Centering and Racial Disparities (CRADLE study): rationale and design of a randomized controlled trial of centeringpregnancy and birth outcomes

Pregnancy Anxiety and Risk of Gestational Diabetes Mellitus Among a Diverse U.S. Cohort

Background: Pregnancy anxiety increases the risk of preterm birth but less is known about the impacts on glucose intolerance during pregnancy, such as gestational diabetes mellitus (GDM). The present study examined the relationship between pregnancy anxiety and the risk of GDM in a prospective cohort Centering and Racial Disparities (CRADLE) study of racially diverse pregnant women in the United States. Methods: This is a prospective analysis among racially diverse pregnant women in the United States who enrolled in the CRADLE study. Pregnancy anxiety was assessed twice using the Pregnancy-Specific Anxiety Scale (PSAS): the baseline survey at <20 gestational weeks (GW) and the second survey at >30 GW. GDM was screened at 24-30 GW and diagnosed based on the Carpenter and Coustan criteria. The associations of baseline PSAS score (>9 [median] versus ≤9) and PSAS score change with GDM risk were estimated using multivariable logistic regressions with adjustment for potential confounders. Results: Among a total of 2,310 women (40.74% Black, 20.91% Hispanic), 154 (6.67%) developed GDM. No association was found between baseline PSAS and GDM (adjusted odds ratio [OR]: 0.99; 95% confidence interval [CI]: 0.70-1.42) after adjusting for confounders. Individuals with an increased PSAS during pregnancy had 52% higher GDM risk (adjusted OR: 1.52, 95% CI: 1.04-2.23) compared with those with no change or decreased scores. Conclusions: Pregnant individuals who increased their pregnancy-specific anxiety level during pregnancy had a higher risk of developing GDM. Clinical Trials Registration Identifier: NCT02640638. Registered with ClinicalTrials.gov December 29, 2015. Study recruitment began February 24, 2016. URL of ClincialTrials.gov registration site: https://clinicaltrials.gov/ct2/show/NCT02640638?term=NCT02640638&draw=2&rank=1.

Examining childhood and adulthood stressors as risk factors for gestational diabetes mellitus in working pregnant individuals: A prospective cohort study

AIMS

This study aimed to examine the individual and joint associations of adverse childhood experiences (ACEs) and maternal work and non-work related stressors with the risk of gestational diabetes mellitus (GDM).

METHODS

Working pregnant individuals (n = 1163) from a United States (U.S.) prospective cohort conducted in South Carolina between 2016 and 2021 were included in the study. ACEs were assessed at study enrollment before 20 gestational weeks (GW), while maternal stressors were assessed in late pregnancy and GDM diagnosis occurred between 24 and 30 GW. Multivariable logistic regressions were performed to assess associations of ACEs and maternal stressors with GDM.

RESULTS

Childhood abuse, an ACE subdomain, was associated with an elevated but statistically insignificant risk of GDM (adjusted OR = 1.47; 95 % CI: 0.85-2.53). Only maternal work stressors were associated with an increased risk of GDM (adjusted OR = 2.11; 95 % CI: 1.17-3.79) and the association became much stronger among those with childhood abuse experiences (adjusted OR = 3.80; 95 % CI:1.68-8.60).

CONCLUSION

Among U.S. working pregnant individuals, having work stressors during pregnancy was associated with an elevated risk of developing GDM, particularly among those who had childhood experience of abuse.

Exploring the feasibility of conducting a randomised controlled trial of group-based pregnancy care and education: a pilot randomised controlled trial in Melbourne, Australia

BACKGROUND

In group-based pregnancy models, antenatal care and childbirth/parenting education are provided in groups of eight to 10 women, usually with two midwives, and six to eight sessions. Current evidence is inconclusive regarding potential benefit or harm. We aimed to explore the feasibility of implementing an adequately powered randomised controlled trial (RCT).

METHODS

A two-arm pilot RCT was conducted in a tertiary maternity hospital in Melbourne, Australia. Women were randomly allocated to either the intervention to receive group-based antenatal care and education (group care) or to usual care, which included hospital-based midwife, caseload midwifery, team midwifery, or GP shared care. Participants were English-speaking, primiparous, low risk, and < 24 weeks gestation at booking.

