A randomized trial of nurse intervention to reduce preterm and low birth weight births

Racial disparities in recurrent preterm delivery risk: mediation analysis of prenatal care timing

OBJECTIVES

We estimated the degree to which the association between race and spontaneous recurrent preterm delivery is mediated by the timing of the first prenatal care visit.

METHODS

A retrospective population-based cohort study was conducted using the U.S. National Center for Health Statistics Natality Files. We identified 644,576 women with a prior PTB who delivered singleton live neonates between 2011 and 2017. A mediation analysis was conducted using log-binomial regression to evaluate the mediating effect of timing of first prenatal care visit.

RESULTS

During the seven-year period, 349,293 (54.2%) White non-Hispanic women, 131,296 (20.4%) Black non-Hispanic women, 132,367 (20.5%) Hispanic women, and 31,620 (4.9%) Other women had a prior preterm delivery. The risk of late prenatal care initiation was higher in Black non-Hispanic women, Hispanic women, and Other women (women of other racial/ethnic backgrounds) compared to White non-Hispanic women, and the risk of preterm delivery was higher in women with late prenatal care initiation. Between 8 and 15% of the association between race and spontaneous recurrent preterm delivery acted through the delayed timing of the first prenatal care visit.

CONCLUSIONS

Racial disparities in spontaneous recurrent preterm delivery rates can be partly, but not primarily, attributed to timing of first prenatal care visit.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.

OBJECTIVES

The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.

Antenatal telephone support intervention with and without uterine artery Doppler screening for low risk nulliparous women: a randomised controlled trial

BACKGROUND

The number of routine antenatal visits provided to low risk nulliparous women has been reduced in the UK, acknowledging this change in care may result in women being less satisfied with their care and having poorer psychosocial outcomes. The primary aim of the study was to investigate whether the provision of proactive telephone support intervention (TSI) with and without uterine artery Doppler screening (UADS) would reduce the total number of antenatal visits required. A secondary aim was to investigate whether the interventions affected psychological outcomes.

METHODS

A three-arm randomised controlled trial involving 840 low risk nulliparous women was conducted at a large maternity unit in North East England. All women received antenatal care in line with current UK guidance. Women in the TSI group (T) received calls from a midwife at 28, 33 and 36 weeks and women in the telephone and Doppler group (T + D) received the TSI and additional UADS at 20 weeks' gestation. The main outcome measure was the total number of scheduled and unscheduled antenatal visits received after 20 weeks' gestation.

RESULTS

The median number of unscheduled (n = 2.0), scheduled visits (n = 7.0) and mean number of total visits (n = 8.8) were similar in the three groups. The majority (67%) of additional antenatal visits were made to a Maternity Assessment Unit because of commonly occurring pregnancy complications. Additional TSI+/-UADS was not associated with differences in clinical outcomes, levels of anxiety, social support or satisfaction with care. There were challenges to the successful delivery of the telephone support intervention; 59% of women were contacted at 29 and 33 weeks gestation reducing to 52% of women at 37 weeks.

CONCLUSIONS

Provision of additional telephone support (with or without UADS) in low risk nulliparous women did not reduce the number of unscheduled antenatal visits or reduce anxiety. This study provides a useful insight into the reasons why this client group attend for unscheduled visits.

TRIAL REGISTRATION

ISRCTN62354584.

Telephone support for women during pregnancy and the first six weeks postpartum

BACKGROUND

Telephone communication is increasingly being accepted as a useful form of support within health care. There is some evidence that telephone support may be of benefit in specific areas of maternity care such as to support breastfeeding and for women at risk of depression. There is a plethora of telephone-based interventions currently being used in maternity care. It is therefore timely to examine which interventions may be of benefit, which are ineffective, and which may be harmful.

OBJECTIVES

To assess the effects of telephone support during pregnancy and the first six weeks post birth, compared with routine care, on maternal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 January 2013) and reference lists of all retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials, comparing telephone support with routine care or with another supportive intervention aimed at pregnant women and women in the first six weeks post birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies identified by the search strategy, carried out data extraction and assessed risk of bias. Data were entered by one review author and checked by a second. Where necessary, we contacted trial authors for further information on methods or results.

