ACOG Committee Opinion No. 736: Optimizing Postpartum Care

Preventive Health Application to Increase Breastfeeding

Background: Mother-infant dyads are not meeting recommended breastfeeding goals. There is lack of consensus regarding any program's ability to increase breastfeeding duration to meet the recommended guidelines, and effective strategies are needed moving forward to help families meet those goals. Primary prevention utilizing consistent visits with lactation professionals with a group of new mothers may efficiently address this care gap. Methods: Mother-infant dyads attending a newborn care clinic for 6 weeks received feeding assessment and standard-of-care guidance from an Internationally Board-Certified Lactation Consultant (IBCLC). Regression analysis was completed with outcome variables "exclusive direct breastfeeding" (EDB) and "any breastfeeding" (AB) at 6 weeks postpartum (PP) and odds ratios were calculated. Results: The number and timing of IBCLC visits was correlated with EDB at 6 weeks PP. Maternal/infant dyads seen at day 3 had 2.5 times higher odds of EDB at 6 weeks than those not receiving IBCLC standard-of-care feeding assessment. Dyads seen at days 3 and 14 had 3.4 times higher odds of EDB than those with less follow-up. Bottle use correlated with decreased odds of AB at 6 weeks PP; similarly, dyads seen only at day 14 PP had decreased odds of EDB. When looking at timing of the first involvement, dyads seen at 3 days had higher odds of EDB than dyads first seen at day 14 PP. Conclusions: This primary prevention strategy of early minimal intervention using an IBCLC increased the odds of EDB and AB at 6 weeks PP. These data support the conclusion that early feeding assessment the first 2 weeks PP with an IBCLC may increase breastfeeding at 6 weeks PP.

Risk for postpartum readmissions and associated complications based on maternal age

PURPOSE

To evaluate risk for postpartum readmissions and associated severe morbidity by maternal age.

MATERIALS AND METHODS

This retrospective cohort study used the Nationwide Readmissions Database to analyze 60-day all-cause postpartum readmission risk from 2010 to 2014. Risk for severe maternal morbidity (SMM) during readmission was ascertained using criteria from the Centers for Disease Control and Prevention. The primary exposure of interest was maternal age. Outcomes included time to readmission, risk of readmission, and risk for SMM during readmission. Multivariable log linear analyses adjusting for patient, obstetric, and hospital factors were conducted to assess readmission and SMM risk with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) as measures of effect.

RESULTS

Between 2010 and 2014, we identified 15.7 million deliveries, 15% of which were to women aged 35 or older. The 60-day all-cause readmission rate was 1.7%. Of these, 13% were complicated by SMM. Age-stratification revealed that women 35 and older were at increased risk for readmission and increased risk for SMM. The majority of readmissions occurred within the first 20 days regardless of age; although, women 35 and older were more likely to be admitted within the first 10 days of discharge. Patients ages 35-39, 40-44, and >44 years had 9% (95% CI 7-10%), 37% (95% CI 34-39%), and 66% (95% CI 55-79%) significantly higher rates of postpartum readmission when compared to women age 25-29. Women 35-39, 40-44, and >44 years of age had a 15% (95% CI 10-21%), 26% (95% CI 18-34%), and 56% (95% CI 25-94%) higher risk of a readmission with SMM than women 25-29.

CONCLUSIONS

AMA women are at higher risk for both postpartum readmission and severe morbidity during readmission. Women older than 35 years represent the group most likely to experience complications requiring readmission, with the highest risk age 40 and older.

Postpartum Patient Navigation and Postpartum Weight Retention

Objective  This study aimed to evaluate postpartum weight retention (PPWR) among women who participated in a postpartum patient navigation (PN) program. Study Design  English-speaking pregnant or postpartum women receiving publicly-funded prenatal care at a hospital-based clinic were invited to receive PN services through 12 weeks postpartum. Women were eligible for this analysis if height and weight values were available. Weights at 4 to 12 weeks and up to 12 months postpartum were compared in PN and non-PN historical-control groups and analyzed as mean PPWR (difference from prepregnancy weight) and categorically as PPWR > 5kg. Results  Among the 311 women, 152 participated in the PN program and 159 were historical controls. There were no differences in age, race and ethnicity, prepregnancy body mass index (BMI), nulliparity, and preterm birth between the groups ( p  > 0.05). At 4 to 12 weeks postpartum, mean PPWR (4.0 ± 6.7 vs. 2.7 ± 6.3 kg, p  = 0.06) and PPWR > 5 kg (61/144 [42%] vs. 50/145 [34%], p  = 0.15) did not differ between groups. Similarly, up to 12 months postpartum, mean PPWR (4.5 ± 7.1 vs. 5.0 ± 7.5 kg, p  = 0.59) and PPWR > 5 kg (22/50 [44%] vs. 30/57 [53%], p  = 0.55) did not differ between groups. Conclusion  Although PN is a promising intervention to improve women's health care utilization and other associated health outcomes, in this particular navigation program, participation was not associated with PPWR at 4 to 12 weeks and up to 12 months postpartum.

Depressive symptoms during pregnancy and postpartum: a prospective cohort study

PURPOSE

The aim was to determine the prevalence and risk factors of postpartum depression, and changes over time from pregnancy to postpartum period.

DESIGN AND METHODS

A prospective cohort study was conducted in 23 cities in Turkey, with 497 pregnant women.

FINDINGS

Of women, 13.5% had a high level of depressive symptoms during pregnancy and 4.8% during the postpartum period. Significant relationships emerged between total Edinburgh Postnatal Depression Scale score and mean age of participants and their husbands, duration of marriage, parity, and history of receiving professional psychological support.

PRACTICE IMPLICATIONS

Family planning education could be an important intervention to prevent depression in young couples.

Factors associated with postpartum use of long-acting reversible contraception

BACKGROUND

Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception, including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low.

