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Arrington LA, Kramer B, Ogunwole SM, Harris TL, Dankwa L, Knight S, Creanga AA, Bower KM. Interrupting false narratives: applying a racial equity lens to healthcare quality data. BMJ Qual Saf 2024; 33:340-344. [PMID: 38216312 DOI: 10.1136/bmjqs-2023-016612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/08/2023] [Indexed: 01/14/2024]
Affiliation(s)
| | - Briana Kramer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Lois Dankwa
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Andreea A Creanga
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly M Bower
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Stierman EK, Kramer B, Bower KM, Creanga AA. A call to address teamwork and patient safety culture in hospital maternity units: findings from a survey of maternal healthcare professionals in Maryland. Am J Obstet Gynecol MFM 2024; 6:101274. [PMID: 38184012 DOI: 10.1016/j.ajogmf.2024.101274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/13/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Affiliation(s)
- Elizabeth K Stierman
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205.
| | - Briana Kramer
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205
| | - Kelly M Bower
- Johns Hopkins University School of Nursing in Baltimore, MD
| | - Andreea A Creanga
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Stierman EK, O'Brien BT, Stagg J, Ouk E, Alon N, Engineer LD, Fabiyi CA, Liu TM, Chew E, Benishek LE, Harding B, Terhorst RG, Latif A, Berenholtz SM, Mistry KB, Creanga AA. Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas. Qual Manag Health Care 2023; 32:177-188. [PMID: 36913770 PMCID: PMC10290572 DOI: 10.1097/qmh.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.
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Affiliation(s)
- Elizabeth K Stierman
- Departments of International Health (Drs Stierman and Creanga) and Health Policy and Management (Drs Engineer and Berenholtz), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Oklahoma Perinatal Quality Improvement Collaborative, Oklahoma City, (Mss O'Brien and Ouk); The University of Oklahoma Health Sciences Center, Oklahoma City (Mss O'Brien and Ouk); Community Health Improvement Division, Texas Department of State Health Services, Austin (Ms Stagg); Alliance for Innovation on Maternal Health, American College of Obstetricians and Gynecologists, Washington, District of Columbia (Ms Alon); Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs Engineer, Benishek, Latif, and Berenholtz, Ms Liu, and Mr Terhorst); Departments of Anesthesiology and Critical Care Medicine (Drs Engineer, Benishek, Latif, and Berenholtz) and Gynecology and Obstetrics (Dr Creanga), Johns Hopkins School of Medicine, Baltimore, Maryland; and Agency for Healthcare Research and Quality, Rockville, Maryland (Drs Fabiyi and Mistry and Mss Chew and Harding)
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Creanga AA, Dohlsten MA, Stierman EK, Moran AC, Mary M, Katwan E, Maliqi B. Maternal health policy environment and the relationship with service utilization in low- and middle-income countries. J Glob Health 2023; 13:04025. [PMID: 36892948 PMCID: PMC9997690 DOI: 10.7189/jogh.13.04025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
Background The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using χ2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Creanga AA, Connery HS, Gray KJ, Vine SM, Jones HE, Bateman BT. Postpartum Opioid-Related Mortality in Patients With Public Insurance. Obstet Gynecol 2023; 141:657-665. [PMID: 36897177 PMCID: PMC10125002 DOI: 10.1097/aog.0000000000005115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/15/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To assess the incidence and risk factors for postpartum opioid overdose death and describe other causes of postpartum death in individuals with opioid use disorder (OUD). METHODS We conducted a cohort study that used health care utilization data from the Medicaid Analytic eXtract linked to the National Death Index in the United States from 2006 to 2013. All pregnant individuals with live births or stillbirths and continuous enrollment for 3 months before delivery were eligible, including 4,972,061 deliveries. A subcohort of individuals with a documented history of OUD in the 3 months before delivery was identified. We estimated the cumulative incidence of death as occurring between delivery and 1 year postpartum among all individuals and individuals with OUD. Risk factors for opioid overdose death were assessed using odds ratios (ORs) and descriptive statistics, including demographics, health care utilization, obstetric conditions, comorbidities, and medications. RESULTS The incidence of postpartum opioid overdose death per 100,000 deliveries was 5.4 (95% CI 4.5-6.4) among all individuals and 118 (95% CI 84-163) among individuals with OUD. Individuals with OUD had a sixfold higher incidence of all-cause postpartum death than all individuals. Common causes of death in individuals with OUD were other drug- and alcohol-related deaths (47/100,000), suicide (26/100,000), and other injuries, including accidents and falls (33/100,000). Risk factors strongly associated with postpartum opioid overdose death included mental health and other substance use disorders. Among patients with OUD, postpartum use of medication to treat OUD was associated with 60% lower odds of opioid overdose death (OR 0.4, 95% CI 0.1-0.9). CONCLUSION Postpartum individuals with OUD have a high incidence of postpartum opioid overdose death and other preventable deaths, including nonopioid substance-related injuries, accidents, and suicide. Use of medications for OUD is strongly associated with lower opioid-related mortality.
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Affiliation(s)
- Elizabeth A Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health, and the Department of Psychiatry, Harvard Medical School, Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts; the Departments of International Health and Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Mary M, Maliqi B, Stierman EK, Dohlsten MA, Moran AC, Katwan E, Creanga AA. Assessing the neonatal health policy landscape in low- and middle-income countries: Findings from the 2018 WHO SRMNCAH policy survey. J Glob Health 2023; 13:04024. [PMID: 36867415 PMCID: PMC9983710 DOI: 10.7189/jogh.13.04024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Background We aimed to describe the availability of newborn health policies across the continuum of care in low- and middle-income countries (LMICs) and to assess the relationship between the availability of newborn health policies and their achievement of global Sustainable Development Goal and Every Newborn Action Plan (ENAP) neonatal mortality and stillbirth rate targets in 2019. Methods We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) Policy Survey and extracted key newborn health service delivery and cross-cutting health systems policies that align with the WHO health system building blocks. We constructed composite measures to represent packages of newborn health policies for five components along the continuum of care: antenatal care (ANC), childbirth, postnatal care (PNC), essential newborn care (ENC), and management of small and sick newborns (SSNB). We used descriptive analyses to present the differences in the availability of newborn health service delivery policies by World Bank income group in 113 LMICs. We employed logistic regression analysis to assess the relationship between the availability of each composite newborn health policy package and achievement of global neonatal mortality and stillbirth rate targets by 2019. Results In 2018, most LMICs had existing policies regarding newborn health across the continuum of care. However, policy specifications varied widely. While the availability of the ANC, childbirth, PNC, and ENC policy packages was not associated with having achieved global NMR targets by 2019, LMICs with existing policy packages on the management of SSNB were 4.4 times more likely to have reached the global NMR target (adjusted odds ratio (aOR) = 4.40; 95% confidence interval (CI) = 1.09-17.79) after controlling for income group and supporting health systems policies. Conclusions Given the current trajectory of neonatal mortality in LMICs, there is a dire need for supportive health systems and policy environments for newborn health across the continuum of care. Adoption and implementation of evidence-informed newborn health policies will be a crucial step in putting LMICs on track to meet global newborn and stillbirth targets by 2030.
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Affiliation(s)
- Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Thakkar A, Hameed AB, Makshood M, Gudenkauf B, Creanga AA, Malhamé I, Grandi SM, Thorne SA, D’Souza R, Sharma G. Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity. JACC Adv 2023; 2:100275. [PMID: 37560021 PMCID: PMC10410605 DOI: 10.1016/j.jacadv.2023.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.
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Affiliation(s)
- Aarti Thakkar
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Afshan B. Hameed
- Department of Obstetrics & Gynecology, Department of Medicine, University of California-Irvine, Irvine, California, USA
| | - Minhal Makshood
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent Gudenkauf
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia M. Grandi
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D’Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Stierman EK, Maliqi B, Mary M, Dohlsten MA, Katwan E, Moran AC, Creanga AA. Changes in the health systems and policy environment for maternal and newborn health, 2008-2018: An analysis of data from 78 low-income and middle-income countries. Soc Sci Med 2023; 321:115765. [PMID: 36801755 PMCID: PMC10024243 DOI: 10.1016/j.socscimed.2023.115765] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/31/2022] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Political, social, economic, and health system determinants play an important role in creating an enabling environment for maternal and newborn health. This study assesses changes in health systems and policy indicators for maternal and newborn health across 78 low- and middle-income countries (LMICs) during 2008-2018, and examines contextual factors associated with policy adoption and systems changes. METHODS We compiled historical data from WHO, ILO, and UNICEF surveys and databases to track changes in ten maternal and newborn health systems and policy indicators prioritized for tracking by global partnerships. Logistic regression was used to examine the odds of systems and policy change based on indicators of economic growth, gender equality, and country governance with available data from 2008 to 2018. RESULTS From 2008 to 2018, many LMICs (44/76; 57·9%) substantially strengthened systems and policies for maternal and newborn health. The most frequently adopted policies were national guidelines for kangaroo mother care, national guidelines for use of antenatal corticosteroids, national policies for maternal death notification and review, and the introduction of priority medicines in Essential Medicines Lists. The odds of policy adoption and systems investments were significantly greater in countries that experienced economic growth, had strong female labor participation, and had strong country governance (all p < 0·05). CONCLUSIONS The widespread adoption of priority policies over the past decade is a notable step in creating an environment supportive for maternal and newborn health, but continued leadership and resources are needed to ensure robust implementation that translates into improved health outcomes.
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Affiliation(s)
- Elizabeth K Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA.
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Martin Aj Dohlsten
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Elizabeth Katwan
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Allisyn C Moran
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA; Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
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Qian J, Wolfson C, Neale D, Johnson CT, Atlas R, Sheffield JS, Zadzielski E, Jones MM, Creanga AA. Evaluating a pilot, facility-based severe maternal morbidity surveillance and review program in Maryland-an American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine Rx at work. Am J Obstet Gynecol MFM 2023; 5:100888. [PMID: 36764455 DOI: 10.1016/j.ajogmf.2023.100888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Jiage Qian
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Carrie Wolfson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Donna Neale
- Howard County General Hospital, Columbia, MD
| | - Clark T Johnson
- Sinai Hospital of Baltimore, Baltimore, MD; Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD; Department of Obstetrics and Gynecology, George Washington School of Medicine and Health Sciences, Washington DC
| | | | - Jeanne S Sheffield
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Monica M Jones
- Luminis Health Anne Arundel Medical Center, Annapolis, MD
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD; Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room E8138, Baltimore, MD 21205.
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Bower KM, Kramer B, Warren N, Ahmed S, Callaghan-Koru J, Stierman E, Wilson C, Lawson S, Creanga AA. Development of an instrument to measure awareness and mitigation of bias in maternal healthcare. Am J Obstet Gynecol MFM 2023; 5:100872. [PMID: 36682457 DOI: 10.1016/j.ajogmf.2023.100872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/03/2023] [Accepted: 01/14/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. STUDY DESIGN We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). RESULTS Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals. CONCLUSION We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.
