The fourth trimester: a critical transition period with unmet maternal health needs

Trend Toward Older Maternal Age Contributed To Growing Racial Inequity In Very-Low-Birthweight Infants In The US

In 2016 the Centers for Disease Control and Prevention reported that for the first time, US women in their thirties were bearing more children than those in their twenties. Analyzing US vital statistics data from the period 1989-2019, we simulated the effect that the distributional shift to older maternal ages at first birth had on health inequity between Black and White infants. Net of maternal socioeconomic indicators, this shift increased the relative odds that White women gave birth to very-low-birthweight (VLBW) infants by 10 percent, versus 19 percent for Black women, largely accounting for the rise in VLBW and the increase in racial inequity seen in the years analyzed. Reductions in infant mortality over the period were dampened by the maternal age shift, especially among Black babies, exacerbating Black-White inequity. Policy implications for promoting reproductive justice include universal tertiary care access, increasing the supply and distribution of maternity care providers, addressing the holistic needs of mothers throughout pregnancy and postpartum, and expanding family support policies. Conceptually, we recommend centering the realities of pregnancy and parenting from the perspective of the populations at highest risk-centering on the margins-and taking into account their implications for maternal weathering (accelerated deterioration due to disparate impacts of structural racism).

A Qualitative Study on Challenges Faced by Postnatal Mothers

The core variable arrived at were Challenges of postnatal motherhood phenomenon from mothers’ perspective, eight essential themes were developed, and they were as follows: ‘Contented with the birth experience; A wider perspective of womanhood’. ‘Coming up with physiological and emotional challenges; a note worthy experience’. ‘Being happy with the gender of the baby; A God given gift’. ‘Glad to be a mother with a good family support’. ‘Happy to receive the intended care in the hospital; a boon to every mother’. ‘Ready to face challenges; marital perspective’. ‘Newborn care; a tender loving care of womanhood’. ‘Joyous moment to be with the newborn but unhappy due to physical and psychological alteration’.

Interpretation and Conclusion

The findings of the study throw light on various challenges faced by mothers and their coping strategies. In this study majority of the mothers had least to moderately expressed challenges and highly expressed challenges were minimal. This could be hypothesised that the study participants were from a rural setting where most of the mothers are unemployed and most of the mothers have a good support system which helps them to face challenges positively. Nevertheless, literature shows that Emotional challenges, Breastfeeding challenges and newborn care challenges are faced globally which can be addressed by creating awareness programmes. This can be achieved through nurse-led clinics on childbirth education in the OBG and Paediatric units with Mathr Shiksha Abhiyaan which will benefit most of the Pregnant and lactating mothers coming to OPD.

The Power and Promise of Postpartum Self Care: Evaluation of a Web-Based Tool for Underserved Women

OBJECTIVES

Joyuus is a culturally diverse, comprehensive online tool designed to address the self-care needs of underserved postpartum women. The tool provides actionable self-care information, knowledge, and skills to improve postpartum health and identifies red flags for when self-care shifts to seeking care.

METHODS

We employed a mixed-methods multiphase design to evaluate the Joyuus prototype, including a pre-post evaluation (N = 87) to assess behavioral health outcomes before and after using the tool for a one-month period. 91% completed the post-test (N = 79). The analysis focused on estimation of treatment effect (via 95% confidence intervals) and fitness of instruments in this population.

RESULTS

Participants were between 6 months pregnant and one year postpartum, a mean age of 30 years, 100% female, 99% Black, with nearly equal distribution of married (55%) and not married (44%), and above (47%) and below (46%) annual income of $60 K. Key measures saw significant improvement from pre- (mean = 26.44, SD = 5.39) to post (mean = 28.29, SD = 5.26) on the Connor-Davidson Resilience Scale (p < 0.001) Trends toward improvement (not statistically significant) were noted for Depression (EPDS) (p = 0.624) and Anxiety (STAI) (p = 0.286), and no meaningful change on MOS Social Support or COVID-19 Mental Health Impacts Measures.

CONCLUSIONS FOR PRACTICE

This pilot study demonstrates that a self-care mobile tool has the potential to address significant health outcomes related to maternal morbidity and mortality. By providing a continuously available companion addressing physical, mental, and real-life questions, it creates value during postpartum for mothers who can often feel overwhelmed or isolated.

