BACKGROUND: Women in the sex trade encounter significant challenges in obtaining reproductive healthcare. Reports of reproductive healthcare for women in the sex trade center on the prevention and termination of pregnancies, yet most women in the sex trade globally experience full term pregnancies and bear children. This study aimed to explore barriers and enabling factors to providing reproductive healthcare for women in the sex trade in Israel.
METHODS: We conducted a qualitative study utilizing a grounded theory method. Data were collected through semi-structured interviews, conducted between June 2021 and July 2022. Interviews were conducted with practitioners in healthcare settings (n = 20), practitioners in social services settings (n = 15), and women in the sex trade who received reproductive health care-related medical services (n = 13) in Israel. The interviews were audiotaped, transcribed, and thematically analyzed.
RESULTS: The findings indicated a multilayered structure of healthcare system-related factors and women-related factors. Stigma was noted as a multidimensional barrier, reflected in service providers\' attitude towards women in the sex trade, impairing the patient-provider relationship and impeding women\'s help-seeking. However, the creation of a relationship of trust between the women and healthcare providers enabled better health outcomes.
CONCLUSIONS: Based on the findings, we propose recommendations for designing and implementing reproductive healthcare services for women in the sex trade. The recommendations offer to (a) include women with lived experiences in planning and providing reproductive healthcare services, (b) adopt a trauma-informed approach, (c) emphasize nonjudgmental care, (d) train healthcare providers to reduce stigma and bias, and (e) enhance the affordability of health services for women experiencing marginalization.

OBJECTIVE: Midwifery retention is a global issue, but less is known regarding what motivates midwives\' intention to stay or leave within individual organisations. In 2021, NHS England funded maternity organisations to employ retention midwives. To date, the impact of these roles has not been evaluated.
OBJECTIVE: To explore the views of midwives regarding their intentions to leave or stay within one English organisation and to provide insights into the perceived impact of the role of retention midwives.
METHODS: An instrumental case study was carried out in one organisation. Data a mixed methods survey (n=67/91) and interview data (n=7). Quantitative data was analysed using descriptive and inferential statistics; qualitative data using thematic analysis. All data was synthesised together.
RESULTS: The three themes included \'Values-based tensions: The eroding role of the midwife\'; \'Discerning differences: Intentions to leave or stay\'; \'Retention midwives: Activities and impact\'.
CONCLUSIONS: We found that there was a clear link between midwives\' intention to leave or stay and their workplace roles; specialist midwives were more likely to stay, report satisfaction, autonomy, and feel a sense of contribution or effectiveness in their role compared to those in other roles. The retention midwives were making a positive difference to midwives\' experience of the workplace.
CONCLUSIONS: Midwives working within the same organisation have different experiences of their role and job satisfaction. Future work should consider applying the positive elements of the specialist roles to the wider midwifery workforce to enhance retention. The retention midwife role shows promise, but further evaluation is required.

OBJECTIVE: Midwifery Continuity of Care (MCoC) remains inaccessible for most Australian women; this is especially true in rural and regional areas.
BACKGROUND: Strong evidence demonstrates MCoC models improve experiences for women and their babies and are also shown to improve midwifery workforce wellbeing. However, implementation and upscale remains limited.
OBJECTIVE: To explore the views and experiences of implementing MCoC for both staff and women, understanding their experiences, concerns and solutions in a regional context.
METHODS: Qualitative data was collected via focus groups with women and healthcare staff, at six and twelve month post implementation. Data was thematically analysed using Braun and Clarke six step process.
RESULTS: The findings support that \'women love it\' and midwives working in the new MCoC model \'loved their job\'. The major concern was that not all women could access the model and disconnected communication was problematic during implementation. \'Sharing stories\' was a solution to overcoming these issues and promoting the positive impact of MCoC - in particular ways of working and adaption to an all-risk midwifery group practice.
CONCLUSIONS: This study supports widespread evidence that MCoC is valued by both women and staff. In a regional context it is important to recognise challenges faced during implementation and identifying solutions that other maternity services could consider when implementing MCoC.
CONCLUSIONS: The study offers strong recommendation for regional areas to consider MGP to maintain safe, quality local maternity services.