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Affiliation(s)
- Kelly M Bower
- Johns Hopkins University School of Nursing, Baltimore, MD (Drs Bower and Warren).
| | - Briana Kramer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Ms Kramer and Drs Stierman and Creanga)
| | - Nicole Warren
- Johns Hopkins University School of Nursing, Baltimore, MD (Drs Bower and Warren)
| | - Saifuddin Ahmed
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Dr Ahmed)
| | - Jennifer Callaghan-Koru
- Department of Sociology, Anthropology, and Public Health, University of Maryland, Baltimore, MD (Dr Callaghan-Koru)
| | - Elizabeth Stierman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Ms Kramer and Drs Stierman and Creanga)
| | - Cheri Wilson
- Office of Diversity, Inclusion and Health Equity, Johns Hopkins Medicine, Baltimore, MD (Ms Wilson)
| | - Shari Lawson
- Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Drs Lawson and Creanga)
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Ms Kramer and Drs Stierman and Creanga); Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Drs Lawson and Creanga)
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Wolfson C, Qian J, Chin P, Downey C, Mattingly KJ, Jones-Beatty K, Olaku J, Qureshi S, Rhule J, Silldorff D, Atlas R, Banfield A, Johnson CT, Neale D, Sheffield JS, Silverman D, McLaughlin K, Koru G, Creanga AA. Findings From Severe Maternal Morbidity Surveillance and Review in Maryland. JAMA Netw Open 2022; 5:e2244077. [PMID: 36445707 PMCID: PMC9709651 DOI: 10.1001/jamanetworkopen.2022.44077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities. OBJECTIVE To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records. EXPOSURES Hospitalization during pregnancy or within 42 days post partum. MAIN OUTCOMES AND MEASURES The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care. RESULTS A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such. CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.
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Affiliation(s)
- Carrie Wolfson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jiage Qian
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Cathy Downey
- Howard County General Hospital, Columbia, Maryland
| | | | - Kimberly Jones-Beatty
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joanne Olaku
- Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sadaf Qureshi
- Luminis Health Anne Arundel Medical Center, Annapolis, Maryland
| | | | | | | | | | - Clark T. Johnson
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Sinai Hospital of Baltimore, Baltimore, Maryland
- Department of Obstetrics and Gynecology, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Donna Neale
- Howard County General Hospital, Columbia, Maryland
| | - Jeanne S. Sheffield
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Kacie McLaughlin
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - Güneş Koru
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Fayetteville
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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12
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Wolfson C, Qian J, Creanga AA. Levels, Trends, and Risk Factors for Stillbirths in the United States: 2000-2017. Am J Perinatol 2022. [PMID: 35973798 DOI: 10.1055/a-1925-2131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study documents 2000 to 2017 trends in stillbirth rates and changes in associations between known maternal and fetal risk factors and stillbirths for 2000 to 2002 versus 2015 to 2017 in the United States. STUDY DESIGN We conducted a retrospective, population-based analysis of stillbirths and live-births using national vital statistics data. We calculated annual stillbirth rates overall and by gestational age; and examined stillbirth rates by maternal age, race-ethnicity, and state for 2000 to 2002 versus 2015 to 2017. We used Chi-squared tests to examine associations between maternal and fetal risk factors separately for early (20-27 weeks) and late (28+ weeks) stillbirths compared with live-births for 2000 to 2002 versus 2015 to 2017. RESULTS Stillbirth rates declined by 7.5% (p < 0.001) during 2000 to 2006 but remained flat at approximately 6 stillbirths per 1,000 births thereafter. Throughout 2000 to 2017, there were significant improvements in stillbirth rates at 39+ weeks nationally (p < 0.001), but rates varied greatly between and within states. Sociodemographic (advanced maternal age, Black race, low education, unmarried status, and rural residence), obstetric, and other medical factors (>3 births, use of infertility treatment, maternal obesity, diabetes, chronic hypertension, eclampsia, no prenatal care, and tobacco use) were significantly more prevalent in women with late than early stillbirths or live births. Notably, late and total stillbirth rates were approximately 30% higher for women >35 years than for women <35 years and twice as high for non-Hispanic Black than non-Hispanic White women; American Indian/Alaska Native women represented the only racial-ethnic group with significantly higher late stillbirth rates in 2015 to 2017 than in 2000 to 2002. Pregnancy and fetal factors (multiple pregnancy, male fetus, and breech presentation) were more prevalent in women with early than late stillbirths or live births. CONCLUSION U.S. stillbirth rates have plateaued since 2006. There are persistent differential risk profiles for early versus late stillbirths which can inform stillbirth prevention strategies (e.g., close observation of women with risk factors for stillbirth) and new research into the causes of stillbirths by gestational age. KEY POINTS · U.S. stillbirth rates have plateaued since 2006.. · Stillbirth rates vary between and within U.S. states and by maternal and fetal factors.. · Early versus late stillbirths have different risk profiles which can guide stillbirth prevention strategies..
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Affiliation(s)
- Carrie Wolfson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jiage Qian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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13
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Affiliation(s)
- Andreea A Creanga
- From the Departments of International Health and Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, and the Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine - both in Baltimore (A.A.C.); the Mother Infant Research Institute, Tufts Medical Center, and the Department of Obstetrics and Gynecology, Tufts University School of Medicine - both in Boston (P.M.C.); and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA (B.T.B.)
| | - Patrick M Catalano
- From the Departments of International Health and Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, and the Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine - both in Baltimore (A.A.C.); the Mother Infant Research Institute, Tufts Medical Center, and the Department of Obstetrics and Gynecology, Tufts University School of Medicine - both in Boston (P.M.C.); and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA (B.T.B.)
| | - Brian T Bateman
- From the Departments of International Health and Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, and the Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine - both in Baltimore (A.A.C.); the Mother Infant Research Institute, Tufts Medical Center, and the Department of Obstetrics and Gynecology, Tufts University School of Medicine - both in Boston (P.M.C.); and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA (B.T.B.)
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14
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Callaghan-Koru JA, Wahid I, Lawson SM, Bower KM, Wilburn CS, Creanga AA. Maternal Warning Signs Education During Home Visiting: Results from a Formative Evaluation in Maryland. Women's Health Reports 2022; 3:633-642. [PMID: 35982773 PMCID: PMC9380880 DOI: 10.1089/whr.2022.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
Abstract
Background: Maternal mortality rate reviews have identified the need for improved patient education regarding the warning signs of maternal complications to reduce preventable deaths. Maternal and child home visiting programs have the potential to deliver this education in communities. Aims: This study sought to evaluate the baseline provision of warning signs education among home visiting programs in Maryland and to assess the acceptability of and preferences for warning signs education materials among program staff. Materials and Methods: This sequential exploratory, mixed-methods study included qualitative interviews and focus group discussions followed by a web-based survey of all home visiting programs providing early postpartum visits in Maryland. Results: Twenty-five home visiting program staff took part in qualitative data collection, and survey responses were submitted by a manager from 40 of 58 eligible home visiting programs (69% response rate). All survey respondents agreed that home visiting programs should provide warning signs education and more than 80% of programs provided some warning signs education during pregnancy and the postpartum period. Printed pamphlets were provided by 68% of programs for pregnancy complications and 43% for postpartum complications. Only 33% of respondents were satisfied with their existing warnings signs education materials; 98% were interested in new illustrated pamphlets and 88% were interested in education videos. Qualitative participants considered pamphlets with simple designs, limited text, and visuals, as the most accessible for home visiting clients. Conclusions: There are opportunities to strengthen and expand warning signs education in Maryland through home visiting programs using new printed and video education materials.
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Affiliation(s)
- Jennifer A. Callaghan-Koru
- Department of Sociology, Anthropology, and Public Health, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Inaya Wahid
- Department of Sociology, Anthropology, and Public Health, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Shari M. Lawson
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly M. Bower
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Colleen S. Wilburn
- Maternal and Child Health Bureau, Maryland Department of Health, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Kwapong YA, Boakye E, Obisesan OH, Shah LM, Ogunwole SM, Hays AG, Blumenthal RS, Creanga AA, Blaha MJ, Cainzos-Achirica M, Nasir K, Douglas PS, Wang X, Sharma G. Nativity-Related Disparities in Preterm Birth and Cardiovascular Risk in a Multiracial U.S. Cohort. Am J Prev Med 2022; 62:885-894. [PMID: 35597568 DOI: 10.1016/j.amepre.2021.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Having a preterm birth is associated with future cardiovascular risk. Non-Hispanic Black women have higher rates of preterm birth than non-Hispanic White and Hispanic women, but nativity-related disparities in preterm birth are not well understood. METHODS Data from 6,096 women in the Boston Birth Cohort: non-Hispanic Black (2,699), non-Hispanic White (997), or Hispanic (2,400), were analyzed in June 2021. Differences in cardiovascular risk factors were assessed. The association of preterm birth with nativity and duration of U.S. residence were investigated using multivariable logistic regression. RESULTS U.S.-born women in all 3 racial-ethnic groups had a higher prevalence of obesity, smoking, and severe stress than foreign-born women. Foreign-born non-Hispanic Black and Hispanic women had lower odds of preterm birth than U.S.-born counterparts (non-Hispanic Black: AOR=0.79, 95% CI=0.65, 0.97; Hispanic: AOR=0.72, 95% CI=0.56, 0.93). In all the 3 groups, foreign-born women with shorter (<10 years) duration of U.S. residence had lower odds of preterm birth than the U.S.-born women (non-Hispanic Black: AOR=0.57, 95% CI=0.43, 0.75; Hispanic: AOR=0.72, 95% CI=0.55, 0.94; non-Hispanic White: AOR=0.46, 95% CI=0.25, 0.85), whereas the odds of preterm birth in foreign-born women with ≥10 years of residence were not significantly different. CONCLUSIONS Foreign-born women had better cardiovascular risk profiles in all groups and lower odds of preterm birth in non-Hispanic Black and Hispanic groups. In all the 3 groups, a shorter duration of U.S. residence was associated with lower odds of preterm birth. Further studies are needed to understand the biological and social determinants underlying these nativity-related disparities and the impact of acculturation.
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Affiliation(s)
- Yaa A Kwapong
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ellen Boakye
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Olufunmilayo H Obisesan
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lochan M Shah
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - S Michelle Ogunwole
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Allison G Hays
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Roger S Blumenthal
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Andreea A Creanga
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michael J Blaha
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Miguel Cainzos-Achirica
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Khurram Nasir
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas; Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Pamela S Douglas
- Duke Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Garima Sharma
- The Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland.