OBJECTIVES

We sought to estimate prevalence of long-acting reversible contraception use among postpartum women and examine factors associated with long-acting reversible contraception use among those using any reversible contraception.

STUDY DESIGN

We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of long-acting reversible contraception use in our sample (n = 143,335). We examined maternal factors associated with long-acting reversible contraception use among women using reversible contraception (n = 97,013) using multivariable logistic regression (long-acting reversible contraception vs other type of reversible contraception) and multinomial regression (long-acting reversible contraception vs other hormonal contraception and long-acting reversible contraception vs other nonhormonal contraception).

RESULTS

The prevalence of long-acting reversible contraception use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported long-acting reversible contraception use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum long-acting reversible contraception use vs use of another reversible contraceptive method included age ≤24 years (adjusted odds ratio = 1.43; 95% confidence interval = 1.33-1.54) and ≥35 years (adjusted odds ratio = 0.87; 95% confidence interval = 0.80-0.96) vs 25-34 years; public insurance (adjusted odds ratio = 1.15; 95% confidence interval = 1.08-1.24) and no insurance (adjusted odds ratio = 0.73; 95% confidence interval = 0.55-0.96) vs private insurance at delivery; having a recent unintended pregnancy (adjusted odds ratio = 1.44; 95% confidence interval = 1.34-1.54) or being unsure about the recent pregnancy (adjusted odds ratio = 1.29; 95% confidence interval = 1.18-1.40) vs recent pregnancy intended; having ≥1 previous live birth (adjusted odds ratio = 1.40; 95% confidence interval = 1.31-1.48); and having a postpartum check-up after recent live birth (adjusted odds ratio = 2.70; 95% confidence interval = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of long-acting reversible contraception use (26.6% and 23.4%, respectively) compared to non-Hispanic white women (21.5%), and there was significant race/ethnicity interaction with educational level.

CONCLUSION

Nearly 1 in 6 (15.3%) postpartum women with a recent live birth and nearly 1 in 4 (22.5%) postpartum women using reversible contraception reported long-acting reversible contraception use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum long-acting reversible contraception use. Ensuring all postpartum women have access to the full range of contraceptive methods, including long-acting reversible contraception, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of long-acting reversible contraception (and other methods), as well as providing full reimbursement for contraceptive services and removal of administrative and logistical barriers.

Implementation of a Perinatal Depression Care Bundle in a Nurse-Managed Midwifery Practice

OBJECTIVE

To implement a perinatal depression care bundle at a midwifery practice to help certified nurse-midwives (CNMs) educate women about perinatal depression and direct those affected to mental health services.

DESIGN

Quality improvement project to implement a perinatal depression care bundle for care of pregnant women between 24 and 29 weeks gestation.

SETTING/LOCAL PROBLEM

CNMs practicing in a nurse-managed midwifery practice systematically screen all women for perinatal depression during pregnancy and the postpartum period but do not have a consistent method of providing anticipatory guidance about perinatal depression.

PARTICIPANTS

All CNMs in the midwifery practice providing prenatal care (n = 16) participated in implementation.

INTERVENTION/MEASUREMENTS

The perinatal depression care bundle included three elements: (a) an educational handout; (b) a brief, provider-initiated discussion about perinatal depression; and (c) lists of local and online mental health resources. Four weeks after the care bundle was implemented, we conducted a retrospective chart review to assess CNMs' adherence to the new bundle.

RESULTS

Over 4 weeks, 51 prenatal visits met eligibility criteria for participation. CNMs implemented the perinatal depression care bundle for 22 (43.1%) eligible visits. CNM feedback indicated that the care bundle was brief, easy to incorporate into routine care, and well received by women.

CONCLUSION

This project incorporated the use of a perinatal depression care bundle for women seen during routine prenatal care. Using a systematic approach to deliver perinatal depression education and resources reduces process variability and may destigmatize the illness, allowing women to feel empowered to seek help before depression symptoms become severe.

Strategies to Promote Postpartum Visit Attendance Among Medicaid Participants

Background: Postpartum care is important for promoting maternal and infant health and well-being. Nationally, less than 60% of Medicaid-enrolled women attend their postpartum visit. The Strong Start for Mothers and Newborns II Initiative, an enhanced prenatal care program, intended to improve birth outcomes among Medicaid beneficiaries, enrolled 45,599 women, and included a variety of approaches to increasing engagement in postpartum care. Methods: This study analyzes qualitative case studies that include coded notes from 739 interviews with 1,074 key informants and 133 focus groups with 951 women; 4 years of annual memos capturing activities by each of 27 awardees and 24 Birth Center sites; and a review of interview and survey data from Medicaid officials in 20 states. Results: Strong Start prenatal care included education and support regarding postpartum care and concerns. Key informants identified Strong Start services and other strategies they perceived as increasing access to postpartum care, including provider and/or care coordinator continuity across prenatal, delivery, and postpartum visits; efforts to address information gaps and link women to appropriate resources; enhancing services to meet needs such as treatment for depression; addressing barriers related to transportation and childcare; and aligning incentives to encourage prioritization of postpartum care among patients and providers. They also identified ongoing barriers to postpartum visit attendance. Conclusions: Postpartum care is essential to maternal and infant health. Medicaid enrolls many high-risk women and is the largest payer for postpartum care. Using lessons from Strong Start, providers who serve Medicaid-enrolled women can advance strategies to improve postpartum visit access and attendance.

Immediate Postpartum Contraception: Intrauterine Device Insertion

Insertion of an intrauterine device (IUD) in the immediate postpartum period is a safe, evidence-based form of contraception appropriate for most women. Despite the higher risk of expulsion as compared with interval insertion, the benefits of insertion in the immediate postpartum period are significant and include improved rates of contraception continuance and reduced instances of short interval birth. Through shared decision making, midwives and other clinicians can assist women in clarifying their reproductive goals and understanding of contraceptive options, including this method. In response to identified gaps in knowledge and insertion technique among midwives, this article provides an overview of immediate postpartum IUD insertion, risks and benefits, and eligibility criteria and describes preinsertion, insertion, and postinsertion care.

