Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

Reduced Compared With Traditional Schedules for Routine Antenatal Visits: A Systematic Review

OBJECTIVE

To assess differences in maternal and child outcomes in studies comparing reduced routine antenatal visit schedules with traditional schedules.

DATA SOURCES

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, searching for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS

Five randomized controlled trials and five nonrandomized comparative studies compared reduced routine antenatal visit schedules with traditional schedules. Studies did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight. There was insufficient evidence for numerous prioritized outcomes of interest, including completion of the American College of Obstetricians and Gynecologists-recommended services and patient experience measures.

CONCLUSION

The evidence base is limited and heterogeneous and allowed few specific conclusions. Reported outcomes included, for the most part, standard birth outcomes that do not have strong plausible biological connection to structural aspects of antenatal care. The evidence did not find negative effects of reduced routine antenatal visit schedules, which may support implementation of fewer routine antenatal visits. However, to enhance confidence in this conclusion, future research is needed, particularly research that includes outcomes of most importance and relevance to changing antenatal care visits.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

Televisits Compared With In-Person Visits for Routine Antenatal Care: A Systematic Review

OBJECTIVE

To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care.

DATA SOURCES

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS

Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82-1.28) or preterm births (summary OR 0.93, 95% CI 0.84-1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported.

CONCLUSION

People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

Frequency Of pRenatal CAre viSiTs (FORCAST): study protocol to develop a core outcome set for prenatal care schedules

BACKGROUND

Prenatal care, one of the most common preventive care services in the United States, endeavors to improve pregnancy outcomes through evidence-based screenings and interventions. Despite the prevalence of prenatal care and its importance to maternal and infant health, there are several debates about the best methods of prenatal care delivery, including the most appropriate schedule frequency and content of prenatal visits. Current U.S. national guidelines recommend that low-risk individuals receive a standard schedule of 12 to 14 in-office visits, a care delivery model that has remained unchanged for almost a century.

OBJECTIVE

In early 2020, to mitigate individuals' exposure to the SARS-CoV-2 virus, prenatal care providers implemented new paradigms that altered the schedule frequency, interval, and modality (e.g., telemedicine) of how prenatal care services were offered. In this manuscript, we describe development of a core outcome set (COS) that can be used to evaluate the effect of the frequency of prenatal care schedules on maternal and infant outcomes.

METHODS

We will systematically review the literature to identify previously reported outcomes important to individuals who receive prenatal care and the people who care for them. Stakeholders with expertise in prenatal care delivery (i.e., patients/family members, healthcare providers, and public health professionals and policymakers) will rate the importance of identified outcomes in an online survey using a three-round Delphi process. A virtual consensus meeting will be held for a group of stakeholder representatives to discuss and vote on the outcomes to include in the final COS.

RESULTS

The Delphi survey was initiated in July 2022 with 71 stakeholders invited. A virtual consensus conference was conducted on October 11, 2022. Data is currently under analysis with plans to submit in a subsequent manuscript.

CONCLUSIONS

More research about the optimal schedule frequency and modality for prenatal care delivery is needed. Standardizing outcomes that are measured and reported in evaluations of the recommended prenatal care schedules will assist evidence synthesis and results reported in systematic reviews and meta-analyses. Overall, this COS will expand the consistency and patient-centeredness of reported outcomes for various prenatal care delivery schedules and modalities, hopefully improving the overall efficacy of recommended care delivery for pregnant people and their families.

CLINICALTRIAL

This study was registered in the Core Outcome Measures for Effectiveness (COMET) database on January 18, 2022, registration #2021 http://www.comet-initiative.org/Studies/Details/2021.

Experiences With Prenatal Care Delivery Reported by Black Patients With Low Income and by Health Care Workers in the US: A Qualitative Study

IMPORTANCE

Black pregnant people with low income face inequities in health care access and outcomes in the US, yet their voices have been largely absent from redesigning prenatal care.

