Christine Morton

All Publications

• "We don't really address the trauma": Patients' Perspectives on Postpartum Care Needs after Severe Maternal Morbidities. Maternal and child health journal Niles, P. M., Nack, A., Eniola, F., Searing, H., Morton, C. 2024; 28 (8): 1432-1441

  Abstract

  This qualitative study explored experiences of 15 women in New York City who suffered physical, emotional, and socioeconomic consequences of severe maternal morbidity (SMM). This study aimed to increase our understanding of additional burdens these mothers faced during the postpartum period.Qualitative analysis of in-depth interviews (n = 15) with women who had given birth in NYC hospitals and experienced SMM. We focused on how experiences of SMM impacted postpartum recoveries. Grounded theory methodology informed analysis of participants' one-on-one interviews. To understand the comprehensive experience of postpartum recovery after SMM, we drew on theories about social stigma, reproductive equity, and quality of care to shape constant-comparative analysis and data interpretation.Three themes were generated from data analysis: 'Caring for my body' defined by challenges during physical recuperation, 'caring for my emotions' which highlighted navigation of mental health recovery, and 'caring for others' defined by care work of infants and other children. Most participants identified as Black, Latinx and/or people of color, and reported the immense impacts of SMM across aspects of their lives while receiving limited access to resources and insufficient support from family and/or healthcare providers in addressing postpartum challenges.Findings confirm the importance of developing a comprehensive trauma-informed approaches to postpartum care as a means of addressing SMM consequences.

  View details for DOI 10.1007/s10995-024-03927-1

  View details for PubMedID 38864991

  View details for PubMedCentralID 3880915

• Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study. Journal of perinatology : official journal of the California Perinatal Association Razdan, S., Hedli, L. C., Sigurdson, K., Profit, J., Morton, C. H. 2023

  Abstract

  Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explored expert opinion on their etiology, potential solutions, and the ability of health equity dashboards to meaningfully capture NICU disparities.We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis.We identified three sources of disparity: interpersonal bias, care process and institutional barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited, because clinical metrics do not account for many of the aforementioned sources of disparities.Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

  View details for DOI 10.1038/s41372-023-01856-5

  View details for PubMedID 38155228

  View details for PubMedCentralID 6503514

• National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., Hall, M., Shaefer, S. M., Karsnitz, D., Pratt, S. D., Klassen, M., Semenuk, K., Chazotte, C. 2021; 50 (1): 88–101

  Abstract

  Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.

  View details for DOI 10.1016/j.jogn.2020.09.160

  View details for Web of Science ID 000609424300009

  View details for PubMedID 33220179

• Former NICU Families Describe Gaps in Family-Centered Care. Qualitative health research Sigurdson, K., Profit, J., Dhurjati, R., Morton, C., Scala, M., Vernon, L., Randolph, A., Phan, J. T., Franck, L. S. 2020: 1049732320932897

  Abstract

  Care and outcomes of infants admitted to neonatal intensive care vary and differences in family-centered care may contribute. The objective of this study was to understand families' experiences of neonatal care within a framework of family-centered care. We conducted focus groups and interviews with 18 family members whose infants were cared for in California neonatal intensive care units (NICUs) using a grounded theory approach and centering the accounts of families of color and/or of low socioeconomic status. Families identified the following challenges that indicated a gap in mutual trust and power sharing: conflict with or lack of knowledge about social work; staff judgment of, or unwillingness to address barriers to family presence at bedside; need for nurse continuity and meaningful relationship with nurses and inconsistent access to translation services. These unmet needs for partnership in care or support were particularly experienced by parents of color or of low socioeconomic status.