A Call for Comprehensive Care in the Fourth Trimester

Childbirth is an event that is remembered for years to come. At the time of discharge from a hospital, new mothers are sent home with many instructions on how to properly care for their newborns, but many may be unprepared for the changes to their bodies and their emotions. Unfortunately, the postpartum period can be a time of great angst and unanswered questions. This commentary describes the personal experience of one of the authors, who encountered difficulty navigating the health care system during the postpartum period. She shares her experience with the hope of promoting change for other women. After reading the account of her birth and recovery, individuals are encouraged to advocate for regular care of new mothers in the fourth trimester. The time to advocate for change is now.

Pregnancy-Associated Death in Utah: Contribution of Drug-Induced Deaths

OBJECTIVE

Drug-induced deaths, defined as intentional or unintentional consumption of illicit substances or diverted medications leading to death, are the leading cause of death for reproductive-age women in the United States. Our objective was to describe pregnancy-associated deaths attributed to drug-induced causes to identify opportunities for intervention.

METHODS

Using the Utah Perinatal Morality Review Committee database, we performed a retrospective cohort study of all pregnancy-associated deaths-death of a woman during pregnancy or within 1 year from the end of pregnancy-from 2005 to 2014. We performed a detailed descriptive analysis of women with drug-induced deaths. We compared characteristics of women with drug-induced and other pregnancy-associated deaths.

RESULTS

From 2005 to 2014, 136 pregnancy-associated deaths were identified. Drug-induced death was the leading cause of pregnancy-associated death (n=35, 26%) and 89% occurred in the postpartum period. More specifically, those with a drug-induced death were more likely to die in the late postpartum period, defined as death occurring within 43 days to 1 year of the end of the pregnancy, (n=28/35, 80%) compared with women whose deaths were from other pregnancy-associated causes (n=34/101, 34%) (P<.001). The majority of drug-induced deaths were attributed to opioids (n=27/35, 77%), prescription opioids (n=21/35, 60%), and polysubstance use (n=29/35, 83%). From 2005 to 2014, the pregnancy-associated mortality ratio increased 76%, from 23.3 in 2005 to 41.0 in 2014. During this same time period, the drug-induced pregnancy-associated mortality ratio increased 200%, from 3.9 in 2005 to 11.7 in 2014.

CONCLUSION

Drug-induced death is the leading cause of pregnancy-associated death in Utah and occurs primarily in the late postpartum period. Interventional studies focused on identifying and treating women at risk of drug-induced death are urgently needed.

Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017

Background

Approximately 700 women die from pregnancy-related complications in the United States every year.

Methods

Data from CDC’s national Pregnancy Mortality Surveillance System (PMSS) for 2011–2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013–2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors.

Results

For 2011–2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1–6 days postpartum, 21.4% 7–42 days postpartum, and 11.7% 43–365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.

Conclusions

Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable.

Implications for Public Health Practice

Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels.

Maternal outcomes by race during postpartum readmissions

BACKGROUND

Maternal race may be an important risk factor for postpartum readmissions and associated adverse outcomes.

OBJECTIVE

To determine the association of race with serious complications during postpartum readmissions.

STUDY DESIGN

This repeated cross-sectional analysis used the National (Nationwide) Inpatient Sample from the Healthcare Cost and Utilization Project from 2012 to 2014. Women ages 15-54 readmitted postpartum after a delivery hospitalization were identified by Centers for Disease Control and Prevention criteria. Race and ethnicity were characterized as non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific islander, Native American, other, and unknown. Overall risk for readmission by race was determined. Risk for severe maternal morbidity during readmissions by race was analyzed. Individual outcomes including pulmonary edema/acute heart failure and stroke also were analyzed by race. Log-linear regression models including demographics, hospital factors, and comorbid risk were used to analyze risk for severe maternal morbidity during postpartum readmissions.

RESULTS

Of 11.3 million births, 207,730 (1.8%) women admitted postpartum from 2012 to 2014 were analyzed, including 96,670 white, 47,015 black, and 33,410 Hispanic women. Compared with non-Hispanic white women, non-Hispanic black women were at 80% greater risk of postpartum readmission (95% confidence interval, 79%-82%) whereas Hispanic women were at 11% lower risk of readmission (95% confidence interval, 10%-12%). In unadjusted analysis, compared with non-Hispanic white women, non-Hispanic black women admitted postpartum were at 27% greater risk of severe maternal morbidity (95% confidence interval, 24%-30%) whereas Hispanic women were at 10% lower risk (95% confidence interval, 7%-13%). In the adjusted model, non-Hispanic black women were at 16% greater risk for severe maternal morbidity during readmission than non-Hispanic white women (95% confidence interval, 10%-22%), whereas Hispanic women were at 7% lower risk (95% confidence interval, 1%-12%). Differences in severe maternal morbidity risk between other racial groups and non-Hispanic white women were not significant. In addition to overall morbidity, non-Hispanic black women were at significantly greater risk for eclampsia, acute respiratory distress syndrome, and renal failure than other racial groups (P<.05 all). Black women were at 126% greater risk for pulmonary edema/acute heart failure than white women (95% confidence interval, 117%-136%).

CONCLUSION

Black women were more likely (1) to be readmitted postpartum, (2) to suffer severe maternal morbidity during readmission, and (3) to suffer life threatening complications such as pulmonary edema/acute heart failure. At-risk women including black women with cardiovascular risk factors may benefit from short-term postpartum follow-up.

