Content of First Prenatal Visits

Physician's Knowledge and Practices Surrounding Low-Dose Aspirin for Preeclampsia Risk Reduction

OBJECTIVE

 Preeclampsia is a leading cause of pregnancy-related deaths. Up to 60% of maternal deaths associated with preeclampsia may be prevented. Clinical trials have shown that low-dose aspirin reduces preeclampsia up to 30% among women at increased risk. Since 2014, multiple professional societies and the U.S. Preventive Services Task Force have released guidelines on the use of low-dose aspirin to reduce the risk of preeclampsia. We aimed to evaluate physician's knowledge and practices surrounding low-dose aspirin for preeclampsia risk reduction.

STUDY DESIGN

 We distributed an anonymous electronic survey to licensed physicians in the Rio Grande Valley of Texas who provide prenatal care, including general obstetrician-gynecologists, maternal fetal medicine subspecialists, and family medicine physicians. The survey consisted of 20 items assessing demographics, provider practices, and knowledge on the use of low-dose aspirin for preeclampsia risk reduction.

RESULTS

 We received 48 surveys with a response rate of 55%. More than 90% of physicians reported recommending low-dose aspirin for preeclampsia risk reduction, of which 98% correctly identified the dose. Of the physicians recommending aspirin, 83% initiate dosing between 12 and 16 weeks, but only 52% continue it until the day of delivery. Nearly 80% of respondents identified that one high-risk factor for preeclampsia is an indication for prophylaxis, but only 56% identified that two or more moderate risk factors should prompt aspirin recommendation.

CONCLUSION

 Despite clear professional guidelines, physicians demonstrated gaps in knowledge and differences in practices. Enhancing screening tools to assess patient's risk of developing preeclampsia and tailored medical education on moderate risk factors are needed to identify patients who may benefit from this intervention. Increasing the use of aspirin in patients at risk is critical given the benefits of low-dose aspirin in the reduction of poor maternal and neonatal outcomes related to preeclampsia.

KEY POINTS

· Low-dose aspirin reduces preeclampsia in patients up to 30%.. · Physicians have gaps in knowledge despite guidelines.. · Following guidelines reduces poor outcomes associated with preeclampsia..

Redesigning the First Prenatal Visit: A Quality Improvement Initiative

BACKGROUND/PURPOSE

In an era of rising maternal mortality, a thorough first prenatal visit is essential; however, in our clinic we confirmed that many important topics were not being addressed. To rectify this problem, we redesigned the first prenatal visit to improve the coverage of topics, collect social determinants of health, increase patient access, and maintain patient satisfaction.

METHODS

We designed a quality improvement project to improve the first prenatal visit in a faculty obstetrics and gynecology clinic. To assess effectiveness, data before and after the implementation were compared. The intervention divided the first prenatal visit into two patient encounters: a nurse-led telemedicine visit and an in-person visit with an obstetric clinician.

RESULTS

The median percentage of topics covered in the first prenatal visit increased from 70.0% to 95.6%, and improvements were observed for all key themes ( p < .001). Social determinants of health was routinely collected postintervention (98.8%). A reduction in no-shows (9.9%-4.2%) improved patient access for all patients. Patient satisfaction for the first prenatal visit remained unchanged ( p = .370).

CONCLUSIONS

Significant improvements in addressing important topics at the first prenatal visit are achievable by separating one prenatal visit into two visits while increasing patient access and maintaining high patient satisfaction.

Evaluating adherence to American College of Obstetricians and Gynecologists guidelines at the first obstetric visit

Objective:

This is a prospective observational cohort study with the objective of assessing adherence to the American College of Obstetricians and Gynecologists guidelines regarding the first prenatal visit and determining what patient and provider factors are associated with high adherence in a faculty obstetric clinic at an academic medical center.

Methods:

The American College of Obstetricians and Gynecologists guidelines recommend addressing 72 topics early in prenatal care. A research assistant observed the first prenatal encounter and noted which topics were discussed during the visit. Patient and clinic characteristics were also collected. The primary outcome was the percentage of topics covered at each visit. After analyzing all encounters, patient encounters that scored above the median score were compared with encounters scoring below the median using bivariate comparisons with respect to patient and clinic characteristics. A multivariable Poisson regression model with robust error variance was performed on characteristics with a p value of ⩽0.2.