  View details for DOI 10.1177/1049732320932897

  View details for PubMedID 32713256

• Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., VanOtterloo, L. R., Seacrist, M. J., Main, E. K. 2019; 48 (3): 252–62

  Abstract

  To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee.Qualitative, descriptive design using thematic analysis.A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007.We coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework.We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women's signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care.Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

  View details for DOI 10.1016/j.jogn.2019.03.003

  View details for Web of Science ID 000467251700002

  View details for PubMedID 30981725

• Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth BIRTH-ISSUES IN PERINATAL CARE Morton, C. H., Henley, M. M., Seacrist, M., Roth, L. 2018; 45 (3): 263–74

  Abstract

  Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada.Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care.Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43).Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

  View details for DOI 10.1111/birt.12373

  View details for Web of Science ID 000441423800007

  View details for PubMedID 30058157

• The Problem of Increasing Maternal Morbidity: Integrating Normality and Risk in Maternity Care in the United States BIRTH-ISSUES IN PERINATAL CARE Morton, C. H. 2014; 41 (2): 119-121

  View details for DOI 10.1111/birt.12117

  View details for Web of Science ID 000337298500001

  View details for PubMedID 24851998

• Mobile-enhanced Family Integrated Care for preterm infants: A qualitative study of parents' views. PEC innovation Franck, L. S., Magaña, J., Bisgaard, R., Lothe, B., Sun, Y., Morton, C. H. 2024; 4: 100284

  Abstract

  The Family Integrated Care (FICare) model improves outcomes for preterm infants and parents compared with family-centered care (FCC). FICare with mobile technology (mFICare) may improve uptake and impact. Research on FICare in the United States (US) is scarce and little is known about parents' experience.We conducted qualitative interviews with nine parents, exploring their NICU experiences, participation in and perceptions of the mFICare program. A directed content analysis approach was used, and common themes were derived from the data.Overall, parents had positive NICU experiences and found mFICare helpful in meeting three common parenting priorities: actively caring for their infant, learning how to care for their infant, and learning about the clinical status of their infant. They described alignment and misalignment with mFICare components relative to their personal parenting priorities and offered suggestions for improvement. Nurses were noted to play key roles in providing or facilitating parent support and encouragement to participate in mFICare and parenting activities.The mFICare program showed potential for parental acceptance and participation in US NICUs.The mFICare model is an innovation in neonatal care that can advance the consistent delivery of NICU family-centered care planning and caregiving.Clinical Trial Registration:NCT03418870 01/02/2018.

  View details for DOI 10.1016/j.pecinn.2024.100284

  View details for PubMedID 38737891

  View details for PubMedCentralID PMC11087992

• Spatial and Racial/Ethnic Variation in the Prevalence of Cesarean Delivery in a South Carolina Medical Center. Journal of racial and ethnic health disparities Howard, J. T., Lawton, S., Wilson, D., Gore, A., Hebbar, L., Morton, C., Goodier, C., Alfred, M. 2024

  Abstract

  While racial/ethnic disparities in cesarean delivery have been noted in the literature, less is known about the intersection between individual-level race/ethnicity and community-level social vulnerability as factors in cesarean delivery. The goal was to use medical record data from a large medical center combined with census tract-level data to examine patterns of social vulnerability, racial population distribution, and prevalence of cesarean delivery.Data were obtained from electronic medical records of patients from a large medical center in South Carolina from 2019 to 2020. The outcome variable was cesarean delivery (yes/no), and covariates included the year of delivery; age of patient; race/ethnicity; spoken language; BMI categories; clinical indications of anemia, hypertension, preeclampsia, and diabetes; and census tract Social Vulnerability Index (SVI). Generalized linear mixed models for multilevel binary logistic regression were used to test the main hypothesis that the census tract level Social Vulnerability Index is positively associated with cesarean delivery.Among a total of 5011 patients, we found that non-Hispanic Black mothers were more likely to have cesarean deliveries compared with non-Hispanic White mothers. After controlling for census tract-level SVI, the individual-level race/ethnicity association was no longer significant. Significant spatial autocorrelation across census tracts was evident for cesarean delivery prevalence, non-Hispanic Black population, and SVI. A high prevalence of cesarean delivery tended to cluster with high SVI and a high non-Hispanic Black population.We found that non-Hispanic Black mothers were more likely to have cesarean deliveries, which was explained by census tract differences in the SVI.

