OBJECTIVE:To estimate the association between pregnancy-associated death or severe maternal morbidity and infant outcomes. METHODS:We conducted a retrospective cohort study using Massachusetts statewide data from 1999 to 2021. The dataset included hospital records longitudinally linked to births and maternal and infant death records. The primary exposures were pregnancy-associated death (deaths during pregnancy or in the year postpartum), severe maternal morbidity, and pregnancy-associated death after severe maternal morbidity. The main outcomes were infant death in the first year and, for those infants who survived, hospitalization in the first year of life. Bivariate and robust Poisson regression analyses through generalized estimating equations regression were used to estimate the association between the exposures and outcomes. RESULTS:Of 1,617,054 live births in Massachusetts between 1999 and 2020, there were 474 pregnancy-associated deaths. Pregnancy-associated death ratios were highest among individuals who were aged 40 years or older (49.3/100,000), who were non-Hispanic Black (43.0/100,000), who had public insurance (51.1/100,000), or who had a parity of four or more (80.6/100,000). Among individuals experiencing severe maternal morbidity (745.3/100,000), those who had a hospital encounter associated with opioid use (721.2/100,000) or a documented prepregnancy comorbidity (200.7/100,000) had the highest pregnancy-associated death ratios. In cases of pregnancy-associated death, the infant mortality rate per 1,000 live births was 55.0 (95% CI, 34.9-75.2) compared with 4.0 (95% CI, 3.9-4.1) when the mother survived. When the pregnancy-associated death followed severe maternal morbidity, the infant mortality rate was 87.9 per 1,000 live births (95% CI, 29.7-146.1). After a pregnancy-associated death, when a full-term infant survived to 1 year of age, there was a 35% greater likelihood of rehospitalization in the first year of life (adjusted risk ratio 1.35, 95% CI, 1.01-1.82) than when the mother did not die. CONCLUSION:Pregnancy-associated death was associated with infant death and worse health of surviving children in the first year of life, further demonstrating the far-reaching consequences of maternal deaths and the clear link between maternal and infant health.

BACKGROUND:Black-White inequities in severe maternal morbidity in the United States are extreme and growing. Maternal safety bundles (MSBs) have been associated with closing racial equity gaps in maternal health in some states. The objective of this study was to explore clinician perspective and experiences of implementing an Equity maternal safety bundle across five hospitals in Massachusetts to address inequities in perinatal care and birth outcomes. METHODS:Focus group discussions and interviews were conducted in Fall 2022 and Fall 2023 (before and after Equity MSB implementation) among obstetric nurses, resident physicians, and attending physicians. Discussions were facilitated using a semi-structured guide developed using the Consolidated Framework for Implementation Research (CFIR). Transcripts were independently coded by two analysts using NVivo 14. A codebook was developed using CFIR for deductive coding. We added inductive codes as appropriate. We calculated Cohen's kappa coefficients to assess interrater reliability. Themes were generated through an iterative process and compared across study time points. RESULTS:Fifteen clinicians participated at each time point with similar distributions across race, ethnicity, gender, and profession. Seven themes emerged from these interviews: 1) the importance of leadership support to prioritize equity, 2) a culture of equity as a facilitator for implementation, 3) the need for improved processes for self-reported race, ethnicity, and language data collection, stratification, and dissemination, 4) staff, time, and funding as necessary resources, 5) the need for an early focus on staff education, 6) existing siloes between physicians and nurses and exclusion of trainees as barriers to implementation, and 7) differences between an Equity-MSB and other MSBs. CONCLUSIONS:Leadership prioritization of equity and a culture of equity emerged as facilitators to successful implementation of elements of the Equity MSB. Challenges identified included resistance to change among colleagues, limited resources, and clinician siloes. When compared to previously implemented MSBs, participants found that leadership made this work a priority. As future hospital teams embark on implementing equity-focused action, these known facilitators and barriers should be considered and addressed during the pre- and early-implementation phases.

