Introduction: Studies have linked midwifery practice laws to the availability of midwives but have generally not related workforce data to potential demand for reproductive health services. We examined state regulatory structure for midwives and its relationship to midwifery distribution and vital statistics data at the state and county level. Methods: Midwifery distribution data came from the Area Health Resources Files, distribution of women of reproductive age came from the US Census, and birth statistics came from US Natality Files from 2012 to 2016. Midwifery regulations were drawn from American College of Nurse-Midwives Annual Reports. We used bivariate analysis to examine the relationship between state midwifery practice regulations and the number of midwives available in states and counties to potentially meet women's health care needs. Results: Twenty states and the District of Columbia had autonomous practice regulatory frameworks, whereas 24 states had collaborative practice regulatory frameworks during the years between 2012 and 2016. Six states changed regulations during that period. In 2016, the number of midwifeattended births per number of midwives in a state was not related to the regulatory framework. However, states with autonomous frameworks had 2.2 times as many midwives per women of reproductive age (P Ͻ .0001) and 2.3 times as many midwives per total births when compared with states with collaborative statutory frameworks (P Ͻ .0001). At the county level, 70.1% of US counties had no midwife. Of those states with autonomous practice, only 59.7% of counties had no midwives, compared with 74.1% in states with collaborative models (P Ͻ .0001). Discussion: Midwives have the potential to help address the shortage of maternity and reproductive health service providers. Our research suggests that increasing the number of states with autonomous regulatory frameworks can be one way to expand access to care for women in the United States.

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IMPORTANCEImproving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits. OBJECTIVE To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics.

Objective Postpartum visits are an important opportunity to address ongoing maternal health. Experiences of discrimination in healthcare can impact healthcare use, including postpartum visits. However, it is unknown whether discrimination is associated with postpartum visit content. This study aimed to examine the relationship between perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content. Research design Data were from Listening to Mothers in California, a population-based survey of people with a singleton hospital birth in California in 2016. Adjusted logistic regression models estimated the association between perceived discrimination during the childbirth hospitalization and 1) postpartum visit attendance, and 2) topics addressed at the postpartum visit (birth control, depression and breastfeeding) for those who attended. Results 90.6% of women attended a postpartum visit, and 8.6% reported discrimination during the childbirth hospitalization. In adjusted models, any discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit, respectively. There was a 7pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%), a 15pp lower predicted probability of being asked about depression (64% vs. 79%), and a 9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%). Conclusions Amid heightened attention to the importance of postpartum care, there is a need to better understand determinants of postpartum care quality. Our findings highlight the potential consequences of healthcare discrimination in the perinatal period, including lower quality of postpartum care.

BACKGROUND: In the context of inpatient general medicine, "rounding" refers to the process of seeing, assessing, and caring for patients as a team. The clinical leadership skills required of residents to lead rounds are essential to inpatient care and clinical education. Assessment of these skills has relevance to developing competent physicians; however, there is an absence of widely accepted tools to specifically measure this competency. OBJECTIVE: To develop and collect validity evidence for a direct observation instrument of internal medicine residents' leadership skills during daily inpatient care rounds for future formative assessment. DESIGN: Prospective observational study. PARTICIPANTS: PGY2 and PGY3 internal medicine residents. MAIN MEASURES: The authors collected inferences of validity evidence according to Kane's validity model. They performed direct observations of PGY2 and PGY3 residents by individual faculty and trained raters and measured inter-rater reliability, using the kappa statistic. Mixed linear regression models were used to compare PGY2 and PGY3 residents. Surveys captured faculty perceptions about value of the instrument. KEY RESULTS: A total of 223 observations were performed in 92 unique individuals. Twenty-four faculty used the observation instrument, of which 18 (75%) completed the post-survey, and 100% agreed that the instrument represented the resident's global leadership abilities. Inter-rater reliability was strong, with an overall kappa statistic equaling 0.82. The mean performance for PGY2 and PGY3 residents was 15.9 (SD 5.1) and 17.7 (SD 4.1), respectively. Adjusting for repeated measures, there was no statistically significant difference between groups. CONCLUSIONS: The authors reported evidence for all four stages of validity and use of the instrument in clinical practice. Their work provides a codification of best practices of rounding leadership, which directly impacts the education of trainees, care of hospitalized patients, and use for formative assessment. The instrument also has the potential to be used for summative assessment.