ACOG Committee Opinion No. 736: Optimizing Postpartum Care

Pregnancy-related risk factors and receipt of postpartum care among Texas Medicaid pregnant enrollees: Opportunities for pharmacist services

BACKGROUND

The United States (US) experiences the highest rate of maternal mortality of similar countries. Postpartum care (PPC) focused on chronic disease management is potentially lifesaving, especially among pregnancies complicated by risk factors such as diabetes, hypertension, and mental health conditions (MHCs), which are conditions in which pharmacists can have an impact.

OBJECTIVE

To evaluate the prevalence of maternal mortality risk factors and their relationships with receipt of PPC among Texas Medicaid enrollees.

METHODS

A retrospective study included women with a delivery between 3/25/2014-11/1/2019 who were continuously enrolled in Texas Medicaid during the study period from 84 days pre-delivery to 60 days post-delivery. PPC was defined as ≥1 visit associated with postpartum follow-up services. Maternal mortality risk factors (diabetes, hypertension, and MHCs) during and after pregnancy were identified using diagnoses and medication utilization. Age, race/ethnicity, cesarean delivery, and preterm birth served as covariates. Multivariable logistic regression was used to address the study objective.

RESULTS

The sample (N = 617,010) was 26.5±5.7 years, primarily (52.8%) Hispanic, and 33.0% had cesarean deliveries and 9.3% had preterm births. Risk factor prevalence included: diabetes (14.0%), hypertension (14.3%), and MHCs during (6.3%) and after (9.1%) pregnancy. A majority (77.9%) had a PPC visit within 60 days of delivery. The odds of receiving PPC were 1.2 times higher for patients with diabetes (OR = 1.183; 95% CI = 1.161-1.206; P < 0.0001), 1.1 times higher for patients with hypertension (OR = 1.109; 95% CI= 1.089-1.130; P < 0.0001), and 1.1 times higher for patients with MHCs (OR=1.138; 95% CI = 1.108-1.170; P < 0.0001) than patients without, respectively.

CONCLUSION

Over three-quarters of Texas Medicaid pregnant enrollees received PPC within 60 days of delivery and risk factors were prevalent and predictive of receipt of PPC. Pharmacists can have a positive impact on maternal health by addressing hypertension, diabetes, and MHC risk factors.

A Visit to the Pediatrician as a Part of Comprehensive Prenatal Care?

INTRODUCTION

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that expectant parents receive a preventive visit with a pediatrician in the prenatal period (a pediatric prenatal visit, or PPV). Discussing newborn health topics in the prenatal period tends to be more effective than immediately postpartum, and research suggests, for example, that the PPV increases timely childhood immunizations. However, only 22% of expectant parents have these visits, and there are significant disparities by race and income.

METHODS

A 2-min online survey with open-ended questions was emailed to 304 eligible obstetrics providers in Rochester, NY. Simple descriptive statistics and chisquare analysis were applied to survey responses. Responses were organized within the framework of knowledge, attitudes, and practices to identify barriers to guideline adherence resulting in chronic under-utilization of the PPV.

RESULTS

Ninety obstetric providers completed the survey. 66 reported awareness of the PPV, and 45 reported referring patients for a PPV. However, in open-ended questions, respondents expressed confusion between the PPV and a "meet and greet" visit with a pediatrician. Some respondents believed that the PPV is not covered by insurance, even though these visits are covered by Medicaid and marketplace insurance. Providers who had personally received one as a parent expressed positive attitudes.

DISCUSSION

These findings indicate that unfamiliarity with the PPV is one barrier to referral. Educating providers about the guideline recommendations, evidence base, and insurance coverage could overcome this barrier. Doing so could reduce disparities in utilization of the pediatric prenatal visit.

Association of Antenatal Housing Instability with Perinatal Care Utilization and Outcomes

Background: Social determinants of health are important contributors to maternal and child health outcomes. Limited existing research examines the relationship between housing instability during pregnancy and perinatal care utilization. Our objective was to evaluate whether antenatal housing instability is associated with differences in perinatal care utilization and outcomes. Materials and Methods: Participants who were surveyed during their postpartum hospitalization were considered to have experienced housing instability if they answered affirmatively to at least one of six screening items. The primary outcome was adequacy of prenatal care measured by the Adequacy of Prenatal Care Utilization index. Maternal, neonatal, and postpartum outcomes, including utilization and breastfeeding, were also collected as secondary outcomes. Multivariable logistic regression models were adjusted for sociodemographic and clinical covariates. Results: In this cohort (N = 490), 11.2% (N = 55) experienced housing instability during pregnancy. Participants with unstable housing were more likely to have inadequate prenatal care (17.3% vs. 3.9%; odds ratio [OR] 5.11, 95% confidence interval [CI] 2.15-12.14, p < 0.001), but findings were not significant after adjustment (aOR 1.72, 95% CI 0.55-5.41, p = 0.35). Similarly, postpartum visit attendance was lower for individuals with unstable housing (79.6% vs. 91.2%), but there was no difference in the odds of the postpartum visit attendance after adjustment (OR 0.69, 95% CI 0.29-1.66, p = 0.14). Conclusions: There were no statistically significant association with the maternal, neonatal, and other postpartum secondary outcomes. Housing instability appears to be a risk marker that is related to other social determinants of health. Given the range of housing instability experiences, future research must account for specific types and degrees of housing instability and their potential perinatal consequences.

Respectful Maternity Care : A Systematic Review

BACKGROUND

Severe maternal morbidity and mortality are worse in the United States than in all similar countries, with the greatest effect on Black women. Emerging research suggests that disrespectful care during childbirth contributes to this problem.

PURPOSE

To conduct a systematic review on definitions and valid measurements of respectful maternity care (RMC), its effectiveness for improving maternal and infant health outcomes for those who are pregnant and postpartum, and strategies for implementation.

DATA SOURCES

Systematic searches of Ovid Medline, CINAHL, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and SocINDEX for English-language studies (inception to July 2023).

STUDY SELECTION

Randomized controlled trials and nonrandomized studies of interventions of RMC versus usual care for effectiveness studies; additional qualitative and noncomparative validation studies for definitions and measurement studies.

DATA EXTRACTION

Dual data abstraction and quality assessment using established methods, with resolution of disagreements through consensus.

DATA SYNTHESIS

Thirty-seven studies were included across all questions, of which 1 provided insufficient evidence on the effectiveness of RMC to improve maternal outcomes and none studied RMC to improve infant outcomes. To define RMC, authors identified 12 RMC frameworks, from which 2 main concepts were identified: disrespect and abuse and rights-based frameworks. Disrespect and abuse components focused on recognizing birth mistreatment; rights-based frameworks incorporated aspects of reproductive justice, human rights, and antiracism. Five overlapping framework themes include freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Twelve tools to measure RMC were validated in 24 studies on content validity, construct validity, and internal consistency, but lack of a gold standard limited evaluation of criterion validity. Three tools specific for RMC had at least 1 study demonstrating consistency internally and with an intended construct relevant to U.S. settings, but no single tool stands out as the best measure of RMC.

LIMITATIONS

No studies evaluated other health outcomes or RMC implementation strategies. The lack of definition and gold standard limit evaluation of RMC tools.

CONCLUSION

Frameworks for RMC are well described but vary in their definitions. Tools to measure RMC demonstrate consistency but lack a gold standard, requiring further evaluation before implementation in U.S. settings. Evidence is lacking on the effectiveness of implementing RMC to improve any maternal or infant health outcome.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42023394769).

Telehealth Use by Pregnancy Stage Among Commercially Insured Patients in the United States, 2016-2019

Introduction: Relatively little is known about the proportion of maternal health services utilized through telehealth and whether rural-urban disparities in telehealth use exist throughout antenatal, delivery, and postpartum phases of maternal services. In this study, we describe patterns of care, including telehealth utilization, by rurality and racial/ethnic composition of the health service area during the antenatal, labor/delivery, and postpartum stages of pregnancy among commercially insured patients between 2016 and 2019. Methods: We present univariate and comparative descriptive statistics of patient and facility characteristics and site of care by the degree of rurality and racial/ethnic composition of the health service area (defined as geozips). The individual-level utilization data for 238,695 patients were aggregated to the geo-zip level (n = 404). Results: Between 2016 and 2019, 3.5% of pregnancy, delivery, and postpartum-related visits among commercially insured patients were delivered through telehealth. Telehealth use was higher in the antenatal (3.5% of claim lines) and postpartum (4.1% of claim lines) periods, compared with labor and delivery (0.7% of claim lines). We also found that the proportion of telehealth services (of total services billed) increased with the share of Black and Latinx residents at the geozip level. Discussion: Our findings highlight disparities in telehealth use, consistent with findings from studies using different data sources and time periods. Future research is needed to examine whether the relative differences in proportion of telehealth services, even if small, are associated with telehealth capacity in the hospital or community and why the proportion of telehealth services differs across community-level characteristics, specifically rurality and proportion of Black and Latinx residents.

