Nurse Midwife

There are two dependent variables both defined as three-category ordered variables: timing of first ANC visit and type of delivery assistance, derived from the following questions: "How many months pregnant were you when you first received antenatal care for this pregnancy?" and "Who assisted with the delivery of (NAME OF CHILD)?" The World Health Organization (WHO) recommends that for the majority of normal pregnancies, ANC should consist of at least four visits during the course of the pregnancy, the first of which should occur within the first trimester [28 (link)]. Timing of first ANC visit was thus recoded as "None" for those who did not receive ANC at all; "Late" when the visit took place during the second or third trimester, and "Early" when it occurred during the first trimester. Type of delivery assistance was recoded into three categories: "None" for no assistance, assistance from relatives or others without professional skills; "TBA" for assistance from traditional birth attendants (TBA); and "Skilled professional" for assistance from either a doctor or a nurse/midwife.
Based on previous studies on the use of maternal services, the independent variables used in this study include education (coded as none, primary and secondary/higher); household wealth; urban-rural residence; and ethnicity [9 (link),25 (link),29 (link)-32 (link)]. Since DHS do not collect data on income or expenditures, the economic status of household is proxied by a household wealth variable constructed from household possessions and amenities and dwelling characteristics, using principal component analysis [33 ]. For the purpose of this study, the resulting continuous variable (wealth index) was recoded as tertiles with categories labelled poor, middle and rich. Other control variables are parity, age at birth of the child and marital status.

All women 15–45 years old who had delivered within 24–48 hours in a participating facility were eligible for inclusion, regardless of pregnancy outcome. Heshima researchers approached all postpartum women discharged from the postnatal ward, described the study and its interview process, emphasizing its privacy and confidentiality, and their consent to participate was requested, utilizing a structured consent form in the woman’s preferred language. Women were recruited until the necessary sample sizes were reached for all 13 study facilities [13 ]. During the September 2011 through January 2012 baseline period, a total of 641 women consented to participate; during the January and February 2014 endline, 728 women consented to participate. Fifty percent (50 %) of all women who delivered in the facilities in the previous 48 hours participated in the study’s baseline survey, and 60 % participated in the endline survey.
Interviews were conducted in a specially designated room at each facility by interviewers trained in the study procedures to ensure that patient privacy was maintained. The questionnaire includes modules that examine women’s demographic and household characteristics including their socio-economic status, past service utilization, characteristics of their deliveries, their perceived quality and satisfaction, and experiences of D & A. Table 2 presents the questions used to assess D & A experiences. Portable digital assistant (PDA) devices were used to collect the data, which were downloaded into an MS Access database before their export to Stata 11 for data management.Table 2

Questions for assessment and corresponding categories

Study methods and examples of Questions used	Corresponding categories
Client exit survey
Were you physically abused by any of the health care workers	Physical abuse
Were you treated in a way that violated your privacy?	Privacy violation
Were you treated in a way that violated your confidentiality	Confidentiality violated
Did any healthcare provider talk or use a tone or facial expression that made feel uncomfortable?	Verbal abuse
Were you or your baby prevented from leaving this facility because you could not pay	Detainment
Were you left un attended by health providers when you needed care	Abandonment
Observations of provider-patient interactions
Examination
Provider did not obtain permission from the mother before the initial examination or did not seek the mother’s consent for the vaginal examination	Non-consented care
When the provider did not use “dignified language” or using “harsh tones or shouting” during the history taking	Verbal abuse
When either there were no separating partitions between the beds or the partitions didn’t provide privacy	Lack of privacy
Delivery period
Assessed as the staff being aggressive in any way and the midwife/nurse research assistant indicating whether it was physical aggression or verbal aggression (or both)	Physical aggression
	Verbal aggression
Assessed as the mother not being covered while being moved from pre-labor ward to the delivery room or not having closed partitions or being uncovered (excluding the perineal area).	Lack of privacy
Postnatal period
Was the mother not having a bed allocated only to herself	Bed sharing

In Nepal, the Ministry of Health and Population (MoHP) has implemented GMP for over 20 years as a core child health and nutrition service [15 (link)]. The MoHP aims for monthly contacts for children from birth to two years of age [16 ]. With support from female community health volunteers (FCHVs), trained auxiliary health workers and auxiliary nurse midwives deliver GMP through health facilities and monthly primary health care outreach clinics (PHC ORCs) where they offer additional primary health care services, such as antenatal care, family planning, health education, and counseling. The Expanded Program on Immunization clinics may also be held on the same day (and location) as PHC ORCs.