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16
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Ogunwole SM, Turkson-Ocran RAN, Boakye E, Creanga AA, Wang X, Bennett WL, Sharma G, Cooper LA, Commodore-Mensah Y. Disparities in cardiometabolic risk profiles and gestational diabetes mellitus by nativity and acculturation: findings from 2016-2017 National Health Interview Survey. BMJ Open Diabetes Res Care 2022; 10:10/1/e002329. [PMID: 35168940 PMCID: PMC8852664 DOI: 10.1136/bmjdrc-2021-002329] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 01/19/2022] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) is a common complication of pregnancy with implications for cardiovascular health. Among reproductive-aged women, less is known about nativity-related disparities in cardiometabolic risk profiles and GDM history. We examined how cardiometabolic risk profiles and GDM history differed by nativity and explored associations between acculturation, cardiometabolic risk profiles and GDM history. RESEARCH DESIGN AND METHODS We analyzed cross-sectional data from the 2016-2017 National Health Interview Survey among reproductive-aged women (18-49 years) who both reported ever being pregnant and answered the question on GDM history. Using multivariable logistic regression, we examined the percentage with GDM history and compared cardiometabolic profiles by nativity status and acculturation (duration of US residence). RESULTS Of 9525 women, 22.5% were foreign-born. Also, 11.7% of foreign-born women had a GDM history vs 9.6% of US-born women. Foreign-born women with ≥10 years US residence had the highest age-standardized percentage with GDM history (11.0%) compared with US-born women (9.2%) and foreign-born women with <10 years US residence (6.7%). US-born women had a higher prevalence of hypertension, current smoking, and alcohol use than foreign-born women. Among foreign-born women, those with ≥10 years US residence had a higher prevalence of hypertension, current smoking, and alcohol use than those with <10 years US residence. In the fully adjusted model, foreign-born women with ≥10 years US residence had higher odds of GDM history than US-born women (OR 1.43; 95% CI 1.17 to 1.76) while foreign-born women with <10 years US residence and US-born women has similar odds of GDM history. CONCLUSIONS Greater duration of US residence may be associated with nativity-related disparities in GDM. Acculturation, including changing health-related behaviors may explain the disparities among foreign-born women and should be further investigated to appropriately target interventions to prevent GDM and future cardiometabolic diseases.
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Affiliation(s)
- S Michelle Ogunwole
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Ellen Boakye
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A Creanga
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wendy L Bennett
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Garima Sharma
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisa A Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yvonne Commodore-Mensah
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Community-Public Health, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Boakye E, Kwapong YA, Obisesan O, Ogunwole SM, Hays AG, Nasir K, Blumenthal RS, Douglas PS, Blaha MJ, Hong X, Creanga AA, Wang X, Sharma G. Nativity-Related Disparities in Preeclampsia and Cardiovascular Disease Risk Among a Racially Diverse Cohort of US Women. JAMA Netw Open 2021; 4:e2139564. [PMID: 34928357 PMCID: PMC8689384 DOI: 10.1001/jamanetworkopen.2021.39564] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Preeclampsia is an independent risk factor for future cardiovascular disease and disproportionally affects non-Hispanic Black women. The association of maternal nativity and duration of US residence with preeclampsia and other cardiovascular risk factors is well described among non-Hispanic Black women but not among women of other racial and ethnic groups. OBJECTIVE To examine differences in cardiovascular risk factors and preeclampsia prevalence by race and ethnicity, nativity, and duration of US residence among Hispanic, non-Hispanic Black, and non-Hispanic White women. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis of the Boston Birth Cohort included a racially diverse cohort of women who had singleton deliveries at the Boston Medical Center from October 1, 1998, to February 15, 2016. Participants self-identified as Hispanic, non-Hispanic Black, or non-Hispanic White. Data were analyzed from March 1 to March 31, 2021. EXPOSURES Maternal nativity and duration of US residence (<10 vs ≥10 years) were self-reported. MAIN OUTCOME AND MEASURES Diagnosis of preeclampsia, the outcome of interest, was retrieved from maternal medical records. RESULTS A total of 6096 women (2400 Hispanic, 2699 non-Hispanic Black, and 997 non-Hispanic White) with a mean (SD) age of 27.5 (6.3) years were included in the study sample. Compared with Hispanic and non-Hispanic White women, non-Hispanic Black women had the highest prevalence of chronic hypertension (204 of 2699 [7.5%] vs 65 of 2400 [2.7%] and 28 of 997 [2.8%], respectively), obesity (658 of 2699 [24.4%] vs 380 of 2400 [15.8%] and 152 of 997 [15.2%], respectively), and preeclampsia (297 of 2699 [11.0%] vs 212 of 2400 [8.8%] and 71 of 997 [7.1%], respectively). Compared with their counterparts born outside the US, US-born women in all 3 racial and ethnic groups had a significantly higher prevalence of obesity (Hispanic women, 132 of 556 [23.7%] vs 248 of 1844 [13.4%]; non-Hispanic Black women, 444 of 1607 [27.6%] vs 214 of 1092 [19.6%]; non-Hispanic White women, 132 of 776 [17.0%] vs 20 of 221 [9.0%]), smoking (Hispanic women, 98 of 556 [17.6%] vs 30 of 1844 [1.6%]; non-Hispanic Black women, 330 of 1607 [20.5%] vs 53 of 1092 [4.9%]; non-Hispanic White women, 382 of 776 [49.2%] vs 42 of 221 [19.0%]), and severe stress (Hispanic women, 76 of 556 [13.7%] vs 85 of 1844 [4.6%]; non-Hispanic Black women, 231 of 1607 [14.4%] vs 120 of 1092 [11.0%]; non-Hispanic White women, 164 of 776 [21.1%] vs 26 of 221 [11.8%]). After adjusting for sociodemographic and cardiovascular risk factors, birth status outside the US (adjusted odds ratio [aOR], 0.74 [95% CI, 0.55-1.00]) and shorter duration of US residence (aOR, 0.62 [95% CI, 0.41-0.93]) were associated with lower odds of preeclampsia among non-Hispanic Black women. However, among Hispanic and non-Hispanic White women, maternal nativity (aOR for Hispanic women, 1.07 [95% CI, 0.72-1.60]; aOR for non-Hispanic White women, 0.98 [95% CI, 0.49-1.96]) and duration of US residence (aOR for Hispanic women <10 years, 1.04 [95% CI, 0.67-1.59]; aOR for non-Hispanic White women <10 years, 1.20 [95% CI, 0.48-3.02]) were not associated with preeclampsia. CONCLUSIONS AND RELEVANCE Nativity-related disparities in preeclampsia persisted among non-Hispanic Black women but not among Hispanic and non-Hispanic White women after adjusting for sociodemographic and cardiovascular risk factors. Further research is needed to explore the interplay of factors contributing to nativity-related disparities in preeclampsia, particularly among non-Hispanic Black women.
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Affiliation(s)
- Ellen Boakye
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yaa Adoma Kwapong
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - S. Michelle Ogunwole
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Allison G. Hays
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Khurram Nasir
- DeBakey Heart & Vascular Center and Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
| | - Roger S. Blumenthal
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Pamela S. Douglas
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Michael J. Blaha
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Xiumei Hong
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andreea A. Creanga
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Garima Sharma
- Ciccarone Center for Prevention of Cardiovascular Diseases, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland
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18
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Minhas AS, Boakye E, Obisesan OH, Kwapong YA, Zakaria S, Creanga AA, Vaught AJ, Mehta LS, Davis MB, Bello NA, Cainzos-Achirica M, Nasir K, Blaha MJ, Blumenthal RS, Douglas PS, Wang X, Sharma G. The Association of Preterm Birth With Maternal Nativity and Length of Residence Among Non-Hispanic Black Women. CJC Open 2021; 4:289-298. [PMID: 35386126 PMCID: PMC8978076 DOI: 10.1016/j.cjco.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background Preterm birth (PTB) is associated with future cardiovascular disease (CVD) risk and disproportionally affects non-Hispanic Black (NHB) women. Limited data exist on the influence of length of US residence on nativity-related disparities in PTB. We examined PTB by maternal nativity (US born vs foreign born) and length of US residence among NHB women. Methods We analyzed data from 2699 NHB women (1607 US born; 1092 foreign born) in the Boston Birth Cohort, originally designed as a case-control study. Using multivariable logistic regression, we investigated the association of PTB with maternal nativity and length of US residence. Results In the total sample, 29.1% of women delivered preterm (31.4% and 25.6% among US born and foreign born, respectively). Compared with foreign born, US-born women were younger (25.8 vs 29.5 years), had higher prevalence of obesity (27.6% vs 19.6%), smoking (20.5% vs 4.9%), alcohol use (13.2% vs 7.4%), and moderate to severe stress (73.5% vs 59.4%) (all P < 0.001). Compared with US-born women, foreign-born women had lower odds of PTB after adjusting for sociodemographic characteristics, alcohol use, stress, parity, smoking, body mass index, chronic hypertension, and diabetes (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI], 0.65-0.97). Foreign-born NHB women with < 10 years of US residence had 43% lower odds of PTB compared with US-born (aOR, 0.57; 95% CI, 0.43-0.75), whereas those with ≥ 10 years of US residence did not differ significantly from US-born women in their odds of PTB (aOR, 0.76; 95% CI, 0.54-1.07). Conclusions The prevalence of CVD risk factors and proportion of women delivering preterm were lower in foreign-born than US-born NHB women. The "foreign-born advantage" was not observed with ≥ 10 years of US residence. Our study highlights the need to intensify public health efforts in exploring and addressing nativity-related disparities in PTB.
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Affiliation(s)
- Anum S. Minhas
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Olufunmilayo H. Obisesan
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yaa A. Kwapong
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sammy Zakaria
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arthur J. Vaught
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Laxmi S. Mehta
- Division of Cardiology, the Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Melinda B. Davis
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Natalie A. Bello
- Division of Cardiology, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Miguel Cainzos-Achirica
- Houston Methodist Hospital and DeBakey Heart & Vascular Center, Center for Outcomes Research, Houston, Texas, USA
| | - Khurram Nasir
- Houston Methodist Hospital and DeBakey Heart & Vascular Center, Center for Outcomes Research, Houston, Texas, USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Pamela S. Douglas
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Garima Sharma
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Corresponding author: Dr Garima Sharma, Johns Hopkins University School of Medicine–Ciccarone Center of Prevention of Cardiovascular Disease, 565 C Carnegie Building, 600 N Wolfe Street, Baltimore, Maryland 21287, USA.
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Mehta LS, Sharma G, Creanga AA, Hameed AB, Hollier LM, Johnson JC, Leffert L, McCullough LD, Mujahid MS, Watson K, White CJ. Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association. Circulation 2021; 144:e251-e269. [PMID: 34493059 DOI: 10.1161/cir.0000000000001000] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.
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20
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Stierman EK, Ahmed S, Shiferaw S, Zimmerman LA, Creanga AA. Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia. BMJ Glob Health 2021; 6:e006698. [PMID: 34610906 PMCID: PMC8493923 DOI: 10.1136/bmjgh-2021-006698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards. METHODS We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume. RESULTS Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices. CONCLUSION SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.
