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The purpose of this paper is to report on a study investigating the limits of the applicability of the focused factory concept (FFC) in health care. The case setting comes from the Dutch obstetric care system, which is organised by principles in sync with the FFC; the organisation for “simple” pregnancies (independent midwifery practices) is fully separated from that for “complex” pregnancies (obstetric departments in hospitals). The paper investigates the degree of fit between how the Dutch obstetric care system is organised and how it operates (internal fit).

This study analyses one year of patient data from one obstetric hospital department and from one midwifery practice in its immediate geographical proximity. Data were collected regarding the medical condition, consultations, and delivery. These data were used to test the degree to which the obstetric care system operates in line with the FFC; one would expect the midwifery practice to operate as a “line process”, and the obstetric department as a “jobbing process”.

Findings suggest that the Dutch obstetric care sector is designed in line with the FFC, but does not operate accordingly. Root causes for this misalignment can be found in the characteristics of the medical condition of pregnancy.

The fact that the data concern only one region must raise caution for generalisation. However, the fact that medical conditions, which can be assumed to be universal, lead to an intrinsic mismatch between the FFC organisation and medical operational reality, suggests that this paper may have broad implications for theory and practice.

For the Dutch obstetric case system, this paper is one in a series that casts doubts on the sustainability of the two‐tiered system. For obstetric care in general, integrated care seems preferable to the FFC. For health care in general, this paper suggests that caution is required in applying the FFC. Moreover, in OM research for health care, more efforts should be made to understand how medical conditions affect the daily operational processes and, hence, the organisational design.

Most of the studies focusing on the applicability of the FFC look at financial and medical outcomes. This paper is original in that it looks at what drives these outcomes, i.e. the degree of fit between strategy, organisational design and operational performance.

Obstetric violence is the mistreatment of women in the setting of obstetric care, which includes preconception, medically assisted reproduction, pregnancy, childbirth and postpartum. Obstetric violence follows and perpetuates the devaluation and subjugation of women in patriarchal societies, where socio-cultural conceptions contribute to a view of the female body as faulty and deviating from the male prototype. These shape the perception that female reproductive processes require technological corrections. The medicalisation of reproductive processes and the mechanisation of a normal life event, with the threat of death and other life-changing consequences, disempower women and objectify the body and its functions.

The entrance of women into the workforce and the specialised fields, feminising care professions, failed to shift this paradigm. Female health workers are trained in the procedures instituted by dominant patriarchal structures, expressing values encoded in the professional culture and the institutions where they work. As women conform to the models they are exposed to during their training, perpetuating corporate hierarchies and practices, they act as agents and perpetrators of obstetric violence. Thus, obstetric violence also constitutes a specific type of violence against women at the hands of other women.

Huge gap exists between demand and supply of seeking health care leads to remain high maternal mortality in rural areas of Uttar Pradesh, India. The purpose of this paper is to make an effort in this direction.

This paper draws on Three Delays Model to understand the reasons behind poor maternal health outcomes among 964 currently married women aged 15–34, given birth in last two years preceding the survey including six case studies in poor settings of Northern India.

Receiving minimum four antenatal care and identifying the severity of obstetric complications during pregnancy was quite low (7 and 34 per cent, respectively). Major delay in seeking care in district was decision delay (average four days) followed by arranging transportation (average 4 hours) and start treatment within an hour after reaching health facility. Health services and trained human resources are mainly concentrated at towns and poor supply of drugs and equipment in labour room is always in demand at primary level in the district in area. Delays in decision making, travel and treatment compounded by ignorance of obstetric complications and poor healthcare infrastructure are the major contributing factors of maternal deaths in the district in area.

Interventions to improve timely seeking of medical care for obstetric complications may need to more effectively target husbands and family members rather than women. Strengthening of primary and secondary level facilities and timely referral to tertiary level care can play a crucial role in improving obstetric care in the district in rural areas.

Obstetric adverse outcomes (AOs) are an important topic and the use of composite measures may favor the understanding of their impact on patient safety. The aim of the present study was to estimate AO frequency and obstetric care quality in low and high-risk maternity hospitals.