Glucose screening in pregnancy and future risk of cardiovascular disease in women: a retrospective, population-based cohort study

BACKGROUND

In studies to date, gestational diabetes has consistently been associated with an increased future risk of cardiovascular disease, irrespective of the antepartum screening protocol or diagnostic criteria by which gestational diabetes is diagnosed. We reasoned that the resultant heterogeneity in the severity of dysglycaemia in women with gestational diabetes suggests that the relationship between gestational glycaemia and subsequent cardiovascular disease probably extends into the non-diagnostic range. Thus, we hypothesised that glucose screening in pregnancy would identify future risk of cardiovascular disease in women who did not have gestational diabetes.

METHODS

We did a population-based cohort study using information from health-care administrative databases from the Ministry of Health and Long Term Care of Ontario (Canada). We identified all women in Ontario who had a 50 g oral glucose challenge test in pregnancy between 24 and 28 weeks gestation with a livebirth delivery between July 1, 2007, and Dec 31, 2015. Women who had a history of diabetes before pregnancy or had been previously hospitalised for cardiovascular disease were excluded. Women with a 1-h post-challenge plasma glucose concentration of 11·1 mmol/L or greater were considered to have gestational diabetes, as were women with a reading between 7·8 and 11·0 mmol/L inclusive for whom diabetes was recorded as a diagnosis on the delivery hospital record. The study population was divided into six groups based on the results of the glucose challenge test (≤4·8 mmol/L; 4·9-5·5 mmol/L; 5·6-6·2 mmol/L; 6·3-6·9 mmol/L; 7·0-7·9 mmol/L; and ≥8·0 mmol/L). The primary outcome was cardiovascular disease (a composite of hospitalisation for myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy). All women were followed up from the index pregnancy until cardiovascular disease event, death, migration, or Sept 30, 2017, whichever came first.

FINDINGS

259 164 women were identified as eligible for this study: 13 609 who had gestational diabetes, and 245 555 women without gestational diabetes. The women were followed up over a median 3·9 years (IQR 2·8-5·6) for the development of cardiovascular disease. Each 1 mmol/L increment in the glucose challenge test result was associated with a 13% higher risk of cardiovascular disease (after adjustment for age, ethnicity, income, and rurality, adjusted hazard ratio [HR] 1·13, 95% CI 1·04-1·22). This relationship persisted after excluding women with gestational diabetes (1·14, 1·01-1·28). In women without gestational diabetes, those with an abnormal glucose challenge test result (≥7·8 mmol/L) and those with a result between 7·2 and 7·7 mmol/L had an increased risk of cardiovascular disease (HR 1·94, 95% CI 1·29-2·92; and 1·65, 0·99-2·76, respectively), compared with those with a result of 7·1 mmol/L or less (overall p=0·003).

INTERPRETATION

The relationship between gestational glycaemia and subsequent risk of cardiovascular disease extends into the normoglycaemic range. Accordingly, glucose screening in pregnancy could identify future risk of cardiovascular disease in women who do not have gestational diabetes.

FUNDING

None.

Prepregnancy counseling: Committee Opinion No. 762

The goal of prepregnancy care is to reduce the risk of adverse health effects for the woman, fetus, and neonate by working with the woman to optimize health, address modifiable risk factors, and provide education about healthy pregnancy. All those planning to initiate a pregnancy should be counseled, including heterosexual, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals. Counseling can begin with the following question: "Would you like to become pregnant in the next year?" Prepregnancy counseling is appropriate whether the reproductive-aged patient is currently using contraception or planning pregnancy. Because health status and risk factors can change over time, prepregnancy counseling should occur several times during a woman's reproductive lifespan, increasing her opportunity for education and potentially maximizing her reproductive and pregnancy outcomes. Many chronic medical conditions such as diabetes, hypertension, psychiatric illness, and thyroid disease have implications for pregnancy outcomes and should be optimally managed before pregnancy. Counseling patients about optimal intervals between pregnancies may be helpful to reduce future complications. Assessment of the need for sexually transmitted infection screening should be performed at the time of prepregnancy counseling. Women who present for prepregnancy counseling should be offered screening for the same genetic conditions as recommended for pregnant women. All patients should be routinely asked about their use of alcohol, nicotine products, and drugs, including prescription opioids and other medications used for nonmedical reasons. Screening for intimate partner violence should occur during prepregnancy counseling. Female prepregnancy folic acid supplementation should be encouraged to reduce the risk of neural tube defects.

Improved Perinatal and Postpartum Human Immunodeficiency Virus Outcomes After Use of a Perinatal Care Coordination Team

In a high-volume clinic in the Southeastern United States, pregnant women living with human immunodeficiency virus (HIV) had improved HIV outcomes up to 6 months after delivery following the introduction of a multidisciplinary perinatal care coordination team.

Maternal risk factor index and cesarean delivery among women with nulliparous, term, singleton, vertex deliveries, Texas, 2015

BACKGROUND

Cesarean delivery accounts for over one-third of the ~400 000 annual births in Texas, with first-time cesarean accounting for 20% of the overall cesareans. We examined associations of maternal medical comorbidities with cesarean delivery among nulliparous, term, singleton, vertex (NTSV) deliveries in Texas.

METHODS

Nulliparous, term, singleton, vertex deliveries to women aged 15-49 years were identified using the 2015 Texas birth file (Center for Health Statistics, Texas Department of State Health Services). A risk factor index was constructed (score range 0-4), including preexisting/gestational diabetes mellitus, preexisting/gestational hypertension/eclampsia, infertility treatment, smoking during pregnancy, and prepregnancy overweight/obesity, and categorized as 0, 1, 2, and 3+ based on the number of risk factors present. Multivariable logistic regression analyses were conducted to examine associations between the categorized risk factor index and cesarean delivery, overall and by maternal race and ethnicity.

RESULTS

Among the 114 535 NTSV deliveries in Texas in 2015, 27.2% were by cesarean. The most prevalent maternal risk among all deliveries was prepregnancy overweight/obesity (42.4%). The odds of cesarean delivery increased significantly with increasing number of risk factors [one risk factor: 1.72 (95% CI 1.67-1.78); two risk factors: 2.58 (95% CI 2.46-2.71); and three or more risk factors: 3.91 (95% CI 3.45-4.44)].