BACKGROUND: Shared decision-making (SDM) in maternity care involves women actively in decisions, thereby reducing decisional conflicts and enhancing satisfaction with care.
OBJECTIVE: To investigate SDM and the factors associated with it, and its correlation with respect in maternity care in Saudi Arabia.
METHODS: A comprehensive, nationwide online questionnaire-based study was conducted between January to May 2023, involving women aged 18 years and above who were either pregnant or had experienced pregnancy/childbirth in the past 12 months. The Mothers\' Autonomy in Decision-Making (MADM) scale and the Mothers of Respect Index (MORi) were used. Low to very low SDM was defined as a score of ≤ 24 on the MADM and low to very low respected was defined as a score of ≤ 49 on the MORi.
RESULTS: A total of 505 women completed the survey. Low to very low SDM was reported by 137 (34.1 %, 95 confidence interval (CI), 29.6 % - 38.9 %) women. Factors significantly associated with low to very low SDM included seeing different obstetricians of different gender at each visit (adjusted odds ratio (AOR) 2.0, 95 % CI, 1.0 - 3.9), not meeting the same obstetrician throughout the pregnancy (AOR 2.6, 95 % CI, 1.2 - 5.6) and having an instrumental vaginal birth (AOR 6.67, 95 % CI, 1.6 - 28.1). There was a positive association between low to very SDM and feeling of low to very low respect ((χ2 = 83.8173, p < 0.001).
CONCLUSIONS: More than one-third of women experienced low to very low SDM in maternity care. This should alert healthcare providers to the importance of continuity of care in Saudi Arabia.

BACKGROUND: Pregnant women with obesity face heightened focus on weight during pregnancy due to greater risk of medical complications. Closer follow-up in maternety care may contribute to reduce risk and promote health in these women. The aim of this study was to gain a deeper insight in how pregnant women with obesity experience encounters with healthcare providers in maternity care. How is the received maternity care affected by their weight, and how do they describe the way healthcare providers express attitudes towards obesity in pregnancy?
METHODS: We conducted in-depth interviews with 14 women in Trøndelag county in Norway with pre-pregnancy BMI of ≥ 30 kg/m2, between 3 and 12 months postpartum. The study sample was strategic regarding age, relationship status, education level, obesity class, and parity. Themes were developed using reflexive thematic analysis. The analysis was informed by contextual information from a prior study, describing the same participants\' weight history from childhood to motherhood along with their perceptions of childhood quality.
RESULTS: This study comprised of an overarching theme supported by three main themes. The overarching theme, Being pregnant with a high BMI: a vulnerable condition, reflected the challenge of entering maternity care with obesity, especially for women unprepared to be seen as \"outside the norm\". Women who had grown up with body criticism and childhood bullying were more prepared to have their weight addressed in maternity care. The first theme, Loaded conversations: a balancing act, emphasizes how pregnant women with a history of body criticism or obesity-related otherness proactively protect their integrity against weight bias, stigma and shame. The women also described how some healthcare providers balance or avoid weight and risk conversations for the same reasons. Dehumanization: an unintended drawback of standardized care makes apparent the pitfalls of prioritizing standardization over person-centered care. Finally, the third theme, The ambivalence of discussing weight and lifestyle, represent women\'s underlying ambivalence towards current weight practices in maternity care.
CONCLUSIONS: Our findings indicate that standardized weight and risk monitoring, along with lifestyle guidance in maternity care, can place the pregnant women with obesity in a vulnerable position, contrasting with the emotionally supportive care that women with obesity report needing. Learning from these women\'s experiences and their urge for an unloaded communication to protect their integrity highlights the importance of focusing on patient-centered practices instead of standardized care to create a safe space for health promotion.