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Affiliation(s)
- Elizabeth K Stierman
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Saifuddin Ahmed
- Department of Population, Family And Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Oromia, Ethiopia
| | - Linnea A Zimmerman
- Department of Population, Family And Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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21
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Mary M, DAS P, Creanga AA. Perinatal telemedicine at lower-level birthing hospitals in Maryland. Lessons learned from a landscape analysis. Minerva Obstet Gynecol 2021; 75:93-102. [PMID: 34498838 DOI: 10.23736/s2724-606x.21.04933-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To assess the current perinatal telemedicine (PTM) landscape and inform the design and implementation of a PTM network linking Level I/II birthing hospitals with the two Level IV hospitals in Maryland to improve access to maternal-fetal medicine (MFM) specialist care. METHODS Qualitative in-depth interviews were conducted with 24 clinicians and telemedicine experts during July-September 2020. We obtained data on 12 Level I/II and both Level IV hospitals. RESULTS Less than half of Level I/II hospitals currently offer obstetric services through telemedicine, and both Level IV hospitals have interest and technical capacity to support implementation of a PTM network in Maryland. The Covid-19 related shift to telehealth and telemedicine was identified as a facilitator for such PTM programs. Perceived barriers to provider adoption of PTM services and network in Maryland included hospital leadership buy-in, information technology (IT) literacy, and patient triage complexities. Perceived barriers to patient adoption of PTM were access to technology, IT literacy, and language. Key benefits of PTM services included overall improved patient access, convenience, cost-savings, and safety during the COVID-19 pandemic. Influential factors for implementing a PTM network in Maryland included buy-in and approval from hospital and health system administration, a streamlined telehealth platform allowing for electronic medical record integration and interoperability, program funding, and sustainability. CONCLUSIONS Gaps in availability of MFM care at Level I/II birth hospitals call for expanded telemedicine programming to improve high-risk patients' access to specialty obstetric care and support the development of a PTM network in Maryland.
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Affiliation(s)
- Meighan Mary
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA -
| | - Priyanka DAS
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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22
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Wilhelm J, Mahapatra T, Das A, Sonthalia S, Srikantiah S, Galavotti C, Shah H, Creanga AA. From direct engagement to technical support: a programmatic evolution to improve large community health worker programs in Bihar, India. BMJ Glob Health 2021; 6:bmjgh-2020-004389. [PMID: 33853844 PMCID: PMC8054080 DOI: 10.1136/bmjgh-2020-004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/02/2021] [Accepted: 03/20/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In 2011, through a multipartner Integrated Family Health Initiative (IFHI), CARE started supporting maternal and neonatal health (MNH) improvement goals in 8 of 38 districts in Bihar, India. The programme included a frontline health worker (FHW) component offering health advice through household visits and benefited from CARE's direct engagement during IFHI, which then evolved into statewide Technical Support Unit (TSU) to the Government of Bihar in 2014. METHODS Using eight rounds of state-representative household surveys with mothers of infants aged 0-2 months (N=73 093) linked with two facility assessments conducted during 2012-2017, we assessed changes in FHW visit coverage, intensity and quality between IFHI and TSU phases. Using logistic regression models, we ascertained associations between FHW outputs and three MNH core practices: ≥3 antenatal care check-ups (ANC3+), institutional delivery and early breastfeeding initiation. RESULTS Women's receipt of 1+ FHW visits declined from 60.2% (IFHI phase) to 46.3% (TSU phase) in the eight IFHI districts, being below 40% statewide during the TSU phase. Despite a parallel decline in FHW visit quality measured as the number of health advice received, all three outcomes improved during the TSU versus IFHI phase in IFHI districts. We found significant positive associations between all three outcomes and receipt of 1+ FHW visits and programme phase (TSU vs IFHI) in the eight IFHI districts. During the TSU phase, receipt of 2+ FHW visits in the third trimester increased the odds of women receiving ANC3+ (adjusted OR (aOR)=1.21; 95% CI: 1.13 to 1.31), delivering in a facility (aOR=1.64; 95% CI: 1.51 to 1.77) and initiating breast feeding early (aOR=1.18; 95% CI: 1.05 to 1.18). Independent of the number and timing of FHW visits, we also found positive associations between women reporting higher than lower quality of FHW interactions and receiving outcome-specific advice and all three MNH outcomes. CONCLUSION Implementation of large community-based interventions under the technical support model should be continuously and strategically evaluated and adapted.
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Affiliation(s)
- Jess Wilhelm
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India.,CARE USA, Atlanta, Georgia, USA
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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23
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Ogunwole M, Turkson-Ocran RAN, Boakye E, Bennett WL, Cooper LA, Creanga AA, Sharma G, Wang X, Commodore-mensah Y. Abstract 048: Disparities In Gestational Diabetes Mellitus Among US- Vs. Foreign-born Women: An Analysis Of 2016-2017 National Health Interview Survey. Circulation 2021. [DOI: 10.1161/circ.143.suppl_1.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Gestational diabetes mellitus (GDM) is a common complication of pregnancy. Although GDM is associated with increased risk of cardiovascular disease it is unclear whether the associations between GDM prevalence and cardiometabolic risk factors differ between US- and foreign-born women and whether length of US residence influences these associations.
Methods:
We analyzed cross-sectional data from the 2016-2017 National Health Interview Survey among women currently living in the US who both reported ever being pregnant and responded to the survey question about GDM. Using generalized linear models with binomial distribution and logit link, we examined the prevalence of GDM by nativity status and length of US residence adjusting for potential confounders (Table).
Results:
Of 24,466 women, 14.3% were foreign-born. The crude prevalence of GDM was higher among foreign-born (9.0%) compared to US-born women (7.1%). Foreign-born women with ≥10 years of residence in the US had the highest age-standardized GDM prevalence (8.3%) compared to US-born (7.5%) and foreign-born women with <10 years US residence (4.8%). Among women with a history of GDM, US-born women were more likely to be overweight/ obese, report a history of hypertension, be current smokers and alcohol drinkers than foreign-born women. Among foreign-born women, those with ≥10 years of US residence had higher prevalence of hypertension, smoking and alcohol use than those with <10 years in the US. In the fully adjusted regression model, only foreign-born women with ≥10 years of residence in the US had a significantly higher prevalence of GDM than US-born women (PR=1.43; 95% CI:1.22-1.67).
Conclusions:
In this sample of women with self-reported GDM, greater length of US residence contributes to nativity-related disparities in GDM. Acculturation, including changing health-related behaviors, may have a larger impact on maternal health outcomes of foreign-born women, and should be a target of interventions to reduce GDM and future cardiovascular diseases.
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24
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Woldu B, Shah LM, Shaddeau AK, Goerlich E, Zakaria S, Hays AG, Vaught AJ, Creanga AA, Blumenthal RS, Sharma G. The Role of Biomarkers and Imaging to Predict Preeclampsia and Subsequent Cardiovascular Dysfunction. Curr Treat Options Cardio Med 2021. [DOI: 10.1007/s11936-021-00913-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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25
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Boakye E, Sharma G, Ogunwole SM, Zakaria S, Vaught AJ, Kwapong YA, Hong X, Ji Y, Mehta L, Creanga AA, Blaha MJ, Blumenthal RS, Nasir K, Wang X. Relationship of Preeclampsia With Maternal Place of Birth and Duration of Residence Among Non-Hispanic Black Women in the United States. Circ Cardiovasc Qual Outcomes 2021; 14:e007546. [PMID: 33563008 PMCID: PMC7887058 DOI: 10.1161/circoutcomes.120.007546] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preeclampsia is one of the leading causes of maternal mortality in the United States. It disproportionately affects non-Hispanic Black (NHB) women, but little is known about how preeclampsia and other cardiovascular disease risk factors vary among different subpopulations of NHB women in the United States. We investigated the prevalence of preeclampsia by nativity (US born versus foreign born) and duration of US residence among NHB women. METHODS We analyzed cross-sectional data from the Boston Birth Cohort (1998-2016), with a focus on NHB women. We performed multivariable logistic regression to investigate associations between preeclampsia, nativity, and duration of US residence after controlling for potential confounders. RESULTS Of 2697 NHB women, 40.5% were foreign born. Relative to them, US-born NHB women were younger, in higher percentage current smokers, had higher prevalence of obesity (body mass index ≥30 kg/m2) and maternal stress, but lower educational level. The age-adjusted prevalence of preeclampsia was 12.4% and 9.1% among US-born and foreign-born women, respectively. When further categorized by duration of US residence, the prevalence of all studied cardiovascular disease risk factors except for diabetes was lower among foreign-born NHB women with <10 versus ≥10 years of US residence. Additionally, the odds of preeclampsia in foreign-born NHB women with duration of US residence <10 years was 37% lower than in US-born NHB women. In contrast, the odds of preeclampsia in foreign-born NHB women with duration of US residence ≥10 years was not significantly different from that of US-born NHB women after adjusting for potential confounders. CONCLUSIONS The prevalence of preeclampsia and other cardiovascular disease risk factors is lower in foreign-born than in US-born NHB women. The healthy immigrant effect, which typically results in health advantages for foreign-born women, appears to wane with longer duration of US residence (≥10 years). Further research is needed to better understand these associations.
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Affiliation(s)
- Ellen Boakye
- Johns Hopkins Ciccarone Center for Prevention of
Cardiovascular Diseases, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
| | - Garima Sharma
- Johns Hopkins Ciccarone Center for Prevention of
Cardiovascular Diseases, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
| | - S. Michelle Ogunwole
- Division of General Internal Medicine, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arthur J. Vaught
- Department of Maternal Fetal Medicine, Division of
Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore,
MD, USA
| | - Yaa Adoma Kwapong
- Department of Population, Family and Reproductive Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Xiumei Hong
- Department of Population, Family and Reproductive Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yuelong Ji
- Department of Population, Family and Reproductive Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laxmi Mehta
- Division of Cardiology, Ohio State University School of
Medicine, Columbus, OH, USA
| | - Andreea A. Creanga
- Department of Population, Family and Reproductive Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD, USA
- Department of Gynecology and Obstetrics, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for Prevention of
Cardiovascular Diseases, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for Prevention of
Cardiovascular Diseases, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
| | - Khurram Nasir
- Houston Methodist Hospital and DeBakey Heart & Vascular
Center, Center for Outcomes Research, Houston, TX, USA
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Gupta J, Patwa MC, Khuu A, Creanga AA. Approaches to motivate physicians and nurses in low- and middle-income countries: a systematic literature review. Hum Resour Health 2021; 19:4. [PMID: 33407597 PMCID: PMC7789684 DOI: 10.1186/s12960-020-00522-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/08/2020] [Indexed: 05/24/2023]
Abstract
Poor health worker motivation, and the resultant shortages and geographic imbalances of providers, impedes the provision of quality care in low- and middle-income countries (LMICs). This systematic review summarizes the evidence on interventions used to motivate health workers in LMICs. A standardized keyword search strategy was employed across five databases from September 2007 -September 2017. Studies had to meet the following criteria: original study; doctors and/or nurses as target population for intervention(s); work motivation as study outcome; study design with clearly defined comparison group; categorized as either a supervision, compensation, systems support, or lifelong learning intervention; and conducted in a LMIC setting. Two independent reviewers screened 3845 titles and abstracts and, subsequently, reviewed 269 full articles. Seven studies were retained from China (n = 1), Ghana (n = 2), Iran (n = 1), Mozambique (n = 1), and Zambia (n = 2). Study data and risk of bias were extracted using a standardized form. Though work motivation was the primary study outcome, four studies did not provide an outcome definition and five studies did not describe use of a theoretical framework in the ascertainment. Four studies used a randomized trial-group design, one used a non-randomized trial-group design, one used a cross-sectional design, and one used a pretest-posttest design. All three studies that found a significant positive effect on motivational outcomes had a supervision component. Of the three studies that found no effects on motivation, two were primarily compensation interventions and the third was a systems support intervention. One study found a significant negative effect of a compensation intervention on health worker motivation. In conducting this systematic review, we found there is limited evidence on successful interventions to motivate health workers in LMICs. True effects on select categories of health workers may have been obscured given that studies included health workers with a wide range of social and professional characteristics. Robust studies that use validated and culturally appropriate tools to assess worker motivation are greatly needed in the Sustainable Development Goals era.