MAIN RESULTS

We have included data from 27 randomised trials involving 12,256 women. All of the trials examined telephone support versus usual care (no additional telephone support). We did not identify any trials comparing different modes of telephone support (for example, text messaging versus one-to-one calls). All but one of the trials were carried out in high-resource settings. The majority of studies examined support provided via telephone conversations between women and health professionals although a small number of trials included telephone support from peers. In two trials women received automated text messages. Many of the interventions aimed to address specific health problems and collected data on behavioural outcomes such as smoking cessation and relapse (seven trials) or breastfeeding continuation (seven trials). Other studies examined support interventions aimed at women at high risk of postnatal depression (two trials) or preterm birth (two trials); the rest of the interventions were designed to offer women more general support and advice.For most of our pre-specified outcomes few studies contributed data, and many of the results described in the review are based on findings from only one or two studies. Overall, results were inconsistent and inconclusive although there was some evidence that telephone support may be a promising intervention. Results suggest that telephone support may increase women's overall satisfaction with their care during pregnancy and the postnatal period, although results for both periods were derived from only two studies. There was no consistent evidence confirming that telephone support reduces maternal anxiety during pregnancy or after the birth of the baby, although results on anxiety outcomes were not easy to interpret as data were collected at different time points using a variety of measurement tools. There was evidence from two trials that women at high risk of depression who received support had lower mean depression scores in the postnatal period, although there was no clear evidence that women who received support were less likely to have a diagnosis of depression. Results from trials offering breastfeeding telephone support were also inconsistent, although the evidence suggests that telephone support may increase the duration of breastfeeding. There was no strong evidence that women receiving telephone support were less likely to be smoking at the end of pregnancy or during the postnatal period.For infant outcomes, such as preterm birth and infant birthweight, overall, there was little evidence. Where evidence was available, there were no clear differences between groups. Results from two trials suggest that babies whose mothers received support may have been less likely to have been admitted to a neonatal intensive care unit (NICU), although it is not easy to understand the mechanisms underpinning this finding.

AUTHORS' CONCLUSIONS

Despite some encouraging findings, there is insufficient evidence to recommend routine telephone support for women accessing maternity services, as the evidence from included trials is neither strong nor consistent. Although benefits were found in terms of reduced depression scores, breastfeeding duration and increased overall satisfaction, the current trials do not provide strong enough evidence to warrant investment in resources.

The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review

BACKGROUND

Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated.

METHODS

We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)) RESULTS: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'.

CONCLUSIONS

There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

Care for women with prior preterm birth

Women who have delivered an infant between 16 and 36 weeks' gestation have an increased risk of preterm birth in subsequent pregnancies. The risk increases with more than 1 preterm birth and is inversely proportional to the gestational age of the previous preterm birth. African American women have rates of recurrent preterm birth that are nearly twice that of women of other backgrounds. An approximate risk of recurrent preterm birth can be estimated by a comprehensive reproductive history, with emphasis on maternal race, the number and gestational age of prior births, and the sequence of events preceding the index preterm birth. Interventions including smoking cessation, eradication of asymptomatic bacteriuria, progestational agents, and cervical cerclage can reduce the risk of recurrent preterm birth when employed appropriately.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.

Healthy start program and feto-infant morbidity outcomes: evaluation of program effectiveness

OBJECTIVE

We evaluate the impact of the Healthy Start intervention program on feto-infant morbidity within a community setting.

METHODS

Prospective data from 2002 to 2007 within the ongoing Federally funded Healthy Start intervention project in Central Hillsborough County were merged with corresponding birth outcomes data from the Florida Department of Health. The impact of the project on the following feto-infant morbidity indices was assessed among service recipients: low birth weight (LBW), very low birth weight (VLBW), preterm, very preterm, small for gestational age (SGA) and a composite feto-infant morbidity outcome. Program effectiveness and impact were measured using odds ratios from logistic regression models and number needed to treat (NNT).