DISCUSSION

In Texas in 2015, nearly half of NTSV deliveries had at least one maternal risk factor and the odds of cesarean delivery were significantly elevated for women with a higher risk index score. The findings from this study highlight the need for intervening during the preconception and interconception period as intrapartum care practices have an important influence on birth outcomes.

HIV Care Continuum among Postpartum Women Living with HIV in Atlanta

Introduction

While increased healthcare engagement and antiretroviral therapy (ART) adherence occurs during pregnancy, women living with HIV (WLWH) are often lost to follow-up after delivery. We sought to evaluate postpartum retention in care and viral suppression and to identify associated factors among WLWH in a large public hospital in Atlanta, Georgia.

Methods

Data from the time of entry into prenatal care until 24 months postpartum were collected by chart review from WLWH who delivered with ≥20 weeks gestational age from 2011 to 2016. Primary outcomes were retention in HIV care (two HIV care visits or viral load measurements >90 days apart) and viral suppression (<200 copies/mL) at 12 and 24 months postpartum. Obstetric and contraception data were also collected.

Results

Among 207 women, 80% attended an HIV primary care visit in a mean 124 days after delivery. At 12 and 24 months, respectively, 47% and 34% of women were retained in care and 41% and 30% of women were virally suppressed. Attending an HIV care visit within 90 days postpartum was associated with retention in care at 12 months (aOR 3.66, 95%CI 1.72-7.77) and 24 months (aOR 4.71, 95%CI 2.00-11.10) postpartum. Receiving ART at pregnancy diagnosis (aOR 2.29, 95%CI 1.11-4.74), viral suppression at delivery (aOR 3.44, 95%CI 1.39-8.50), and attending an HIV care visit within 90 days postpartum (aOR 2.40, 95%CI 1.12-5.16) were associated with 12-month viral suppression, and older age (aOR 1.09, 95% CI 1.01-1.18) was associated with 24-month viral suppression.

Conclusions

Long-term retention in HIV care and viral suppression are low in this population of postpartum WLWH. Prompt transition to HIV care in the postpartum period was the strongest predictor of optimal HIV outcomes. Efforts supporting women during the postpartum transition from obstetric to HIV primary care may improve long-term HIV outcomes in women.

Interventions to Prevent Perinatal Depression: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Perinatal depression, which is the occurrence of a depressive disorder during pregnancy or following childbirth, affects as many as 1 in 7 women and is one of the most common complications of pregnancy and the postpartum period. It is well established that perinatal depression can result in adverse short- and long-term effects on both the woman and child.

OBJECTIVE

To issue a new US Preventive Services Task Force (USPSTF) recommendation on interventions to prevent perinatal depression.

EVIDENCE REVIEW

The USPSTF reviewed the evidence on the benefits and harms of preventive interventions for perinatal depression in pregnant or postpartum women or their children. The USPSTF reviewed contextual information on the accuracy of tools used to identify women at increased risk of perinatal depression and the most effective timing for preventive interventions. Interventions reviewed included counseling, health system interventions, physical activity, education, supportive interventions, and other behavioral interventions, such as infant sleep training and expressive writing. Pharmacological approaches included the use of nortriptyline, sertraline, and omega-3 fatty acids.

FINDINGS

The USPSTF found convincing evidence that counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, are effective in preventing perinatal depression. Women with a history of depression, current depressive symptoms, or certain socioeconomic risk factors (eg, low income or young or single parenthood) would benefit from counseling interventions and could be considered at increased risk. The USPSTF found adequate evidence to bound the potential harms of counseling interventions as no greater than small, based on the nature of the intervention and the low likelihood of serious harms. The USPSTF found inadequate evidence to assess the benefits and harms of other noncounseling interventions. The USPSTF concludes with moderate certainty that providing or referring pregnant or postpartum women at increased risk to counseling interventions has a moderate net benefit in preventing perinatal depression.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. (B recommendation).

Continued Disparities in Postpartum Follow-Up and Screening Among Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review

The postpartum period represents a critical window to initiate targeted interventions to improve cardiometabolic health following pregnancies complicated by gestational diabetes mellitus and/or a hypertensive disorder of pregnancy. The purpose of this systematic review was to examine studies published since 2011 that report rates of postpartum follow-up and risk screening for women who had gestational diabetes and/or a hypertensive disorder of pregnancy and to identify disparities in care. Nine observational studies in which postpartum follow-up visits and/or screening rates were measured among US women following pregnancies complicated by gestational diabetes and/or a hypertensive disorder of pregnancy were reviewed. Rates of postpartum follow-up ranged from 5.7% to 95.4% with disparities linked to black race and Hispanic ethnicity, low level of education, and coexisting morbidities such as mental health disorders. Follow-up rates were increased if the provider was an obstetrician/endocrinologist versus primary care. Payer source was not associated with follow-up rates. The screening rate for diabetes in women who had gestational diabetes did not exceed 58% by 4 months across the studies analyzed, suggesting little improvement in the last 10 years. While women who had a hypertensive disorder appear to have had a postpartum blood pressure measured, it is unclear whether follow-up intervention occurred. Overall, postpartum screening rates for at-risk women remain suboptimal and vary substantially. Further research is warranted including reliable population-level data to inform equitable progress to meeting the evidence-informed guidelines.

Interpregnancy Care

Interpregnancy care aims to maximize a woman's level of wellness not just in between pregnancies and during subsequent pregnancies, but also along her life course. Because the interpregnancy period is a continuum for overall health and wellness, all women of reproductive age who have been pregnant regardless of the outcome of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy care as a continuum from postpartum care. The initial components of interpregnancy care should include the components of postpartum care, such as reproductive life planning, screening for depression, vaccination, managing diabetes or hypertension if needed, education about future health, assisting the patient to develop a postpartum care team, and making plans for long-term medical care. In women with chronic medical conditions, interpregnancy care provides an opportunity to optimize health before a subsequent pregnancy. For women who will not have any future pregnancies, the period after pregnancy also affords an opportunity for secondary prevention and improvement of future health.