Background Cesarean delivery rates in the United States far exceed the World Health Organization (WHO)’s recommended population cesarean rate of 15%. This has resulted in calls from experts to reduce cesarean delivery rates. However, crude cesarean delivery rates are not necessarily comparable across populations since different birthing populations have different distributions of underlying cesarean delivery risk factors. WHO recommends using the Robson classification system to compare standardized cesarean delivery rates across populations, though it has been rarely used within the U.S. Objective The objectives of this study were to understand the distribution of cesarean deliveries using the Robson Classification system and to identify associated conditions (and potential drivers) of cesarean delivery across Robson groups. Study Design Our data comes from the Pregnancy and Early Life Longitudinal Data System from the Massachusetts Department of Health, which contains all birth certificate records for Massachusetts from 2011 to 2018. Using the WHO Robson Classification System Implementation guide, we categorized births into one of its 10 categories based on data from birth certificate records and ICD-9 and ICD-10 codes from billing records. Using the linked birth certificate records and hospital discharge records we went beyond the Robson classifications and examined patterns in maternal comorbidities and labor and delivery complications of cesarean deliveries across Robson groups. Results Among the 25% of birthing people who had singleton, term, vertex births with spontaneous labor, the cesarean delivery rate was 15% for nulliparous and 3% for multiparous (with no prior cesarean). The prevalence of maternal risk factors was 28% in the former and 30% in the latter. Labor and delivery complications were present in 46% and 35% of births, respectively. Birthing people with breech or transverse fetal presentation had the highest cesarean delivery rates around 95%. Multiparous birthing people with a prior cesarean delivery and cephalic, singleton, term births were the largest contributor to the cesarean delivery rate (38% of all cesareans). Almost all births for malpresentation or malposition of fetus had at least one labor and delivery complication but much lower rates of risk factors (between 25% and 46%). Conclusion While cesarean delivery rates, maternal risk factors, and labor and delivery complications followed similar patterns across Robson groups, there were notable discrepancies, especially in births with noncephalic presentations where maternal comorbidity rates matched lower cesarean-risk groups like the nulliparous single-term cephalic births.

Importance Pregnant individuals who repeatedly use emergency care during pregnancy represent a population who could be disproportionately vulnerable to harm, including severe maternal morbidity (SMM). Objective To explore patterns of unscheduled care visits during pregnancy and ascertain its association with SMM at the time of birth. Design, Setting, and Participants This cohort study used data from a statewide database that linked hospital records to births and fetal deaths occurring between October 1, 2002, and March 31, 2020, in Massachusetts. Pregnant individuals experiencing births or fetal deaths during the study period were included. Data analysis was conducted from June 2022 to September 2024. Exposure The exposure was 4 or more cases of emergency use, defined as either an emergency department visit or observational stay during pregnancy not resulting in hospital admission. Pregnancy episode was ascertained by subtracting the gestational age at birth from the date of birth. Main Outcomes and Measures The outcome of interest was the odds ratio (OR) for SMM at the time of birth. The algorithm includes 20 conditions or procedures (excluding transfusion) identified through International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes across the study period. Results A total of 774 092 pregnant individuals (mean [SD] age, 31.2 [5.8] years; 16.8% Hispanic, 9.3% non-Hispanic Asian or Pacific Islander, 9.5% non-Hispanic Black, 63.1% non-Hispanic White) with emergency care visits during the pregnancy were included; 31.3% of these individuals had at least 1 visit. Overall, 18.1% had 1 visit and 3.3% had 4 or more visits. Four or more unscheduled visits were common among those younger than age 25 years (8.7%), with Hispanic (5.7%) or non-Hispanic Black (4.9%) race and ethnicity, with public insurance (6.5%), or with a comorbidity (19.0%) or an opioid use-related hospitalization (26.8%) in the year prior to pregnancy. Of those with 4 or more unscheduled visits, 43.8% visited more than 1 hospital during pregnancy. In a multivariable analysis of the likelihood of SMM, those with 4 or more unscheduled visits had an adjusted OR of 1.46 (95% CI, 1.29-1.66) compared with those with 0 visits. Conclusions and Relevance This cohort study found that high emergency care use during pregnancy was associated with an increased risk for SMM. With a significant proportion of those with frequent unscheduled visits also using multiple hospitals, solutions that are community-based and integrated across health systems may be most beneficial.