RESULTS

The risk for low birth weight (OR = 0.7; 95% CI = 0.5-1.0), preterm (OR = 0.7; 95% CI = 0.5-0.9) and the composite feto-infant morbidity outcome (OR = 0.8; 95% CI = 0.6-0.9) was reduced among service recipients (N = 536) as compared to non-recipients (N = 2,815). A clinically important level of risk reduction was also noted for very low birth weight (OR = 0.5; 95% CI = 0.2-1.1) and very preterm (OR = 0.6; 95% CI = 0.3-1.2) although these did not reach statistical significance. The adjusted NNT was lowest for the composite feto-infant morbidity outcome (18), preterm birth (21) and low birth weight (24), and highest for very preterm (86) and very low birth weight (74) events.

CONCLUSIONS

In a disadvantaged community setting, the Healthy Start intervention program was found to reduce the risk for very low birth weight and preterm births by about one-third.

Group prenatal care and perinatal outcomes: a randomized controlled trial

OBJECTIVE

To determine whether group prenatal care improves pregnancy outcomes, psychosocial function, and patient satisfaction and to examine potential cost differences.

METHODS

A multisite randomized controlled trial was conducted at two university-affiliated hospital prenatal clinics. Pregnant women aged 14-25 years (n=1,047) were randomly assigned to either standard or group care. Women with medical conditions requiring individualized care were excluded from randomization. Group participants received care in a group setting with women having the same expected delivery month. Timing and content of visits followed obstetric guidelines from week 18 through delivery. Each 2-hour prenatal care session included physical assessment, education and skills building, and support through facilitated group discussion. Structured interviews were conducted at study entry, during the third trimester, and postpartum.

RESULTS

Mean age of participants was 20.4 years; 80% were African American. Using intent-to-treat analyses, women assigned to group care were significantly less likely to have preterm births compared with those in standard care: 9.8% compared with 13.8%, with no differences in age, parity, education, or income between study conditions. This is equivalent to a risk reduction of 33% (odds ratio 0.67, 95% confidence interval 0.44-0.99, P=.045), or 40 per 1,000 births. Effects were strengthened for African-American women: 10.0% compared with 15.8% (odds ratio 0.59, 95% confidence interval 0.38-0.92, P=.02). Women in group sessions were less likely to have suboptimal prenatal care (P<.01), had significantly better prenatal knowledge (P<.001), felt more ready for labor and delivery (P<.001), and had greater satisfaction with care (P<.001). Breastfeeding initiation was higher in group care: 66.5% compared with 54.6%, P<.001. There were no differences in birth weight nor in costs associated with prenatal care or delivery.

CONCLUSION

Group prenatal care resulted in equal or improved perinatal outcomes at no added cost.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00271960

LEVEL OF EVIDENCE

I.

Born too soon: the continuing challenge of preterm labor and birth in the United States

Prematurity is the single greatest cause of morbidity and mortality in obstetrics. Families, health care services, and education systems experience the impact of prematurity for the lifetime of the preterm-born child. Health care providers have tried to lower the preterm birth rate with prevention both before and during pregnancy and intervention for symptomatic women. The inability of the health care system to significantly decrease the incidence of preterm birth continues to be a challenge. To further complicate the situation, new data shows that infants born between 34 and 37 weeks' gestation who were thought to have minimal long-term effects of preterm birth may be more at risk than previously appreciated. This article reviews evidence-based risk identification, prevention, and management of women experiencing preterm labor and birth.

Follow-up care for infants with chronic lung disease: a randomized comparison of community- and center-based models

OBJECTIVES

Premature infants with chronic lung disease benefit from comprehensive care, which typically is based in tertiary medical centers. When such centers are not easily accessible, alternative models of care are needed. The purpose of this work was to compare community-based follow-up, provided via telephone contacts, to traditional center-based follow-up of premature infants with chronic lung disease.