Association between short inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery

OBJECTIVE

To explore the association between inter-pregnancy intervals and placenta previa and placenta accreta spectrum among women who had prior cesarean deliveries with respect to maternal age at first cesarean delivery.

METHODS

This retrospective study included clinical data from 9981 singleton pregnant women with a history of cesarean delivery at 11 public tertiary hospitals in seven provinces of China between January 2017 and December 2017. The study population was divided into four groups (<2, 2-5, 5-10, ≥10 years of the interval) according to the inter-pregnancy interval. The rate of placenta previa and placenta accreta spectrum among the four groups was compared, and multivariate logistic regression was used to analyze the relationship between inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery.

RESULTS

Compared to women aged 30-34 years old at first cesarean delivery, the risk of placenta previa (aRR, 1.48; 95% CI, 1.16-1.88) and placenta accreta spectrum (aRR, 1.74; 95% CI, 1.28-2.35) were higher among women aged 18-24. Multivariate regression results showed that women at 18-24 with <2 years intervals exhibited a 5.05-fold increased risk for placenta previa compared with those with 2-5-year intervals (aRR, 5.05; 95% CI, 1.13-22.51). In addition, women aged 18-24 with less than 2 years intervals had an 8.44 times greater risk of developing PAS than women aged 30-34 with 2 to 5 years intervals (aRR, 8.44; 95% CI, 1.82-39.26).

CONCLUSIONS

The findings of this study suggested that short inter-pregnancy intervals were associated with increased risks for placenta previa, and placenta accreta spectrum for women under 25 years at first cesarean delivery, which may be partly attributed to obstetrical outcomes.

Preliminary impact of an mHealth education and social support intervention on maternal health knowledge and outcomes among postpartum mothers in Punjab, India

Background

Significant disruptions in the perinatal continuum of care occur postpartum in India, despite it being a critical time to optimize maternal health and wellbeing. Group-oriented mHealth approaches may help mitigate the impact of limited access to care and the lack of social support that characterize this period. Our team developed and pilot tested a provider-moderated group intervention to increase education, communication with providers, to refer participants to in-person care, and to connect them with a virtual social support group of other mothers with similarly aged infants through weekly calls and text chat.

Methods

We analyzed the preliminary effectiveness of the pilot intervention on maternal health knowledge through 6 months postpartum among 135 participants in Punjab, India who responded to baseline and endline surveys. We described change in knowledge of maternal danger signs, birth preparedness, postpartum care use, postpartum physical and mental health, and family planning use over time between individuals in group call (synchronous), other intervention (asynchronous), and control groups.

Results

Participant knowledge regarding danger signs was low overall regarding pregnancy, childbirth and the postpartum period (mean range of 1.13 to 2.05 at baseline and 0.79 to 2.10 at endline). Group call participants had a significantly higher increase over time in knowledge of danger signs than other intervention and control group participants. Birth preparedness knowledge ranged from mean 0.89-1.20 at baseline to 1.31-2.07 at baseline, with group call participants having significantly greater increases in comparison to the control group. Group call participants had nearly three-fold increased odds of postpartum health check with a clinical provider than other intervention participants (OR 2.88, 95% CI 1.07-7.74). No differences were noted in postpartum depressive and anxiety symptoms.

Conclusions

Preliminary effectiveness results are promising, yet further robust testing of the MeSSSSage intervention effectiveness is needed. Further development of strategies to support health knowledge and behaviors and overcoming barriers to postpartum care access can improve maternal health among this population.

Health problems experienced by women during the first year postpartum: A systematic review

INTRODUCTION

During pregnancy and childbirth, health issues can arise that can negatively influence women's postpartum health. Although it is imperative to identify these health problems in order to tailor care to women's needs, they often remain unrecognized. A comprehensive overview of postpartum health problems does not exist in the current literature. This systematic review aimed to explore the health problems experienced by women residing in high-income countries during the first year postpartum.

METHODS

Scientific databases were searched for articles on health problems experienced by women during the first year postpartum, published between January 2000 and 2 July 2021. Studies investigating the experiences of healthy women from the age of 18 years, residing in high-income countries, who gave birth to a healthy neonate, were included. Identified health issues were divided into five categories and presented in an overview.

RESULTS

A total of 25 articles were eligible for inclusion. In all, 83 health problems were identified and divided into five different categories (physical health problems, mental health problems, social health problems, problems related to feeding the infant, and other challenges). Common health issues postpartum were exhaustion, urinary incontinence, painful breasts, depressive symptoms, problems related to sexuality and sleep, lack of social support, and problems with breastfeeding.

CONCLUSIONS

This systematic review contributes to a wider understanding of postpartum health problems and can be used to adapt healthcare to women's needs. It distinguishes itself from previous studies by the wide variety of identified health problems and its specific focus on women's experiences in the postpartum period.

Development and psychometric testing of a Chinese version of the postnatal care experience scale for postpartum women

BACKGROUND

Postnatal period is a critical transitional phase in the lives of mothers and newborn babies. In recent years the importance on promoting a positive experience of care following childbirth is increasingly emphasized. Yet published evidence of the methodological and psychometric quality of instruments to evaluate women's experience of comprehensive postnatal care is still lacking.

OBJECTIVE

This study aimed to develop and validate a unique scale (the Chinese version of the Postnatal Care Experience Scale, PCES) to measure women's overall experience of care during postnatal periods.

METHODS

The PCES instrument was developed and validated over three phases, including item development, scale development, and scale evaluation. The item pool of the PCES was generated through existing literature and in-depth semi-structured interviews, followed by assessment of content validity and rating of importance and feasibility of items through two-round Delphi surveys. Psychometric properties were examined in a convenience sample of 736 postpartum women. Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to assess the construct validity of the developed PCES. The relationship between the total PCES score and the global item construct was estimated using Pearson product-moment coefficient. Reliability was assessed using Cronbach's alpha and Spearman Brown coefficients.

RESULTS

The content validity index of the Chinese version PCES was 0.867. Following item reduction analysis, this instrument consisted of 30 five-point Likert items. The Kaiser-Meyer-Olkin statistic was 0.964 and the chi-square value of the Bartlett spherical test was 11665.399 (P < .001). The scale explained 75.797% of the total variance and consisted of three subscales, including self-management, social support, and facility- and community-based care. The Pearson correlation coefficient between the total PCES score and the global item construct was 0.909. The CFA showed that the 3-factor model had suitable fitness for the data. Cronbach's alpha value and Spearman-Brown Split-half reliability for the total scale were 0.979 and 0.941, respectively.

CONCLUSIONS

The newly developed 30-item PCES is a psychometrically reliable and valid instrument that assesses women's overall experience of postnatal care. Future research should aim to use the PCES in various populations to obtain further evidence for its validity and reliability.

Effectiveness of photobiomodulation therapy on pain intensity in postpartum women with nipple or perineal trauma: protocol for a multicentre, double-blinded, parallel-group, randomised controlled trial

INTRODUCTION

Photobiomodulation (PBM) using low-level laser can affect tissue repair mechanisms and seems promising in reducing pain intensity. However, few studies support the effectiveness of PBM on postpartum period complications, such as nipple and/or perineal trauma and pain, probably due to the low doses used. The primary objective of this study is to analyse the effectiveness of PBM on pain intensity in the nipple and perineal trauma in women in the immediate postpartum period. Secondary objectives are to evaluate the effect on tissue healing and the women's satisfaction.

METHODS AND ANALYSIS

A double-blind, multicentre, parallel-group, randomised controlled trial will be performed in two public referral maternity hospitals in Brazil with 120 participants, divided into two arms: 60 participants in the nipple trauma arm and 60 participants in the perineal trauma arm. Participants will be women in the immediate postpartum period, who present with nipple trauma or perineal trauma and report pain intensity greater than or equal to 4 points on the Numerical Rating Scale for Pain. Block randomisation will be performed, followed by blinding allocation. In the experimental group, one application of PBM will be performed between 6 hours and 36 hours after birth. For the sham group, the simulation will be carried out without triggering energy. Both participants and the research evaluator will be blinded to the allocation group. Intention-to-treat method and the between-group and within-group outcome measures analysis will be performed.

ETHICS AND DISSEMINATION

This research protocol was approved by the Research Ethics Committees of the University of Campinas, Brazil, and of the School Maternity Assis Chateaubriand, Brazil (numbers CAAE: 59400922.1.1001.5404; 59400922.1.3001.5050). Participants will be required to sign the informed consent form to participate. Results will be disseminated to the health science community.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (RBR-2qm8jrp).

Postpartum experiences of women, birthing people, and their families during COVID-19: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to explore and understand the postpartum experiences of birthing people and their families during COVID-19.