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Affiliation(s)
- Jaya Gupta
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Mariya C. Patwa
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Angel Khuu
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Andreea A. Creanga
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, 615 N. Wolfe Street, Room E8646, Baltimore, MD 21205 USA
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Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020; 10:021008. [PMID: 33425332 PMCID: PMC7759019 DOI: 10.7189/jogh.10.021008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND CARE India designed and implemented a comprehensive, statewide quality improvement (QI) initiative to improve reproductive, maternal, newborn, and child health and nutrition (RMNCHN) services in public facilities in Bihar. We provide a description of this initiative and its key results during 2014-2017. METHODS We reviewed program documents to identify QI strategies employed and ascertain their coverage. We analysed data from: a) two public facility assessments to ascertain the availability of essential equipment and supplies and the distribution of human resources by facility level; b) a four-phase provider mentoring and training intervention covering 319 facilities to examine changes in emergency obstetric and newborn care (EmONC) practices; and c) four state-representative household surveys to explore changes in selected RMNCHN service utilisation by health sector. Associations of interest were ascertained using χ2 tests. RESULTS Thirty-eight District Quality Assurance Committees and QI teams in 98% of facilities were formed to develop an implementation plan for the QI initiative and oversee its execution. QI strategies were to strengthen facilities' infrastructure; build the state's contracting, procurement, and inventory management capacities; rationalise human resources; improve providers' skills; and modernise data systems. Implementation led to facility infrastructure upgrades, improved clinical staff distribution, and higher availability of equipment and supplies over time, especially in higher-level facilities. Following the mentoring and training intervention in facilities offering both basic and comprehensive EmONC, performance of key practices (eg, adequate administration of uterotonics <1 minute after birth, initiation of skin-to-skin care <5 minutes after birth) improved significantly (P < 0.05). CARE India collected program data and assisted with modernising data systems for tracking human resources, supplies, and program progress statewide. Of women seeking antenatal care, the proportion obtaining key screenings (eg, weight, blood pressure measurements) in public facilities increased over time (P < 0.05). A 6-percentage point decline in home deliveries during 2016-2017 was accompanied by a higher increase of deliveries in public than private facilities (5- vs 1-percentage point; P < 0.05). CONCLUSION Substantial advances were made in improving RMNCHN service quality in Bihar. Continued improvement building on the established QI platform is expected and should be guided by data from now functional data systems.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sanjiv Daulatrao
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Rohini Durbha
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Kaul
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
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Creanga AA, Jiwani S, Das A, Mahapatra T, Sonthalia S, Gore A, Kaul S, Srikantiah S, Galavotti C, Shah H. Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices. J Glob Health 2020; 10:021009. [PMID: 33425333 PMCID: PMC7759016 DOI: 10.7189/jogh.10.021009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND To address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named - Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) - in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees' competency to provide such services in Bihar, India during 2015-2017. METHODS We used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees' practices. We examined changes in nurse-mentees' knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees' knowledge and practices after adjusting for potential confounders. RESULTS On average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees' knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes. CONCLUSION The AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions. STUDY REGISTRATION ClinicalTrials.gov number NCT02726230.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Safia Jiwani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Sonthalia
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aboli Gore
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Sunil Kaul
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | | | - Hemant Shah
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
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Creanga AA, Jiwani S, Das A, Mahapatra T, Sonthalia S, Gore A, Kaul S, Srikantiah S, Galavotti C, Shah H. Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Creanga AA, Srikantiah S, Mahapatra T, Das A, Sonthalia S, Moharana PR, Gore A, Daulatrao S, Durbha R, Kaul S, Galavotti C, Laterra A, Pepper KT, Darmstadt GL, Shah H. Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Minhas AS, Ying W, Ogunwole SM, Miller M, Zakaria S, Vaught AJ, Hays AG, Creanga AA, Cedars A, Michos ED, Blumenthal RS, Sharma G. The Association of Adverse Pregnancy Outcomes and Cardiovascular Disease: Current Knowledge and Future Directions. Curr Treat Options Cardio Med 2020; 22. [DOI: 10.1007/s11936-020-00862-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Creanga AA, Woo M, Seifu Estifanos A, Feleke H, Woldesenbet D, Kebede E, Oguntade H, Liu L, Gebremariam MY. Qualitative assessment of patient-provider communication and provider reporting on misclassification of stillbirths and early neonatal deaths in Ethiopia. Minerva Ginecol 2020; 72:138-148. [PMID: 33000614 DOI: 10.23736/s0026-4784.20.04549-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Poor communication between patients and providers can lead to misunderstanding and misclassification of clinical information, including pregnancy outcomes by women. This qualitative study with maternity care providers explores patient-provider communications regarding stillbirths (SB) and early neonatal deaths (END) and potential SB-END misclassification in Ethiopia. METHODS Qualitative data were collected through 8 in-depth interviews and 3 focus group discussions with maternity care providers at Tikur Anbessa and Gandhi Memorial hospitals in Addis-Ababa. RESULTS Twenty-six maternity care providers (10 physicians;16 nurses/midwives) were interviewed. Providers noted that high patient loads negatively influence their provision of quality care to patients. Yet, despite patients generally not asking many questions during their delivery hospitalization, maternity care providers reported offering information about pregnancy outcomes at hospital discharge. The level of education was the most cited factor influencing patients' understanding of the information communicated to them, especially with regard to adverse pregnancy outcomes. Respondents reported that women do not have significant misconceptions about either SB or END. Nevertheless, they also revealed that both purposeful and accidental SB-END misclassification occurs. Reports of the direction of such misclassification differed by type of provider - physicians noted that misclassification of SB as END is most common, while nurses and midwives identified the opposite direction for this type of misclassification. CONCLUSIONS Maternity care providers' reporting practices and the quality of their communication with patients contribute to the SB-END misclassification in Ethiopia. There is need to increase providers' awareness of the importance of capturing and reporting reliable and valid information on pregnancy outcomes.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA -
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA -
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA -
| | - Madeline Woo
- Department of Health Policy and Management, Tulane University, New Orleans, LA, USA
| | - Abiy Seifu Estifanos
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis-Ababa, Ethiopia
| | - Hanna Feleke
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis-Ababa, Ethiopia
| | - Dorka Woldesenbet
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis-Ababa, Ethiopia
| | - Eskinder Kebede
- Department of Obstetrics and Gynecology, School of Medicine, Addis Ababa University, Addis-Ababa, Ethiopia
| | - Habibat Oguntade
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Li Liu
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mahlet Y Gebremariam
- Department of Obstetrics and Gynecology, School of Medicine, Addis Ababa University, Addis-Ababa, Ethiopia
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Abstract
This article provides a review of maternal mortality data and their limitations in the United States. National maternal mortality data, which rely heavily on vital statistics, document that the risk of death from pregnancy-related causes has not declined for >25 years and that striking racial disparities persist. State-based maternal mortality reviews, functional in many states, obtain detailed information on medical and nonmedical factors contributing to maternal deaths. Without this detailed knowledge from state-level data and without addressing recognized quality problems with vital statistics data at the national-level, we will have difficulty understanding maternal death trends and preventing future such deaths.
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Affiliation(s)
- Andreea A Creanga
- Departments of International Health.,Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
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Creanga AA. Maternal obesity and severe maternal morbidity-It is time to ask new research questions. Paediatr Perinat Epidemiol 2019; 33:17-18. [PMID: 30633370 DOI: 10.1111/ppe.12533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/02/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Sheffel A, Karp C, Creanga AA. Use of Service Provision Assessments and Service Availability and Readiness Assessments for monitoring quality of maternal and newborn health services in low-income and middle-income countries. BMJ Glob Health 2018; 3:e001011. [PMID: 30555726 PMCID: PMC6267320 DOI: 10.1136/bmjgh-2018-001011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/15/2018] [Accepted: 09/07/2018] [Indexed: 12/03/2022] Open
Abstract
Improving the quality of maternal and newborn health (MNH) services is key to reducing adverse MNH outcomes in low-income and middle-income countries (LMICs). The Service Provision Assessment (SPA) and Service Availability and Readiness Assessment (SARA) are the most widely employed, standardised tools that generate health service delivery data in LMICs. We ascertained the use of SPA/SARA surveys for assessing the quality of MNH services using a two-step approach: a SPA/SARA questionnaire mapping exercise in line with WHO's Quality of Care (QoC) Framework for pregnant women and newborns and the WHO quality standards for care around the time of childbirth; and a scoping literature review, searching for articles that report SPA/SARA data. SPA/SARA surveys are well suited to assess the WHO Framework's cross-cutting dimensions (physical and human resources); SPA also captures elements in the provision and experience of care domains for antenatal care and family planning. Only 4 of 31 proposed WHO quality indicators around the time of childbirth can be fully generated using SPA and SARA surveys, while 19 and 23 quality indicators can be partially obtained from SARA and SPA surveys, respectively; most of these are input indicators. Use of SPA/SARA data is growing, but there is considerable variation in methods employed to measure MNH QoC. With SPA/SARA data available in 30 countries, MNH QoC assessments could benefit from guidance for creating standard metrics. Adding questions in SPA/SARA surveys to assess the WHO QoC Framework's provision and experience of care dimensions would fill significant data gaps in LMICs.
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Affiliation(s)
- Ashley Sheffel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Reid LD, Creanga AA. Severe maternal morbidity and related hospital quality measures in Maryland. J Perinatol 2018; 38:997-1008. [PMID: 29593355 DOI: 10.1038/s41372-018-0096-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/18/2018] [Accepted: 02/26/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine hospital characteristics and quality metrics associated with severe maternal morbidity (SMM) in Maryland. STUDY DESIGN A population-based observational study of 364,113 statewide delivery hospitalizations during 2010-2015 linked with socio-economic community measures and hospital characteristics and quality measures. Multivariable logistic regression models with generalized estimating equations estimated SMM adjusting for individual, community, and hospital-level factors and clustering within hospitals and residence zip codes. RESULTS The SMM prevalence was 197 per 10,000 deliveries. Adjusted SMM risk ratios were higher for younger (<20 years), older (35+ years), non-White non-Hispanic, unmarried, multiple substance users, women with multiple gestations, and chronic medical and mental health conditions than their counterparts. Communities with greater socio-economic disadvantage and hospitals with poorer patient experience and clinical care quality had higher rates of SMM. CONCLUSION Addressing socio-economic disparities and improving quality of care in delivery hospitals are key to reducing the SMM burden in Maryland.