OBJECTIVE

To examine patients' and health care workers' experiences with prenatal care delivery in a largely low-income Black population to inform care innovations to improve care coordination, access, quality, and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

For this qualitative study, human-centered design-informed interviews were conducted at prenatal care clinics with 19 low-income Black patients who were currently pregnant or up to 1 year post partum and 19 health care workers (eg, physicians, nurses, and community health workers) in Detroit, Michigan, between October 14, 2019, and February 7, 2020. Questions focused on 2 human-centered design phases: observation (understanding problems from the end user's perspective) and ideation (generating novel potential solutions). Questions targeted participants' experiences with the 3 goals of prenatal care: medical care, anticipatory guidance, and social support. An eclectic analytic strategy, including inductive thematic analysis and matrix coding, was used to identify promising strategies for prenatal care redesign.

MAIN OUTCOMES AND MEASURES

Preferences for prenatal care redesign.

RESULTS

Nineteen Black patients (mean [SD] age, 28.4 [5.9] years; 19 [100%] female; and 17 [89.5%] with public insurance) and 17 of 19 health care workers (mean [SD] age, 47.9 [15.7] years; 15 female [88.2%]; and 13 [76.5%] Black) completed the surveys. A range of health care workers were included (eg, physicians, doulas, and social workers). Although all affirmed the 3 prenatal care goals, participants reported failures and potential solutions for each area of prenatal care delivery. Themes also emerged in 2 cross-cutting areas: practitioners and care infrastructure. Participants reported that, ideally, care structure would enable strong ongoing relationships between patients and practitioners. Practitioners would coordinate all prenatal services, not just medical care. Finally, care would be tailored to individual patients by using care navigators, flexible models, and colocation of services to reduce barriers.

CONCLUSIONS AND RELEVANCE

In this qualitative study of low-income, Black pregnant people in Detroit, Michigan, and the health care workers who care for them, prenatal care delivery failed to meet many patients' needs. Participants reported that an ideal care delivery model would include comprehensive, integrated services across the health care system, expanding beyond medical care to also include patients' social needs and preferences.

Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations: A Practical Guide for Maternity Care Clinicians

Prenatal care is an important preventive service designed to improve the health of pregnant patients and their infants. Prenatal care delivery recommendations have remained unchanged since 1930, when the 12-14 in-person visit schedule was first established to detect preeclampsia. In 2020, the American College of Obstetricians and Gynecologists, in collaboration with the University of Michigan, convened a panel of maternity care experts to determine new prenatal care delivery recommendations. The panel recognized the need to include emerging evidence and experience, including significant changes in prenatal care delivery during the COVID-19 pandemic, pre-existing knowledge of the importance of individualized care plans, the promise of telemedicine, and the significant influence of social and structural determinants of health (SSDoH) on pregnancy outcomes. Recommendations were derived using the RAND-UCLA appropriateness method, a rigorous e-Delphi method, and are designed to extend beyond the acute public health crisis. The resulting Michigan Plan for Appropriate Tailored Healthcare in pregnancy (MiPATH) includes recommendations for key aspects of prenatal care delivery: (1) the recommended number of prenatal visits, (2) the frequency of prenatal visits, (3) the role of monitoring routine pregnancy parameters (blood pressure, fetal heart tones, weight, and fundal height), (4) integration of telemedicine into routine care, and (5) inclusion of (SSDoH). Resulting recommendations demonstrate a new approach to prenatal care delivery that incorporates medical, SSDoH, and patient preferences, to develop individualized prenatal care delivery plans. The purpose of this document is to outline the new MiPATH recommendations and to provide practical guidance on implementing them in routine practice.

"Mourning the Experience of What Should Have Been": Experiences of Peripartum Women During the COVID-19 Pandemic

OBJECTIVES

The ongoing COVID-19 pandemic may significantly affect the peripartum experience; however, little is known about the perceptions of women who gave birth during the COVID-19 pandemic. Thus, the purpose of our study was to describe the peripartum experiences of women who gave birth during the COVID-19 pandemic in the United States.

METHODS

Using a cross-sectional design, we collected survey data from a convenience sample of postpartum women recruited through social media. Participants were 18 years of age or older, lived in the United States, gave birth after February 1, 2020, and could read English. This study was part of the COVID-19 Maternal Attachment, Mood, Ability, and Support study, which was a larger study that collected survey data describing maternal mental health and breastfeeding during the COVID-19 pandemic. This paper presents findings from the two free-text items describing peripartum experiences. Using the constant comparative method, responses were thematically analyzed to identify and collate major and minor themes.

