not receive treatment because of inadequate screening, mental health stigma, and lack of access to mental health care professionals. The purpose of this study was to evaluate the 6-week and 6-month postpartum effects of the Creating Opportunities for Personal Empowerment (COPE)-Pregnancy (COPE-P) program, administered by midwives, compared with a health promotion education program on mental health and healthy lifestyle behaviors and beliefs of Black and Hispanic women experiencing depression, anxiety, or stress. METHODS:The study was a longitudinal, 2-group randomized controlled trial with 299 Black and Hispanic participants who screened high on depression, anxiety, or stress scales. In total, 41% of women screened met study eligibility criteria. Two 6-session group prenatal care interventions-the COPE-P cognitive-behavioral skills-building (CBSB) program and a health promotion with discussion attention control-were evaluated. Valid and reliable measures included the General Anxiety Disorder-7 scale, Edinburgh Postnatal Depression Scale, Perceived Stress Scale, Healthy Lifestyle Beliefs Scale, and Healthy Lifestyle Behaviors Scale, which were assessed at baseline, postintervention, 6 weeks postpartum, and 6 months postpartum. RESULTS:Two-way analyses of variance and longitudinal multilevel growth models assessed outcomes. Both groups demonstrated rapid, significant decreases in depression, anxiety, and stress (P <.001) over time through 6 months postpartum. Only the COPE-P group's significant improvement in healthy lifestyle behaviors was sustained through 6 weeks postpartum (P <.001). Participants who completed more CBSB activities showed greater improvements in outcomes than all other participants. DISCUSSION:CBSB and health promotion content provided in group prenatal care by midwives decreased depression, anxiety, and stress that persisted through 6 months postpartum. CBSB programming sustained longer-term improvements in healthy lifestyle beliefs and behaviors. Performing more CBSB activities led to greater improvements in outcomes. The study was registered at the US National Institutes of Health (ClinicalTrials.gov) (NCT03416010).
INTRODUCTION:Prenatal mental health, perception of pain, and pregnancy histories can affect a birthing person's sense of control during labor. Although recent research has focused on cesarean births, less attention has been given to the role those factors play in perceived control during vaginal births. These gaps are particularly critical for Latinas, who experience health care intrapartum disparities in the United States. This study addresses these gaps by examining how prenatal depression symptoms, history of pregnancy loss, and pain severity are related to perceived control during labor among Latinas birthing vaginally. The findings may inform intrapartum care for a patient population at increased risk of health care inequities. METHODS:This secondary data analysis included 119 self-identified Latina women who had a vaginal childbirth in North Carolina. Hierarchical linear regressions tested associations between prenatal depressive and anxiety symptoms, history of pregnancy loss, labor pain severity, and perceived control of labor. RESULTS:A history of pregnancy loss was associated with lower perceived control during labor across all models, even after controlling for covariates, mental health, and perinatal variables (B = -0.450; P = .024). Prenatal depressive symptoms were also a robust predictor, showing an inverse association with perceived control of labor in the final model with all predictors (B = -0.076; P = .014). Lastly, there was a significant and negative association between pain severity and perceived control of labor, even after controlling for covariates, histories of pregnancy loss, prenatal depressive symptoms, and analgesia use in labor (B = -0.355; P < .001). DISCUSSION:Latinas in the United States encounter health care inequalities during and after childbirth. The findings underscore the need for clinicians to screen for depressive symptoms, discuss patients' pregnancy histories, support pain management during labor, and implement shared decision-making protocols.