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Affiliation(s)
- Lawrence D Reid
- Office of Maternal and Child Health Epidemiology, Maryland Department of Health, Baltimore, MD, USA.
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Creanga AA, Singh KK, Li Q, Fruhauf T, Tsui AO. Changes in abortion service provision in Bihar and Jharkhand states, India between 2004 and 2013. PLoS One 2018; 13:e0197300. [PMID: 29879132 PMCID: PMC5991730 DOI: 10.1371/journal.pone.0197300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 04/28/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Medical Termination of Pregnancy (MTP) Act of 1971 liberalized abortion laws in India. This study examines changes in abortion service provision and characteristics of abortion providers in Bihar and Jharkhand states, India between 2004 and 2013. METHODS We used state-representative data from cross-sectional surveys of reproductive health service providers we conducted in 2004 (N = 1,323) and 2012/2013 (N = 1,020). We employed chi-squared tests to examine and compare abortion providers' characteristics, and fitted separate multivariate logistic regression models for provision of surgical, medical, and any abortion services, respectively, adjusting for potential confounders to identify factors associated with abortion service provision at the two survey time points. RESULTS Of providers interviewed in 2004 and 2012/2013, 63.7% and 84.5%, respectively, offered abortion services. Among abortion providers, 21.1% offered surgical and 10.7% offered medical abortions in 2004; 15.8% and 94.1% did so, respectively, in 2012/2013. Private providers were more likely than public providers to offer abortion services at both time points. Compared to female providers, male providers were significantly less likely to provide both surgical and medical abortions in 2004, and significantly less likely to provide surgical abortions in 2012/2013. Pharmacists and community health workers played increasingly important roles in abortion service provision, especially medical abortion, during the period. CONCLUSION This study documents important changes in abortion provision in the two Indian states during 2004-2013.
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Affiliation(s)
- Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
- * E-mail:
| | | | - Qingfeng Li
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Timothee Fruhauf
- Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Amy O. Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Bill and Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Kanyangarara M, Chou VB, Creanga AA, Walker N. Linking household and health facility surveys to assess obstetric service availability, readiness and coverage: evidence from 17 low- and middle-income countries. J Glob Health 2018; 8:010603. [PMID: 29862026 PMCID: PMC5963736 DOI: 10.7189/jogh.08.010603] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Improving access and quality of obstetric service has the potential to avert preventable maternal, neonatal and stillborn deaths, yet little is known about the quality of care received. This study sought to assess obstetric service availability, readiness and coverage within and between 17 low- and middle-income countries. Methods We linked health facility data from the Service Provision Assessments and Service Availability and Readiness Assessments, with corresponding household survey data obtained from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Based on performance of obstetric signal functions, we defined four levels of facility emergency obstetric care (EmOC) functionality: comprehensive (CEmOC), basic (BEmOC), BEmOC-2, and low/substandard. Facility readiness was evaluated based on the direct observation of 23 essential items; facilities “ready to provide obstetric services” had ≥20 of 23 items available. Across countries, we used medians to characterize service availability and readiness, overall and by urban-rural location; analyses also adjusted for care-seeking patterns to estimate population-level coverage of obstetric services. Results Of the 111 500 health facilities surveyed, 7545 offered obstetric services and were included in the analysis. The median percentages of facilities offering EmOC and “ready to provide obstetric services” were 19% and 10%, respectively. There were considerable urban-rural differences, with absolute differences of 19% and 29% in the availability of facilities offering EmOC and “ready to provide obstetric services”, respectively. Adjusting for care-seeking patterns, results from the linking approach indicated that among women delivering in a facility, a median of 40% delivered in facilities offering EmOC, and 28% delivered in facilities “ready to provide obstetric services”. Relatively higher coverage of facility deliveries (≥65%) and coverage of deliveries in facilities “ready to provide obstetric services” (≥30% of facility deliveries) were only found in three countries. Conclusions The low levels of availability, readiness and coverage of obstetric services documented represent substantial missed opportunities within health systems. Global and national efforts need to prioritize upgrading EmOC functionality and improving readiness to deliver obstetric service, particularly in rural areas. The approach of linking health facility and household surveys described here could facilitate the tracking of progress towards quality obstetric care.
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Affiliation(s)
- Mufaro Kanyangarara
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Victoria B Chou
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Creanga AA. Maternal mortality in the developed world: a review of surveillance methods, levels and causes of maternal deaths during 2006-2010. Minerva Obstet Gynecol 2017; 69:608-617. [PMID: 28714660 DOI: 10.23736/s0026-4784.17.04111-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article provides an overview of surveillance methods, levels, and causes of maternal mortality in developed countries, in Europe and the United States, during 2006-2010. Accurate identification of maternal deaths is not always possible, and no two countries in the world use the same surveillance methods for maternal mortality. Despite limitations (e.g. underestimation, misclassification), routine vital registration systems are the backbone of maternal mortality surveillance systems in developed countries. Enhanced surveillance methods involve linkages between deaths of women of reproductive age and births within the preceding year, or the use of additional data sources for maternal deaths. Confidential enquiries into maternal deaths, in place in France, the Netherlands, and the UK are the gold standard in maternal mortality surveillance. Levels of maternal mortality in Europe were the lowest in the world during 2006-2010. While Europe has not seen major changes in maternal mortality in recent years, pregnancy-related mortality increased considerably in the USA, where improvements in the identification of deaths appear to play a part. The triad of infection, hemorrhage, and hypertensive disorders of pregnancy, which in the past accounted for >90% of all maternal deaths, now accounts for 60-70% of such deaths in developed countries. Maternal mortality surveillance provides learning opportunities to prevent future maternal deaths. There is need for integration of linked, multiple data sources into current maternal mortality surveillance systems to improve their utility.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA - .,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA -
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Sigakis MJG, Leffert LR, Mirzakhani H, Sharawi N, Rajala B, Callaghan WM, Kuklina EV, Creanga AA, Mhyre JM, Bateman BT. The Validity of Discharge Billing Codes Reflecting Severe Maternal Morbidity. Anesth Analg 2017; 123:731-8. [PMID: 27387839 DOI: 10.1213/ane.0000000000001436] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Discharge diagnoses are used to track national trends and patterns of maternal morbidity. There are few data regarding the validity of the International Classification of Diseases (ICD) codes used for this purpose. The goal of our study was to try to better understand the validity of administrative data being used to monitor and assess trends in morbidity. METHODS Hospital stay billing records were queried to identify all delivery admissions at the Massachusetts General Hospital for the time period 2001 to 2011 and the University of Michigan Health System for the time period 2005 to 2011. From this, we identified patients with ICD-9-Clinical Modification (CM) diagnosis and procedure codes indicative of severe maternal morbidity. Each patient was classified with 1 of 18 different medical/obstetric categories (conditions or procedures) based on the ICD-9-CM code that was recorded. Within each category, 20 patients from each institution were selected at random, and the corresponding medical charts were reviewed to determine whether the ICD-9-CM code was assigned correctly. The percentage of correct codes for each of 18 preselected clinical categories was calculated yielding a positive predictive value (PPV) and 99% confidence interval (CI). RESULTS The overall number of correctly assigned ICD-9-CM codes, or PPV, was 218 of 255 (86%; CI, 79%-90%) and 154 of 188 (82%; CI, 74%-88%) at Massachusetts General Hospital and University of Michigan Health System, respectively (combined PPV, 372/443 [84%; CI, 79-88%]). Codes within 4 categories (Hysterectomy, Pulmonary edema, Disorders of fluid, electrolyte and acid-base balance, and Sepsis) had a 99% lower confidence limit ≥75%. Codes within 8 additional categories demonstrated a 99% lower confidence limit between 74% and 50% (Acute respiratory distress, Ventilation, Other complications of obstetric surgery, Disorders of coagulation, Cardiomonitoring, Acute renal failure, Thromboembolism, and Shock). Codes within 6 clinical categories demonstrated a 99% lower confidence limit <50% (Puerperal cerebrovascular disorders, Conversion of cardiac rhythm, Acute heart failure [includes arrest and fibrillation], Eclampsia, Neurotrauma, and Severe anesthesia complications). CONCLUSIONS ICD-9-CM codes capturing severe maternal morbidity during delivery hospitalization demonstrate a range of PPVs. The PPV was high when objective supportive evidence, such as laboratory values or procedure documentation supported the ICD-9-CM code. The PPV was low when greater judgment, interpretation, and synthesis of the clinical data (signs and symptoms) was required to support a code, such as with the category Severe anesthesia complications. As a result, these codes should be used for administrative research with more caution compared with codes primarily defined by objective data.
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Affiliation(s)
- Matthew J G Sigakis
- From the *Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; †Division of Obstetric Anesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; ‡Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; §Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; ‖Epidemiology & Surveillance Branch, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; and ¶Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Lind JN, Interrante JD, Ailes EC, Gilboa SM, Khan S, Frey MT, Dawson AL, Honein MA, Dowling NF, Razzaghi H, Creanga AA, Broussard CS. Maternal Use of Opioids During Pregnancy and Congenital Malformations: A Systematic Review. Pediatrics 2017; 139:peds.2016-4131. [PMID: 28562278 PMCID: PMC5561453 DOI: 10.1542/peds.2016-4131] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2017] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Opioid use and abuse have increased dramatically in recent years, particularly among women. OBJECTIVES We conducted a systematic review to evaluate the association between prenatal opioid use and congenital malformations. DATA SOURCES We searched Medline and Embase for studies published from 1946 to 2016 and reviewed reference lists to identify additional relevant studies. STUDY SELECTION We included studies that were full-text journal articles and reported the results of original epidemiologic research on prenatal opioid exposure and congenital malformations. We assessed study eligibility in multiple phases using a standardized, duplicate review process. DATA EXTRACTION Data on study characteristics, opioid exposure, timing of exposure during pregnancy, congenital malformations (collectively or as individual subtypes), length of follow-up, and main findings were extracted from eligible studies. RESULTS Of the 68 studies that met our inclusion criteria, 46 had an unexposed comparison group; of those, 30 performed statistical tests to measure associations between maternal opioid use during pregnancy and congenital malformations. Seventeen of these (10 of 12 case-control and 7 of 18 cohort studies) documented statistically significant positive associations. Among the case-control studies, associations with oral clefts and ventricular septal defects/atrial septal defects were the most frequently reported specific malformations. Among the cohort studies, clubfoot was the most frequently reported specific malformation. LIMITATIONS Variabilities in study design, poor study quality, and weaknesses with outcome and exposure measurement. CONCLUSIONS Uncertainty remains regarding the teratogenicity of opioids; a careful assessment of risks and benefits is warranted when considering opioid treatment for women of reproductive age.
