Research and Professional Literature to Inform Practice, March/April 2026

In this section, recent updates on the perennial issues of maternal morbidity and mortality are presented. The first article by Fuller et al presents severe maternal morbidity data for American Indian and Alaskan Native parturients, members of communities who are frequently omitted from epidemiologic articles because they make up a small proportion of births in the United States. The second article focuses on postpartum readmission (PPR), an aspect of morbidity that is only recently gaining traction as an important metric of maternity outcomes. In this research letter, authors describe the trends in severe maternal morbidity (SMM) among American Indian and Alaska Native (AIAN) people from 2000 to 2021. To do this, they used the National Inpatient Sample and included births to people aged 15 to 54 years. SMM was defined by the CDC's composite definition and excluded blood transfusion. Of 83.7 million births from 2000 to 2021, only 0.6% (517, 903) were to AIAN individuals. These births were significantly more likely to occur in rural hospitals when compared with individuals from other races (eg, 30.1% for AIAN compared with 13.5% for White, P < .001). The authors state that AIAN women were more likely to have obesity, pregestational diabetes, chronic hypertension, tobacco use, and substance use disorders (SUDs) complicating their pregnancies than women from other races and ethnicities. Some of these statistics, however, may not be clinically significantly different. For example, the prevalence of chronic hypertension was 1.6% in AIAN and 1.5% in White women; likewise, the prevalence of tobacco use is 3.5% among AIAN and 3.1% among White women. Over the period, the proportion of births complicated by SMM for AIAN women increased from 59 to 134 per 10,000 births. How this compared with changes seen in other racial or ethnic groups is not mentioned. In logistic regressions controlling for demographic and clinical factors, AIAN women had an increased odds of SMM compared with White women (adjusted odds ratio [aOR], 1.28; 95% CI, 1.18-1.39), although the effect size was not as large as it was for Black women (aOR, 1.72; 95% CI, 1.67-1.76). The authors do state in their conclusion that the rate of SMM increase is the steepest for AIAN women, but they do not present the data to support that statement. They also refer to the odds of SMM as risk, which is not strictly accurate. The odds ratio and risk are both types of probability; odds ratios are cases divided by noncases (ranges from 0 to infinity), whereas risk is cases divided by the total population (ranges from 0% to 100%). We like to talk about risk because it is easier to think about, but that is not what the authors present here. Black women experience PPR at a 3-times-greater rate than White women. PPR is most frequently associated with mental health disorders (MHDs) and SUDs, with increased difficulty in accessing care in rural areas. The current study examines the association of rurality and race or ethnicity, and their interaction, with PPR overall and for MHDs and SUDs, specifically through the end of the postpartum year. The authors conducted a statewide retrospective cohort study with birth certificates linked with hospital administrative discharge abstracts for birth admissions of women aged 15 to 50 years in South Carolina from 2018 to 2021. Of the 190,645 births to 166,330 unique individuals in hospitals during this time, there was a 4.7% PPR frequency. Readmission for MHDs was 1.5%, and for SUB, it was 0.8%. Black women living in urban areas had an increased adjusted hazard ratio (aHR) of PRR compared with White women (aHR, 1.38; 95% CI, 1.31-.145). Unfortunately, the way some of the models were described does not promote reader understanding. The authors ran a regression model with an interaction term. Ostensibly, the interaction is between race and rurality, but the table shows the interaction of Black race and rural. The reader is left to assume that the reference categories are White and urban. The authors report in the text that living in rural areas attenuates the Black and White disparity in PPR (interaction aHR, 0.86; 96% CI, 0.77-0.97). In both the article and the abstract, the authors interpret the aHR to suggest a reduction in racial disparities associated with rurality. What the aHR is saying, however, is that Black women are statistically significantly less likely to experience PPR than White women, while keeping all the other control variables the same, if they live in a rural versus and urban area. This is not a reduction in disparity if Black women do not experience PPR when needed (whether because of access issues, variation in provider decision-making on admissions, etc). In the discussion, the authors write that the finding that rurality was not independently associated with PPR risk suggests “individual-level characteristics, rather than geography alone, may be the primary factor associated with PPR disparities in our sample.” This statement essentially erases the contribution of racism, or other non–individual-level features, to disparities in PPR. The authors call for increased access to care—MHD and SUD treatment for non-Hispanic White populations, specifically—obliterating the known racial disparity by which Black women are less likely to receive that same care. Cesarean birth is the most common surgery in the United States. In the 