  View details for DOI 10.1007/s40615-024-02218-3

  View details for PubMedID 39422829

  View details for PubMedCentralID 9603953

• Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States. Proceedings of the Human Factors and Ergonomics Society ... Annual Meeting. Human Factors and Ergonomics Society. Annual meeting Akintunde, T., Howard, J., Wilson, D., Gore, A., Morton, C., Hebbar, L., Goodier, C., Alfred, M. C. 2023; 67 (1): 609-613

  Abstract

  Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

  View details for DOI 10.1177/21695067231192873

  View details for PubMedID 38214000

  View details for PubMedCentralID PMC10782179

• Disparities and Equity Dashboards in the Neonatal Intensive Care Unit: A Qualitative Study of Expert Perspectives. Research square Razdan, S., Hedli, L., Sigurdson, K., Profit, J., Morton, C. 2023

  Abstract

  Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explore expert opinion on their root causes, potential solutions, and the ability of health equity dashboards to meaningfully address NICU disparities.We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis.Participants identified three sources of disparity: interpersonal bias, care process barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited because clinical metrics do not account for many of the aforementioned sources of disparities.Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

  View details for DOI 10.21203/rs.3.rs-3002217/v1

  View details for PubMedID 37461712

  View details for PubMedCentralID PMC10350244

• Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports. Joint Commission journal on quality and patient safety Alfred, M. C., Wilson, D., DeForest, E., Lawton, S., Gore, A., Howard, J. T., Morton, C., Hebbar, L., Goodier, C. 2023

  Abstract

  BACKGROUND: Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.METHODS: The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.RESULTS: Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54).CONCLUSION: Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

  View details for DOI 10.1016/j.jcjq.2023.06.007

  View details for PubMedID 37481433

• Enhanced maternal mortality surveillance identifies higher mortality ratios and greater racial/ethnic disparity than death certificates Krakowiak, P., Sun, D., McCain, C., Morton, C. H., Ramos, D. E., Reynen, D. J., Main, E. K., Mitchell, C. MOSBY-ELSEVIER. 2021: S229–S230

  View details for Web of Science ID 000621547400349

• Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease Van Otterloo, L., Main, E., Seacrist, M., Morton, C. H. ELSEVIER SCIENCE INC. 2020: S13

  View details for Web of Science ID 000583918100020

• Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 133 (6): 1151–59

  Abstract

  OBJECTIVE: To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California.METHODS: The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined.RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement.CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

  View details for DOI 10.1097/AOG.0000000000003290

  View details for PubMedID 31135728

• Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING VanOtterloo, L. R., Morton, C. H., Seacrist, M. J., Main, E. K. 2019; 48 (3): 263–74

  Abstract

  To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from cardiovascular disease (CVD) by the California Pregnancy-Associated Mortality Review committee.Qualitative descriptive design using thematic analysis.A total of 269 QIOs identified from 87 pregnancy-related deaths from CVD in California from 2002 to 2007.We coded and thematically organized the 269 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.The most prevalent theme within the Readiness domain was the care of women in a facility or a department within a facility that was not equipped to handle the severity of their CVD conditions. For Recognition, a common theme was an underappreciation of the severity of illness, including high-risk factors and clinical warning signs, which led to inaccurate diagnoses, such as anxiety or asthma, and missed diagnoses of CVD. The lack of recognition of CVD led to delays in treatment or inaccurate treatment, the leading themes in the Response domain.Identification of CVD or its risk factors during pregnancy can lead to timely, multidisciplinary approaches to management and birth in facilities that offer appropriately trained health care professionals and appropriate equipment. Maternal mortality can be reduced if signs and symptoms of CVD in women are recognized early and treatment modalities are implemented quickly during pregnancy, childbirth, and the postpartum period.

  View details for DOI 10.1016/j.jogn.2019.03.001

  View details for Web of Science ID 000467251700003

  View details for PubMedID 30998902

• Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., Seacrist, M. J., VanOtterloo, L. R., Main, E. K. 2019; 48 (3): 275–87

  Abstract

  To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive design using thematic analysis.A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007.We coded and thematically organized the 242 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted.Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

  View details for DOI 10.1016/j.jogn.2019.02.008

  View details for Web of Science ID 000467251700004

  View details for PubMedID 30980787

• Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Sepsis JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Seacrist, M. J., Morton, C. H., VanOtterloo, L. R., Main, E. K. 2019; 48 (3): 311–20

  Abstract

  To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive design using thematic analysis.A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007.We coded and thematically organized the 118 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Women's delay in seeking care was the central theme in the Readiness domain. In the Recognition domain, health care providers missed the signs and symptoms of sepsis, including elevated temperature, elevated white blood cell count, increased heart rate, decreased blood pressure, mottled skin, preterm labor, headache, and pain. For Response, late antibiotic administration was a central theme; multiple emergent themes included administration of the wrong antibiotics, failure to investigate women's complaints of pain, lack of nurse/provider communication, and lack of follow-up care after hospital discharge.To reverse the contribution of sepsis to the rising rate of maternal mortality in the United States, health care facilities and providers need to reduce barriers for women who seek care, recognize early symptoms, and respond with appropriate treatment. This could be achieved by implementation of the Maternal Early Warning Criteria, standardized guidelines such as those from the Surviving Sepsis campaign, and comprehensive discharge education.