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Affiliation(s)
- Jennifer N. Lind
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,US Public Health Service, Atlanta, Georgia
| | - Julia D. Interrante
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Elizabeth C. Ailes
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M. Gilboa
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sara Khan
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia,Carter Consulting, Atlanta, Georgia
| | - Meghan T. Frey
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - April L. Dawson
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Margaret A. Honein
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nicole F. Dowling
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hilda Razzaghi
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia,US Public Health Service, Atlanta, Georgia
| | - Andreea A. Creanga
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,International Center for Maternal and Newborn Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cheryl S. Broussard
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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Creanga AA, Gullo S, Kuhlmann AKS, Msiska TW, Galavotti C. Is quality of care a key predictor of perinatal health care utilization and patient satisfaction in Malawi? BMC Pregnancy Childbirth 2017; 17:150. [PMID: 28532462 PMCID: PMC5440969 DOI: 10.1186/s12884-017-1331-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Malawi government encourages early antenatal care, delivery in health facilities, and timely postnatal care. Efforts to sustain or increase current levels of perinatal service utilization may not achieve desired gains if the quality of care provided is neglected. This study examined predictors of perinatal service utilization and patients' satisfaction with these services with a focus on quality of care. METHODS We used baseline, two-stage cluster sampling household survey data collected between November and December, 2012 before implementation of CARE's Community Score Card© intervention in Ntcheu district, Malawi. Women with a birth during the last year (N = 1301) were asked about seeking: 1) family planning, 2) antenatal, 3) delivery, and 4) postnatal care; the quality of care received; and their overall satisfaction with the care received. Specific quality of care items were assessed for each type of service, and up to five such items per type of service were used in analyses. Separate logistic regression models were fitted to examine predictors of family planning, antenatal, delivery, and postnatal service utilization and of complete satisfaction with each of these services; all models were adjusted for women's socio-demographic characteristics, perceptions of the closest facility to their homes, service use indicators, and quality of care items. RESULTS We found higher levels of perinatal service use than previously documented in Malawi (baseline antenatal care 99.4%; skilled birth attendance 97.3%; postnatal care 77.5%; current family planning use 52.8%). Almost 73% of quality of perinatal care items assessed were favorably reported by > 90% of women. Women reported high overall satisfaction (≥85%) with all types of services examined, higher for antenatal and postnatal care than for family planning and delivery care. We found significant associations between perceived and actual quality of care and both women's use and satisfaction with the perinatal health services received. CONCLUSIONS Quality of care is a key predictor of perinatal health service utilization and complete patient satisfaction with such services in Malawi. The current heightened attention toward perinatal health services and outcomes should be coupled with efforts to improve the actual quality of care offered to women in this country.
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Affiliation(s)
- Andreea A Creanga
- Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Room E8141, Baltimore, MD, 21205, USA. .,Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, USA.
| | - Sara Gullo
- Sexual, Reproductive, and Maternal Health Team, CARE USA, Atlanta, GA, USA
| | - Anne K Sebert Kuhlmann
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
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Khanam R, Ahmed S, Creanga AA, Begum N, Koffi AK, Mahmud A, Rosen H, Baqui AH. Antepartum complications and perinatal mortality in rural Bangladesh. BMC Pregnancy Childbirth 2017; 17:81. [PMID: 28270117 PMCID: PMC5341426 DOI: 10.1186/s12884-017-1264-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 02/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite impressive improvements in maternal survival throughout the world, rates of antepartum complications remain high. These conditions also contribute to high rates of perinatal deaths, which include stillbirths and early neonatal deaths, but the extent is not well studied. This study examines patterns of antepartum complications and the risk of perinatal deaths associated with such complications in rural Bangladesh. METHODS We used data on self-reported antepartum complications during the last pregnancy and corresponding pregnancy outcomes from a household survey (N = 6,285 women) conducted in Sylhet district, Bangladesh in 2006. We created three binary outcome variables (stillbirths, early neonatal deaths, and perinatal deaths) and three binary exposure variables indicating antepartum complications, which were antepartum hemorrhage (APH), probable infection (PI), and probable pregnancy-induced hypertension (PIH). We then examined patterns of antepartum complications and calculated incidence rate ratios (IRR) to estimate the associated risks of perinatal mortality using Poisson regression analyses. We calculated population attributable fraction (PAF) for the three antepartum complications to estimate potential risk reductions of perinatal mortality associated them. RESULTS We identified 356 perinatal deaths (195 stillbirths and 161 early neonatal deaths). The highest risk of perinatal death was associated with APH (IRR = 3.5, 95% CI: 2.4-4.9 for perinatal deaths; IRR = 3.7, 95% CI 2.3-5.9 for stillbirths; IRR = 3.5, 95% CI 2.0-6.1 for early neonatal deaths). Pregnancy-induced hypertension was a significant risk factor for stillbirths (IRR = 1.8, 95% CI 1.3-2.5), while PI was a significant risk factor for early neonatal deaths (IRR = 1.5, 95% CI 1.1-2.2). Population attributable fraction of APH and PIH were 6.8% and 10.4% for perinatal mortality and 7.5% and 14.7% for stillbirths respectively. Population attributable fraction of early neonatal mortality due to APH was 6.2% and for PI was 7.8%. CONCLUSIONS Identifying antepartum complications and ensuring access to adequate care for those complications are one of the key strategies in reducing perinatal mortality in settings where most deliveries occur at home.
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Affiliation(s)
- Rasheda Khanam
- International Center for Maternal and Newborn Health, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Room - E8153, 615 North Wolfe Street, Baltimore, MD, 21205, USA.,International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Saifuddin Ahmed
- Department of Population and Family Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA
| | - Andreea A Creanga
- International Center for Maternal and Newborn Health, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Room - E8153, 615 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Nazma Begum
- International Center for Maternal and Newborn Health, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Room - E8153, 615 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Alain K Koffi
- International Center for Maternal and Newborn Health, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Room - E8153, 615 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Arif Mahmud
- International Center for Maternal and Newborn Health, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Room - E8153, 615 North Wolfe Street, Baltimore, MD, 21205, USA
| | | | - Abdullah H Baqui
- International Center for Maternal and Newborn Health, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Room - E8153, 615 North Wolfe Street, Baltimore, MD, 21205, USA.
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Khanam R, Creanga AA, Koffi AK, Mitra DK, Mahmud A, Begum N, Moin SMI, Ram M, Quaiyum MA, Ahmed S, Saha SK, Baqui AH. Patterns and Determinants of Care-Seeking for Antepartum and Intrapartum Complications in Rural Bangladesh: Results from a Cohort Study. PLoS One 2016; 11:e0167814. [PMID: 27997537 PMCID: PMC5172566 DOI: 10.1371/journal.pone.0167814] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/21/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The burden of maternal complications during antepartum and intrapartum periods is high and care seeking from a trained provider is low, particularly in low middle income countries of sub-Saharan Africa and South Asia. Identification of barriers to access to trained care and development of strategies to address them will contribute to improvements in maternal health. Using data from a community-based cohort of pregnant women, this study identified the prevalence of antepartum and intrapartum complications and determinants of care-seeking for these complications in rural Bangladesh. METHODS The study was conducted in 24,274 pregnant women between June 2011 and December 2013 in rural Sylhet district of Bangladesh. Women were interviewed during pregnancy to collect data on demographic and socioeconomic characteristics; prior miscarriages, stillbirths, live births, and neonatal deaths; as well as data on their ability to make decision to go to health center alone. They were interviewed within the first 7 days of child birth to collect data on self-reported antepartum and intrapartum complications and care seeking for those complications. Bivariate analysis was conducted to explore association between predisposing (socio-demographic), enabling (economic), perceived need, and service related factors with care-seeking for self-reported antepartum and intrapartum complications. Multivariable multinomial logistic regression was performed to examine the association of selected factors with care-seeking for self-reported antepartum and intrapartum complications adjusting for co-variates. RESULTS Self-reported antepartum and intrapartum complications among women were 14.8% and 20.9% respectively. Among women with any antepartum complication, 58.9% sought care and of these 46.5% received care from a trained provider. Of the women with intrapartum complications, 61.4% sought care and of them 46.5% did so from a trained provider. Care-seeking for both antepartum and intrapartum complications from a trained provider was significantly higher for women with higher household wealth status, higher literacy level of both women and their husbands, and for those living close to a health facility (<10 km). Women's decision making ability to go to health centre alone was associated with untrained care only for antepartum complications, but was associated with both trained and untrained care for intrapartum complications. CONCLUSIONS Nearly 40.0% of the women who experienced either an antepartum or intrapartum complications did not seek care from any provider and 11.5% -14.9% received care from untrained providers, primarily because of economic and geographic barriers to access. Development and evaluation of context specific, cost-effective, and sustainable strategies that will address these barriers to access to care for the maternal complications will enhance care seeking from trained health care providers and improve maternal health.
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Affiliation(s)
- Rasheda Khanam
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
- * E-mail:
| | - Andreea A. Creanga
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alain K. Koffi
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Arif Mahmud
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nazma Begum
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Syed Mamun Ibne Moin
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Malathi Ram
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Md Abdul Quaiyum
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Samir K. Saha
- Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Abdullah H. Baqui
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G, Creanga AA. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol 2016; 215:539-547. [PMID: 27373599 DOI: 10.1016/j.ajog.2016.06.038] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/25/2016] [Accepted: 06/20/2016] [Indexed: 11/30/2022]
Abstract
Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy. While harmful and costly, it is often ignored or managed poorly. Screening, brief intervention, and referral to treatment is an evidence-based approach to manage substance use. In September 2012, the US Centers for Disease Control and Prevention convened an Expert Meeting on Perinatal Illicit Drug Abuse to help address key issues around drug use in pregnancy in the United States. This article reflects the formal conclusions of the expert panel that discussed the use of screening, brief intervention, and referral to treatment during pregnancy. Screening for substance use during pregnancy should be universal. It allows stratification of women into zones of risk given their pattern of use. Low-risk women should receive brief advice, those classified as moderate risk should receive a brief intervention, whereas those who are high risk need referral to specialty care. A brief intervention is a patient-centered form of counseling using the principles of motivational interviewing. Screening, brief intervention, and referral to treatment has the potential to reduce the burden of substance use in pregnancy and should be integrated into prenatal care.