Using publicly available provider directories for Massachusetts Medicaid ACOs and data on provider supply, we quantified inclusion of obstetrician-gynecologists (OB/GYN), maternal-fetal medicine (MFM) specialists, certified nurse-midwives (CNM), and acute care hospitals with obstetrics departments in Medicaid ACOs. We then compared the number and type of providers across ACO types, across ACOs within ACO type, and to the total number of providers within Massachusetts.
In Massachusetts, Medicaid ACO models were implemented starting in March 2018 with two ACO distinct models available as of 2021 [27 , 28 ]. The first model, Accountable Care Partnership Plans (ACPP), operates within a specific service area and restricts the provider network to those within the contracted Managed Care Organization. The second model, Primary Care ACOs (PCACO), rely on specific in-network primary care providers, but provide access to the entire Medicaid specialist and hospital network [29 ]. Both models consist of a two-sided risk payment structure in which the ACO can either receive a greater portion of savings for high value care, or pay a penalty to Medicaid if the cost of care exceeds predefined targets [28 ]. PCACOs are only eligible to receive shared savings if they reach a minimum benchmark on quality metrics, including prenatal care metrics [30 ]. ACPP ACOs have similar quality metrics factored into the shared risk payment arrangements to provide accountability [31 ]. As of January 2021, over three quarters of Medicaid enrollees’ primary coverage is through an ACO [32 ]. Among ACO enrollees, 60% are enrolled in an Accountable Care Partnership Plan and 40% are enrolled in a Primary Care ACO [32 ]. This study used publicly available information and did not include data on human subjects. Therefore, Institutional Review Board approval was not necessary.

We analyzed obstetric provider inclusion in the 13 ACPP ACOs and three PCACOs operating in Massachusetts Medicaid in January 2021. We analyzed the inclusion of OB/GYNs, MFMs, and CNMs using ACO provider directories available online between December 2020 and January 2021. Five ACPP ACOs provided print directories generated directly from online directories located on the ACO websites. Eight ACPP ACOs provided separate, distinct printed directories available on the ACO websites. The three PCACOs utilized the MassHealth provider network for specialists, and we used the MassHealth online directory for these ACOs. Enrollment data for each ACO is determined as of July 2018 [28 ].
For ACPP plans, clinicians included in the analysis were those listed in the categories of obstetrician, obstetrician/gynecology, gynecology, or maternal-fetal medicine within the provider directories. For certified nurse midwives (CNM), the directories which included CNMs had a separate section listing those who were included. For directories including a provider identification number (such as an NPI), the identifier was extracted, and duplicates were removed to determine the total number of providers included in that plan. For all others, duplicates were removed manually based on clinician name. If provider directories included practice names, we did not count these practices towards the number of included clinicians; we checked a number of these by hand in each directory to ensure that the majority of clinicians practicing in those organizations were included in the provider directory and discuss in the results where there were any deviations from this. We were not able to include family medicine physicians who provide maternity care due to the difficulty of systematically identifying these specific physicians.
For the PCACO plans, we searched the online provider directory by specialty for “Obstetrics (OB/GYN)” and included individual clinicians in the count. MFMs were not classified separately in the online provider directory but were included within OB/GYN provider listings. To determine MFM inclusion, MFM providers listed within the 2019 Massachusetts Registration of Provider Organizations Physician Roster (MA RPO) were manually identified within the covered Medicaid OB/GYN providers [33 ]. The MA RPO includes physicians practicing in organizations meeting certain patient and revenue thresholds, and may not include MFMs practicing independently or in small organizations. We then searched the directory using categorical drop down boxes of “nurse midwives” for CNMs. No duplicates by name appeared in these directories. We used the same procedure as above to exclude listed practices in this directory. The provider directory online notes, “Please Note: Some providers in this directory may no longer accept MassHealth. Before making an appointment, please contact the provider to confirm that they are accepting new MassHealth patients.”
The Medicaid waiver implementing the Medicaid ACOs includes a policy that PCACOs may designate a “referral circle” of ACO-preferred specialists that patients may visit without a required PCP referral [34 ]; however, enrollees still have access to the full MassHealth network. Publicly available information demonstrates only one of the three PCACOs states that they include a referral circle and none actually list providers included in the referral circle, so we do not analyze these further.
The total number of OB/GYNs and CNMs in Massachusetts for comparison to provider directories is based on estimates from the Area Health Resources File from the Health Resources and Services Administration [35 ]. We calculate the number of OB/GYNs as MDs and DOs within the Obstetrics and Gynecology health profession subcategory (2019–2020). The number of CNMs are from the nurse midwife category (2019–2020). The Area Health Resources File from the Health Resources and Services Administration does not offer an estimate of MFMs. Therefore, we utilize the 2019 Massachusetts Registration of Provider Organizations Physician Roster to estimate the total number of MFMs practicing in Massachusetts based on a primary or secondary specialty of Maternal-Fetal Medicine [33 ]. We compare the number of OB/GYNs and MFMs included in ACOs to the overall number of practicing OB/GYNs and MFMs in Massachusetts to contextualize the comprehensiveness of specialist networks.
We used the MassHealth Enrollment Guide (January 2019) to determine hospital inclusion for each ACO, limited to in-state acute care hospitals with an obstetrics department that conducts deliveries [29 ]. Acute care hospitals in Massachusetts were identified by those included in the Massachusetts’ Center for Health Information and Analysis (CHIA) Acute Hospitals Profiles [36 ]. Birth and obstetric department information was primarily determined by hospital profile data from the American Hospital Association (AHA) [37 ]. For any hospitals that did not have AHA data, data from the 2017 Massachusetts Birth Report [38 ] as well as individual hospital websites was used. The service areas for each ACO and hospital location was used to determine which hospital referral region(s) applied to specific ACOs and hospitals. MassHealth service areas and hospital locations were matched to hospital service areas and then subsequently to hospital referral regions. No service area has fewer than four ACOs to choose from, and some areas in Greater Boston and the South Shore have as many as 11 [39 ].