  View details for DOI 10.1016/j.jogn.2019.02.007

  View details for Web of Science ID 000467251700007

  View details for PubMedID 30974075

• Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Obstetric Hemorrhage JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Seacrist, M. J., VanOtterloo, L. R., Morton, C. H., Main, E. K. 2019; 48 (3): 288–99

  Abstract

  To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from obstetric hemorrhage by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive using thematic analysis.A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007.We coded and thematically organized the 159 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Thematic findings indicated that facility Readiness would be improved through practice standardization, better organization of equipment to treat hemorrhage, and planning for care of women with risk factors for hemorrhage. Recognition of hemorrhage by health care providers could be improved through accurate assessment of blood loss, risk factors, and early clinical signs of deterioration. Provider Response could be improved through reducing delays in administering blood, seeking consultations, transferring women to higher levels of care within or outside of the facility, and moving on to other treatments if a woman does not respond to current treatment.Hemorrhage is the most preventable cause of maternal death in California. Morbidity and mortality from hemorrhage can be prevented if birth facilities and maternity care clinicians align local practices with national safety guidelines.

  View details for DOI 10.1016/j.jogn.2019.03.002

  View details for Web of Science ID 000467251700005

  View details for PubMedID 30981726

• Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Venous Thromboembolism JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING VanOtterloo, L. R., Seacrist, M. J., Morton, C. H., Main, E. K. 2019; 48 (3): 300–310

  Abstract

  To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee.Qualitative, descriptive design using thematic analysis.A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007.We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge.To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.

  View details for DOI 10.1016/j.jogn.2019.02.006

  View details for Web of Science ID 000467251700006

  View details for PubMedID 30986370

• Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review. Pediatrics Sigurdson, K. n., Mitchell, B. n., Liu, J. n., Morton, C. n., Gould, J. B., Lee, H. C., Capdarest-Arest, N. n., Profit, J. n. 2019

  Abstract

  Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear.To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting.Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care."English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected.Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities.Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included.Quantitative meta-analysis was not possible because of study heterogeneity.Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.

  View details for DOI 10.1542/peds.2018-3114

  View details for PubMedID 31358664

• In Reply. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 134 (4): 880–81

  View details for DOI 10.1097/AOG.0000000000003494

  View details for PubMedID 31568351

• Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care. Journal of perinatology : official journal of the California Perinatal Association Dhurjati, R., Wahid, N., Sigurdson, K., Morton, C. H., Kaplan, H. C., Gould, J. B., Profit, J. 2018

  Abstract

  OBJECTIVE: To identify key features in the NICU care delivery context that influence quality of care delivery.STUDY DESIGN: Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory.RESULTS: Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital.CONCLUSIONS: Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.

  View details for PubMedID 29593356

• Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of perinatology : official journal of the California Perinatal Association Sigurdson, K. n., Morton, C. n., Mitchell, B. n., Profit, J. n. 2018

  Abstract

  To identify how family advocates and clinicians describe disparities in NICU quality of care in narrative accounts.Qualitative analysis of a survey requesting disparity stories at the 2016 VON Quality Congress. Accounts (324) were from a sample of RNs (n = 114, 35%), MDs (n = 109, 34%), NNPs (n = 55, 17%), RN other (n = 4, 1%), clinical other (n = 25, 7%), family advocates (n = 16, 5%), and unspecified (n = 1, <1%).Accounts (324) addressed non-exclusive disparities: 151 (47%) language; 97 (30%) culture or ethnicity; 72 (22%) race; 41 (13%) SES; 28 (8%) drug use; 18 (5%) immigration status or nationality; 16 (4%) sexual orientation or family status; 14 (4%) gender; 10 (3%) disability. We identified three types of disparate care: neglectful care 85 (26%), judgmental care 85 (26%), or systemic barriers to care 139 (44%).Nearly all accounts described differential care toward families, suggesting the lack of equitable family-centered care.