DATA COLLECTION

feasibility measures throughout pilot, baseline questionnaire at recruitment, clinical outcome data from the medical record, and a telephone-administered questionnaire 6 weeks postpartum. A focus group explored midwives' views.

RESULTS

Seventy-four women were recruited from May to June 2017 (group care = 40, usual care = 34). Study uptake was 35%. Women allocated to group care rated their overall pregnancy care more highly (88% good/very good vs 77% in usual care). There was no evidence of harm related to group care. Overarching themes from the midwives were that group care helped 'build connections' and 'empower women'. All midwives would work in the model again and believed it should be expanded.

CONCLUSION

Group care was acceptable to both women and midwives with no evidence of harm. The pilot demonstrated the feasibility of undertaking a large adequately powered RCT, important given the inconclusive evidence on clinical outcomes regarding the model, and its current relatively widespread implementation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000858695.

Providers' Perspectives of a Culturally Adapted CenteringPregnancy Intervention for Marshallese Women in Arkansas

OBJECTIVE

To explore health care providers' perspectives on the successes, challenges, and suggestions for future directions regarding the implementation of CenteringPregnancy for Marshallese women in Arkansas.

DESIGN

A descriptive qualitative design was used as an exploratory method.

SETTING/LOCAL PROBLEM

This study took place in northwest Arkansas. Arkansas is home to the largest Marshallese Pacific Islander population in the United States. Marshallese Pacific Islanders residing in the United States have disproportionally high rates of poor maternal and infant health outcomes, even compared to other Pacific Islanders.

PARTICIPANTS

Seven CenteringPregnancy providers from the University of Arkansas for Medical Sciences Northwest.

INTERVENTION/MEASUREMENTS

Individual interviews were conducted from February to March of 2023. Data were managed using MAXQDA12 software. Content analysis was used to analyze the data. Initial coding was completed to identify each data segment with short summations of emergent themes. The focused thematic codes that emerged were used to identify and develop the most salient thematic categories of the data, which became the thematic codes.

RESULTS

Three overarching themes emerged: Implementation Successes, Challenges to Implementation, and Future Suggestions to Improve Implementation and Sustainability. Each theme had representative subthemes.

CONCLUSION

Findings provide insight for future implementation of CenteringPregnancy for Marshallese and other Pacific Islander individuals.

Discrimination and Adverse Perinatal Health Outcomes: A Latent Class Analysis

INTRODUCTION

An intersectionality framework recognizes individuals as simultaneously inhabiting multiple intersecting social identities embedded within systems of disadvantage and privilege. Previous research links perceived discrimination with worsened health outcomes yet is limited by a focus on racial discrimination in isolation. We applied an intersectional approach to the study of discrimination to examine the association with adverse perinatal health outcomes.

METHODS

We analyzed data from a cohort of 2,286 pregnant participants (Black, n = 933; Hispanic, n = 471; White, n = 853; and Other, n = 29) from the Centering and Racial Disparities trial. Perceived discrimination was assessed via the Everyday Discrimination Scale (EDS) and perinatal health outcomes collected via electronic medical record review. Latent class analysis was used to identify subgroups of discrimination based on EDS item response and the rate of adverse perinatal health outcomes compared between subgroups using a Bolck, Croon and Hagenaars 3-step approach.

RESULTS

Four discrimination subgroups were identified: no discrimination, general discrimination, discrimination attributed to one or several social identities, and discrimination attributed to most or all social identities. Experiencing general discrimination was associated with postpartum depression symptoms when compared with experiencing no discrimination among Black (9% vs 5%, P = .04) and White participants (18% vs 9%, P = .01). White participants experiencing general discrimination gave birth to low birthweight infants at a higher rate than those experiencing no discrimination (11% vs 6%, P = .04). No significant subgroup differences were observed among Hispanic participants.

CONCLUSION

Perceived discrimination may play an influential role in shaping perinatal health. More research applying an intersectional lens to the study of discrimination and perinatal health outcomes is needed.