Results:

Fifty-one patient encounters met inclusion criteria and the median score for topics covered was 74%. Patients with chronic disease were more likely to have a higher percentage of topics covered (odds ratio 1.67, 95% confidence interval: 0.91–3.09). Patients who completed a prenatal questionnaire were also more likely to have a higher percentage (odds ratio 2.28, 95% confidence interval: 1.00–5.15) as well as patients who had nurse-led education integrated into their visit during (odds ratio 1.82, 95% confidence interval: 1.19–2.78). Patient satisfaction had no correlation with the number of topics covered.

Conclusion:

The number of topics to cover at the first prenatal visit has expanded creating challenges for patients and providers. Integration of prenatal questionnaires and nurse-led education has the potential to address gaps in antenatal care.

Physician Referrals During Prenatal Care

OBJECTIVE

Referrals are an important component of patient care, and have been increasing over time. During pregnancy, people have intensive contact with the healthcare system, but little is known about the involvement of different physicians for pregnant patients during this period. This study examines referral patterns during prenatal care visits.

METHODS

Using the 2006-2015 National Ambulatory Medical Care Survey and national birth certificate data, we estimate the number of referrals per pregnancy from prenatal care visits with OB/GYN and family medicine physicians. We use multivariable regression analysis to compare the probability of receiving a referral during a prenatal visit for visits with family medicine and OB/GYN physicians, controlling for visit, patient, and physician characteristics. Analyses are weighted to make results nationally representative.

RESULTS

224,335,436 prenatal visits over 19,893,015 pregnancies were included; 60% of these visits were covered by private insurance. On average, 0.3 referrals are made per pregnancy (95% confidence interval [CI] 0.22, 0.38). A prenatal visit with an OB was 5.5% points less likely to result in a referral than a visit with a family medicine physician, controlling for other characteristics.

CONCLUSIONS

Referrals are relatively common in prenatal care, and are more commonly initiated by family medicine physicians than by OB/GYNs. Understanding the contribution of multiple clinicians to a pregnant person's health during the prenatal period and how coordination among clinicians impacts care receipt is an important next step. As healthcare becomes more specialized, better understanding care teams of individuals during the perinatal period is important for improving prenatal care.

Perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content: Evidence from the Listening to Mothers in California survey

OBJECTIVE

Postpartum visits are an important opportunity to address ongoing maternal health. Experiences of discrimination in healthcare can impact healthcare use, including postpartum visits. However, it is unknown whether discrimination is associated with postpartum visit content. This study aimed to examine the relationship between perceived discrimination during the childbirth hospitalization and postpartum visit attendance and content.

RESEARCH DESIGN

Data were from Listening to Mothers in California, a population-based survey of people with a singleton hospital birth in California in 2016. Adjusted logistic regression models estimated the association between perceived discrimination during the childbirth hospitalization and 1) postpartum visit attendance, and 2) topics addressed at the postpartum visit (birth control, depression and breastfeeding) for those who attended.

RESULTS

90.6% of women attended a postpartum visit, and 8.6% reported discrimination during the childbirth hospitalization. In adjusted models, any discrimination and insurance-based discrimination were associated with 7 and 10 percentage point (pp) lower predicted probabilities of attending a postpartum visit, respectively. There was a 7pp lower predicted probability of discussing birth control for women who had experienced discrimination (81% vs. 88%), a 15pp lower predicted probability of being asked about depression (64% vs. 79%), and a 9 pp lower predicted probability of being asked about breastfeeding (57% vs. 66%).

CONCLUSIONS

Amid heightened attention to the importance of postpartum care, there is a need to better understand determinants of postpartum care quality. Our findings highlight the potential consequences of healthcare discrimination in the perinatal period, including lower quality of postpartum care.

The Use of a Game-Based Decision Aid to Educate Pregnant Women about Prenatal Screening: A Randomized Controlled Study

PURPOSE

This project developed and evaluated the efficacy of a game decision aid among pregnant women about prenatal screening in a randomized controlled study.

STUDY DESIGN

Participants were recruited from an obstetric clinic of an academic urban medical center and randomized (n = 73) to one of two study groups: the control group (n = 39) that used a brochure or the intervention group (n = 34) that also used a game decision aid.

RESULT

Participants who played the game had higher knowledge scores (m = 21.41, standard deviation [SD] = 1.74) than participants in the control group (m = 19.59; SD = 3.31), p = 0.004. The median time of game playing was 6:43 minutes (range: 2:17-16:44). The groups were similar in frequency of completing screening after the study, control = 6 (15%) versus intervention = 11 (32%), p = 0.087. However, the more interaction with the game resulted in more positive attitudes toward screening.

CONCLUSION

The addition of a game decision aid was effective in educating pregnant women about prenatal screening. As other genetic testing decisions continue to increase within clinical care, game-based decision tools may be a constructive method of informed decision-making.