  View details for PubMedID 29622778

• National Partnership for Maternal Safety Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period OBSTETRICS AND GYNECOLOGY Bernstein, P. S., Martin, J. N., Barton, J. R., Shields, L. E., Druzin, M. L., Scavone, B. M., Frost, J., Morton, C. H., Ruhl, C., Slager, J., Tsigas, E. Z., Jaffer, S., Menard, M. 2017; 130 (2): 347–57

  Abstract

  Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

  View details for PubMedID 28697093

• National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period ANESTHESIA AND ANALGESIA Bernstein, P. S., Martin, J. N., Barton, J. R., Shields, L. E., Druzin, M. L., Scavone, B. M., Frost, J., Morton, C. H., Ruhl, C., Slager, J., Tsigas, E. Z., Jaffer, S., Menard, M. 2017; 125 (2): 540–47

  Abstract

  Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

  View details for PubMedID 28696959

• North American Nurses' and Doulas' Views of Each Other. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN Roth, L., Henley, M. M., Seacrist, M. J., Morton, C. H. 2016

  Abstract

  To analyze factors that lead nurses and doulas to have positive views of each other.A multivariate analysis of a cross-sectional survey, the Maternity Support Survey.Online survey with labor and delivery nurses, doulas, and childbirth educators in the United States and Canada.A convenience sample of 704 labor and delivery nurses and 1,470 doulas.Multiple regression analysis was used to examine five sets of hypotheses about nurses' and doulas' attitudes toward each other. Scales of nurses' attitudes toward doulas and doulas' attitudes toward nurses included beliefs that nurses/doulas enhance communication, are collaborative team members, enhance a woman's birth experience, interfere with the ability to provide care, or interfere with relationships with the women for whom they care.For nurses, exposure to doulas in their primary hospitals was associated with more positive views, whereas working more hours, feeling overworked, and a preference for clinical tasks over labor support were associated with more negative views of doulas. For doulas, working primarily in one hospital and certification were associated with more positive views of nurses. Nurses with more positive attitudes toward common obstetric practices had more negative attitudes toward doulas, whereas doulas with more positive attitudes toward common obstetric practices had more positive attitudes toward nurses.Our findings show factors that influence mutual understanding and appreciation of nurses and doulas for each other. These factors can be influenced by educational efforts to improve interprofessional collaboration between these maternity care support roles.

  View details for DOI 10.1016/j.jogn.2016.06.011

  View details for PubMedID 27622848

• Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues. Obstetrics and gynecology MacDorman, M. F., Declercq, E., Cabral, H., Morton, C. 2016; 128 (3): 447-55

  Abstract

  To develop methods for trend analysis of vital statistics maternal mortality data, taking into account changes in pregnancy question formats over time and between states, and to provide an overview of U.S. maternal mortality trends from 2000 to 2014.This observational study analyzed vital statistics maternal mortality data from all U.S. states in relation to the format and year of adoption of the pregnancy question. Correction factors were developed to adjust data from before the standard pregnancy question was adopted to promote accurate trend analysis. Joinpoint regression was used to analyze trends for groups of states with similar pregnancy questions.The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington, DC (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, whereas Texas had a sudden increase in 2011-2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported.Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington, DC, increased from 2000 to 2014; the international trend was in the opposite direction. There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year.

  View details for DOI 10.1097/AOG.0000000000001556

  View details for PubMedID 27500333

  View details for PubMedCentralID PMC5001799

• Women's Experiences Being Diagnosed With Peripartum Cardiomyopathy: A Qualitative Study. Journal of midwifery & women's health Dekker, R. L., Morton, C. H., Singleton, P., Lyndon, A. 2016; 61 (4): 467-473

  Abstract

  Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM.This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29 [6] years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience.The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from "new mom anxiety" to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again.Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.