Randomized Controlled Trial on the Effect of Group Versus Individual Prenatal Care on Psychosocial Outcomes

OBJECTIVE

To assess the effect of group prenatal care (GPNC) compared with individual prenatal care (IPNC) on psychosocial outcomes in late pregnancy, including potential differences in outcomes by subgroups.

DESIGN

Randomized controlled trial.

SETTING

An academic medical center in the southeastern United States.

PARTICIPANTS

A total of 2,348 women with low-risk pregnancies who entered prenatal care before 20 6/7 weeks gestation were randomized to GPNC (n = 1,175) or IPNC (n = 1,173) and stratified by self-reported race and ethnicity.

METHODS

We surveyed participants during enrollment (M = 12.21 weeks gestation) and in late pregnancy (M = 32.51 weeks gestation). We used standard measures related to stress, anxiety, coping strategies, empowerment, depression symptoms, and stress management practices in an intent-to-treat regression analysis. To account for nonadherence to GPNC treatment, we used an instrumental variable approach.

RESULTS

The response rates were high, with 78.69% of participants in the GPNC group and 83.89% of participants in the IPNC group completing the surveys. We found similar patterns for both groups, including decrease in distress and increase in anxiety between surveys and comparable levels of pregnancy empowerment and stress management at the second survey. We identified greater use of coping strategies for participants in the GPNC group, particularly those who identified as Black or had low levels of partner support.

CONCLUSION

Group prenatal care did not affect stress and anxiety in late pregnancy; however, the increased use of coping strategies may suggest a benefit of GPNC for some participants.

Participation in the CenteringPregnancy Program and Pregnancy-Induced Hypertension

INTRODUCTION

CenteringPregnancy emphasizes nutrition, learning, and peer support through a group meeting format in contrast to the standard of prenatal care that maximizes a pregnant patient's time with their provider. It was hypothesized that the program may yield a reduced risk of pregnancy-induced hypertension. In this observational study, authors examined the impacts of the CenteringPregnancy program versus those of standard of prenatal care on pregnancy-induced hypertension.

METHODS

In 2021, birth certificate data were linked to hospital discharge records of women who delivered in obstetric clinics in the Midlands of South Carolina between 2015 and 2019. Logistic regression models were used to estimate the association between CenteringPregnancy participation (n=547) and any pregnancy-induced hypertension and specific pregnancy-induced hypertension diagnoses (gestational hypertension/unspecified hypertension, mild pre-eclampsia, and severe pre-eclampsia/eclampsia). Propensity score techniques (e.g., inverse probability of treatment weighting) were used to adjust for self-selection into the program versus into standard of prenatal care.

RESULTS

CenteringPregnancy participants had higher odds of developing any pregnancy-induced hypertension under all specifications (OR=1.48, 95% CI=1.15, 1.92) and specifically gestational hypertension/unspecified hypertension (OR=1.76, 95% CI=1.28, 2.42) than those in standard of prenatal care. However, CenteringPregnancy participants did not experience significantly higher odds of mild pre-eclampsia (OR=1.06, 95% CI=0.65, 1.78) and severe pre-eclampsia/eclampsia (OR=1.21, 95% CI=0.78, 1.89) compared with standard of prenatal care participants.

CONCLUSIONS

Participation in CenteringPregnancy was associated with higher odds of pregnancy-induced hypertension, particularly gestational hypertension, than participation in standard of prenatal care. Additional research is warranted to definitely rule out selection bias and identify contributing factor(s) that increased pregnancy-induced hypertension despite efforts to improve pregnancy-related health outcomes among CenteringPregnancy participants.