INTRODUCTION

Positive postpartum experiences are formative for the long-term health and well-being of parents and babies. However, the COVID-19 pandemic has complicated the transition to parenthood and existing postpartum challenges through evolving policies and practices, including visiting limitations, masking requirements, and reduced accessibility of supports. Understanding the impact of COVID-19 on the postpartum experiences of women, birthing people (people who give birth but may not identify as women), and their families through the synthesis of qualitative evidence can help inform public health and government directives in comparable future contexts.

INCLUSION CRITERIA

Studies including women, birthing people, and their families who experienced postpartum during the COVID-19 pandemic will be considered. This review will include studies published after January 2020 that explore postpartum experiences up to 1 year following birth. We will examine qualitative data, including, but not limited to, research designs such as phenomenology, ethnography, grounded theory, feminist research, and action research.

METHODS

The following databases will be searched: MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), and LitCovid. PsyArXiv and Google Scholar will be searched for gray literature. Studies will be assessed and appraised independently by 2 reviewers and disagreements will be resolved through discussion or with a third reviewer. Data extraction will be completed by 2 reviewers. The JBI tools and resources will be used for assessing confidence and meta-aggregation, including the creation of categories and synthesized findings.

REVIEW REGISTRATION

PROSPERO CRD42022364030.

Association between maternity care practitioner type and postpartum depression screening

BACKGROUND

Postpartum depression (PPD) is increasingly common in the United States and poses a significant threat to maternal and neonatal health. Universal screening for postpartum depression is recommended by numerous organizations, including the American College of Obstetricians and Gynecologists, but is not achieved in practice.

METHODS

A cross-sectional, weighted, state-representative study of California residents who gave birth in 2016 using the Listening to Mothers in California 2018 data set. Primary exposure was type of maternity care professional providing care during pregnancy, and the primary outcome was PPD screening. The secondary exposure was self-reported depression or anxiety during pregnancy, and the secondary outcome was attending a postpartum office visit. Bivariate analyses were conducted using Rao-Scott chi-square tests, and multivariate analyses were conducted using logistic regression.

RESULTS

Compared to participants cared for by obstetricians, participants cared for by midwives had 2.6 times the odds of reporting being screened for PPD after controlling for covariates (95% CI = 1.5, 4.4). Receiving care from any other practitioner type compared with an obstetrician was not associated with a different rate of postpartum depression screening. Reporting depression or anxiety during pregnancy was associated with 0.7 times the odds (95% CI = 0.5, 1.0) of returning for postpartum care after controlling for covariates.

CONCLUSIONS

Being cared for by a midwife during pregnancy increases the likelihood of being screened for postpartum depression. In addition, even perfectly implemented universal screening will miss a vulnerable sector of the population that is at high risk for postpartum depression and is less likely to return for postpartum care.

Interconception care in Australian general practice: a qualitative study

BACKGROUND

GPs provide care for women across the lifespan. This care currently includes preconception and postpartum phases of a woman's life. Interconception care (ICC) addresses women's health issues between pregnancies that then have impact on maternal and infant outcomes, such as lifestyle and biomedical risks, interpregnancy intervals, and contraception provision. However, ICC in general practice is not well established.

AIM

To explore GP perspectives about ICC.

DESIGN AND SETTING

Qualitative interviews were undertaken with GPs between May and July 2018.

METHOD

Eighteen GPs were purposively recruited from South-Eastern Australia. Audiorecorded semi- structured interviews were transcribed verbatim and analysed thematically using the Framework Method.

RESULTS

Most participants were unfamiliar with the concept of ICC. Delivery was mainly opportunistic, depending on the woman's presenting need. Rather than a distinct and required intervention, participants conceptualised components of ICC as forming part of routine practice. GPs described many challenges including lack of clarity about recommended ICC content and timing, lack of engagement and perceived value from mothers, and time constraints during consultations. Facilitators included care continuity and the availability of patient education material.

CONCLUSION

Findings indicate that ICC is not a familiar concept for GPs, who feel that they have limited capacity to deliver such care. Further research to evaluate patient perspectives and potential models of care is required before ICC improvements can be developed, trialled, and evaluated. These models could include the colocation of multidisciplinary services and services in combination with well-child visits.

To leave or not to leave: American Association for the Surgery of Trauma (AAST) panel discussion on personal, parental, and family leave

Navigating planned and emergent leave during medical practice is very confusing to most physicians. This is especially challenging to the trauma and acute care surgeon, whose practice is unique due to overnight in-hospital call, alternating coverage of different services, and trauma center's staffing challenges. This is further compounded by a surgical culture that promotes the image of a 'tough' surgeon and forgoing one's personal needs on behalf of patients and colleagues. Frequently, surgeons find themselves having to make a choice at the crossroads of personal and family needs with work obligations: to leave or not to leave. Often, surgeons prioritize their professional commitment over personal wellness and family support. Extensive research has been conducted on the topic of maternity leave and inequality towards female surgeons, primarily focused on trainees. The value of paternity leave has been increasingly recognized recently. Consequently, significant policy changes have been implemented to support trainees. Practicing surgeon, however, often lack such policy support, and thus may default to local culture or contractual agreement. A panel session at the American Association for the Surgery of Trauma 2022 annual meeting was held to discuss the current status of planned or unanticipated leave for practicing surgeons. Experiences, perspectives, and propositions for change were discussed, and are presented here.

Timing of Postpartum Depressive Symptoms

Introduction

Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period.

Methods

We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods.

Results

Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression.

Conclusion

Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Differences in Healthcare Utilization in Women with and without Inflammatory Bowel Diseases During Preconception, Pregnancy and Postpartum: A Population-Based Cohort Study

BACKGROUND AND AIMS

Compared to those without inflammatory bowel disease [IBD], women with IBD may have increased healthcare utilization during pregnancy and postpartum, though this remains to be confirmed. We aimed to characterize this healthcare use between these groups.

METHODS

Administrative databases were accessed to identify women [aged 18-55 years] with and without IBD who had a live, singleton pregnancy between 2003 and 2018. Differences in emergency department [ED] visits, hospitalizations and prenatal care during 12 months preconception, pregnancy and 12 months postpartum were characterized. Multivariable negative binomial regression was performed to report incidence rate ratios [IRRs] with 95% confidence intervals [95% CIs]. Covariates included maternal age at conception, location of residence, socioeconomic status and maternal comorbidity.

RESULTS

In total, 6163 women with IBD [9158 pregnancies] and 1091 013 women without IBD [1729 411 pregnancies] were included. Women with IBD were more likely to visit the ED [IRR 1.13, 95% CI 1.08-1.18] and be hospitalized [IRR 1.11, 95% CI 1.01-1.21] during pregnancy, and visit the ED [IRR 1.21, 95% CI 1.15-1.27] and be hospitalized [IRR 1.18, 95% CI 1.05-1.32] during postpartum. On unadjusted analysis, women with IBD were more likely to be hospitalized for venous thromboembolic events. There was no difference in healthcare use in preconception. Finally, women with IBD also had a greater number of prenatal visits during pregnancy and were more likely to receive a first-trimester prenatal visit.

CONCLUSION

Women with IBD have increased healthcare utilization during pregnancy and postpartum. Efforts should be made to increase ambulatory care access during this period, which in turn may reduce this health-services utilization.

Using a Patient Educational Video to Improve Knowledge of Maternal Mortality Warning Signs: A Randomized Controlled Trial

OBJECTIVE

To determine whether a community-informed, language-concordant postpartum video education campaign, developed with community input, improves patients' knowledge of warning signs for postpartum maternal mortality (infection, hemorrhage, hypertensive disorders, and postpartum depression) compared with routine discharge procedures.

METHODS

A single-center, investigator-blinded, parallel-group randomized controlled trial of postpartum individuals who delivered at a large, urban, tertiary care hospital. Eligible participants were enrolled and completed a baseline knowledge questionnaire. After delivery, they were randomized to routine discharge education (control) or routine education plus video education (intervention). After discharge education, patient knowledge was again assessed in both groups before participants left the hospital. The primary outcome was the percentage of participants who showed improvement in their knowledge, measured by the number of correct questionnaire responses after education compared with their baseline, assessed as a binary outcome. A sample size of 150 (75 per group) was planned to detect a 25% absolute increase in the frequency of the primary outcome.

RESULTS

From July to August 2022, 296 participants were screened and 200 were randomized (100 per group). Eighty-two percent of participants had college or graduate education, and 71.5% had commercial insurance. There was no significant difference in baseline characteristics. There was no statistically significant difference in the percentage of participants who improved their scores between the baseline and posteducation questionnaires (64.5% vs 50.0%, P =.09). However, the median posteducation questionnaire total score was significantly higher in the video education group (14 [interquartile range 12-15] vs 13 [interquartile range 12-14], P =.003). In addition, they more frequently reported that video education was "very helpful" (83.9% vs 72.5%, P =.23) and that they were "very satisfied" with their education (86.1% vs 75.5%, P =.29).