Objectives: Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization. Methods: We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period. Our outcome measure was recurrence of SMM in the second birth. We calculated the prevalence of SMM at second birth, compared SMM conditions between births, and estimated the adjusted risk ratios and 95% confidence intervals for having an SMM event at second birth among those who had an SMM at the first birth. We also examined overall hospital utilization including inpatient admissions, emergency room visits, and observational stays, and hospital utilization by interpregnancy intervals (IPIs) between the first and second birth. Results: There were 2,814 birthing people with at least one birth after the first SMM singleton birth. Among those, 198 (7.0%) had a subsequent SMM. The percentage of people with a second SMM event varied by age, race/ethnicity, insurance, IPI, and history of hypertension at first case of SMM (all p < .05). Between births, people with a second SMM event had significantly higher proportions of inpatient admissions (60.1% vs. 33.2.0%; p < .001), emergency room visits (71.7% vs. 57.7%; p < .001), and observational stays (35.4% vs. 19.5%; p < .001) compared with those who did not experience a second SMM event. Conclusion: Hospital utilization after a birth with SMM might indicate an elevated risk of a second SMM event. Providers should counsel their patients about prevention and warning signs. (c) 2024 The Authors. Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health, George Washington University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).

BACKGROUND:The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.DESIGN AND METHODS:The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).RESULTS:We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).CONCLUSION:This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

OBJECTIVE:To examine pregnancy-related mortality ratios before (January 2019-March 2020) and during (April 2020-December 2020 and 2021) the coronavirus disease 2019 (COVID-19) pandemic overall, by race and ethnicity, and by rural-urban classifications using vital records data.METHODS:Mortality and natality data (2019-2021) were obtained from the Centers for Disease Control and Prevention's WONDER database to estimate pregnancy-related mortality ratios, which correspond to any death during pregnancy or up to 1 year after the end of a pregnancy from causes related to the pregnancy per 100,000 live births. Pregnancy-related mortality ratios were determined from International Classification of Diseases, Tenth Revision codes A34, O00-O96, and O98-O99. Overall pregnancy-related mortality ratios were partitioned by whether COVID-19 was listed as a contributory cause, and quarterly estimates were compared between 2019 and 2021. Pregnancy-related mortality ratios were compared by race and ethnicity and rural-urban residence before (2019-March 2020) and during (April 2020-December 2020 and 2021) the COVID-19 pandemic.RESULTS:Pregnancy-related mortality was significantly higher in 2021 (45.5/100,000 live births) compared with during the pandemic in 2020 (36.7/100,000 live births) and before the pandemic (29.0/100,000 live births). Pregnancy-related mortality ratios increased across all race and ethnicity and rural-urban residence categories in 2021. The largest increase occurred among American Indian/Alaska Native people during 2021 compared with April-December of 2020 (pregnancy-related mortality ratio 160.8 vs 79.0/100,000 live births, 104% relative change, P =.017). Medium-small metropolitan (52.4 vs 37.7/100,000 live births, 39.0% relative change, P <.001) and rural (56.2 vs 46.5/100,000 live births, 21.0% relative change, P =.05) areas had a larger increase in 2021 compared with April-December 2020 compared with large urban areas (39.1 vs 33.7/100,000 live births, 15.9% relative change, P =.009).CONCLUSION:Pregnancy-related mortality ratios increased more rapidly in 2021 than in 2020, consistent with rising rates of COVID-19-associated mortality among women of reproductive age. This further exacerbated racial and ethnic disparities, especially among American Indian/Alaska Native birthing people.