PATIENTS AND METHODS

After discharge from neonatal intensive care, 150 premature infants with chronic lung disease were randomly assigned to either community-based (n = 75) or center-based (n = 75) follow-up. In community-based follow-up, a nurse specialist maintained telephone contact with the infant's primary caregiver and health care providers. Center-based follow-up consisted of visits to a medical center-based multidisciplinary clinic staffed by a neonatologist, a nurse specialist, and a social worker. The outcomes of interest were Bayley Scales of Infant Development mental developmental index and psychomotor developmental index, Vineland Adaptive Behavioral Composite, and growth delay (weight for length <5th percentile) at 1-year adjusted age and respiratory rehospitalizations through 1-year adjusted age.

RESULTS

In each randomization group, 73 infants survived, and 69 were evaluated at 1-year adjusted age. The median mental development index (corrected for gestational age) was 90 for both groups. The median psychomotor developmental index was 82 for the center-based group and 81 for the community-based group. The median Vineland Adaptive Behavioral Composite was 100 and 102 for the center-based and community-based groups, respectively. In the center-based and community-based groups, respectively, the proportions with growth delay were 13% and 26%, and the proportions rehospitalized for respiratory illness were 33% and 29%.

CONCLUSIONS

Infants randomly assigned to community-based, as compared with those randomly assigned to center-based follow-up, had similar developmental and health outcomes. The former approach might be a preferred alternative for families in rural settings or families for whom access to a tertiary care medical center is difficult.

The association between pregnancy processes, preterm delivery, low birth weight, and postpartum depressions--the need for interdisciplinary integration

Pregnancy and peripartum/perinatal periods are characterized by significant biologic as well as psychosocial processes and changes that influence the 2 individuals at focus (mother and fetus), as well as their interactions with the immediate environment. Multiple intertwined pathologic pregnancy processes (hormonal, biologic, stress and other mental occurrences) may lead to fetal distress, preterm delivery (PTD), low birth weight (LBW), and other delivery complications as well as to postpartum disorders. PTD and LBW in particular have been demonstrated to be associated with significant mortality as well as short- and long-term morbidity. Underlying processes and risk factors for PTD, LBW and postpartum disorders may overlap. Their impact on the offspring is compounded. Currently, the multiple clinical and research disciplines that are concerned with the various aspects of pregnancy, delivery, and postpartum period are not conceptually and practically integrated. Specifically, obstetricians are more concerned with delivery complications, whereas mental health professionals are concerned with postpartum depression. An interdisciplinary approach is needed for better understanding of developmental processes and the development of measurements and interventions to prevent long-term impact on the offspring.

Overview of current state of research on pregnancy outcomes in minority populations

Pregnancy outcomes improved significantly over the 20th century in the United States but currently vary widely between women of different ethnic and racial backgrounds. The current health disparities that exist are based, in part, only on differences in socioeconomic status or education. There is wide variability in pregnancy outcomes within specific subgroups of women. Disparities may be due to underlying differences in health before pregnancy, differences in community norms, and individual lifestyle choices and to differences in health care delivery systems. Areas for needed research and promising new models of care are reviewed.

[Threat of premature labor, stress, psychosocial support and psychotherapy: a review of the literature]

From the hypothesis that preterm labour is a physical expression of a difficulty to have a cheerful pregnancy, we wanted to assess from a literature review:--the link between stress, anxiety, and preterm birth for one part--and the medical advantage of psychosocial or psychological support among women having a high risk of preterm birth for another. According to the available publications, stress, psychological disturbances, and anxiety can increase the risk of preterm birth. However, psychosocial support is not associated with an improvement of the perinatal outcome. On the other hand, psychological support for women having a preterm labour, with or without hospitalisation, seems an interesting medical approach to reduce the preterm birth rate.