2 articles presented below, the authors report on the association of adverse childhood experiences (ACEs) with postcesarean pain and the incidence of pain during cesarean birth. ACEs include abuse, neglect, and household dysfunction and affect more than 60% of adults. ACEs are linked with higher pain and opioid use in populations that are nonpregnant. The authors conducted a prospective cohort study to examine the association between ACEs, pain scores, and opioid use after cesarean birth. The cohort study was conducted at a tertiary care academic health center and included women aged 18 to 55 years who spoke English or Spanish, carried a singleton fetus, and gave birth via cesarean (planned or first stage of labor only) with neuraxial anesthesia in 2023-2024. Participants were recruited between 24 and 48 hours postpartum. Women were given a validated questionnaire to assess ACEs and placed into 2 groups based on any ACEs or none. The primary outcome was total opioid dose in milligram morphine equivalents during hospitalization from 0 to 48 hours postpartum. The second outcome was pain assessed via regular numerical pain scale assessments and a validated questionnaire. Per an a priori power analysis, the study required 122 participants and recruited 129 in the final sample. Of the 129, 53 (41%) reported ACEs, and 76 (59%) did not. Most participants were Hispanic or Latino (69). The use of any opioids in the first 48 hours postpartum varied significantly between women with ACEs and those without (59% vs 89%, respectively; P < .001). Higher ACE scores were also associated with increased opioid use (R = .24; P = .006) and with worse reported pain levels (R = 0.23; P = .01). In summary, the authors found an association between ACEs and pain and opioid use postcesarean, suggesting that screening for ACEs is an important aspect of providing whole-person care. Cesarean birth is the most common surgery in the United States and accounts for nearly one-third of all births. Although neuraxial anesthesia is the preferred technique for pain management during cesarean birth, adequate anesthesia is not completely guaranteed. The authors of the present study prospectively determined the incidence of pain during cesarean birth with neuraxial anesthesia. They conducted a prospective cohort study over 8 weeks at 15 centers in the United States and Canada and included all patients who had a cesarean birth with neuraxial anesthesia. Participants were surveyed on postpartum day one regarding the presence of intraoperative pain, including scoring the pain and reporting satisfaction with pain management. The 15 centers were invited to participate via the Society for Obstetric Anesthesia and Perinatology research network. Informed consent was waived by the designation of the data collection as a quality improvement initiative or by explicit waiver of informed consent by the local institutional review board at each site. Participating centers agreed to collect data for 8 consecutive weeks with a goal of enrolling at least 95% of women having a cesarean with neuraxial anesthesia. All patients undergoing a cesarean with neuraxial anesthesia were eligible; patients who declined or were unable to participate (eg, admitted to intensive care) were excluded. Within 24 hours of birth, local study investigators who were not part of the direct care team approached patients with a predefined script and asked whether they experienced pain during their surgery. If they did, they were asked to grade it and report whether they were satisfied with their pain management. Other sociodemographic and obstetric history variables were collected from the health records. The authors had a minimum sample size of 545 participants, with a final sample size of 3693 participants. Of these, 45.6% had an elective cesarean birth, and most (49%) had spinal anesthesia. The overall incidence of pain during cesarean was 7.6% (95% CI, 6.8%-8.5%). Those who underwent cesarean with an epidural top-off had the highest incidence of pain (13.1%; 95% CI, 6.4%-10.2%). The authors found that a participant's odds of cesarean pain varied significantly by hospital, although not between institutions in Canada versus the United States. Pain reported during cesarean ranged from moderate to severe. The authors recommend discussing these risks with patients and understanding their preferences preoperatively. The following 2 articles focus on midwifery regulation in the United Kingdom and from a global perspective. Although neither of these focus specifically on the US context, they provide insight into transferable processes: how midwives perceive a committee inquiry and report resulting from poor birth outcomes and the development of a tool to assess the midwifery regulatory environment (MRE). In 2022, an independent inquiry was made of services at hospitals in the United Kingdom following the deaths of 2 newborn girls, although the inquiry grew to include evidence from more than 1500 families. The report concluded that the hospital (called a trust in the United Kingdom) “failed to investigate, failed to learn, and failed to improve and therefore often failed to safeguard mothers and babies.” The report, and others like it, noted poor governance procedures and interprofessional work environment as well as inadequate risk assessment. Fifteen recommendations were made for immediate action that the National Health Service is instructing all hospitals to review and