Introduction: The 1978 Alma Ata Declaration initiated international recognition of non-biomedical healing systems and their relevance for primary health. World Health Assembly (WHA) resolutions have called for the study and inclusion of traditional and complementary medicine (T&CM) into national health systems through policy development. The increased public, political, and scholarly attention given to T&CM has focused on clinical efficacy, cost-effectiveness, mechanisms of action, consumer demand, and supply-side regulation. Although >50% of WHO member states have T&CM policies, scant research has focused on these policies and their public health implications. This paper defines a novel term "therapeutic pluralism," and it aims at characterizing related policies in Latin America.Methods: A qualitative content analysis of Latin American therapeutic pluralism policies was performed. Policies' characteristics and the reported social, political, and economic forces that have made possible their development were assessed. Pre-defined policy features were categorized on an MS-Excel; in-depth text analyses were conducted in NVivo. Analyses followed the steps described by Bengtsson: decontextualization, recontextualization, categorization, and compilation.Results: Seventy-four (74) policy documents from 16 of the 20 sovereign Latin American countries were included. Mechanisms for policy enactment included: Constitution, National Law, National Policy, National Healthcare Model, National Program Guideline, Specific Regulatory Norms, and Supporting Legislation, Policies, and Norms. We propose a four-category typology of policy approaches in Latin America: Health Services-centered, Model of Care-based, Participatory, and Indigenous People-focused. Common themes countries used when justifying developing these policies included: benefits to the health system, legal and political mandates, supply and demand, and culture and identity. Social forces these policies referenced as influencing their development included: pluralism, self-determination and autonomy, anticapitalism and decolonization, safeguarding cultural identity, bridging cultural barriers, and sustainability.Conclusion: Policy approaches to therapeutic pluralism in Latin America go beyond integrating non-biomedical interventions into health services; they offer perspectives for transforming health systems. Characterizing these approaches has implications for policy development, implementation, evaluation, international collaboration, the development of technical cooperation tools and frameworks, and research.

BACKGROUND:Severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman's health. A statewide longitudinally linked database was used to examine hospitalization during and before pregnancy for birthing people with severe maternal morbidity at delivery. OBJECTIVE:This study aimed to examine the association between hospital visits during pregnancy and 1 to 5 years before pregnancy and severe maternal morbidity at delivery. STUDY DESIGN:This study was a retrospective, population-based cohort analysis of the Massachusetts Pregnancy to Early Life Longitudinal database between January 1, 2004, and December 31, 2018. Nonbirth hospital visits, including emergency department visits, observational stays, and hospital admissions during pregnancy and 5 years before pregnancy, were identified. The diagnoses for hospitalizations were categorized. We compared medical conditions leading to antecedent, nonbirth hospital visits among primiparous birthing individuals with singleton births with and without severe maternal morbidity, excluding transfusions. RESULTS:Of 235,398 birthing individuals, 2120 had severe maternal morbidity, a rate of 90.1 cases per 10,000 deliveries, and 233,278 did not have severe maternal morbidity. Compared with 4.3% of patients without severe maternal morbidity, 10.4% of patients with severe maternal morbidity were hospitalized during pregnancy. In multivariable analysis, there was a 31% increased risk of hospital admission during the prenatal period, a 60% increased risk of hospital admission in the year before pregnancy, and a 41% increased risk of hospital admission in 2 to 5 years before pregnancy. Compared with 9.8% of non-Hispanic White birthing people, 14.9% of non-Hispanic Black birthing people with severe maternal morbidity experienced a hospital admission during pregnancy. For those with severe maternal morbidity, prenatal hospitalization was most common for those with endocrine (3.6%) or hematologic (3.3%) conditions, with the largest differences between those with and without severe maternal morbidity for musculoskeletal (relative risk, 9.82; 95% confidence interval, 7.06-13.64) and cardiovascular (relative risk, 9.73; 95% confidence interval, 7.26-13.03) conditions. CONCLUSION:This study found a strong association between previous nonbirth hospitalizations and the likelihood of severe maternal morbidity at delivery.