Improving pregnancy outcome and reducing avoidable clinical resource utilization through telephonic perinatal care coordination

The effects of telephonic nursing case management and standard care in a low-income, high-risk pregnancy population, controlling for gestational age at referral and risk factors (medical, demographic, and behavioral) were compared. The hypothesis was that a program of telephonic perinatal nursing care coordination and case management would increase mean gestational ages and mean birth weights and would reduce clinical resource utilization, compared with standard nursing care. The methods focused on a telephonic model developed during the past 16 years that included risk assessment, patient education, coordination of care for home services and clinic appointments, coordination of interventions requested by care providers, and patient advocacy. The patient population, primarily of minority cultural and racial backgrounds, obtained prenatal care from two large obstetric clinics and delivered at a level-3 tertiary care center. They were randomly assigned to treatment (N = 61) and control (N = 50) conditions. Interpreters were used for any contacts with non-English-speaking patients. The results demonstrated increased mean birth weights for the treatment group when intervening variables were controlled. Mean gestational age at delivery was not significantly different between groups. Telephonic case management saved an average of 501.31 dollars per patient in inpatient and outpatient costs combined. In the treatment group, for every dollar spent on case management costs, the savings were 4.08 dollars.

Public health nursing care for adolescent mothers: impact on infant health and selected maternal outcomes at 1 year postbirth

PURPOSE

To compare effects of an early intervention program (EIP) of intense home visitation by public health nurses (PHNs) with effects of traditional public health nursing care (TPHN) on infant health and selected maternal outcomes of adolescent mothers.

METHODS

EIP adolescents (N = 102) received preparation-for-motherhood classes and individual home visits (from pregnancy through 1 year postpartum) from PHNs employed in a county health department. Participants were predominantly Latina (64%) and African-American (11%) and from impoverished backgrounds. Infant health outcomes were determined based on medical record data; interviews and standardized questionnaires evaluated other program effects (e.g., maternal educational achievement and psychological status). Data were analyzed using Chi-square and repeated measures ANOVA.

RESULTS

Infants of EIP mothers experienced significantly fewer total days (n = 74) and actual episodes (n = 14) of hospitalization during the first year of life than those receiving TPHN (n = 154, n = 24, respectively). Similarly, positive program effects were found for immunization rates. There were no group differences in emergency room visits or repeat pregnancy rates. Alcohol, tobacco, and marijuana use significantly increased from pregnancy through 1 year postpartum in both groups but remained markedly lower than rates prior to pregnancy (lifetime rates).

CONCLUSIONS

These findings demonstrate the positive effects of a PHN home visitation program on health outcomes for children of adolescent mothers. Days of infant hospitalization were substantially reduced and immunization rates increased during the first year of life for children of EIP mothers. Greater efforts need to be directed toward preventing repeat pregnancy and return to substance use following childbirth in at-risk adolescent mothers.

The influence of telephonic nursing care coordination on patient satisfaction in a predominantly low-income, high-risk pregnancy population

The effect of telephonic nursing case management on patient satisfaction in a predominantly non-Caucasian low-income, high-risk pregnancy population was studied. Patient satisfaction of care was significantly higher for treatment group participants than for controls on 9 of 10 items measuring satisfaction. The satisfaction score of the treatment patients, constructed by summing scores for each item, averaged 8 points higher than the control group's score. Demographics made little difference. Telephonic case management was the strongest predictor of satisfaction in a multiple regression analysis. Satisfaction was unrelated to mode of delivery, infant birth weight, or gestational age. The satisfaction levels of treatment patients were high, whether or not they had outpatient charges. Participants rated the program highly for the nurses' ability to answer questions, overall program experience, the opportunity to ask the nurses questions, health teachings and instructions received, and confidence in the nurse coordinating their care or their child's care.

A preterm birth prevention project in Nova Scotia, Canada

OBJECTIVE

The Halifax County Preterm Birth Prevention Project was designed to evaluate the effectiveness of a population-based preterm birth (PTB) prevention program in Nova Scotia from January 1995 through June 1997 (n = 10,326).