implement. There have, of course, been some criticism of the recommendations, and the present study explores midwives’ perceptions of the report. Midwives are the primary providers of maternity care in the United Kingdom, but they typically lack influence in policy development. The authors conducted an exploratory qualitative study using semistructured interviews. Data were analyzed inductively via thematic analysis. Participants were eligible if they were registered midwives working in a National Health Service midwifery position; they were recruited via social media (Twitter, Instagram, and Facebook). Nine midwives were included in the final sample. There were 2 key themes. First was the context in which the report was undertaken and produced. This included 2 subthemes: “we've seen this before” and “the problems are complicated.” The second theme focused on the impact of the report on practice. This theme had 3 subthemes: “a tool for change,” “perceptions of midwifery,” and “fueling the obstetric paradigm.” Midwives recognized the major issues identified: culture, inappropriate risk assessment of patients, and poor interprofessional teamwork. They also noted that these had been repeatedly identified by other reports as well, which left them with a sense that the recommendations themselves were not resulting in change and that radical system-level change was necessary. With regard to a need for culture change, the midwives told the researchers that hierarchy within teams and a lack of psychological safety were significant barriers to raising concerns in the clinical setting. The second theme focused on the impact of the report on practice. The report has had positive impacts, including increased funding for hospitals and improvements in governance. The midwives were critical, however, of creating national recommendations based on the problems at a single hospital. That said, the midwives also noted that the report's findings echoed those of prior reports conducted at other trusts. Midwives noted a negative perception of midwives in the media after the report, despite the report focusing on multidisciplinary or obstetric-led—rather than midwifery-led—problems. This negative perception extended to the midwifery continuity of care model and pushback against physiologic birth. The final subtheme was the largest and related midwives’ perception that the report was fueling a medical (obstetric) paradigm for pregnancy and birth. Participants reported that an obstetric paradigm for birth predominated and was further enforced by the report, leading to a devaluation of midwifery-led care and patient choice. The report repeatedly mentioned centralized electronic fetal monitoring, which the midwives criticized because of the lack of evidence to support its use and its potential to negatively impact one-on-one care provision during labor. The participants noted an overreliance on technology and devaluation of midwifery skills. Indeed, the authors point out in the discussion that reports are shaped by the chair and are not consistently evidence based. There was also, concurrently, a fear of being perceived as pushing for physiologic birth, even though the poor outcomes described in the report were related to an inappropriate use of oxytocin and instrumental birth, neither of which are a feature of physiologic birth. Some of the midwives noted that they worked on units with a cesarean rate over 50%, which they attributed to negative attention generated by the report. Having a unit with a cesarean rate over 50% is surprising, but the current rate of cesareans in the United Kingdom is approximately 45%, notably higher than in the United States. The authors quote Downe and McCourt, that “the telling factor which indicates where the beliefs of the current system lie is the allocation of resources.” The authors note that, moving forward, there is the opportunity to run investigations using an evidence-based approach to the inquiry process and the recommendations, including involving service users and providers and sharing positive examples. Midwifery regulation has been suggested as a means to improve access to midwives and the care quality they provide. Quantifying MREs globally, however, is difficult. The authors of the present study used survey data from the Global Midwives’ Association, which included data over 5 regulation domains, to create a composite index of the MRE. The 5 regulatory domains included overall regulatory policy and legislation, which then trickles down to education and qualification, licensure, registration and relicensure, and scope and conduct of practice. The regulatory environment is a precursor to the integration of midwives into the health system, which then leads to midwifery density and care quality, resulting in maternal health outcomes. The Global Midwives’ Association survey included 115 countries. The authors looked to see how the regulatory items in the survey best performed for maternal mortality ratio, low birthweight prevalence, and stillbirth rate. They found that different scoring methods best fit the different outcomes (eg, all-or-none scoring best fit low birthweight prevalence). This is interesting because it means that, depending on which outcome is of interest (eg, maternal mortality or low birthweight), researchers would use a different scoring process. The authors make some important methodologic comments. 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