INTRODUCTION: Interventions designed to address high rates of severe maternal morbidity (SMM) and improve maternal health equity often lack comprehensive data on the relative burden of specific SMM indicators across populations. This study examines variation in indicators of delivery-related SMM among non-Hispanic Black compared with non-Hispanic White Medicaid beneficiaries in 27 states. METHODS: We conducted a pool, cross-sectional analysis of the 2016–2018 Transformed Medicaid Statistical Information System. Unadjusted estimates of indicator frequency were generated for 27 states with adequate quality data on non-Hispanic Black and non-Hispanic White race and ethnicity. We estimated rates for each indicator for each racial group overall and within each state. This study was approved by the IRB at Boston University. RESULTS: Among deliveries to the non-Hispanic Black population (n=629,774), six indicators occurred at overall rates greater than 25 per 10,000 deliveries: eclampsia (leading indicator in 15 states), pulmonary edema/heart failure (3 states), renal failure (1 state), adult respiratory distress syndrome (3 states), sepsis (2 states), and disseminated intravascular coagulation (2 states). Among deliveries to the non-Hispanic White population (n=1,051,459), indicators occurred in different rank-order and at rates typically less than half of those identified among the non-Hispanic Black population. Morbidity indicators among the non-Hispanic White population were distributed differently across states. CONCLUSION: These findings provide opportunities for interventions designed to reduce SMM and improve maternal health equity in Medicaid to be tailored to the leading causes of SMM, which differ among non-Hispanic Black and White populations across and within states.

Population Medicine considers the following types of articles:• Research Papers -reports of data from original research or secondary dataset analyses.• Review Papers -comprehensive, authoritative, reviews within the journal's scope.These include both systematic reviews and narrative reviews.• Short Reports -brief reports of data from original research.• Policy Case Studies -brief articles on policy development at a regional or national level.• Study Protocols -articles describing a research protocol of a study.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.• Methodology Papers -papers that present different methodological approaches that can be used to investigate problems in a relevant scientific field and to encourage innovation.

OBJECTIVE: To examine demographic and clinical precursors to pregnancy-associated deaths overall and when pregnancy-related deaths are excluded. METHODS: We conducted a retrospective cohort study based on a Massachusetts population–based data system linking data from live birth and fetal death certificates to corresponding delivery hospital discharge records and a birthing individual's nonbirth hospital contacts and associated death records. Exposures included maternal demographics, severe maternal morbidity (without transfusion), hospitalizations in the 3 years before pregnancy, comorbidities during pregnancy, and opioid use. In cases of postpartum deaths, hospitalization between delivery and death was examined. The primary outcome measure was pregnancy-associated death , defined as death during pregnancy or up to 1 year postpartum. RESULTS: There were 1,291,626 deliveries between 2002 and 2019, of which 384 were linked to pregnancy-associated deaths. Pregnancy-associated but not pregnancy-related deaths (per 100,000 deliveries) were highest for birthing people with opioid use before pregnancy (498.3), severe maternal morbidity (387.3), a comorbidity (106.3), or a prior hospitalization (88.9). In multivariable analysis, the adjusted risk ratios associated with severe maternal morbidity (9.37, 95% CI, 6.14–14.31) and opioid use (6.49, 95%, CI, 3.71–11.35) were highest. Individuals with pregnancy-associated deaths were also more likely to have been hospitalized before or during pregnancy (2.30, 95% CI, 1.62–3.26). Among postpartum deaths, more than two-thirds (69.9%) of birthing people had a hospital contact after delivery and before their death. CONCLUSION: Severe maternal morbidity and opioid use disorder were precursors to pregnancy-associated deaths. Individuals with pregnancy-associated but not pregnancy-related deaths experienced a history of hospital contacts during and after pregnancy before death.