CONCLUSION

Enhanced postpartum education through a novel video did not result in a statistically significant difference in frequency of improved score on the posteducation questionnaires but was associated with increased satisfaction with care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT05159726.

Timeliness of Delivery Care and Maternal and Neonatal Health Outcomes in Private Facilities in Masaka Area, Uganda: A Quasi-Experimental Study

OBJECTIVES

While access to basic emergency obstetric and newborn care is necessary to reduce maternal and neonatal morbidity in low- and middle-income countries, data on the timeliness and quality of care at lower-level facilities is limited. This study examines timeliness of labor and delivery interventions and maternal and neonatal health status following deliveries in Uganda.

METHODS

Women were recruited from 6 rural, private facilities in the greater Masaka area, Uganda on admission to the labor ward. Research assistants directly observed timeliness and quality of care from admission through discharge. Research assistants also abstracted medical chart information. All 6 facilities received training from LifeNet International on quality-of-care interventions for maternal and newborn health.

RESULTS

321 participants were directly observed during delivery, and 304 participants were followed at 28 days postpartum. Labor and delivery processes were overall timely and reflect international guidance on labor interventions. Maternal and neonatal health was good at discharge (90.6% and 88.8%) and 28 days postpartum (93.1% and 87.5%). However, there was no association between health at discharge and at 28 days for mothers or neonates (p = 0.67, p = 1.0, respectively). Demographic characteristics associated with maternal and neonatal health on discharge were different than those associated with maternal and neonatal health at 28 days.

CONCLUSIONS FOR PRACTICE

Evidence on timeliness and quality of care can help inform strategies to further decrease maternal and neonatal morbidity. Additional focus is needed to retain patients in care to identify those developing poor health after delivery.

Postpartum readmission for hypertension and pre-eclampsia: development and validation of a predictive model

OBJECTIVE

To develop a model for predicting postpartum readmission for hypertension and pre-eclampsia at delivery discharge and assess external validation or model transportability across clinical sites.

DESIGN

Prediction model using data available in the electronic health record from two clinical sites.

SETTING

Two tertiary care health systems from the Southern (2014-2015) and Northeastern USA (2017-2019).

POPULATION

A total of 28 201 postpartum individuals: 10 100 in the South and 18 101 in the Northeast.

METHODS

An internal-external cross validation (IECV) approach was used to assess external validation or model transportability across the two sites. In IECV, data from each health system were first used to develop and internally validate a prediction model; each model was then externally validated using the other health system. Models were fit using penalised logistic regression, and accuracy was estimated using discrimination (concordance index), calibration curves and decision curves. Internal validation was performed using bootstrapping with bias-corrected performance measures. Decision curve analysis was used to display potential cut points where the model provided net benefit for clinical decision-making.

MAIN OUTCOME MEASURES

The outcome was postpartum readmission for either hypertension or pre-eclampsia <6 weeks after delivery.

RESULTS

The postpartum readmission rate for hypertension and pre-eclampsia overall was 0.9% (0.3% and 1.2% by site, respectively). The final model included six variables: age, parity, maximum postpartum diastolic blood pressure, birthweight, pre-eclampsia before discharge and delivery mode (and interaction between pre-eclampsia × delivery mode). Discrimination was adequate at both health systems on internal validation (c-statistic South: 0.88; 95% confidence interval [CI] 0.87-0.89; Northeast: 0.74; 95% CI 0.74-0.74). In IECV, discrimination was inconsistent across sites, with improved discrimination for the Northeastern model on the Southern cohort (c-statistic 0.61 and 0.86, respectively), but calibration was not adequate. Next, model updating was performed using the combined dataset to develop a new model. This final model had adequate discrimination (c-statistic: 0.80, 95% CI 0.80-0.80), moderate calibration (intercept -0.153, slope 0.960, Emax 0.042) and provided superior net benefit at clinical decision-making thresholds between 1% and 7% for interventions preventing readmission. An online calculator is provided here.

CONCLUSIONS

Postpartum readmission for hypertension and pre-eclampsia may be accurately predicted but further model validation is needed. Model updating using data from multiple sites will be needed before use across clinical settings.

Disparities in Perinatal and Emergency Care Receipt Among Women With Perinatal Opioid Use Disorder in Medicaid, 2007 to 2012

OBJECTIVES

This study aimed to better understand receipt of perinatal and emergency care among women with perinatal opioid use disorder (OUD) and explore variation by race/ethnicity.

METHODS

We used 2007-2012 Medicaid Analytic eXtract (MAX) data from all 50 states and the District of Columbia to examine 6,823,471 deliveries for women 18 to 44 years old. Logistic regressions modeled the association between (1) OUD status and receipt of perinatal and emergency care, and (2) receipt of perinatal and emergency care and race/ethnicity, conditional on OUD diagnosis and controlling for patient and county characteristics. We used robust SEs, clustered at the individual level, and included state and year fixed effects.

RESULTS

Women with perinatal OUD were less likely to receive adequate prenatal care (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.44-0.46) and attend the postpartum visit (aOR, 0.46; 95% CI, 0.45-0.47) and more likely to seek emergency care (aOR, 1.48; 95% CI, 1.45-1.51) than women without perinatal OUD. Among women with perinatal OUD, Black, Hispanic, and American Indian and Alaskan Native (AI/AN) women were less likely to receive adequate prenatal care (aOR, 0.68 [95% CI, 0.64-0.72]; aOR, 0.86 [95% CI, 0.80-0.92]; aOR, 0.71 [95% CI, 0.64-0.79]) and attend the postpartum visit (aOR, 0.85 [95% CI, 0.80-0.91]; aOR, 0.86 [95% CI, 0.80-0.93]; aOR, 0.83 [95% CI, 0.73-0.94]) relative to non-Hispanic White women. Black and AI/AN women were also more likely to receive emergency care (aOR, 1.13 [95% CI, 1.05-1.20]; aOR, 1.12 [95% CI, 1.00-1.26]).

CONCLUSIONS

Our findings suggest that women with perinatal OUD, in particular Black, Hispanic, and AI/AN women, may be missing opportunities for preventive care and comprehensive management of their physical and behavioral health during pregnancy.

Prevalence of metabolic syndrome and metabolic dysfunction-associated fatty liver disease in Malaysia 2023: study protocol for a community-based nationwide cross-sectional survey

INTRODUCTION

Metabolic syndrome (MetS) is a cluster of cardio-metabolic dysfunctions characterised by increased fasting plasma glucose, waist circumference, blood pressure, triglycerides and reduction in high-density lipoprotein cholesterol. Meanwhile, metabolic dysfunction-associated fatty liver disease (MAFLD) is the new term for fatty liver associated with MetS. People with MetS or MAFLD have higher risks for adverse cardiovascular outcomes and mortalities. However, large-scale data on MetS and MAFLD prevalence in Malaysia is mainly unknown. This study aims to determine the prevalence of MetS and MAFLD among the general adult population in Malaysia.

METHODS AND ANALYSIS

This is a community-based nationwide cross-sectional study in Malaysia. The data collection period is from July 2023 until September 2023, with a planned sample size of 1296 participants. We use a two-stage proportionate stratified random sampling method to ensure national representativeness. The definition of MetS follows the Harmonised Joint Interim Statement in 2009. A diagnosis of MAFLD is made if a participant has fatty liver, defined as having a Fatty Liver Index ≥60 and has type 2 diabetes, a body mass index ≥23 kg/m2, or ≥2 metabolic risk abnormalities. Complex sample analysis will be conducted, and the disease prevalence will be reported with 95% CIs, unweighted counts and estimated populations.

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR ID-22-02845-GUT). The findings will be disseminated through a formal report, policy brief, scientific publications, conference presentations, social media, print media and stakeholder engagement activities.

Herbal Medicine for Postpartum Pain: A Systematic Review of Puerperal Wind Syndrome (Sanhupung)

Mothers in the postpartum period often experience musculoskeletal disorders and pain, impacting their ability to care for themselves and their infants. Conventional treatments have limitations, prompting interest in alternative options like herbal medicine. This systematic review aimed to confirm the effectiveness and safety of herbal medicine treatment to improve maternal health in patients with postpartum pain (puerperal wind syndrome). We searched eight electronic databases for randomized controlled trials (RCTs) to evaluate the effects of herbal medicines on puerperal wind syndrome. Nine RCTs, including 652 patients, were selected. Following a meta-analysis of RCTs, both herbal medicine and combination treatments improved the visual analog scale scores, total effective rate, scores of Traditional Chinese Medicine syndromes, Oswestry Disability Index, and quality of life in patients with role-emotional puerperal wind syndrome. All adverse events were minor, and the incidence rate was not high compared with that of the control group. In conclusion, herbal medicine supports the improvement in pain, other systemic symptoms, and the quality of life of patients with puerperal wind syndrome. Moreover, no serious side effects were observed; therefore, herbal medicines appear to be safe. It can be the preferred treatment option for puerperal wind syndrome, which is currently managed symptomatically.