Mothers with eating disorders can face additional challenges with infant feeding, and there is evidence they are likely to cease breastfeeding earlier than intended. However, there is little research exploring this. The present study used interpretative phenomenological analysis to explore the lived experience of infant feeding for mothers suffering from or recovering from an eating disorder. Semistructured interviews were conducted with six women-five who had breastfed and one who formula-fed. The women experienced two incompatible worlds-motherhood and an eating disorder. Tensions were sometimes resolved by reducing eating disordered behaviour alongside immersion in motherhood. Two participants did not find infant feeding particularly important for their journey into motherhood. Four recounted a positive shift in their relationship to their body through breastfeeding and felt their embodied experience of mothering provided a route out of eating disordered behaviour. However, doubts about their mothering and infant feeding capabilities could be amplified by feeling mistrusted by others and by the relative silence around eating disorders within maternity care services. Respectful dialogue with health care professionals was particularly valued where this occurred. Although long-term outcomes for the participants are unknown, the study suggests women with a history of eating disorders can form successful breastfeeding relationships and may be motivated to engage in collaborative risk assessment. However, they need support in managing emotional challenges. Training around eating disorders for maternity care professionals is likely to be useful for enhancing confidence in engaging mothers proactively to share concerns about eating, weight and body shape.

BACKGROUND: Midwifery continuity of carer (MCoC) is a model of care in which the same midwife or small team of midwives supports women throughout pregnancy, birth and the postnatal period. The model has been prioritised by policy makers in a number of high-income countries, but widespread implementation and sustainability has proved challenging.
METHODS: In this narrative review and synthesis of the global literature on the implementation and sustainability of midwifery continuity of carer, we identify barriers to, and facilitators of, this model of delivering maternity care. By mapping existing research evidence onto the Consolidated Framework for Implementation Research (CFIR), we identify factors for organisations to consider when planning and implementing midwifery continuity of carer as well as gaps in the current research evidence.
RESULTS: Analysing international evidence using the CFIR shows that evidence around midwifery continuity of carer implementation is patchy and fragmented, and that the impetus for change is not critically examined. Existing literature pays insufficient attention to core aspects of the innovation such as the centrality of on call working arrangements and alignment with the professional values of midwifery. There is also limited attention to the political and structural contexts into which midwifery continuity of carer is introduced.
CONCLUSIONS: By synthesizing international research evidence with the CFIR, we identify factors for organisations to consider when planning and implementing midwifery continuity of carer. We also call for more systematic and contextual evidence to aid understanding of the implementation or non-implementation of midwifery continuity of carer. Existing evidence should be critically evaluated and used more cautiously in support of claims about the model of care and its implementation, especially when implementation is occurring in different settings and contexts to the research being cited.

BACKGROUND: By addressing physical and psychosocial needs, group care (GC) improves health-related behaviours, peer support, parent-provider interactions and may improve birth outcomes. Hence, global implementation of GC is encouraged. Context analyses prior to implementation are vital to elucidate which local factors may support or hinder implementation.
METHODS: Contextual analyses conducted in the Netherlands and Suriname were compared to identify the factors relevant to the implementability of GC as perceived by healthcare professionals (HCPs). 32 semi-structured interviews were conducted with Dutch and Surinamese healthcare professionals. Audio recordings were transcribed verbatim and coded using the Framework approach. The Consolidated Framework for Implementation Research guided the development of the interview guide and of the coding tree.
RESULTS: Outer setting: Concerns regarding funding surfaced in both countries. Due to limited health insurance coverage, additional fees would limit accessibility in Suriname. In the Netherlands, midwives dreaded lower revenue due to reimbursement policies that favour one-on-one care. Inner setting: Appropriate space for GC was absent in one Dutch and three Surinamese facilities. Role division regarding GC implementation was clearer in the Netherlands than in Suriname.
METHODS: HCPs from both countries expected increased social support, health knowledge among women, and continuity of care(r). Individuals/innovation deliverers: Self-efficacy and motivation emerged as intertwined determinants to GC implementation in both countries. Individuals/innovation recipients: Competing demands can potentially lower acceptability of GC in both countries. While Dutch HCPs prioritised an open dialogue with mothers, Surinamese HCPs encouraged the inclusion of partners.
METHODS: Campaigns to raise awareness of GC were proposed. Language barriers were a concern for Dutch but not for Surinamese HCPs.
CONCLUSIONS: While the most striking differences between both countries were found in the outer setting, they trickle down and affect all layers of context. Ultimately, at a later stage, the process evaluation will show if those outer setting barriers we identified prior to implementation actually hindered GC implementation. Changes to the health care systems would ensure sustained implementation in both countries, and this conclusion feeds into a more general discussion: how to proceed when contextual analyses reveal barriers that cannot be addressed with the time and resources available.