A one-year longitudinal follow-up study in two public Brazilian maternity hospitals. The frequency of AOs was measured in 2,880 randomly selected subjects, 1,440 in each institution, consisting of women and their newborn babies. The frequency of 14 AOs was estimated every two weeks for one year, as well as three obstetric care quality indices based on their frequency and severity as follows: the Adverse Outcome Index (AOI), the Weighted Adverse Outcome Score and the Severity Index.

A significant number of mothers and newborns exhibited AOs. The most prevalent maternal AOs were admission to the ICU and postpartum hysterectomy. Regarding newborns, hospitalization for > seven days and neonatal infection were the most common complications. Adverse outcomes were more frequent at the high-risk maternity, however, they were more severe at the low-risk facility. The AOI was stable at the high-risk center but declined after interventions during the follow-up year.

High AO frequency was identified in both mothers and newborns. The results demonstrate the need for public patient safety policies for low-risk maternity hospitals, where AOs were less frequent but more severe.

The purpose of this paper is to investigate inter-organizational designs for care–cure conditions in which low-risk patients are cared for in specialized care organizations and high-risk patients are cared for in specialized cure organizations. Performance impacts of increasing levels of integration between these organizations are analyzed.

Mixed methods were used in Dutch perinatal care: analysis of archival data, clinical research and system dynamics simulation modeling.

Inter-organizational design has an effect on inter-organizational dynamics such as collaboration and trust, and also on the operational aspects such as patient flows through the system. Solutions are found in integrating care and cure organizations. However, not all levels of integrated designs perform better than a design based on organizational separation of care and cure.

A clear split between midwifery practices (care) and obstetric departments (cure) will not work since all pregnant women need both care and cure. Having midwifery practices only works well when there are high levels of collaboration and trust with obstetric departments in hospitals. Integrated care designs are likely to exhibit superior performance. However, these designs will have an adverse effect on organizations that are not part of this integration, since integrating only a subset of organizations will feed distrust, low collaboration and hence low performance.

The originality of this research is derived from its multi-method approach. Archival data and clinical research revealed the dynamic relations between organizations. The caveat of some integrated care models was found through simulation.

The US prison population has recently reached an all-time high, with women representing the fastest growing subpopulation. Correctional health-care system in the USA remains fragmented and nonuniform in practice, particularly in women’s health care, with poor transitions between incarceration and release. This study aims to examine the qualitative health-care experiences of women while incarcerated and their transition into the community health-care setting. Additionally, this study also examined the experiences of a subset of women who were pregnant while incarcerated.

After obtaining institutional review board approval, adult, English-speaking women with a history of incarceration within the past 10 years were interviewed using a semi-structured interview tool. Interview transcripts were analyzed using inductive content analysis.

The authors completed 21 full interviews and identified six themes that were both the most significant and most novel: “feeling stigmatized and insignificant,” “care as punishment,” “delay in care,” “exceptions to the rule,” “fragmentation of care” and “obstetric trauma and resilience.”

Women face numerous barriers and hardships when accessing basic and reproductive health-care services while incarcerated. This hardship is particularly challenging for women with substance use disorders. The authors were able to describe for the first time, partially through their own words, novel challenges described by women interacting with incarceration health care. Community providers should understand these barriers and challenges so as to effectively reengage women in care upon release and improve the health-care status of this historically marginalized group.

The routine use of intrapartum electronic fetal monitoring (EFM) has resulted in an increased burden of operative and vaginal instrumental deliveries for women at low obstetric risk. Such modes of delivery increase maternal mortality and morbidity risks. This study aims to explore midwives' values, attitudes and beliefs when using intrapartum fetal monitoring techniques in clinical practice.

A total of 58 registered midwives across two NHS Trusts in one region in the north of England were interviewed using a qualitative approach.

Midwives attempted to manage the psychological burden of the threat from clinical negligence by using EFM. This meant that some midwives used electronic monitoring regardless of clinical need. Midwives lack confidence in the ability of EFM to accurately detect fetal compromise but are aware that the visual monitoring record is recognised as a valuable piece of legal evidence. The midwives' perceptions of professional self‐efficacy in seeking to avoid a claim in clinical negligence contributed to defensive practice. Research limitations/implications – The study was conducted in only two hospitals in one region of England; however the Trust demographics were similar and midwifery practice within the unit reflects national maternity standards of care.