Using Community-Based Participatory Research to Design a Patient and Practitioner-Centered Group Prenatal Care Model

In response to disproportionately high rates of infant mortality and preterm birth among women of color and women in poverty in Fresno County, California, community and academic partners coordinated a community-based participatory research (CBPR) project with local residents. Social isolation and stress, inaccessible prenatal care, and dissatisfaction with care experiences were identified as leading predictors of poor birth outcomes. The PRECEDE-PROCEED framework was used to lead the CBPR effort that resulted in the development of a model of group prenatal care, named Glow! Group Prenatal Care Program (Glow! Program). Group prenatal care (GPNC), which focuses on pregnancy health assessments, education, and peer support, has the potential to address the health and social priorities of women during pregnancy. As a result of the employed CBPR process and the extensive participation from stakeholders, this modified GPNC model responds to the unique needs of the at-risk community members, the agencies aiming to improve maternal-child health experiences and outcomes, and the prenatal care providers offering it to their patients. The methods from this study can be applied in the design and implementation of community-based health care interventions. Returning to community partners throughout the design, implementation, and evaluation phases underscored that health care interventions cannot be designed in silos, and require flexibility to respond to factors that promote improved maternal and infant outcomes, which affect the end goal for the intervention.

Postpartum resolution of hypertension, proteinuria and acute kidney injury among women with preeclampsia and severe features at Mulago National Referral Hospital, Uganda: a cohort study

Background

The resolution of hypertension, proteinuria and AKI postpartum among women with preeclampsia is not well documented in Uganda.

Objective

To determine the time to resolution of hypertension, proteinuria and AKI postpartum until 6 weeks among women with preeclampsia in Mulago Hospital, Uganda.

Methods

Between August 2017 and April 2018, we measured blood pressure, urine protein and serum creatinine on days 1,7,21 and 42 postpartum among 86 women with preeclampsia. The primary outcomes were time to the resolution of hypertension, proteinuria and AKI. We fitted accelerated failure models using Stata 17's stintreg. command with a log normal distribution and obtained time ratios of selected exposures on time to resolution of hypertension, proteinuria and AKI intervals.

Results

The median time to resolution of hypertension, proteinuria and AKI was seven (7) days (Inter quartile range, IQR 1-21). The time to resolution of hypertension among primiparous women was 3.5 times that of multiparous women [TR 3.5, 95%CI 1.1, 11.3]. No differences were observed in resolution of hypertension, proteinuria and acute kidney injury.

Conclusion

The time to resolution of hypertension, proteinuria and AKI was seven days. We recommend larger studies with longer follow-up beyond six-weeks postpartum to inform revision of our guidelines.

Group vs Individual Prenatal Care and Gestational Diabetes Outcomes: A Secondary Analysis of a Randomized Clinical Trial

Importance

The impact of group-based prenatal care (GPNC) model in the US on the risk of gestational diabetes (GD) and related adverse obstetric outcomes is unknown.

Objective

To determine the effects of the GPNC model on risk of GD, its progression, and related adverse obstetric outcomes.

Design, Setting, and Participants

This is a single-site, parallel-group, randomized clinical trial conducted between February 2016 and March 2020 at a large health care system in Greenville, South Carolina. Participants were individuals aged 14 to 45 years with pregnancies earlier than 21 weeks' gestational age; follow-up continued to 8 weeks post partum. This study used an intention-to-treat analysis, and data were analyzed from March 2021 to July 2022.

Interventions

Eligible participants were randomized to receive either CenteringPregnancy, a widely used GPNC model, with 10 group-based sessions or traditional individual prenatal care (IPNC).

Main Outcomes and Measures

The primary outcome was the incidence of GD diagnosed between 24 and 30 weeks of gestation. The secondary outcomes included progression to A2 GD (ie, GD treated with medications) and GD-related adverse obstetric outcomes (ie, preeclampsia, cesarean delivery, and large for gestational age). Log binomial models were performed to estimate risk differences (RDs), 95% CIs, and P values between GPNC and IPNC groups, adjusting for all baseline covariates.