BACKGROUND: In 2018, the Dutch government initiated the Solid Start program to provide each child with the best start in life. Key program elements are a biopsychosocial perspective on pregnancy and children\'s development and stimulating local collaborations between social and health domains, with a specific focus on (future) families in vulnerable situations. Two programs for interprofessional collaboration between maternity and social care professionals to optimize care for pregnant women in vulnerable situations were developed and implemented, in Groningen in 2017 and in South Limburg in 2021. This paper describes the extent of implementation of these programs and the perceptions of involved professionals about determinants that influence program implementation.
METHODS: We conducted a mixed-methods study in 2021 and 2022 in two Dutch regions, Groningen and South Limburg. Questionnaires were sent to primary care midwives, hospital-based midwives, obstetricians (i.e. maternity care professionals), (coordinating) youth health care nurses and social workers (i.e. social care professionals), involved in the execution of the programs. Semi-structured interviews were held with involved professionals to enrich the quantitative data. Quantitative and qualitative data were collected and analyzed using Fleuren\'s implementation model.
RESULTS: The findings of the questionnaire (n = 60) and interviews (n = 28) indicate that professionals in both regions are generally positive about the implemented programs. However, there was limited knowledge and use of the program in Groningen. Promoting factors for implementation were mentioned on the determinants for the innovation and the user. Maternity care professionals prefer a general, conversational way to identify vulnerabilities that connects to midwives\' daily practice. Low-threshold, personal contact with clear agreements for referral and consultation between professionals contributes to implementation. Professionals agree that properly identifying vulnerabilities and referring women to appropriate care is an important task and contributes to better care. On the determinants of the organization, professionals indicate some preconditions for successful implementation, such as clearly described roles and responsibilities, interprofessional training, time and financial resources.
CONCLUSIONS: Areas for improvement for the implementation of interprofessional collaboration between maternity care and social care focus mainly on determinants of the organization, which should be addressed both regionally and nationally. In addition, sustainable implementation requires continuous awareness of influencing factors and a process of evaluation, adaptation and support of the target group.

OBJECTIVE: This study aims to identify discrimination in maternity care experienced by Roma women in Hungary, due to ethnic and socio-economic factors.
METHODS: We used data from the Cohort\'18 Hungarian Birth Cohort Study, covering births in 2018-2019 (n = 7805). Face-to-face interviews were conducted by health visitors during pregnancy and six months postpartum. Differences in obstetric care were tested using Welch\'s ANOVA. Logistic regression models estimated the influence of Roma ethnicity on birth position, adjusting for socio-economic variables. Odds ratios with 95 % confidence intervals and adjusted predictions were calculated.
RESULTS: Roma mothers had a lower rate of caesarean section due to fewer planned interventions (13.3% vs. 19.1% for non-Roma mothers). Roma women were less likely than non-Roma women to have a birth attended by a private obstetrician (15% vs. 52.6%) and less likely to have a family member present at the birth (40% vs. 65.5%). For vaginal births, 61.3% of Roma women had their birth position dictated by hospital staff, compared with 40.6% of non-Roma women. Ethnic background significantly influenced the choice of birth position, but these associations were attenuated after adjustment for socio-economic and territorial factors. Variables such as the presence of a private obstetrician, family support, and residence in Central Hungary reduced the likelihood of giving birth in a fixed position.
CONCLUSIONS: Roma women face significant disadvantages in maternity care in Hungary. Ethnic background has a negative impact on the quality of care, but it is also significantly influenced by adverse socio-economic and regional factors.