An Evidence-Based Framework for Creating Inclusive and Personalized mHealth Solutions-Designing a Solution for Medicaid-Eligible Pregnant Individuals With Uncontrolled Type 2 Diabetes

Mobile health (mHealth) apps can be an evidence-based approach to improve health behavior and outcomes. Prior literature has highlighted the need for more research on mHealth personalization, including in diabetes and pregnancy. Critical gaps exist on the impact of personalization of mHealth apps on patient engagement, and in turn, health behaviors and outcomes. Evidence regarding how personalization, engagement, and health outcomes could be aligned when designing mHealth for underserved populations is much needed, given the historical oversights with mHealth design in these populations. This viewpoint is motivated by our experience from designing a personalized mHealth solution focused on Medicaid-enrolled pregnant individuals with uncontrolled type 2 diabetes, many of whom also experience a high burden of social needs. We describe fundamental components of designing mHealth solutions that are both inclusive and personalized, forming the basis of an evidence-based framework for future mHealth design in other disease states with similar contexts.

Promoting adolescent mother self-efficacy for parenting roles, and self-care after childbirth: protocol for a mixed methods study

BACKGROUND

Pregnancy, and childbirth can encounter many challenges for the teen mother, family, and health system. The simultaneity of two transition periods, i.e. transition to adulthood and post-partum period may disrupt the acceptance of new roles. Lack of knowledge, information and life skills in managing this situation may threaten the physical and mental health of the mother, and child, as well as reduce the level of role adaptation. One way to increase women's empowerment in postpartum care is self-efficacy promotion training program. The current mixed methods study will be conducted to provide an interventional program sensitive to the culture of the Iranian society for adolescent mothers to improve their self-efficacy.

METHOD

This study will be conducted as an exploratory sequential mixed methods study (Qual-quan) based on a pragmatism paradigm in four phases. In the first phase, a qualitative study will be performed using a directed content analysis method to explore the needs and strategies related to promote postpartum self-efficacy from the viewpoint of teen mothers, their family, healthcare providers, and policymakers. In the second phase, using a scoping review, self-efficacy promotion strategies, and postpartum care service packages, programs, guidelines, and protocols in other countries will be identified. In the third phase, with integrating the results of qualitative phase and scoping review, the first draft of program will be developed, and validated by an expert panel based on the Delphi approach in three rounds. In the last step, the effectiveness of the interventional program will be evaluated on postpartum self-efficacy of teen mother.

DISCUSSION

Developing an interventional program that includes teen mother's experiences, evidence based practice principles, and health staff opinions in a distinct cultural and social context can supply new direction to lead manager, policymakers, and other health care provider to improve the maternal self-efficacy in infant, family, and self-care with considering their age characteristics.

Identification of postpartum symptom subgroups and associated long-term maternal depressive symptoms and well-being

Many postpartum women experience postpartum symptoms which often occur in clusters (i.e., three or more co-occurring symptoms that are related to each other). To date, research has focused on individual symptoms, which limits our understanding of how postpartum symptom clusters manifest and influence health. This secondary analysis used the Community and Child Health Network study data (N = 1784). No patient or public directly participated or contributed to the current analysis. Guided by the Symptom Management Theory, latent class analysis was performed to identify subgroups of postpartum women with different symptom experiences using observed variables at 6 months postpartum: anxiety (MINI-anxiety), general stress (PSS-10), posttraumatic stress (PCL-C), postpartum depression (EPDS), sleep disturbance (PSQI-sleep disturbance), and sleep duration (PSQI-sleep duration). Bivariate and multiple regression analyses were conducted to examine the association between subgroups and (a) individual characteristics and (b) long-term depressive symptoms (CES-D-9) and well-being at 18 and/or 24 months postpartum. Five subgroups were selected that had better-fit indices, entropy, and interpretability. Subgroups were labeled as (1) Minimum overall, (2) Mild-moderate overall, (3) Moderate-high sleep symptoms, (4) High psychological symptoms, and (5) High overall. After adjusting for covariates, postpartum women in Subgroups 4 and 5 had higher CES-D-9 scores at 18 and 24 months and lower well-being scores at 24 months. More postpartum women in Subgroups 4 and 5 experienced a history of depression or unemployment. Clinicians should provide targeted interventions for postpartum women in high-symptom subgroups.

Reproductive Experiences and Cardiovascular Disease Care in Pregnancy-Capable and Postmenopausal Individuals: Insights From the American Heart Association Research Goes Red Registry

To evaluate preconception health and adverse pregnancy outcome (APO) awareness in a large population-based registry. We examined data from the Fertility and Pregnancy Survey of the American Heart Association Research Goes Red Registry to questions regarding prenatal health care experiences, postpartum health, and awareness of the association of APOs with cardiovascular disease (CVD) risk. Among postmenopausal individuals, 37% were unaware that APOs were associated with long-term CVD risk, significantly varying by race-ethnicity. Fifty-nine percent of participants were not educated regarding this association by their providers, and 37% reported providers not assessing pregnancy history during current visits, significantly varying by race-ethnicity, income, and access to care. Only 37.1% of respondents were aware that CVD was the leading cause of maternal mortality. There is an urgent, ongoing need for more education on APOs and CVD risk, to improve the health-care experiences and postpartum health outcomes of pregnant individuals.

Fetal and Maternal Monitoring

Fetal monitoring in the intrapartum and peripartum periods is important for the well-being of both baby and mother. Electronic fetal monitoring was first designed over 50 years ago in an attempt to improve perinatal outcomes. Its purpose is to assess fetal oxygenation and acid-base status during the antepartum course when indicated and during labor. Maternal assessment begins early in gestation with blood pressure monitoring and urine protein excretion to diagnose potential complications, such as severe hypertension and preeclampsia/eclampsia.

Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care

OBJECTIVES

This study aimed to evaluate the feasibility and acceptability of virtual group contraceptive counseling in the abortion care setting.

STUDY DESIGN

Patients seeking abortion care at an urban university hospital were invited to participate in this cohort study. Prior to their clinical appointments, groups of two to six patients participated in 45-minute virtual contraceptive counseling visits facilitated by study staff. Contraceptive method use, effectiveness, and side effects were reviewed according to group interest. Participant satisfaction scores were collected immediately following the sessions. After their appointments, providers estimated the time spent on contraceptive counseling during the clinical visit.

RESULTS

Of 195 patients approached, 86 (44%) were enrolled. Fifty-seven (66%) enrolled patients completed a session. The most common reason for declining enrollment was concern about the time commitment. Most (93%) participants reported being "satisfied" or "very satisfied" overall, and 96% would recommend group contraceptive counseling to a friend. Providers reported that compared to typical counseling, participants required a shorter amount of time during the clinical visit than nonparticipants (time spent <5 minutes: 74% vs 54%).

CONCLUSIONS

Virtual group contraceptive counseling for patients seeking abortion was feasible and acceptable in this study. Group virtual visits may reduce provider time burden, add value when virtual care delivery is desired or required, and deserve further study.

IMPLICATIONS

Family planning clinics can consider incorporating virtual group counseling as a person-centered and efficient approach to contraceptive counseling at the time of abortion care.

Addressing Maternal Health Disparities: Building a Novel Two-Generation Approach to Comprehensive Postpartum Care

The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.

Postpartum long-acting reversible contraceptive use among active-duty, female US Army soldiers

BACKGROUND

Postpartum use of long-acting reversible contraception has been found to be effective at increasing interpregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military service members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers.

OBJECTIVE

This study aimed to (1) quantify postpartum uptake of long-acting reversible contraception among active-duty female US Army soldiers and (2) identify demographic and military-specific characteristics associated with use.

STUDY DESIGN

This retrospective cohort study used longitudinal data of all digitally recorded health encounters for active-duty US Army soldiers from 2014 to 2017. The servicewomen included in our analysis were aged 18 to 44 years with at least one delivery and a minimum of 4 months of total observed time postdelivery within the study period. We defined postpartum long-acting reversible contraception use as initiation of use within the delivery month or in the 3 calendar months following delivery and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception use with multivariable logistic regression.

RESULTS

The inclusion criteria were met by 15,843 soldiers. Of those, 3162 (19.96%) initiated the use of long-acting reversible contraception in the month of or within the 3 months following delivery. Fewer than 5% of these women used immediate postpartum long-acting reversible contraception. Among women who initiated postpartum long-acting reversible contraceptive use, 1803 (57.0%) received an intrauterine device, 1328 (42.0%) received an etonogestrel implant, and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those who were married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest use rates overall. When compared with these women, the adjusted odds of postpartum use among self-reported Black and Asian or Pacific Islander women were 18% and 30% lower, respectively (both P<.001). There was also a trend of decreasing postpartum use with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential use of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older and among women who identified as Black.