Discharge Readiness and Associated Factors Among Postpartum Women in Tamale, Ghana

Ghana experiences a relatively high maternal mortality ratio, with the majority of maternal deaths occurring in the postpartum period. Discharge readiness is a reliable indicator of maternal health outcomes and involves a postpartum woman's perception of preparedness to leave the hospital following delivery. We measured the discharge readiness of postpartum women in Ghana through an institutional-based cross-sectional study involving 151 participants. Participants completed an interviewer-administered survey, and data analyses included linear regression models. The study sample demonstrated relatively high discharge readiness, with a mean score of 177.57 on a scale from 0.00 to 220.00. Higher gravidity was positively associated with discharge readiness score, while longer length of hospital stay and receiving educational handouts were negatively associated with discharge readiness score. Clinical interventions addressing the factors found to be associated with discharge readiness have significant potential to improve postpartum care and maternal outcomes in Ghana.

Learning from women: Improving experiences of respectful maternity care during unplanned caesarean birth for women with diverse ethnicity and racial backgrounds

PROBLEM

Women from diverse ethnicity and racial backgrounds have few opportunities to share birth experiences to inform improvements in care.

BACKGROUND

Respectful maternity care is recognised as a global women's health priority. Integrating that framework into diverse care systems and models may help bridge care gaps for women who had unexpected birth experiences, including unplanned caesarean birth.

AIM

To describe the experiences of women who had unplanned caesarean births and use knowledge gained to inform best practice recommendations that embody respectful maternity care.

METHODS

Qualitative data were analysed from focus groups involving a convenience sample of 11 English speaking women, from diverse ethnic and racial backgrounds, with prior unplanned caesarean experience. Respectful maternity care was used as the lens for interpreting women's narratives using Thorne's interpretive description. The study site was an outpatient prenatal clinic within an urban academic, tertiary-care medical centre in the United States.

FINDINGS

Two predominant, contrasting themes emerged: "not feeling well cared for" and "feeling well supported". Positive experiences included sources of support and strength from the midwifery practice, group prenatal care, and a doula program. Eight domains of respectful maternity care were applied to findings, highlighting current positive institutional practices and proposing areas for future quality improvement.

CONCLUSION

Key practices promoting respectful maternity care include adequate communication and information sharing between pregnancy care providers and women, and a more robust informed consent process. Further emphasis on respectful maternity care is needed to support women to make shared decisions that best fit their circumstances and preferences.

Prenatal and Childbirth Risk Factors of Postpartum Pain and Depression: A Machine Learning Approach

OBJECTIVES

About 74.91% of U.S. mothers experience postpartum pain at 6 to 10 weeks postpartum, and one in seven U.S. mothers suffer from postpartum depression. We used machine learning to explore physical, psychological, and social factors during pregnancy and childbirth and identify the most important predictors of postpartum pain and depression.

METHODS

Data were from the Listening To Mothers III survey (2012), a national representative sample of postpartum mothers. We randomly split the dataset into a training set (N = 1467) and a test set (N = 723). The final models included 34 risk factors identified from previous literature. Postpartum pain was measured as "to what extent the pain interferes with mothers' daily life". PHQ2 scores measured depression. We used the random forest model, an aggregate of many regression trees, to accommodate potential nonlinear/interaction effects.

RESULTS

In the test data set, our models explained 15.8% of the variance in pain and 27.1% of the variance in depression. The model's strongest predictors for postpartum pain were Cesarean delivery, holding back while communicating with providers, non-use of pain relief medications, and perceived discrimination. For depression scores, the model's strongest predictors included needing help for depression during pregnancy, perceived discrimination, holding back, gestational diabetes, and pain.

CONCLUSIONS FOR PRACTICE

Mental and physical health are intertwined and should be considered integratively in the perinatal period. Besides, practitioners should also be aware of the importance of patient-provider-relationship, which both independently and interact with other risk factors to predict postpartum health.

Association Between Periviable Delivery and New Onset of or Exacerbation of Existing Mental Health Disorders

OBJECTIVE

To evaluate whether there is an association between periviable delivery and new onset of or exacerbation of existing mental health disorders within 12 months postpartum.