Effect of Follow-Up Intervals on Breastfeeding Rates 5-6 Months Postpartum: A Randomized Controlled Trial

OBJECTIVE

To compare the effect of early versus traditional postpartum follow-up intervals on breastfeeding continuation rates 6 months postpartum.

METHODS

This randomized controlled trial enrolled primiparous women planning to breastfeed to a postpartum appointment either 2-3 weeks or 6-8 weeks after delivery. The primary outcome was the breastfeeding rate in each group 5-6 months after delivery. The study was powered to detect a 50% difference between groups assuming a 34% rate of breastfeeding at 6 months. Participants were contacted by phone 5-6 months after delivery to assess outcomes.

RESULTS

From March 2014 to July 2016, 649 women were screened and 344 enrolled as follows: 172 to 2-3 week and 172 to 6-8 week follow-up. Demographic, delivery, and support characteristics were similar between groups; however, average infant birth weight and the distribution of gestational ages at the time of delivery were different between groups (p < 0.05). Participants in the 2-3 week group had a breastfeeding rate of 57.7% 6 months following delivery and participants in the 6-8 week group had a rate of 59.3%. Early follow-up was associated with a relative risk of 0.97 (95% CI 0.79-1.19, p = 0.80) and an adjusted relative risk of 1.45 (95% CI 0.71-2.95, p = 0.31), when adjusted for confounding variables, for breastfeeding continuation at 5-6 months.

CONCLUSIONS

Breastfeeding rates at 5-6 months postpartum were comparable between both groups; early follow-up was not associated with an increased rate of breastfeeding. At 6 months postpartum, the breastfeeding rate in both groups approximated the Surgeon General's Healthy People 2020 goal of 60.6%.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (Identifier NCT02221895).

Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: An updated systematic review

BACKGROUND

This systematic review summarises association between short interpregnancy intervals and adverse perinatal health outcomes in high-resource settings to inform recommendations for healthy birth spacing for the United States.

METHODS

Five databases and a previous systematic review were searched for relevant articles published between 1966 and 1 May 2017. We included studies meeting the following criteria: (a) reporting of perinatal health outcomes after a short interpregnancy interval since last livebirth; (b) conducted within a high-resource setting; and (c) estimates were adjusted for maternal age and at least one socio-economic factor.

RESULTS

Nine good-quality and 18 fair-quality studies were identified. Interpregnancy intervals <6 months were associated with a clinically and statistically significant increased risk of adverse outcomes in studies of preterm birth (eg, aOR ≥ 1.20 in 10 of 14 studies); spontaneous preterm birth (eg, aOR ≥ 1.20 in one of two studies); small-for-gestational age (eg, aOR ≥ 1.20 in 5 of 11 studies); and infant mortality (eg, aOR ≥ 1.20 in four of four studies), while four studies of perinatal death showed no association. Interpregnancy intervals of 6-11 and 12-17 months generally had smaller point estimates and confidence intervals that included the null. Most studies were population-based and few included adjustment for detailed measures of key confounders.

CONCLUSIONS

In high-resource settings, there is some evidence showing interpregnancy intervals <6 months since last livebirth are associated with increased risks for preterm birth, small-for-gestational age and infant death; however, results were inconsistent. Additional research controlling for confounding would further inform recommendations for healthy birth spacing for the United States.

Association of Short Interpregnancy Interval With Pregnancy Outcomes According to Maternal Age

IMPORTANCE

Interpregnancy intervals shorter than 18 months are associated with higher risks of adverse pregnancy outcomes. It is currently unknown whether short intervals are associated with increased risks among older women to the same extent as among younger women.

OBJECTIVE

To evaluate whether the association between short interpregnancy (delivery to conception) interval and adverse pregnancy outcomes is modified by maternal age.

DESIGN, SETTING, AND PARTICIPANTS

A population-based cohort study conducted in British Columbia, Canada, evaluated women with 2 or more singleton pregnancies from 2004 to 2014 with the first (index) pregnancy resulting in a live birth. Data analysis was performed from January 1 to July 20, 2018.

MAIN OUTCOMES AND MEASURES

Risks of maternal mortality or severe morbidity (eg, mechanical ventilation, blood transfusion >3 U, intensive care unit admission, organ failure, death), small-for-gestational age (<10th birthweight percentile for gestational age and sex), fetal and infant composite outcome (stillbirth, infant death, <third birthweight percentile for gestational age and sex, delivery <28 weeks), and spontaneous and indicated preterm delivery. Risks of each outcome for 3- to 24-month interpregnancy intervals were estimated, according to maternal age at index birth (20-34 and ≥35 years). Adjusted risk ratios (aRRs) comparing predicted risks at 3-, 6-, 9-, and 12-month intervals with risks at 18-month intervals for each age group were calculated. The potential role of other factors explaining any differences (unmeasured confounding) was examined in several sensitivity analyses.

RESULTS

Among 148 544 pregnancies, maternal mortality or severe morbidity risks were increased at 6-month compared with 18-month interpregnancy intervals for women aged 35 years or older (0.62% at 6 months vs 0.26% at 18 months; aRR, 2.39; 95% CI, 2.03-2.80), but not for women aged 20 to 34 years (0.23% at 6 months vs 0.25% at 18 months; aRR, 0.92; 95% CI, 0.83-1.02). Increased adverse fetal and infant outcome risks were more pronounced for women aged 20 to 34 years (2.0% at 6 months vs 1.4% at 18 months; aRR, 1.42; 95% CI, 1.36-1.47) than women 35 years or older (2.1% at 6 months vs 1.8% at 18 months; aRR, 1.15; 95% CI, 1.01-1.31). Risks of spontaneous preterm delivery at 6-month interpregnancy intervals were increased for women 20 to 34 years old (5.3% at 6 months vs 3.2% at 18 months; aRR, 1.65; 95% CI, 1.62-1.68) and to a lesser extent for women 35 years or older (5.0% at 6 months vs 3.6% at 18 months; aRR, 1.40; 95% CI, 1.31-1.49). Modest increases in risks of small-for-gestational age and indicated preterm delivery at short intervals did not vary meaningfully by maternal age. Sensitivity analyses suggested that observed associations were not fully explained by unmeasured confounding.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that short interpregnancy intervals are associated with increased risks for adverse pregnancy outcomes for women of all ages.