CONCLUSION

Among active-duty US Army servicewomen, 1 in 5 used postpartum long-acting reversible contraception, and fewer than 5% of these women used an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of use and significant differences in the uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

Screening for Hypertensive Disorders of Pregnancy: US Preventive Services Task Force Final Recommendation Statement

Importance

Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy.

Population

Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension.

Evidence Assessment

The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit.

Recommendation

The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).

Maternal Mortality Crisis and Extension of Medicaid Postpartum Coverage

This Viewpoint discusses the maternal mortality crisis in the US, the need for an extension of Medicaid postpartum coverage, and the residual challenges across the US related to maternal health.

Adaptation and implementation of clinical guidelines on maternal and newborn postnatal care in Iran: study protocol

BACKGROUND

According to World Health Organization (WHO), the postnatal care provision aims to provide care and treatment with the highest quality and the least intervention to obtain the best health and well-being for the family. The present study aims to adapt international guidelines for the clinical recommendations for the postpartum period and implement and determine its effectiveness.

METHODS/DESIGN

This study will be done in two phases. In the first phase, international clinical guidelines for mother and newborn postnatal care will be adapted. The second phase is a randomized controlled trial in which the adapted guideline recommendations will be implemented, and maternal and neonatal outcomes will be measured. The ADAPTE method for adaptation of clinical guidelines, is usedg in the first phase. A systematic review was conducted in the databases and clinical guidelines related to postpartum care were extracted according to the inclusion criteria. The quality of clinical guidelines was evaluated using the AGREE-II tool. The WHO clinical guideline obtained the highest evaluation score and was chosen as the main guideline, and the NICE clinical guideline, with a second higher evaluation score, was also used to fill some gaps in the WHO guideline. Based on the pre-determined questions, recommendations will be sent to the relevant experts and stakeholders for their evaluation. After the external evaluation and the finalization of the recommendations, the postpartum clinical guideline will be compiled and used in the second phase of the study. In the second phase, 272 women in the immediate postnatal stage of the maternity and postpartum ward of Taleghani and AL-Zahra Hospitals in Tabriz will be assigned into the intervention (receiving care based on adapted guidline recommendations) and control (receiving routine hospital care) groups uing individual stratified block randomization. At 6 weeks after birth, we will complete the Edinburgh postnatal depression scale, postpartum specific anxiety scale and Barkin index of maternal functioning (to assess the primary outcomes), as well as a maternal health problems checklist, infant care behavior, and violence assessment questionnaires (to asses the seconadary outcomes). Further, the maternal health problems checklist and the Edinburgh postnatal depression scale will be completed in the second week after birth. The data will be analyzed using an independent t-test and ANCOVA.

DISCUSSION

It is expected that the implementation of evidence-based clinical guidelines improves maternal and neonatal outcomes and experience of the postpartum period. The positive experience can also help to achieve Iran's population policies and the need to increase childbearing in the country.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N76; Date of registration: 27/1/2023. URL: https://en.irct.ir/user/trial/66874/view ; Date of first registration: 27/3/2023.

Experiences of postpartum mental health sequelae among black and biracial women during the COVID-19 pandemic

OBJECTIVE

The objective of this study was to qualitatively examine coping mechanisms and desired supports in pregnant and birthing Black and Biracial adolescent and young adult women during the COVID-19 pandemic.

METHODS

Black and Biracial participants ages 16-23 were recruited for virtual individual semi-structured interviews. Participants (n = 25) were asked about pre- and post-natal experiences with the healthcare system, effects of the pandemic, and participants' experiences of or desires for ideal care within the healthcare system. Interviews were transcribed verbatim and coded for qualitative analysis using nVivo. Discussions around postpartum mental health evolved organically when asked about how participants were coping postpartum.

RESULTS

Nearly half the interviewees organically reported mental health symptoms consistent with postpartum depression (PPD) during questions regarding their postpartum experience. Of the 11 interviewees who reported mental health symptoms consistent with PPD, 2 were afraid to disclose their symptoms to a healthcare provider due to fear of child protective services involvement and their belief they would be treated unfairly because of their race.

CONCLUSION

Clinicians who care for Black and Biracial adolescent and young adult mothers must be particularly attuned to structural barriers for appropriate screening and treatment of postpartum depression. Expanding investigations of intersectional influences on young mothers' perinatal health and PPD are needed.

Educating Women About Pelvic Floor Disorders During Pregnancy From the First to the "Fourth Trimester": A Randomized Clinical Trial

IMPORTANCE

Pregnancy and childbirth are risk factors for developing pelvic floor disorders (PFDs), and this continues postpartum ("fourth trimester"). Knowledge of PFDs among women of childbearing age is lacking and presents an opportunity for education.

OBJECTIVES

The aim of this study was to compare the increase in knowledge of PFDs in patients who received written handouts versus interactive workshops as measured by the Prolapse and Incontinence Knowledge Questionnaire (PIKQ).

STUDY DESIGN

This was a randomized clinical trial of pregnant patients 18 years or older. Patients either received written handouts only or received handouts and attended an interactive workshop. Handouts were created in collaboration with communication specialists focusing on risk factors and prevention strategies. The primary outcome was the change in PIKQ score. Secondary outcomes were Pelvic Floor Distress Inventory score and postpartum phone interviews of workshop group participants. Questionnaires were assessed at recruitment and 6 weeks postpartum. The nonparametric Wilcoxon test compared continuous variables, and the Fisher exact test compared categorical variables.

RESULTS

One hundred twenty patients were randomized. Demographics were similar between groups. Median PIKQ score change showed no difference between groups (P = 0.37). Pelvic Floor Distress Inventory-20 scores were similar between groups at baseline (P = 0.78) and postpartum (P = 0.82). Quantile regression showed posteducation PIKQ scores were significantly higher in the workshop (21.00 vs 17.00; P = 0.011) and written (21.00 vs 17.00; P < 0.001) groups. Phone interviews showed consistent themes: (1) greater awareness of PFDs, (2) more likely to discuss PFDs, and (3) relief that PFDs are treatable. Fifty-nine percent of patients preferred learning through workshops compared with the handouts.

CONCLUSIONS

Both groups showed improvement in knowledge of PFDs. Well-written, illustrated handouts were effective in increasing patient knowledge of PFDs.

Prenatal Contraceptive Counseling

Pregnancy care should include open discussions with patients about their ideal family size and pregnancy spacing. With these patient-voiced goals in mind, clinicians should review contraceptive tools to meet these goals, including special considerations after birth. For patients that desire contraception, it is important to prioritize the provision of their chosen method as soon as safely possible and desired after birth.

Association Between Mental Health Conditions at the Hospitalization for Birth and Postpartum Hospital Readmission

Background: The relationship between physical comorbidities and postpartum hospital readmission is well studied, with less research regarding the impact of mental health conditions on postpartum readmission. Methods: Using hospital discharge data (2016-2019) from the Hospital Cost and Utilization Project Nationwide Readmissions Database (n = 12,222,654 weighted), we evaluated the impact of mental health conditions (0, 1, 2, and ≥3), as well as five individual conditions (anxiety, depressive, bipolar, schizophrenic, and traumatic/stress-related conditions) on readmission within 42 days, 1-7 days ("early"), and 8-42 days ("late") of hospitalization for birth. Results: In adjusted analyses, the rate of 42-day readmission was 2.2 times higher for individuals with ≥3 mental health conditions compared to those with none (3.38% vs. 1.56%; p < 0.001), 50% higher among individuals with 2 mental health conditions (2.33%; p < 0.001), and 40% higher among individuals with 1 mental health condition (2.17%; p < 0.001). We found increased adjusted risk of 42-day readmission for individuals with anxiety (1.98% vs. 1.59%; p < 0.001), bipolar (2.38% vs. 1.60%; p < 0.001), depressive (1.93% vs. 1.60%; p < 0.001), schizophrenic (4.00% vs. 1.61%; p < 0.001), and traumatic/stress-related conditions (2.21% vs. 1.61%; p < 0.001), relative to individuals without the respective condition. Mental health conditions had larger impacts on late (8-42 day) relative to early (1-7 day) readmission. Conclusions: This study found strong relationships between mental health conditions during the hospitalization for birth and readmission within 42 days. Efforts to reduce the high rates of adverse perinatal outcomes in the United States should continue to address the impact of mental health conditions during pregnancy and throughout the postpartum period.

Delivery Strategies for Postpartum Care: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the effects of postpartum health care-delivery strategies on health care utilization and maternal outcomes.

DATA SOURCES

We searched Medline, EMBASE, CENTRAL, CINAHL, and ClinicalTrials.gov for studies in the United States or Canada from inception to November 16, 2022.

METHODS OF STUDY SELECTION

We used duplicate screening for studies comparing health care-delivery strategies for routine postpartum care on health care utilization and maternal outcomes. We selected health care utilization, clinical, and harm outcomes prioritized by stakeholder panels.