METHODS

We conducted a retrospective cohort study of individuals with liveborn singleton neonates delivered at 22 or more weeks of gestation from 2008 to 2017 in the MarketScan Commercial Research Database. The exposure was periviable delivery , defined as delivery from 22 0/7 through 25 6/7 weeks of gestation. The primary outcome was a mental health morbidity composite of one or more of the following: emergency department encounter associated with depression, anxiety, psychosis, posttraumatic stress disorder, adjustment disorder, self-harm, or suicide; new psychotropic medication prescription; new behavioral therapy visit; and inpatient psychiatry admission in the 12 months postdelivery. Secondary outcomes included components of the primary composite. Those with and without periviable delivery were compared using multivariable logistic regression adjusted for clinically relevant covariates, with results reported as adjusted incident rate ratios (aIRRs). Effect modification by history of mental health diagnoses was assessed. Incidence of the primary outcome by 90-day intervals postdelivery was assessed.

RESULTS

Of 2,300,244 included deliveries, 16,275 (0.7%) were periviable. Individuals with periviable delivery were more likely to have a chronic health condition, to have undergone cesarean delivery, and to have experienced severe maternal morbidity. Periviable delivery was associated with a modestly increased risk of the primary composite outcome, occurring in 13.8% of individuals with periviable delivery and 11.0% of individuals without periviable delivery (aIRR 1.18, 95% CI 1.12-1.24). The highest-risk period for the composite primary outcome was the first 90 days in those with periviable delivery compared with those without periviable delivery (51.6% vs 42.4%; incident rate ratio 1.56, 95% CI 1.47-1.66).

CONCLUSION

Periviable delivery was associated with a modestly increased risk of mental health morbidity in the 12 months postpartum.

Refugee women's pregnancy and childbirth experiences in the US: Examining context through a reproductive justice framework

Maternal health in the United States is an area of immediate concern. The compounded disadvantages and unique global positions of refugee women highlight the need for research that explores the experiences of refugee women during pregnancy and childbirth. The present study examines how contextual factors shape pregnancy and childbirth experiences for Syrian, Afghan, Congolese, and Karen women living in Clarkston, Georgia, US. Qualitative data were collected via focus groups facilitated by community interpreters. We used a reproductive justice framework to center women's desires, needs, and experiences, and to highlight the importance of structural factors in the findings and analysis of this study. Using codebook thematic analysis, three themes were developed: (1) isolation and alienated knowledge, (2) gendered disparities and structural inequities, and (3) community support and precarity. The findings reflect both the diversity and constancy of women's experiences and highlight how the context of the US impacts women's ability to exercise agency during pregnancy and childbirth. Systemic change is needed to improve women's access to tools that increase their capacity to exercise agency both during pregnancy and childbirth, and beyond.

Impact of the "39-week rule" on adverse pregnancy outcomes: a statewide analysis

BACKGROUND

The "39-week rule," adopted by the American College of Obstetricians and Gynecologists circa 2009, discouraged routine elective induction of labor in early-term gestations (37 weeks 0 days-38 weeks 6 days) to decrease the risk of adverse neonatal outcomes. However, little research exists regarding any unintended adverse pregnancy outcomes associated with this policy shift.

OBJECTIVE

This study aimed to quantify the difference in incidence of adverse pregnancy outcomes before and after the implementation of the 39-week rule.

STUDY DESIGN

Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Classification of Diseases 9/10 codes were obtained for each birth. Our primary outcome was the incidence of any of the following adverse pregnancy outcomes: cesarean delivery, hypertensive disorders, chorioamnionitis, postpartum hemorrhage, high-degree lacerations, placental abruption, and intensive care unit admission. Propensity score analysis was used to control for age, body mass index, and race. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare the prerule and postrule groups.

RESULTS

A total of 633,985 births were eligible for inclusion-412,632 from 2000 to 2008, and 221,353 from 2013 to 2017. There was a significant increase in the primary outcome in the postrule period (39.94% pre vs 42.76% post; P<.01). The incidence of all hypertensive disorders was significantly increased in the postrule period compared with the prerule period (7.75% pre vs 10.1% post; P<.01). The incidence of chorioamnionitis and cesarean delivery also increased in the postrule period (1.45% pre vs 1.92% post; P<.01; 29.6% pre vs 31.82% post; P<.01; respectively).

CONCLUSION

There was a significant increase in the primary outcome following the implementation of the 39-week rule. Although the policy shift was driven by a desire to decrease adverse neonatal outcomes, aggregate benefit was not observed for pregnancy outcomes.