Results

Of all 2348 participants (mean [SD] age, 25.1 [5.4] years; 952 Black participants [40.5%]; 502 Hispanic participants [21.4%]; 863 White participants [36.8%]), 1176 participants were randomized to the GPNC group and 1174 were randomized to the IPNC group. Among all participants, 2144 (91.3%) completed a GD screening (1072 participants [91.3%] in GPNC vs 1071 [91.2%] in IPNC). Overall, 157 participants (6.7%) developed GD, and there was no difference in GD incidence between the GPNC (83 participants [7.1%]) and IPNC (74 participants [6.3%]) groups, with an adjusted RD of 0.7% (95% CI, -1.2% to 2.7%). Among participants with GD, GPNC did not reduce the risk of progression to A2 GD (adjusted RD, -6.1%; 95% CI, -21.3% to 9.1%), preeclampsia (adjusted RD, -7.9%; 95% CI, -17.8% to 1.9%), cesarean delivery (adjusted RD, -8.2%; 95% CI, -12.2% to 13.9%), and large for gestational age (adjusted RD, -1.2%; 95% CI, -6.1% to 3.8%) compared with IPNC.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial among medically low-risk pregnant individuals, the risk of GD was similar between participants who received GPNC intervention and traditional IPNC, indicating that GPNC may be a feasible treatment option for some patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02640638.

Exploring the feasibility, acceptability, and preliminary effectiveness of a culturally adapted group prenatal program, CenteringPregnancy, to reduce maternal and infant health disparities among Marshallese Pacific Islanders: A study protocol

Background

Marshallese Pacific Islanders residing in the United States have higher rates of adverse perinatal outcomes than the general population and experience numerous barriers to prenatal care. CenteringPregnancy is a group prenatal care model which occurs in the patient's community. CenteringPregnancy, when applied to the Marshallese population, presents a potentially highly successful group-based intervention that can mitigate adverse perinatal outcomes among Marshallese Pacific Islanders.

Methods

This article describes the protocol of a mixed-methods study designed to examine the feasibility, acceptability, and preliminary effectiveness of the implementation of CenteringPregnancy for Marshallese Pacific Islander women. The mixed-methods design collects qualitative and quantitative data at the onset of CenteringPregnancy and during their last session and then augments the data with post-partum data abstraction.

Conclusion

This will be the first study to culturally adapt and implement CenteringPregnancy with Marshallese pregnant women in the United States. This study will be an important first step to exploring the feasibility, acceptability, and preliminary effectiveness of CenteringPregnancy and will better prepare the research team to assess and refine the intervention moving forward.

Trial registration

This study was registered at ClinicalTrials.gov on September 22, 2020 under identifier NCT04558619 and can be accessed at https://clinicaltrials.gov/ct2/show/NCT04558619?term=K%C5%8Dmmour+Prenatal&draw=2&rank=1.

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study

BACKGROUND

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes.

OBJECTIVE

This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients.

STUDY DESIGN

This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned.

RESULTS

A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34).

CONCLUSION

There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

The Experience of Pregnant Women in the Health Management Model of Internet-Based Centering Pregnancy: A Qualitative Study

Background

CenteringPregnancy Care is a promising group prenatal care innovation that combines assessment, education, and peer support. In China, it is not clear how best to integrate the CenteringPregnancy Care into existing maternal health care models. This qualitative study aimed to explore Chinese pregnant women’s experience in the Internet-based CenteringPregnancy management model.

Methods

The Internet-based CenteringPregnancy was applied in a tertiary hospital between 2018 and 2019 in Wuhan, Hubei Province. Through purposive sampling, a total of 9 pregnant women who had experienced Internet-based CenteringPregnancy were recruited. A semi-structured interview was used to collect qualitative data, and Colaizzi’s 7-step method of phenomenological data analysis was used to analyze the collected data.

Results

Three themes were extracted from the participants’ interviews, including: 1) empowerment; 2) psychological and social support; 3) challenges of the Internet-based CenteringPregnancy. The Internet-based CenteringPregnancy management model retained advantages of CenteringPregnancy, emphasizing the pregnant woman as the subject of health care and promoting them to participate in health care. Participants believed that they could exchange pregnancy knowledge, help each other, and improve mood both timely and efficiently from the new model. However, it was found that there were challenges in seminar time arrangement, topic selection, and discussion management.

Conclusion

The Internet-based CenteringPregnancy management model positively affected pregnant women’s empowerment, psychological, and social support. It is recommended to improve the seminar’s design in future studies.