  View details for DOI 10.1111/jmwh.12448

  View details for PubMedID 27285199

• Race, Insurance Status, and Nulliparous, Term, Singleton, Vertex Cesarean Indication: A Case Study of a New England Tertiary Hospital WOMENS HEALTH ISSUES Morris, T., Meredith, O., Schulman, M., Morton, C. H. 2016; 26 (3): 329-335

  Abstract

  The current U.S. cesarean section rate (32.2%) is recognized as too high in light of its negative health impacts on women and infants. Efforts are underway in several states and individual hospitals to lower the rate of cesarean section among low-risk women, defined as nulliparous (first birth), term (≥37 weeks gestation), singleton (one baby), vertex (head down presentation; NTSV).We conducted a case study of one hospital's experience with NTSV cesarean sections to see whether race and insurance status affect the probability of cesarean indication. Many cesarean indications are ambiguous, and biases may seep into decisions with ambiguous diagnoses.We conducted a retrospective chart review of women who had NTSV cesarean sections at a tertiary care hospital in an urban New England city between June 2013 and November 2013. We analyzed the data using multinomial logistic regression to examine the marginal effect of race and health insurance status on the predicted probability for NTSV cesarean indication.We find that Black and Hispanic women have a lower predicted probability of having a cesarean section for cephalopelvic disproportion than do White women and that women with private health insurance have a lower predicted probability of having a cesarean section for nonreassuring fetal heart rate and for a clinical indication than do women without private health insurance.We suggest biases may seep into clinicians' decisions to perform an NTSV cesarean section. Hospital quality improvement efforts are aided by an examination of sociodemographic factors that influence clinician decision making in the specific hospital being studied.

  View details for DOI 10.1016/j.whi.2016.02.005

  View details for PubMedID 27017294

• Pregnancy-Related Mortality in California Causes, Characteristics, and Improvement Opportunities OBSTETRICS AND GYNECOLOGY Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., Lawton, E. S. 2015; 125 (4): 938-947

  Abstract

  To compare specific maternal and clinical characteristics and contributing factors among the five leading causes of pregnancy-related mortality to develop focused clinical and public health prevention programs.California pregnancy-related deaths from 2002-2005 were identified with enhanced surveillance using linked birth and death certificates. A multidisciplinary committee reviewed medical records, autopsy reports, and coroner reports to determine cause of death, clinical and demographic characteristics, chance to alter outcome, contributing factors (at health care provider, facility, and patient levels), and quality improvement opportunities. The five leading causes of death were compared with each other and with the overall California birth population.Among the 207 pregnancy-related deaths, the five leading causes were cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism. Among the leading causes of death, we identified differing patterns for race, maternal age, body mass index, timing of death, and method of delivery. Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths, with the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) deaths. Health care provider, facility, and patient contributing factors also varied by cause of death.Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs.

  View details for DOI 10.1097/AOG.0000000000000746

  View details for Web of Science ID 000351595200026

  View details for PubMedID 25751214

• Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. American journal of obstetrics and gynecology 2015

  Abstract

  Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors.The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data.Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes.African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

  View details for PubMedID 25979616

• California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings MATERNAL AND CHILD HEALTH JOURNAL Mitchell, C., Lawton, E., Morton, C., McCain, C., Holtby, S., Main, E. 2014; 18 (3): 518-526

  Abstract

  After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

  View details for DOI 10.1007/s10995-013-1267-0

  View details for Web of Science ID 000333026600002

  View details for PubMedID 23584929

• California Pregnancy-Associated Mortality Review: Mixed methods approach for improved case identification, cause of death analyses and translation of findings Maternal Child Health Journal Mitchell, C., Elizabeth Lawton MHS, Christine Morton PhD, Christy McCain MPH, Sue Holtby MPH, Elliott Main MD 2013
• Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery OBSTETRICS AND GYNECOLOGY Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., Gould, J. B. 2012; 120 (5): 1194-1198

  Abstract

  Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

  View details for DOI 10.1097/AOG.0b013e31826fc13d

  View details for Web of Science ID 000310512500027

  View details for PubMedID 23090538

• Standardising or individualising?: A critical analysis of the 'discursive imaginaries' shaping maternity care reform International Journal of Childbirth Reiger, K., Christine Morton 2012; 2 (3): 173-186
• Safety in childbirth and the three ‘C’s: community, context, and culture Midwifery Sandall, J., Christine Morton, Debra Bick 2010; 26: 481-482