Objective To examine cross-national differences in gestational age over time in the U.S. and across three wealthy countries in 2020 as well as examine patterns of birth timing by hour of the day in home and spontaneous vaginal hospital births in the three countries. Methods We did a comparative cohort analysis with data on gestational age and the timing of birth from the United States, England and the Netherlands, comparing hospital and home births. For overall gestational age comparisons, we drew on national birth cohorts from the U.S. (1990, 2014 & 2020), the Netherlands (2014 & 2020) and England (2020). Birth timing data was drawn from national data from the U.S. (2014 & 2020), the Netherlands (2014) and from a large representative sample from England (2008–10). We compared timing of births by hour of the day in hospital and home births in all three countries. Results The U.S. overall mean gestational age distribution, based on last menstrual period, decreased by more than half a week between 1990 (39.1 weeks) and 2020 (38.5 weeks). The 2020 U.S. gestational age distribution (76% births prior to 40 weeks) was distinct from England (60%) and the Netherlands (56%). The gestational age distribution and timing of home births was comparable in the three countries. Home births peaked in early morning between 2:00 am and 5:00 am. In England and the Netherlands, hospital spontaneous vaginal births showed a generally similar timing pattern to home births. In the U.S., the pattern was reversed with a prolonged peak of spontaneous vaginal hospital births between 8:00 am to 5:00 pm. Conclusions The findings suggest organizational priorities can potentially disturb natural patterns of gestation and birth timing with a potential to improve U.S. perinatal outcomes with organizational models that more closely resemble those of England and the Netherlands.

This Viewpoint discusses the importance of collaboration among the agencies responsible for documenting rates of maternal mortality to ensure more accurate, reliable, and timely estimates.

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Abstract Background Pregnant and parenting women have low engagement and poor retention in substance use disorder (SUD) treatment. The aim of this study was to analyse the implementation of an adapted experience‐based codesign (EBCD) process involving SUD treatment staff and pregnant or parenting women with lived experience (WWLE) of SUD to launch a residential treatment service where women could coreside with their children and receive long term comprehensive treatment for dual diagnosis of SUD and mental illness. Methods A process evaluation was conducted utilising five data sources: two sets of semistructured interviews with WWLE and SUD treatment staff, ethnographic observation and transcripts from group events, and meeting minutes. Based on the Integrated Promoting Action on Research in Health Services framework constructs (context, recipients, facilitation, innovation) researchers applied thematic analysis to determine main themes within each construct. Results The full sample across the implementation totalled 34 individuals (WWLE = 13 and SUD staff = 21). The EBCD process engaged both cohorts and supported group cohesion and collaborative brainstorming. WWLE felt respected, emotionally safe to share, and empowered by participation. A cohesive, multidisciplinary codesign planning group, inclusive of WWLE, supported a more equitable codesign process. The need for a virtual platform due to the COVID‐19 pandemic impeded human connection and relationship building. The complex environment of residential regulations and uncertainties during start‐up phase of an organisation presented implementation challenges. Conclusion These results highlight the feasibility of, and challenges to, effectively engaging WWLE in a codesign process. The findings also demonstrated a positive influence on WWLE's feelings of empowerment. Identified themes reinforce the purposeful components within EBCD that enhance participation, along with new insights to inform successful codesign with a vulnerable population. The author's team included a WWLE who collaborated throughout the full scope of the research process, enriching the overall research and ensuring the authenticity of the presentation of women in recovery's perspective. Utilising the codesign approach to design and implement new services should improve health equity by enhancing patient engagement and retention in care. Patient Contribution Parenting WWLE of residential SUD treatment were involved in the full scope of the research process and the implementation being evaluated. For the actual codesign work WWLE were key members of the codesign planning team that met weekly throughout the implementation to plan, implement, problem solve and adapt the process over an 18 month timeframe. As is appropriate for codesign the actual ongoing workgroup participants had average 50% WWLE participation. For the research team, this research is a culmination of the lead author's doctoral dissertation. One member of the five‐person dissertation committee was a recovery coach and a WWLE. She was an active participant across the entire research process overseeing and influencing the research design, conduct of the study, analysis, interpretation of findings and approval of the final manuscript. The findings were member checked with the larger codesign planning group that had additional WWLE members.