"When I think of mental healthcare, I think of no care." Mental Health Services as a Vital Component of Prenatal Care for Black Women

PURPOSE

Black people give birth joyously despite disproportionate rates of adverse perinatal outcomes. Given that group prenatal care shows promise in mitigating these inequities, we sought to solicit the opinions of Black peripartum women on how group prenatal care could be tailored to fit their specific needs. In this study, we describe attitudes about a proposed Black group prenatal care in a single focus group of 11 Black women who receive maternal health services from Black Infant Health (BIH, a state and federal funded state-wide program for Black pregnant people with the goal to improve infant and maternal health). These data were used to design a race-conscious group prenatal care curriculum specifically for Black women at UCSF.

DESCRIPTION

This study was an analysis of focus group data generated as part of a larger project focused on community involvement in Black maternal health. English speaking pregnant or recently postpartum women age 18 or older who receive services from BIH were recruited to participated in the focus group analyzed in this study. All facilitators of the focus group were Black women in order to facilitate candid conversation about racism in prenatal care.

ASSESSMENT

The need for mental health care was common thread underlying all conversations about prenatal health improvements desired by our focus groups. Participants expressed the centrality of mental health access during our discussion of other themes (e.g.: ease of access, inclusion of partners, special classes for teen moms) by discussing them in terms of their relationship to mental health. Our participants' clear expression of the centrality of mental health care to their prenatal health guided our decision to focus on mental health as a necessary pillar of any group prenatal care intervention designed to mitigate perinatal healthcare disparities in this paper. Three themes related to mental health integration into group prenatal care emerged from thematic analysis of the transcripts. Participants expressed insufficient access and advocacy, and provider distrust.

CONCLUSION

Evidence exists supporting group prenatal care as a tool for mitigation of perinatal health disparities among Black women. There is also a large body of data describing the disproportionate burden of mental health needs among Black women. The rich data we present here from Black women on their desire for the integration of these two needs fits well into the parallel conversation occurring in the literature. To our knowledge, this is the first study investigating desires of Black women regarding group prenatal care designed specifically for them. They expressed a strong desire for more access to mental health care providers who are racially conscious and aware of white supremacy, and nuanced opinions on the role of racial concordance in health equity.

A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes

BACKGROUND

There are marked disparities between black and nonblack women in the United States in birth outcomes. Yet, there are little data on methods to reduce these disparities. Although the cause of racial disparities in health is multifactorial, implicit bias is thought to play a contributing role. To target differential management, studies in nonobstetrical populations have demonstrated disparity reduction through care standardization. With wide variation by site and provider, labor management practices are the ideal target for standardization.

OBJECTIVE

In this study, we aimed to evaluate the effect of a standardized induction of labor protocol on racial disparities in cesarean delivery rate and maternal and neonatal morbidity.

STUDY DESIGN

We performed a prospective cohort study of women undergoing an induction from 2013 to 2015. Full-term (≥37 weeks' gestation) women carrying a singleton pregnancy with intact membranes and an unfavorable cervix (dilation ≤2 cm, Bishop score of ≤6) were included. We compared the cesarean delivery rate and maternal and neonatal morbidity between 2 groups stratified by race (black vs nonblack) as follows: (1) women induced in a randomized trial (n=491) that utilized an induction protocol with standardized recommendations for interventions such as oxytocin and amniotomy at particular time points and (2) women in an observational arm (n=364) enrolled at the same time whose induction and labor management occurred at provider discretion. Regression modeling was used to test an interaction between the induction protocol and race.

RESULTS

A significant reduction in cesarean delivery rate in black women managed with the induction protocol was noted when compared with those in the observational group (25.7% vs 34.2%; P=.02), whereas there was no difference in cesarean delivery rate in nonblack women (34.6% vs 29.9%; P=.41). The induction protocol reduced the racial disparity in cesarean delivery rate (interaction term, P=.04), even when controlling for parity, body mass index, indication for labor induction, and Bishop score at induction start. In addition, a significant reduction in neonatal morbidity was found in black women managed with the induction protocol (2.9% vs 8.9%; P=.001), with no difference in nonblack women (3.6% vs 5.5%; P=.55). The induction protocol did not significantly affect maternal morbidity for either race.