Multidisciplinary strategies may be required to overcome barriers to the effective implementation of clinical guidelines where intrapartum fetal monitoring is concerned and Trust audit departments must undertake regular audit cycles in order to ascertain practice compliance with best evidence.

The paper provides information so that midwives' knowledge regarding the limitations of EFM can be improved.

Four Washington State associations came together to form a novel organization in response to rising healthcare sector costs, coupled with the need to ensure efficient provision of high quality care that improves health outcomes. This article seeks to explain the work and progress of that organization.

The article takes the form of a historical narrative.

The initiative has evolved from reliance on grants to becoming self‐funding, expanded the scope of its activities, and satisfied the needs of the stakeholders.

This organizational model is more efficient than going it alone on every effort, and may be a desirable solution for other communities.

This is the first published description of a unique, non‐profit organization founded in 1998, which can serve as a model for other regions that wish to promote collaborative benchmarking among competitive independent health care providers.

The purpose of this paper is to measure reliability, validity and accuracy of the 12-item General Health Questionnaire (GHQ-12) as a measure of emotional wellbeing in pregnant women; utility and threshold in particular.

The authors measured self-reported emotional wellbeing responses of 164 low-risk pregnant Dutch women with the GHQ-12 and a dichotomous case-finding item (Gold standard). The authors established internal consistency of the 12 GHQ-items (Cronbach’s coefficient α); construct validity: factor analysis using Oblimin rotation; convergent validity (Pearson’s correlation) and discriminatory ability (area under the receiver operating characteristics curve and index of union); and external validity of the dichotomous criterion standard against the GHQ-12 responses (sensitivity, specificity, likelihood ratios and predictive values), applying a cut-off value of ⩾ 12 and ⩾ 17, respectively.

A coefficient of 0.85 showed construct reliability. The GHQ-12 items in the pattern matrix showed a three-dimensional factorial model: factor 1, anxiety and depression; factor 2, coping; and factor 3, significance/effect on life, with a total variance of 59 per cent. The GHQ-12 showed good accuracy (0.84; p=<0.001) and external validity (r=0.57; p=<0.001) when the cut-off value was set at the ⩾ 17 value. Using a cut-off value of ⩾ 17 demonstrated higher sensitivity (72.32 vs 41.07 per cent) but lower specificity (32.69 vs 55.77 per cent) compared to the commonly used cut-off value of ⩾ 12.

Findings generally support the reliability, validity and accuracy of the Dutch version of the GHQ-12. Further evaluation of the measure, at more than one timepoint during pregnancy, is recommended.

The GHQ-12 holds the potential to measure antenatal emotional wellbeing and women’s emotional responses and coping mechanisms with reduced antenatal emotional wellbeing.

Adapting the GHQ-12 cut-off value enables effective identification of reduced emotional wellbeing to provide adequate care and allows potential reduction of anxiety among healthy pregnant women who are incorrectly screened as positive.

A novel aspect is adapting the threshold of the GHQ-12 to ⩾ 17 in antenatal care.

The provision of and access to healthcare for pregnant women is a complicated labyrinth of social and health‐related issues. The purpose of this paper is to discuss a new approach by the Save the Mothers organization to stimulate changes leading to safer and healthier pregnancies for Ugandan women using a Master of Public Health Leadership (MPHL) as the mechanism for education, advocacy, and network development.

Save the Mothers developed and supports a modular, post‐graduate, multi‐disciplinary MPHL. This training is designed to develop public health leaders who create transformative local projects and networks of professionals advocating for safe motherhood and consequent decreased child mortality.

Students and graduates have begun to change the conditions in Uganda for women and children by promoting safe motherhood practices and policies. Examples include a journalist, a politician, a social worker, and a school principal who have brought the issues into their spheres of influence and practice. Measurement of the impact of this approach is ongoing.

This program provides a locally based, culturally appropriate approach to change, which could be adapted to a variety of other locales and development issues. This program permits practicing professionals to remain employed while undertaking advanced training, establishes the implementation of local projects, and links a graduate university program with diverse community leaders.

This unique approach within Africa may be a model for the development of multidisciplinary, education‐based initiatives to change conditions in developing countries using existing expertise and stimulating effective advancement through safe motherhood networks.