The Ockenden report is a shocking read.1 Families were let down by maternity services resulting in avoidable deaths of women and babies. These tragic events cannot be reversed, but if we are to prevent them from happening again, we must have a clear picture of what went wrong. As researchers from outside the United Kingdom, we were surprised to read some of the recommendations in the report and particularly disappointed by the interpretation of the report in the media. These recommendations and the media reaction may, in fact, aggravate the very problems they are meant to allay. The report makes quite clear that a shortage of staff is a critical contributor to poor quality of care. Several other problems are, at least in part, a consequence of not having enough people to do the job: junior staff could not be properly supervised, overwork created tension between staff within units and between midwife-led and obstetric units, a lack of time prevented the provision of personalised care. Junior doctors and midwives were discouraged from seeking assistance and had to wait for help, even in cases where this was urgently needed. The labour ward coordinator is supposed to be available as a back-up, but was often given a caseload to manage because of the lack of staff, so preventing junior midwives from getting help even when they persistently asked. Midwives were pulled away from midwife-led units to assist in the obstetric unit, leaving midwife-led units severely understaffed. Many of the recommendations in the report make perfect sense, for example, the need to invest in maternity care, employ more staff and reduce attrition of midwives and doctors. Others, like forgoing the monitoring of caesarean section rates, making central cardiotocography (CTG) monitoring systems mandatory and suspending Continuity of Care are more difficult to understand. One of the recommendations in the report is to stop using total caesarean section percentages as a metric for maternity services. A caesarean section is often a life-saving procedure, and we would not recommend specifying a 'target' rate. However, the World Health Organization continues to advise the assessment, monitoring and comparison of caesarean section rates within healthcare facilities over time.2 A caesarean section represents a trade-off – balancing the risks of major surgery against the medical condition that may place a mother or baby at risk – and it is a decision not to be made lightly. Research has shown that caesarean sections at first births are associated with increased rates of stillbirth in second pregnancies and typically lead to repeat caesarean sections in subsequent births.3, 4 In the media, the Ockenden recommendation about caesarean sections has been translated into the assumption that a higher caesarean section rate will lead to lower maternal and perinatal deaths. For example, a headline in the The Daily Mail read, 'Midwives discouraging C-sections in favour of normal births contributed to many deaths in scandal-hit trust' (https://www.dailymail.co.uk/news/article-10672467/Does-damning-Ockenden-report-net-need-cast-WIDER.html). Suggesting that efforts to limit caesarean sections were the cause of poor outcomes may have been true in selected individual cases, but it belies the fact that between 2010 and 2020, among wealthy Organisation for Economic Co-operation and Development (OECD) countries (excluding Mexico and Poland), the United Kingdom experienced the second highest increase in caesarean section rate (31% – from 23.8% in 2010 to 31.2% in 2020), behind only Ireland (33% – from 26.0 in 2010 to 34.7% in 2020). Using National Health Service data for England, we found an even faster 2010–2020 increase in caesarean section rates (35% – from 24.3% in 2010–2011 to 32.9% in 2020–2021) than Ireland. If this trend were to continue, England or Ireland could soon have the highest caesarean section rate in Europe. Notably, this increase came at a time when rates were declining or levelling off among most comparable countries (Figure 1).5 Source: OECD Health Data 2022; England—NHS Maternity Statistics Annual Reports (2000–2001 through 2020–2021). Is a higher caesarean section rate the key to better outcomes? Figure 2 suggests not. It shows the comparison of caesarean section rates with perinatal mortality rates for 2019 and 2020 in comparable countries. Where 2020 data were not available for a given country, we matched 2019 caesarean sections and perinatal mortality rates. Countries with higher caesarean section rates actually had marginally higher rates of perinatal deaths on average than those countries with lower caesarean section rates. However, the clearest message from Figure 2 is a lack of any guaranteed improvement in perinatal mortality based on a higher caesarean section rate. The tragic case of a poor outcome associated with a delayed caesarean section makes for a powerful media narrative. However, the poor outcomes in the Ockenden Report have more to do with insensitive management and limited staffing than with simple solutions like increasing an already rapidly rising caesarean section rate. Source: OECD Health Data 2022. Surprisingly, one of the recommendations of the report is to review and suspend the Continuity of Care model until all Trusts demonstrate that staffing meets safe minimum requirements on all shifts. There is high-level evidence of the many benefits of continuity of carer when compared with other models of care, including 24% fewer preterm births and fewer medical interventions.6 If organised well, continuity of carer is also associated with lower scores for staff burnout.7 Given the fact that 67% of midwives in the United Kingdom suffer from work-related burnout, investing in continuity of care can help to solve staff shortages.8 In a similar vein, the report recommends that centralised CTG monitoring systems be made mandatory in all obstetric units in England. Central monitoring – a technology that allows care providers to see the fetal heart rate tracings and the rate of uterine contractions of all women in labour from one location – seems like a good idea, until you read the research. We know that the use of continuous CTG increases the likelihood of an unnecessary caesarean with no offsetting benefit for mother and baby.9 When the CTG tracing is monitored by staff at a central location, it can undermine clinical safety by disrupting care10 and reducing the time that midwives spend with women in labour.11 As others have pointed out, investing in the maternity care workforce is the most important recommendation of the Ockenden report.1 Simply increasing the caesarean section rate and abandoning continuity of care initiatives will not improve maternal and newborn care in the United Kingdom. If implemented, these policies will lead to resources being spent on medical interventions and the treatment of adverse outcomes, like preterm birth, that will inevitably follow. Those resources can be better used to employ the staff needed to implement Continuity of Care models properly nationwide. We agree that lessons need to be learned from the tragic events at the Shrewsbury and Telford Hospital National Health Service Trust. But why throw out the baby of personal care with the bathwater of mismanagement? The article was conceived, written, and approved by AdJ, RdV and ED. ED developed the figures. None. None declared. Completed disclosure of interests form available to view online as supporting information. All the data used were country level statistics, publicly available from the OECD. As such, ethics approval was not required. Data derived from public domain resources. The data that support the findings of this study are available on the OECD web page (https://www.oecd.org/health/health-statistics.htm). ICMJE Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