CONCLUSION

A standardized induction protocol is associated with reduced cesarean delivery rate and neonatal morbidity in black women undergoing induction. Further studies should determine whether implementation of induction protocols in diverse settings could reduce national racial disparities in obstetrical outcomes.

Effectiveness of integrative medicine group visits in chronic pain and depressive symptoms: A randomized controlled trial

BACKGROUND

Current treatment options for chronic pain and depression are largely medication-based, which may cause adverse side effects. Integrative Medical Group Visits (IMGV) combines mindfulness techniques, evidence based integrative medicine, and medical group visits, and is a promising adjunct to medications, especially for diverse underserved patients who have limited access to non-pharmacological therapies.

OBJECTIVE

Determine the effectiveness of IMGV compared to a Primary Care Provider (PCP) visit in patients with chronic pain and depression.

DESIGN

9-week single-blind randomized control trial with a 12-week maintenance phase (intervention-medical groups; control-primary care provider visit).

SETTING

Academic tertiary safety-net hospital and 2 affiliated federally-qualified community health centers.

PARTICIPANTS

159 predominantly low income racially diverse adults with nonspecific chronic pain and depressive symptoms.

INTERVENTIONS

IMGV intervention- 9 weekly 2.5 hour in person IMGV sessions, 12 weeks on-line platform access followed by a final IMGV at 21 weeks.

MEASUREMENTS

Data collected at baseline, 9, and 21 weeks included primary outcomes depressive symptoms (Patient Health Questionnaire 9), pain (Brief Pain Inventory). Secondary outcomes included pain medication use and utilization.

RESULTS

There were no differences in pain or depression at any time point. At 9 weeks, the IMGV group had fewer emergency department visits (RR 0.32, 95% CI: 0.12, 0.83) compared to controls. At 21 weeks, the IMGV group reported reduction in pain medication use (Odds Ratio: 0.42, CI: 0.18-0.98) compared to controls.

LIMITATIONS

Absence of treatment assignment concealment for patients and disproportionate group attendance in IMGV.

CONCLUSION

Results demonstrate that low-income racially diverse patients will attend medical group visits that focus on non-pharmacological techniques, however, in the attention to treat analysis there was no difference in average pain levels between the intervention and the control group.

TRIAL REGISTRATION

clinicaltrials.gov NCT02262377.

Group Prenatal Care Attendance and Women's Characteristics Associated with Low Attendance: Results from Centering and Racial Disparities (CRADLE Study)

OBJECTIVES

Group prenatal care (GPC), an alternative to individual prenatal care (IPC), is becoming more prevalent. This study aimed to describe the attendance and reasons of low attendance among pregnant women who were randomly assigned to receive GPC or IPC and explore the maternal characteristics associated with low-attendance.

METHODS

This study was a descriptive study among Medically low risk pregnant women (N = 992) who were enrolled in an ongoing prospective study. Women were randomly assigned to receive CenteringPregnany GPC (N = 498) or IPC (N = 994) in a single clinical site The attendance frequency and reason for low-attendance (i.e. ≤ 5/10 sessions in GPC or ≤ 5 visits in IPC) were described separately in GPC and IPC. Multivariable logistic regressions were performed to explore the associations between maternal characteristics and low-attendance.

RESULTS

On average, women in GPC attended 5.32 (3.50) sessions, with only 6.67% attending all 10 sessions. Low-attendance rate was 34.25% in GPC and 10.09% in IPC. The primary reasons for low-attendance were scheduling barriers (23.19%) and not liking GPC (16.43%) in GPC but leaving the practice (34.04%) in IPC. In multivariable analysis, lower perceived family support (P = 0.01) was positively associated with low-attendance in GPC, while smoking in early pregnancy was negatively associated low-attendance (P = 0.02) in IPC.

CONCLUSIONS FOR PRACTICE

Scheduling challenges and preference for non-group settings were the top reasons for low-attendance in GPC. Changes may need to be made to the current GPC model in order to add flexibility to accommodate women's schedules and ensure adequate participation.