Hormonal contraception, breastfeeding and bedside advocacy: the case for patient-centered care

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.

A Prospective Study on the Effects of Medicaid Regulation and Other Barriers to Obtaining Postpartum Sterilization

INTRODUCTION

This study aimed to assess unfulfilled sterilization requests, specifically regarding issues with the Medicaid consent for sterilization, and determine the proportion of women who subsequently received interval sterilization by 3 months postpartum.

METHODS

The authors conducted a prospective observational cohort study of women who gave birth over an 8-month period and requested immediate postpartum sterilization. Records of women with unfulfilled requests were reviewed up to 3 months postpartum to determine rates of postpartum follow-up and interval sterilization. Primary analysis examined unfulfilled sterilization requests associated with the Medicaid consent form and, secondarily, all other reasons for unfulfilled requests, as well as alternative contraceptive methods chosen.

RESULTS

Of the 334 women who requested immediate postpartum sterilization, 173 (52%) received the requested sterilization and 161 (48%) did not. Among those whose request was unfulfilled, 91 (56.5%) still wanted the procedure, and of those women, more than two-thirds were unable to receive it because of Medicaid consent issues. Within this group, only 6 received interval sterilization by 3 months postpartum; more than one-third received a form of long-acting reversible contraception, and 24.6% did not receive postpartum care.

DISCUSSION

A sizable proportion of women requesting postpartum sterilization have unfulfilled requests because of an issue with the Medicaid consent and also have a low likelihood of receiving interval sterilization by 3 months postpartum. The Medicaid consent may create barriers for women requesting postpartum sterilization, the vast majority of whom face subsequent barriers obtaining interval sterilization, thereby increasing the risk for unintended pregnancy in an at-risk population. This has important implications for reproductive justice efforts to protect vulnerable populations while minimizing barriers to desired care.

Risk of hypertension and abnormal biomarkers in the first year postpartum associated with hypertensive disorders of pregnancy among overweight and obese women

OBJECTIVES

Hypertension and obesity are common cardiometabolic risk factors in reproductive age women. The association of hypertensive disorders of pregnancy with later-life cardiovascular disease is well-established, however, it is unknown how obesity and hypertensive disorders of pregnancy converge to accelerate development of hypertension in the postpartum period. The aim of this study was to characterize rates of sustained hypertension at one year postpartum using the new American Heart Association/American College of Cardiology Guidelines among overweight and obese women with a normotensive pregnancy or hypertensive disorder of pregnancy.

STUDY DESIGN

315 early pregnant women were enrolled prospectively and followed up to 12 months after delivery (mean 7.0 ± 1.8 months). At a postpartum research visit, we measured blood pressure and collected blood samples to measure cystatin C and high sensitivity C-reactive protein.

RESULTS

A total of 254 women had a normotensive pregnancy, 39 had gestational hypertension (12.4%) and 22 had preeclampsia (7.0%). 91 women had hypertension at the postpartum study visit (28.9%). After adjustment for maternal age, BMI, lactation and time postpartum, preeclampsia was associated with an aOR 2.35 (95%CI 1.63-3.41) of development of sustained hypertension and an aOR 3.23 (95%CI 1.56-6.68) of hypertension with abnormal biomarkers compared to women with normotensive pregnancies.

CONCLUSIONS

We demonstrate a high prevalence of hypertension and abnormal biomarkers associated with hypertensive disorders of pregnancy among overweight and obese women. Our findings support the need for structured follow up and risk reduction in overweight and obese women with hypertensive disorders of pregnancy as early as the first year postpartum.

Out of Office Blood Pressure Measurement in Pregnancy and the Postpartum Period

PURPOSE

Hypertensive disorders of pregnancy are increasing in prevalence and associated with significant maternal and perinatal morbidity and mortality.

RECENT FINDINGS

Increased emphasis has been placed recently on the use of out-of-office (i.e., home and ambulatory) blood pressure (BP) monitoring to diagnose and manage hypertension in the general population. Current guidelines offer limited recommendations on the use of out-of-office BP monitoring during pregnancy and postpartum. This review will discuss the recent literature on BP measurement outside of the office and its use for screening, diagnosis, and treatment in pregnancy and postpartum, and will illuminate areas for future research.

Postpartum intrauterine devices: clinical and programmatic review

The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long-acting reversible contraception, which includes the insertion of an intrauterine device. The use of the intrauterine device in the postpartum period is a safe practice with few contraindications and many benefits. Although an intrauterine device placed during the postpartum period is more likely to expel compared with one placed at the postpartum visit, women who initiate intrauterine devices at the time of delivery are also more likely to continue to use an intrauterine device compared with women who plan to follow up for an interval intrauterine device insertion. This review will focus on the most recent clinical and programmatic updates on postpartum intrauterine device practice. We discuss postpartum intrauterine device expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum intrauterine devices and encourage those involved in the healthcare system to remove barriers to this worthwhile practice.

Prenatal intent and postpartum receipt of long-acting reversible contraception among women receiving medication-assisted treatment for opioid use disorder

BACKGROUND

Many women with opioid use disorder (OUD) do not use highly effective postpartum contraception such as long-acting reversible contraception (LARC). We evaluated factors associated with prenatal intent and postpartum receipt of LARC among women receiving medication-assisted treatment (MAT) for OUD.