METHODS

Preterm birth rates, adjusted for risk status and maternal age, were evaluated over time in Halifax County and compared to non-Halifax County parturients in Nova Scotia. Physician participation was evaluated by means of a mailed survey.

RESULTS

There was no appreciable change in the overall (<37 weeks) or early (<34 weeks) PTB rates within or outside Halifax County during the intervention period compared to the preintervention period. Although not significant, the very (<30 weeks) PTB rate in Halifax County decreased by 40% from 0.53 to 0.32%, while outside Halifax County it remained stable (0.43-0.42%). There was a statistically significant decrease in early and very PTB associated with spontaneous labour, as well as an apparent shift in the timing of delivery from very preterm to preterm (> or =30 weeks). Participation among responding physicians was greater for high-risk than low-risk women, but full compliance with project recommendations was low.

CONCLUSION

The overall ineffectiveness of the Halifax County Preterm Birth Prevention Project may reflect the reluctance of practitioners to fully incorporate the recommended prevention strategies into their practice. However, such interventions may reduce the risk of spontaneous early preterm birth.

Perinatal nursing research: a 25-year review--1976-2000

Parent-infant nursing research from 1976-2000 is reviewed through four groups of studies: development of research instruments, studies of mothers and fathers through the childbearing years, studies of newborns (both healthy and at risk), and studies of special populations. Potential directions for maternal/parent/newborn nursing research in the 21st century are suggested.

Cost-benefit of a nursing telephone intervention to reduce preterm and low-birthweight births in an African American clinic population

BACKGROUND

A cost-benefit analysis was performed to estimate the cost-savings obtained from a nursing telephone intervention delivered to pregnant women identified as being at risk for preterm or low-birthweight births.

METHODS

After being screened for eligibility, a total of 1,554 women receiving prenatal care in a clinic located in Winston-Salem, North Carolina were randomized to intervention and control groups. Women in the intervention group received telephone calls from a registered nurse one or two times each week from the 24th through the 37th week of gestation.

RESULTS

No clinical benefits were realized by Caucasian participants. The intervention reduced preterm and low-birthweight births, and resulted in cost savings, for African-American mothers ages 19 and over. No significant differences were seen in the rates of low-birthweight or preterm births and no cost savings were realized from intervention with women ages 18 and younger.

CONCLUSIONS

A prenatal nursing support intervention in a clinic population of pregnant African American women was cost-beneficial for these adults (< or =19 years of age).

From randomized trial to community-focused practice

PURPOSE

To describe the use of findings from a randomized trial--a nursing intervention using telephone contacts to reduce the incidence of low-birth-weight and preterm births--in four community settings in North Carolina, to show that implementing research into practice is important. Low-birth-weight and preterm births are the major cause of high infant mortality in the United States. Rates are highest among African-American women. Telephone intervention as a strategy for preventive health care can be cost effective, reduce low-birth-weight and preterm births in African-American women, and provide a means of health consultation for parents of children age five and under.

ORGANIZING FRAMEWORK

Four community programs are discussed in relation to five phases of implementing and sustaining research in communities: research, transfer, transition, regeneration, and empowerment. Modification from the original research, bonuses, and barriers are described for each program.

METHODS

The randomized trial was conducted from 1990-1995. Randomized trial data and data for subsequent projects were collected from telephone interviews and health care records from 1994-1998. A successful adaptation was made from the original randomized trial to the four programs by (a) educating the staff for each program about the methods and findings in the original research, and (b) working with program staff to make appropriate modifications for each site.

CONCLUSIONS

Findings from a randomized trial can be used in a variety of settings. By working together, researchers and community-health nurses can integrate research findings into community-health nursing practice.

Reducing preterm and low birthweight births: still a nursing challenge

Preterm birth and low birthweight are correlated with much of the infant death seen in the United States. Despite 15 years of research, both preterm birth rates and low birthweight rates continue to increase. This article describes what is known about the prevention of preterm birth and low birthweight, and offers advice to nurses for nursing interventions that could prove effective in preventing such tragedies in the future.