RESULTS

371 participants responded to at least one free-text item. Five major themes emerged: (1) Heightened emotional distress; (2) Adverse breastfeeding experiences; (3) Unanticipated hospital policy changes shifted birthing plans; (4) Expectation vs. reality: "mourning what the experience should have been;" and (5) Surprising benefits of the COVID-19 pandemic to the delivery and postpartum experience.

CONCLUSIONS FOR PRACTICE

Peripartum women are vulnerable to heightened stress induced by COVID-19 pandemic sequalae. During public health crises, peripartum women may need additional resources and support to improve their mental health, wellbeing, and breastfeeding experiences.

The Michigan Plan for Appropriate Tailored Health Care in Pregnancy Prenatal Care Recommendations

OBJECTIVE

To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare) in pregnancy panel process and key recommendations for prenatal care delivery.

METHODS

We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine).

RESULTS

The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices.

CONCLUSION

The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

Enhanced Recovery after Surgery for Cesarean Delivery Decreases Length of Hospital Stay and Opioid Consumption: A Quality Improvement Initiative

OBJECTIVE

The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption.

STUDY DESIGN

This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation.

RESULTS

A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05).

CONCLUSION

A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective.

KEY POINTS

· Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.. · Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.. · Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use)..

Impact of 4 Components of Instructional Design Video on Medical Student Medical Decision Making During the Inpatient Rounding Experience

INTRODUCTION

The Four Components of Instructional Design (4C-ID) Model has been used to teach Medical Decision Making (MDM), a core competency recognized by the Liaison Committee for Medical Education. 4 Components of Instructional Design (4C-ID) has been applied in general medical education, but not the inpatient clerkship setting. A 4C-ID video for inpatient rounding, like postpartum rounding in Ob/Gyn, could help improve MDM on busy services.

METHODS

Students in the third year Ob/Gyn clerkship were randomized by clerkship group to receive a 20-minute postpartum rounding video, based on 4C-ID principles, or usual teaching. MDM and knowledge were assessed pre-/postintervention with the Diagnostic Thinking Inventory and a case-based evaluation. Satisfaction was assessed with Likert style questions.

RESULTS

Seventy-eight students were randomized (36 control, 42 intervention). Both groups had equal baseline measures of MDM and knowledge, and similar postclerkship MDM. The intervention group demonstrated higher knowledge postclerkship (17.1, 22.6 p < 0.001). Students in the intervention felt prepared by the video, and would recommend it. Students in the control group reported higher satisfaction with their postpartum rounding experience (3.9, 3.5 p = 0.04).

DISCUSSION

Videos are easy to incorporate teaching platforms for medical students, however, the 4C-ID based video in this study did not increase student MDM. In addition, educators should use caution when integrating video into coursework as use of video may lead to decreased student satisfaction as it did in this study.

Better late than never: why obstetricians must implement enhanced recovery after cesarean

Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for the millions of women who will experience a cesarean delivery each year. Enhanced recovery after surgery, a standardized, evidence-based, interdisciplinary protocol, has been successfully used in other surgical specialties including gynecology to improve quality of care and patient satisfaction while reducing overall health care costs through reduced length of stay. Enhanced recovery after surgery society guidelines for cesarean delivery were just released in August 2018. Obstetric patients, who face the dual challenge of being postpartum and postoperative, could benefit greatly from protocols that optimize their return to physiological function and reduce surgical morbidity. Although enhanced recovery after surgery has been widespread in other surgical specialties, uptake of this protocol in obstetrics has lagged behind. We believe enhanced recovery after surgery for cesarean delivery can effectively address 3 challenges faced by obstetrician/gynecologists. These are: (1) improving care for the high number of women undergoing cesarean deliveries; (2) using evidence-based care bundles to prevent maternal morbidity and mortality, address disparities, and reduce costs; and (3) limiting postoperative opioid prescribing in response to the opioid crisis. Enhanced recovery after surgery for cesarean delivery and other standardized care protocols have the potential to reduce the disproportionately high rates of maternal morbidity and mortality in the United States, and ensure all patients, regardless of demographics or location, receive the same level of high-quality peripartum care.