TABULATION, INTEGRATION, AND RESULTS

We found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480). For general postpartum care, care location (clinic, at home, by telephone) did not affect depression or anxiety symptoms (low strength of evidence), and care integration (by multiple types of health care professionals) did not affect depression symptoms or substance use (low strength of evidence). Providing contraceptive care earlier (compared with later) was associated with greater implant use at 6 months (summary effect size 1.36, 95% CI 1.13-1.64) (moderate strength of evidence). Location of breastfeeding care did not affect hospitalization, other unplanned care utilization, or mental health symptoms (all low strength of evidence). Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month and any breastfeeding at 3-6 months (summary effect size 1.10-1.22) but not other breastfeeding measures (all moderate strength of evidence). Care by a lactation consultant was associated with higher breastfeeding rates at 6 months (summary effect size 1.43, 95% CI 1.07-1.91) but not exclusive breastfeeding (all moderate strength of evidence). Use and nonuse of information technology for breastfeeding care were associated with comparable rates of breastfeeding (moderate strength of evidence). Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing but not random glucose or hemoglobin A 1c testing (moderate strength of evidence).

CONCLUSION

Various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022309756 .

A systematic review of patient-reported outcome measures used in maternal postpartum anxiety

OBJECTIVE

This study aimed to conduct a systematic review and to evaluate the psychometric measurement properties of instruments for postpartum anxiety using the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines to identify the best available patient-reported outcome measure.

DATA SOURCES

We searched 4 databases (CINAHL, Embase, PubMed, and Web of Science in July 2022) and included studies that evaluated at least 1 psychometric measurement property of a patient-reported outcome measurement instrument. The protocol was registered with the International Prospective Register for Systematic Reviews under identifier CRD42021260004 and followed the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines for systematic reviews.

STUDY ELIGIBILITY

Studies eligible for inclusion were those that assessed the performance of a patient-reported outcome measure for screening for postpartum anxiety. We included studies in which the instruments were subjected to some form of psychometric property assessment in the postpartum maternal population, consisted of at least 2 questions, and were not subscales.

METHODS

This systematic review used the Consensus-Based Standards for the Selection of Health Measurement Instruments and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify the best patient-reported outcome measurement instrument for examining postpartum anxiety. A risk of bias assessment was performed, and a modified GRADE approach was used to assess the level of evidence with recommendations being made for the overall quality of each instrument.

RESULTS

A total of 28 studies evaluating 13 instruments in 10,570 patients were included. Content validity was sufficient in 9 with 5 instruments receiving a class A recommendation (recommended for use). The Postpartum Specific Anxiety Scale, Postpartum Specific Anxiety Scale Research Short Form, Postpartum Specific Anxiety Scale Research Short Form Covid, Postpartum Specific Anxiety Scale-Persian, and the State-Trait Anxiety Inventory demonstrated adequate content validity and sufficient internal consistency. Nine instruments received a recommendation of class B (further research required). No instrument received a class C recommendation (not recommended for use).

CONCLUSION

Five instruments received a class A recommendation, all with limitations, such as not being specific to the postpartum population, not assessing all domains, lacking generalizability, or evaluation of cross-cultural validity. There is currently no freely available instrument that assess all domains of postpartum anxiety. Future studies are needed to determine the optimum current instrument or to develop and validate a more specific measure for maternal postpartum anxiety.

Breastfeeding and Hormonal Contraception: A Scoping Review of Clinical Guidelines, Professional Association Recommendations, and the Literature

Background: Postpartum contraceptive use can help prevent short-interval pregnancies, which have been associated with adverse neonatal and maternal health outcomes. Many contraceptive methods are safe for postpartum use, but patients and providers may be confused as to what impact hormonal contraception has on lactation. We performed a scoping review of the most recent U.S.-based guidelines regarding hormonal contraception on lactation to provide synthesis and recommendations to aid providers in counseling their patients. Methods: We conducted a scoping review by identifying the most recent clinical recommendations and guidelines from the Centers for Disease Control and Prevention (CDC) and three maternal and child health professional associations (American College of Obstetricians and Gynecologists [ACOG], Society for Maternal-Fetal Medicine [SMFM], and Academy of Breastfeeding Medicine [ABM]). We also reviewed the citations in these guidelines used in their development. We then conducted an updated literature review to capture studies published since the most recent systematic reviews were conducted. Results: We reviewed 1 clinical guideline from the CDC and 2 systematic reviews cited in its references, 6 professional association recommendations, and 28 publications identified through the updated literature review. Progestin-only contraceptive methods continue to demonstrate safety in breastfeeding patients, while low-quality evidence supports concerns of decreased milk supply with combined hormonal contraception. Discussion: Organizations should consider updating counseling recommendations regarding progestin-only contraceptives and lactation. Further research is needed to examine new contraceptive methods as well as the effect of hormonal contraception on lactation in the setting of preterm birth.

Postpartum Family Planning in Pediatrics: A Survey of Parental Contraceptive Needs and Health Services Preferences

OBJECTIVE

Infant well-child visits are increasingly being explored as opportunities to address parental postpartum health needs, including those related to reproductive health. To inform potential pediatric clinic-based interventions, this study assessed postpartum contraceptive needs and health services preferences.

METHODS

We surveyed postpartum individuals attending 2 to 6-month well-child visits at three Northern California pediatric clinics (2019-20). We examined unmet contraceptive needs; the acceptability of contraceptive education, counseling, and provision at well-child visits; and sociodemographic and clinical correlates. We conducted univariate and multivariable regression modeling to assess associations between sociodemographic and clinical variables, the status of contraceptive needs, and acceptability measures.

RESULTS

Study participants (n = 263) were diverse in terms of race and ethnicity (13% Asian, 9% Black, 37% Latinx, 12% Multi-racial or Other, 29% White), and socioeconomic status. Overall, 25% had unmet contraceptive needs. Unmet need was more common among participants who had delivered more recently, were multiparous, or reported ≥ 1 barrier to obtaining contraception; postpartum visit attendance, education, race, and ethnicity were not associated with unmet need. Most participants deemed the following acceptable in the pediatric clinic: receiving contraceptive information (85%), discussing contraception (86%), and obtaining a contraceptive method (81%). Acceptability of these services was greater among participants with unmet contraceptive needs, better self-rated health, and private insurance (all P < .05).

CONCLUSIONS

A quarter of participants had unmet contraceptive needs beyond the early postpartum period. Most considered the pediatric clinic an acceptable place to address contraception, suggesting the pediatric clinic may be a suitable setting for interventions aiming to prevent undesired pregnancies and their sequelae.

Postpartum long-acting reversible contraception among privately insured: U.S. National analysis 2007-2016, by term and preterm birth

OBJECTIVES

To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery.

STUDY DESIGN

We used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007 to 2016, spontaneous preterm birth, and follow-up ≤12 weeks postpartum. We assessed ≤12-week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC.

RESULTS

Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p < 0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p = 0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p < 0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p = 0.002). State-level analysis showed wide variation in postpartum LARC (range 6%-32%).

CONCLUSIONS

While postpartum LARC use increased among the privately insured 2007-2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike.

IMPLICATIONS

Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

Evaluation of the effect of a nurse navigation program developed for postpartum mothers on maternal health: A randomized controlled study

OBJECTIVE

This study aimed to determine the effects of a nurse navigation program on the capability for self-care, quality of life, risk of anxiety and depression, and severity of the physical symptoms of postpartum mothers.

METHODS

This prospective, parallel-group, randomized controlled study included 64 primiparous pregnant women (32 women each in the intervention and control groups) at ≥36 gestational weeks admitted to the pregnancy outpatient clinic of a public hospital in Turkey. The intervention group received navigation program-based nursing care comprising three home visits, four phone calls, and five text messages aside from the standard hospital care during delivery and the postpartum period. Meanwhile, the control group received only the standard hospital care during delivery and the postpartum period. Data were collected using a sociodemographic data form, the Self-Care Power Scale, the Maternal Postpartum Quality of Life Instrument (MPQoL-I), the Postpartum Specific Anxiety Scale (PSAS), the Edinburgh Postnatal Depression Scale (EPDS), and the Postpartum Physical Symptom Severity Scale.

RESULTS

Mean scores for the capability for self-care and quality of life were higher, while those for the risk of depression and anxiety were lower for the intervention group than the control group (p < .05).

CONCLUSIONS

Navigation program-based care provided to primiparous mothers improved maternal health.

A Prediction Model for Severe Maternal Morbidity and Mortality After Delivery Hospitalization

OBJECTIVE

To develop a risk stratification model for severe maternal morbidity (SMM) or mortality after the delivery hospitalization based on information available at the time of hospital discharge.