INTRODUCTION: Measuring patient experience is core to understanding and addressing inequities in obstetric care quality. METHODS: People who gave birth at one of five hospitals in Massachusetts and identified as non-Hispanic Black (NHB) or non-Hispanic White (NHW) were invited to complete a structured survey 7–16 weeks postpartum, from February to September 2022. The survey included two validated patient experience instruments: the Mothers on Respect index, dichotomized as “very respectful” or not and the Mothers Autonomy in Decision Making scale, dichotomized as “high patient autonomy” or not. We report risk ratios of associations between patient characteristics and respectful or autonomous care, adjusting for hospital cluster using Stata v.17. Institutional review board approval was received from the Social and Behavioral Research IRB at Tufts University. RESULTS: Of 417 respondents (response rate: 25%), 245 (59%) were NHW and 172 (41%) were NHB. Most had a bachelor’s degree (62%). 241 (60%) of births were vaginal. Very respectful treatment was reported by 78% of respondents, whereas high patient autonomy was only reported by 64%. Non-Hispanic White people were 1.2 times as likely to report high respect compared to NHB (95% CI: 1.1, 1.4). Respect was also significantly lower for those with lower education and those with vaginal birth compared to those with cesarean birth. Differences in respect by race remained significant in multivariable models (1.2, 95% CI: 1.0, 1.4). Autonomy did not differ by any of the assessed demographic or delivery characteristics. CONCLUSION: Examining patient experience revealed inequities. To identify opportunities for improvement and monitor change, brief, validated, patient reported experience measures need to be incorporated into routine data collection.