TRIAL REGISTRATION

NCT02640638 Date Registered: 12/20/2015.

Pockets of progress amidst persistent racial disparities in low birthweight rates

Racial disparities persist in adverse perinatal outcomes such as preterm birth, low birthweight (LBW), and infant mortality across the U.S. Although pervasive, these disparities are not universal. Some communities have experienced significant improvements in black (or African American) birth outcomes, both in absolute rates and in rate ratios relative to whites. This study assessed county-level progress on trends in black and white LBW rates as an indicator of progress toward more equal birth outcomes for black infants. County-level LBW data were obtained from the 2003 to 2013 U.S. Natality files. Black LBW rates, black-white rate ratios and percent differences over time were calculated. Trend lines were first assessed for significant differences in slope (i.e., converging, diverging, or parallel trend lines). For counties with parallel trend lines, intercepts were tested for statistically significant differences (sustained equality vs. persistent disparities). To assess progress, black LBW rates were compared to white LBW rates, and the trend lines were tested for significant decline. Each county's progress toward black-white equality was ultimately categorized into five possible trend patterns (n = 408): (1) converging LBW rates with reductions in the black LBW rate (decreasing disparities, n = 4, 1%); (2) converging LBW rates due to worsening white LBW rates (n = 5, 1%); (3) diverging LBW rates (increasing disparities, n = 9, 2%); (4) parallel LBW rates (persistent disparities, n = 373, 91%); and (5) overlapping trend lines (sustained equality, n = 18, 4%). Only four counties demonstrated improvement toward equality with decreasing black LBW rates. There is significant county-level variation in progress toward racial equality in adverse birth outcomes such as low birthweight. Still, some communities are demonstrating that more equitable outcomes are possible. Further research is needed in these positive exemplar communities to identify what works in accelerating progress toward more equal birth outcomes.

Investigating Black-White disparities in gynecologic oncology: Theories, conceptual models, and applications

Within gynecologic oncology are two of the top five widest Black-White mortality gaps among all cancer diagnoses in the United States. A rich body of work from the social sciences, including anthropology, sociology and social epidemiology, have broadened the understanding of and research approaches to the study of health and healthcare inequity experienced by Black Americans. Yet, these intellectual advancements in understanding are virtually absent from the gynecologic oncology literature. The goal of this analytic essay will be to introduce three current frameworks of studying racial inequity: The Ecosocial Theory of Disease Distribution, The Fundamental Cause Theory, and The Public Health Critical Race Praxis. Applications of each conceptual model to gynecologic oncology are illustrated. The Ecosocial Theory, in particular the concept of embodiment, can be used to design and interpret racial differences in molecular and genetic studies. The Fundamental Cause Theory explains the relationship of socioeconomic position with the evolving treatability of a given disease over time, and provides understanding to the contrast in racial disparities within ovarian, endometrial, and cervical cancers. The Public Health Critical Race Praxis is an iterative methodology that helps frame how to study the impact of racism on healthcare delivery. Different analytic approaches that account for the interaction of race and socioeconomic factors are reviewed. Finally, considerations for racial equity research in gynecologic oncology are proposed.

Occupational Health in Community Health Centers: Practitioner Challenges and Recommendations

Primary care clinicians may be the only source of occupational healthcare for many low-wage, high-risk workers who experience disproportionate occupational hazards. The authors explored barriers to providing occupational healthcare and recommendations for overcoming these challenges. The team conducted six focus groups and eleven key-informant interviews in two community health centers and among clinicians, community health workers, and other personnel from similar settings. Clinicians reported not utilizing occupational information during clinical encounters and identified competing priorities, limited appointment time, and lack of training as key barriers. They cited workers' compensation as a source of confusion and frustration. However, most participants recognized occupation as an important social determinant of health and expressed interest in additional training and resources. Participants agreed that referral mechanisms for occupational medicine specialists and worker centers and changes in quality performance measures and electronic health records would be useful and that workers' compensation and immigration policies need reform.