STUDY DESIGN

This was a retrospective cohort study of 791 pregnant women with OUD on MAT who delivered at an academic institution without immediate postpartum LARC services between 2009 and 2012. LARC intent was defined as a documented plan for postpartum LARC during pregnancy and LARC receipt was defined as documentation of LARC placement by 8 weeks postpartum. We organized contraceptive methods into five categories: LARC, female sterilization, short-acting methods, barrier methods and no documented method. Multivariable logistic regression identified characteristics predictive of prenatal LARC intent and postpartum LARC receipt.

RESULTS

Among 791 pregnant women with OUD on MAT, 275 (34.8%) intended to use postpartum LARC and only 237 (29.9%) attended the postpartum visit. Among 275 women with prenatal LARC intent, 124 (45.1%) attended their postpartum visit and 50 (18.2%) received a postpartum LARC. Prenatal contraceptive counseling (OR 6.67; 95% CI 3.21, 13.89) was positively associated with LARC intent. Conversely, older age (OR 0.95; 95% CI 0.91, 0.98) and private practice provider (OR 0.48; 95% CI 0.32, 0.72) were negatively associated with LARC intent. Although parity was not predictive of LARC intent, primiparous patients (CI 0.49; 95% CI 0.26, 0.97) were less likely to receive postpartum LARC.

CONCLUSIONS

Discrepancies exist between prenatal intent and postpartum receipt of LARC among pregnant women with OUD on MAT. Immediate postpartum LARC services may reduce LARC access barriers.

IMPLICATIONS

Despite prenatal interest in using LARC, most pregnant women with OUD on MAT did not receive postpartum LARC. The provision of immediate postpartum LARC services may reduce barriers to postpartum LARC receipt such as poor attendance at the postpartum visit.

Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery

BACKGROUND

Immediate placement of an intrauterine device after vaginal delivery is safe and convenient, but longitudinal data describing clinical outcomes have been limited.

OBJECTIVE

We sought to determine the proportion of TCu380A (copper) intrauterine devices expelled, partially expelled, malpositioned, and retained, as well as contraceptive use by 6 months postpartum, and determine risk factors for expulsion and partial expulsion.

STUDY DESIGN

In this prospective, observational study, women who received a postplacental TCu380A intrauterine device at vaginal delivery were enrolled postpartum. Participants returned for clinical follow-up at 6 weeks, and for a research visit with a pelvic exam and ultrasound at 6 months. We recorded intrauterine device outcomes and 6-month contraceptive use. Partial expulsion was defined as an intrauterine device protruding from the external cervical os, or a transvaginal ultrasound showing the distal end of the intrauterine device below the internal os of the cervix. Multinomial logistic regression models identified risk factors associated with expulsion and partial expulsion by 6 months. The area under the receiver operating characteristics curve was used to assess the ability of a string check to predict the correct placement of a postplacental intrauterine device. The primary outcome was the proportion of intrauterine devices expelled at 6 months.

RESULTS

We enrolled 200 women. Of 162 participants with follow-up data at 6 months, 13 (8.0%; 95% confidence interval, 4.7-13.4%) experienced complete expulsion and 26 (16.0%; 95% confidence interval, 11.1-22.6%) partial expulsion. Of 25 malpositioned intrauterine devices (15.4%; 95% confidence interval, 10.2-21.9%), 14 were not at the fundus (8.6%; 95% confidence interval, 5.2-14.1%) and 11 were rotated within the uterus (6.8%; 95% confidence interval, 3.8-11.9%). Multinomial logistic regression modeling indicated that higher parity (odds ratio, 2.05; 95% confidence interval, 1.21-3.50; P = .008) was associated with expulsion. Provider specialty (obstetrics vs family medicine; odds ratio, 5.31; 95% confidence interval, 1.20-23.59; P = .03) and gestational weight gain (normal vs excess; odds ratio, 9.12; 95% confidence interval, 1.90-43.82; P = .004) were associated with partial expulsion. Long-acting reversible contraceptive method use at 6 months was 80.9% (95% confidence interval, 74.0-86.6%). At 6 weeks postpartum, 35 of 149 (23.5%; 95% confidence interval, 16.9-31.1%) participants had no intrauterine device strings visible. Sensitivity of a string check to detect an incorrectly positioned intrauterine device was 36.2%, and specificity of the string check to predict a correctly positioned intrauterine device was 84.5%. This corresponds to an area under the receiver operating characteristics curve of 0.5.

CONCLUSION

This prospective assessment of postplacental TCu380A intrauterine device placement, with ultrasound to confirm device position, finds a complete intrauterine device expulsion proportion of 8.0% at 6 months. The association of increasing parity with expulsion is consistent with prior research. The clinical significance of covariates associated with partial expulsion (provider specialty and gestational weight gain) is unclear. Due to the observational study design, any associations cannot imply causality. The proportion of partially expelled and malpositioned intrauterine devices was high, and the area under the receiver operating characteristics curve of 0.5 indicates that a string check is a poor test for assessing device position. Women considering a postplacental intrauterine device should be counseled about the risk of position abnormalities, as well as the possibility of nonvisible strings, which may complicate clinical follow-up. The clinical significance of intrauterine device position abnormalities is unknown; future research should evaluate the influence of malposition and partial expulsion on contraceptive effectiveness and side effects.

Healthcare Strategies for Reducing Pregnancy-Related Morbidity and Mortality in the Postpartum Period

The majority of pregnancy-related deaths in the United States occur in the postpartum period, after a woman gives birth. Many of these deaths are preventable. Researchers and health care providers have been focusing on designing and implementing strategies to eliminate preventable deaths and ethnic and racial disparities. Six healthcare strategies for reducing postpartum maternal morbidity and mortality will be described. These strategies, if provided in an equitable manner by all providers to all women, will assist in closing the disparity in outcomes between black women and women of all other races and ethnicities who give birth throughout the United States.