METHODS

This population-based cohort study included all pregnancies among Ohio residents with Medicaid insurance from 2012 to 2017. Pregnant individuals were identified using linked live birth and fetal death records and Medicaid claims data. Inclusion was restricted to those with continuous postpartum Medicaid enrollment and delivery at 20 or more weeks of gestation. The primary outcome of the study was SMM or mortality after the delivery hospitalization and was assessed up to 42 days postpartum and up to 1 year postpartum separately. Variables considered for the model included patient-, obstetric health care professional-, and system-level data available in vital records or Medicaid claims data. Parsimonious models were created with logistic regression and were internally validated. Receiver operating characteristic curves were used to evaluate model performance, and model calibration was assessed.

RESULTS

There were 343,842 pregnant individuals who met inclusion criteria with continuous Medicaid enrollment through 42 days postpartum and 287,513 with continuous enrollment through 1 year. After delivery hospitalization discharge, the incidence of SMM or mortality was 140.5 per 10,000 pregnancies through 42 days of delivery and 330.7 per 10,000 pregnancies through 1 year postpartum. The final model predicting SMM or mortality through 42 days postpartum included maternal prepregnancy body mass index, age, gestational age at delivery, mode of delivery, chorioamnionitis, and maternal diagnosis of cardiac disease, preeclampsia or gestational hypertension, or a mental health condition. Similar variables were included in the model predicting SMM or mortality through 365 days with chronic hypertension, pregestational diabetes, and illicit substance use added and chorioamnionitis removed. Both models demonstrated moderate prediction (area under the curve [AUC] 0.77, 95% CI 0.76-0.78 for 42-day model; AUC 0.72, 95% CI 0.71-0.73 for the 1-year model) and good calibration.

CONCLUSION

A prediction model for SMM or mortality up to 1 year postpartum was created and internally validated with information available to health care professionals at the time of hospital discharge. The utility of this model for patient counseling and strategies to optimize postpartum care for high-risk individuals will require further evaluation.

Genome-wide polygenic risk scores for hypertensive disease during pregnancy can also predict the risk for long-term cardiovascular disease

BACKGROUND

Hypertensive disorders during pregnancy are associated with the risk of long-term cardiovascular disease after pregnancy, but it has not yet been determined whether genetic predisposition for hypertensive disorders during pregnancy can predict the risk for long-term cardiovascular disease.

OBJECTIVE

This study aimed to evaluate the risk for long-term atherosclerotic cardiovascular disease according to polygenic risk scores for hypertensive disorders during pregnancy.

STUDY DESIGN

Among UK Biobank participants, we included European-descent women (n=164,575) with at least 1 live birth. Participants were divided according to genetic risk categorized by polygenic risk scores for hypertensive disorders during pregnancy (low risk, score ≤25th percentile; medium risk, score 25th∼75th percentile; high risk, score >75th percentile), and were evaluated for incident atherosclerotic cardiovascular disease, defined as the new occurrence of one of the following: coronary artery disease, myocardial infarction, ischemic stroke, or peripheral artery disease.

RESULTS

Among the study population, 2427 (1.5%) had a history of hypertensive disorders during pregnancy, and 8942 (5.6%) developed incident atherosclerotic cardiovascular disease after enrollment. Women with high genetic risk for hypertensive disorders during pregnancy had a higher prevalence of hypertension at enrollment. After enrollment, women with high genetic risk for hypertensive disorders during pregnancy had an increased risk for incident atherosclerotic cardiovascular disease, including coronary artery disease, myocardial infarction, and peripheral artery disease, compared with those with low genetic risk, even after adjustment for history of hypertensive disorders during pregnancy.

CONCLUSION

High genetic risk for hypertensive disorders during pregnancy was associated with increased risk for atherosclerotic cardiovascular disease. This study provides evidence on the informative value of polygenic risk scores for hypertensive disorders during pregnancy in prediction of long-term cardiovascular outcomes later in life.

"The Name of This is Fourth Trimester. A Lot of People Don't Know About it": A Qualitative Analysis to Inform the Development of a Web-Based Tool

OBJECTIVE

The purpose of this qualitative study is to understand the pregnant and postpartum experiences of Black women in the United States to inform the development of a web-based mobile tool.

METHODS

Participants were recruited through Facebook Groups. There were a total of 19 women that participated in one of five focus group discussions. Participants ranged from being in their 3rd trimester of pregnancy through 6 months postpartum. Thematic content analysis was performed to identify emerging themes.

RESULTS

Four themes emerged from the focus group discussions: beliefs about postpartum motherhood, experiences during pregnancy, experiences of the postpartum period, and tool recommendations. Key results from these themes demonstrated the difficulties that women faced in having their concerns resolved by healthcare professionals, receiving adequate educational and social support during the COVID-19 pandemic, and having adequate information to help breastfeed and cope with changes they experienced throughout the postpartum period.

CONCLUSION

The results highlight the difficulties that Black women experienced throughout pregnancy and the postpartum period. The main findings show that women lacked support in receiving information about the postpartum period, had their concerns dismissed by healthcare professionals, and received inadequate support. These findings can inform the practice of healthcare professionals and inform the development of other non-clinical, digital resources to fill in these gaps. Future research in this area is planned to further develop and pilot the tool among a broader population of women.

The Postpartum Period: An Opportunity for Alcohol Screening and Counseling to Reduce Adverse Health Impacts

OBJECTIVES

The postpartum period presents an opportunity to engage in discussions about alcohol consumption and related health harms. This study examined the prevalence of alcohol consumption among a sample of postpartum persons with a recent live birth and screening and brief intervention (alcohol SBI) or counseling by their providers.

METHODS

We analyzed 2019 data from a telephone survey conducted 9 to 10 months postpartum among individuals who responded to the standard Pregnancy Risk Assessment Monitoring System survey in 6 states. Weighted prevalence estimates were calculated for alcohol consumption and alcohol SBI after birth through up to 10 months postpartum.

RESULTS

Among 1790 respondents, 53.1% reported consuming alcohol postpartum. Among those who drank postpartum, 70.8% reported being asked about alcohol use by a healthcare provider. Slightly more than half of respondents who drank postpartum and were trying to get pregnant (52.4%) or were not using birth control at the time of the survey (59.8%) reported being asked about alcohol use. Approximately 25% of respondents who drank alcohol postpartum were advised about risky alcohol levels by a healthcare provider. Small proportions of individuals who drank alcohol postpartum and were pregnant or trying to get pregnant at the time of the survey were advised to reduce or stop drinking alcohol (10.6% and 2.3%, respectively).

CONCLUSIONS

These findings suggest missed opportunities to promote health and prevent adverse alcohol-related health outcomes during the postpartum period through evidence-based tools such as alcohol SBI.

Timing of outpatient postpartum care utilization among women with chronic hypertension and hypertensive disorders of pregnancy

BACKGROUND

The postpartum period represents an opportunity to assess the cardiovascular health of women who experience chronic hypertension or hypertensive disorders of pregnancy.

OBJECTIVE

This study aimed to determine whether women with chronic hypertension or hypertensive disorders of pregnancy access outpatient postpartum care more quickly compared to women with no hypertension.

STUDY DESIGN

We used data from the Merative MarketScan Commercial Claims and Encounters Database. We included 275,937 commercially insured women aged 12 to 55 years who had a live birth or stillbirth delivery hospitalization between 2017 and 2018 and continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Using the International Classification of Diseases Tenth Revision Clinical Modification codes, we identified hypertensive disorders of pregnancy from inpatient or outpatient claims from 20 weeks gestation through delivery hospitalization and identified chronic hypertension from inpatient or outpatient claims from the beginning of the continuous enrollment period through delivery hospitalization. Distributions of time-to-event survival curves (time-to-first outpatient postpartum visit with a women's health provider, primary care provider, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and log rank tests. We used Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals. Time points of interest (3, 6, and 12 weeks) were evaluated per clinical postpartum care guidelines.

RESULTS

Among commercially insured women, the prevalences of hypertensive disorders of pregnancy, chronic hypertension, and no documented hypertension were 11.7%, 3.4%, and 84.8%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.5%, 26.4%, and 16.0% for hypertensive disorders of pregnancy, chronic, and no documented hypertension, respectively; by 12 weeks, the proportions increased to 62.4%, 64.5%, and 54.2%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type, and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with hypertensive disorders of pregnancy was 1.42 times the rate for women with no documented hypertension (adjusted hazard ratio, 1.42; 95% confidence interval, 1.39-1.45). Women with chronic hypertension also had higher utilization rates compared to women with no documented hypertension before 6 weeks (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24-1.33). Only chronic hypertension was significantly associated with utilization compared to the no documented hypertension group after 6 weeks (adjusted hazard ratio, 1.09; 95% confidence interval, 1.03-1.14).

CONCLUSION

In the 6 weeks following delivery discharge, women with hypertensive disorders of pregnancy and chronic hypertension attended outpatient postpartum care visits sooner than women with no documented hypertension. However, after 6 weeks this difference extended only to women with chronic hypertension. Overall, postpartum care utilization remained around 50% to 60% by 12 weeks in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.