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Affiliation(s)
- Tricia E Wright
- Departments of Obstetrics, Gynecology, and Women's Health and of Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, HI.
| | | | - Steven J Ondersma
- Merrill-Palmer Skillman Institute, Departments of Psychiatry and Behavioral Neurosciences, and Obstetrics and Gynecology, Wayne State University, Detroit, MI
| | - Cheryl Boyce
- Division of Clinical Neuroscience and Behavioral Research, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD
| | - Kimberly Yonkers
- Departments of Psychiatry and of Obstetrics and Gynecology, and School of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT
| | - Grace Chang
- Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Psychiatry, Department of Veterans Affairs Boston Healthcare System, Brockton, MA
| | - Andreea A Creanga
- Department of International Health and International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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Creanga AA, Odhiambo GA, Odera B, Odhiambo FO, Desai M, Goodwin M, Laserson K, Goldberg H. Pregnant Women's Intentions and Subsequent Behaviors Regarding Maternal and Neonatal Service Utilization: Results from a Cohort Study in Nyanza Province, Kenya. PLoS One 2016; 11:e0162017. [PMID: 27622496 PMCID: PMC5021282 DOI: 10.1371/journal.pone.0162017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/16/2016] [Indexed: 11/18/2022] Open
Abstract
Higher use of maternal and neonatal health (MNH) services may reduce maternal and neonatal mortality in Kenya. This study aims to: 1) prospectively explore women’s intentions to use MNH services (antenatal care, delivery in a facility, postnatal care, neonatal care) at <20 and 30–35 weeks’ gestation and their actual use of these services; 2) identify predictors of intention-behavior discordance among women with positive service use intentions; 3) examine associations between place of delivery, women’s reasons for choosing it, and birthing experiences. We used data from a 2012–2013 population-based cohort of pregnant women in the Demographic Surveillance Site in Nyanza province, Kenya. Of 1,056 women completing the study (89.1% response rate), 948 had live-births and 22 stillbirths, and they represent our analytic sample. Logistic regression analysis identified predictors of intention-behavior discordance regarding delivery in a facility and use of postnatal and neonatal care. At <20 and 30–35 weeks’ gestation, most women intended to seek MNH services (≥93.9% and ≥87.5%, respectively, for all services assessed). Actual service use was high for antenatal (98.1%) and neonatal (88.5%) care, but lower for delivery in a facility (76.9%) and postnatal care (51.8%). Woman’s age >35 and high-school education were significant predictors of intention-behavior discordance regarding delivery in a facility; several delivery-related factors were significantly associated with intention-behavior discordance regarding use of postnatal and neonatal care. Delivery facilities were chosen based on proximity to women’s residence, affordability, and service quality; among women who delivered outside a health facility, 16.3% could not afford going to a facility. Good/very good birth experiences were reported by 93.6% of women who delivered in a facility and 32.6% of women who did not. We found higher MNH service utilization than previously documented in Nyanza province. Further increasing the number of facility deliveries and use of postnatal care may improve MNH in Kenya.
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Affiliation(s)
- Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
| | | | - Benjamin Odera
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Frank O. Odhiambo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Mary Goodwin
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Kayla Laserson
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Howard Goldberg
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
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Weiniger CF, Lyell DJ, Tsen LC, Butwick AJ, Shachar B, Callaghan WM, Creanga AA, Bateman BT. Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States. BMC Pregnancy Childbirth 2016; 16:150. [PMID: 27392035 PMCID: PMC4938982 DOI: 10.1186/s12884-016-0941-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 07/01/2016] [Indexed: 11/25/2022] Open
Abstract
Background We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation. Methods Using the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech. Results Our study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p < 0.001). Compared to women with persistent breech at the time of delivery, women with successful external cephalic version were also less likely to experience several measures of significant maternal morbidity including endometritis (adjusted Odds Ratio (aOR) = 0.36, 95 % Confidence Interval (CI) 0.24–0.52), sepsis (aOR = 0.35, 95 % CI 0.24–0.51) and length of stay > 7 days (aOR = 0.53, 95 % CI 0.40–0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54–2.17). Conclusions Overall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.
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Affiliation(s)
- Carolyn F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, POB 12000, Israel.
| | - Deirdre J Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lawrence C Tsen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - BatZion Shachar
- Maternal-Fetal Medicine Unit, Department of Obstetrics & Gynecology, Sheba Met & March of Dimes Prematurity Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - William M Callaghan
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Andreea A Creanga
- Department of International Health, International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Wegs C, Creanga AA, Galavotti C, Wamalwa E. Community Dialogue to Shift Social Norms and Enable Family Planning: An Evaluation of the Family Planning Results Initiative in Kenya. PLoS One 2016; 11:e0153907. [PMID: 27124177 PMCID: PMC4849797 DOI: 10.1371/journal.pone.0153907] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/06/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction Use of family planning (FP) is powerfully shaped by social and gender norms, including the perceived acceptability of FP and gender roles that limit women’s autonomy and restrict communication and decision-making between men and women. This study evaluated an intervention that catalyzed ongoing community dialogues about gender and FP in Siaya county, Nyanza Province, Kenya. Specifically, we explored the changes in perceived acceptability of FP, gender norms and use of FP. Methods We used a mixed-method approach. Information on married men and women’s socio-demographic characteristics, pregnancy intentions, gender-related beliefs, FP knowledge, attitudes, and use were collected during county-representative, cross-sectional household surveys at baseline (2009; n11 = 650 women; n12 = 305 men) and endline (2012; n21 = 617 women; n22 = 317 men); exposure to the intervention was measured at endline. We assessed changes in FP use at endline vs. baseline, and fitted multivariate logistic regression models for FP use to examine its association with intervention exposure and explore other predictors of use at endline. In-depth, qualitative interviews with 10 couples at endline further explored enablers and barriers to FP use. Results At baseline, 34.0% of women and 27.9% of men used a modern FP method compared to 51.2% and 52.2%, respectively, at endline (p<0.05). Exposure to FP dialogues was associated with 1.78 (95% CI: 1.20–2.63) times higher odds of using a modern FP method at endline for women, but this association was not significant for men. Women’s use of modern FP was significantly associated with higher spousal communication, control over own cash earnings, and FP self-efficacy. Men who reported high approval of FP were significantly more likely to use modern FP if reporting high approval of FP and more equitable gender beliefs. FP dialogues addressed persistent myths and misconceptions, normalized FP discussions, and increased its acceptability. Public examples of couples making joint FP decisions legitimized communication and decision-making with spouses about FP especially for men; women described partner support as key enabler of FP use. Conclusions Our evaluation demonstrates that an intervention that catalyzes open dialogue about gender and FP can shift social norms, enable more equitable couple communication and decision-making and, ultimately, increase use of FP.
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Affiliation(s)
- Christina Wegs
- Sexual, Reproductive and Maternal Health Team, CARE USA, Atlanta, Georgia, United States of America
- * E-mail:
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Christine Galavotti
- Sexual, Reproductive and Maternal Health Team, CARE USA, Atlanta, Georgia, United States of America
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Abstract
PROBLEM/CONDITION Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. REPORTING PERIOD COVERED 2012. DESCRIPTION OF SYSTEM Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2012, data were received from 49 reporting areas. For trend analysis, abortion data were evaluated from 47 areas that reported data every year during 2003-2012. Census and natality data, respectively, were used to calculate abortion rates (number of abortions per 1,000 women) and ratios (number of abortions per 1,000 live births). RESULTS A total of 699,202 abortions were reported to CDC for 2012. Of these abortions, 98.4% were from the 47 reporting areas that provided data every year during 2003-2012. Among these same 47 reporting areas, the abortion rate for 2012 was 13.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 210 abortions per 1,000 live births. From 2011 to 2012, the total number and ratio of reported abortions decreased 4% and the abortion rate decreased 5%. From 2003 to 2012, the total number, rate, and ratio of reported abortions decreased 17%, 18%, and 14%, respectively, and reached their lowest level in 2012 for the entire period of analysis (2003-2012). In 2012 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates; women in their 30s and older accounted for a much smaller percentage of abortions and had lower abortion rates. In 2012, women aged 20-24 and 25-29 years accounted for 32.8% and 25.4% of all abortions, respectively, and had abortion rates of 23.3 and 18.9 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. In contrast, women aged 30-34, 35-39, and ≥40 years accounted for 16.4%, 9.1%, and 3.7% of all abortions, respectively, and had abortion rates of 12.4, 7.3, and 2.8 abortions per 1,000 women aged 30-34 years, 35-39 years, and ≥40 years, respectively. Throughout the period of analysis, abortion rates decreased among women aged 20-24, 25-29, and 30-34 years by 24%, 18%, and 10%, respectively, whereas they increased among women aged ≥40 years by 8%. In 2012, adolescents aged <15 and 15-19 years accounted for 0.4% and 12.2% of all abortions, respectively, and had abortion rates of 0.8 and 9.2 abortions per 1,000 adolescents aged <15 and 15-19 years, respectively. From 2003 to 2012, the percentage of abortions accounted for by adolescents aged 15-19 years decreased 27% and their abortion rate decreased 40%. These decreases were greater than the decreases for women in any older age group. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2012 and throughout the entire period of analysis were highest among adolescents aged ≤19 years and lowest among women aged 30-39 years. Abortion ratios decreased from 2003 to 2012 for women in all age groups. In 2012, the majority (65.8%) of abortions were performed by ≤8 weeks' gestation, and nearly all (91.4%) were performed by ≤13 weeks' gestation. Few abortions (7.2%) were performed between 14-20 weeks' gestation or at ≥21 weeks' gestation (1.3%). From 2003 to 2012, the percentage of all abortions performed at ≤8 weeks' gestation increased 7%; the percentage performed at >13 weeks remained consistently low (≤9.0%). In 2012, among the 40 reporting areas that included medical (nonsurgical) abortion on their reporting form, a total of 69.4% of abortions were performed by curettage at ≤13 weeks' gestation, 20.8% were performed by early medical abortion (a nonsurgical abortion at ≤8 weeks' gestation), and 8.7% were performed by curettage at >13 weeks' gestation; all other methods were uncommon. Among abortions performed at ≤8 weeks' gestation that were eligible on the basis of gestational age for early medical abortion, 30.8% were completed by this method. The percentage of abortions reported as early medical abortions increased 10% from 2011 to 2012. Deaths of women associated with complications from abortions for 2012 are being investigated as part of CDC's Pregnancy Mortality Surveillance System. In 2011, the most recent year for which data were available, two women were identified to have died as a result of complications from known legal induced abortions. No reported deaths were associated with known illegal induced abortions. INTERPRETATION Among the 47 areas that reported data every year during 2003-2012, the notable decreases that occurred during 2008-2011 in the total number, rate, and ratio of reported abortions continued from 2011 to 2012 and resulted in historic lows for all three measures of abortion. PUBLIC HEALTH ACTIONS The data in this report can help to identify groups of women at greatest risk for abortion and can be used to guide and evaluate prevention efforts. Because unintended pregnancy is the major contributor to abortion, and unintended pregnancies are rare among women who use the most effective methods of contraception, increasing access to and use of these methods can help further reduce the number of unintended pregnancies, and therefore abortions, performed in the United States.
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Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol 2015; 213:384.e1-11. [PMID: 25957019 DOI: 10.1016/j.ajog.2015.05.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 03/16/2015] [Accepted: 05/02/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States. STUDY DESIGN We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors. RESULTS From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals. CONCLUSION Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.
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Affiliation(s)
- Andreea A Creanga
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander J Butwick
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA
| | - Lindsay Raleigh
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA
| | - Ayumi Maeda
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Elena Kuklina
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - William M Callaghan
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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