The development of an IT-based intervention to support a healthy postpartum lifestyle through behavioral change

Background: Pregnancy and the postpartum period are difficult times with increased risks of weight gain and weight retention. This study aims to provide new insights into developing and designing information an communication technology interventions to support a healthy postpartum lifestyle through behavioral changes.Methods: A participatory design approach, combined with the behavior change wheel, was applied. The intervention was based on outcomes from co-creation with postpartum parents, healthcare professionals, IT consultants, and researchers.Results: An intervention was developed that reflects users' requests and needs to support a healthy postpartum lifestyle through behavioral change. The intervention includes podcasts, video exercises, weight tracking, and weekly push notifications.Conclusion: Developing an intervention to support a healthy postpartum lifestyle is feasible using both a participatory design and the behavior change wheel.

Postpartum Hospital Readmissions Among Massachusetts Women Who are Deaf or Hard of Hearing

Objectives: Deaf or hard of hearing (DHH) women are at a higher risk of adverse pregnancy and birth outcomes compared with other women. However, little is known about postpartum outcomes among DHH women. The objective was to compare the risk of postpartum hospitalizations for DHH compared with non-DHH women and the leading indications for postpartum admissions. Materials and Methods: We analyzed data from the 1998-2017 Massachusetts Pregnancy to Early Life Longitudinal Data System and identified 3,546 singleton deliveries to DHH women and 1,381,439 singleton deliveries to non-DHH women. We used Cox proportional hazard models to compare the first hospital admission and ≥2 hospital admissions between DHH and non-DHH women within 1-42, 43-90, and 91-365 days after delivery. Results: DHH women had a higher risk for any hospital admissions across all periods (hazard ratios [HR] = 1.84; 95% confidence intervals [CI] 1.46-2.34 within 1-42 days; HR = 2.76; 95%CI 1.99-3.83 within 43-90 days; and HR = 3.10; 95%CI 2.66-3.60 91-365 days) after childbirth compared with non-DHH women. They had an almost seven times higher risk for repeated hospital admissions within 43-90 days (HR = 6.84; 95%CI 1.66-28.21) and nearly four times higher the risk within 91-365 days (HR = 3.63; 95%CI 2.00-6.59) after delivery compared with non-DHH women. The leading indications for readmission among DHH women included: conditions complicating the puerperium/hemorrhage and soft tissues disorders. Conclusion: Compared with other women, DHH women had significantly higher readmissions across all postpartum periods and for repeated admissions >42 days. Leading postpartum indications were distinct from those of non-DHH women.

Postpartum Care Visit Attendance Within 60 Days of Delivery Among Women With and Without Opioid Use During Pregnancy: An Analysis of Commercial Insurance Data

BACKGROUND

Postpartum care (PPC) is a key component of maternal health, particularly for people who use opioids during pregnancy. Little is known about the prevalence and correlates of PPC visit attendance among those using opioids compared with nonusers in a privately insured population.

METHODS

A retrospective cohort study was conducted using nationwide private insurance claims between 2011 and 2017 (N = 1,291,352 women) comparing the following opioid use groups: nonusers, nonchronic prescription users, chronic prescription users, and women with opioid use disorder (OUD). Multivariable logistic and linear regressions evaluated the odds of PPC attendance and the mean time to an initial PPC visit for each user group. Stratified models identified factors associated with PPC attendance by opioid use type.

RESULTS

Overall, 45% of the cohort attended a PPC visit and nearly 10% had any opioid use during pregnancy. More women in the three opioid use categories attended PPC than nonusers (50-56% vs. 45%). Opioid use regardless of type was associated with higher odds and earlier PPC visitation than women with no opioid use; nonchronic and chronic users had 17% and 40% greater odds of PPC than nonusers (adjusted odds ratio [aOR]: 1.17; 95% confidence interval [CI]: 1.16-1.19; aOR: 1.40, 95% CI: 1.34-1.46), whereas women with OUD had 7% higher odds (aOR: 1.07; 95% CI: 1.00-1.13). Antenatal care and psychiatric, hypertensive, and pain conditions were most strongly associated with higher odds of attending PPC; older maternal age was negatively associated with PPC. Stratified analysis showed opioid correlates varied similarly across user groups.

CONCLUSIONS

PPC use was generally low in this study cohort of privately insured women. Women who used opioids and those with chronic conditions had greater odds of attending PPC. Improved efforts are needed to engage people in PPC, as well as service integration and coordination for people who use opioids during pregnancy.

Postpartum care: Discussions and counseling for the peripartum period

BACKGROUND

Traditionally, postpartum care is confined to inpatient care immediately post birth and one appointment approximately six weeks postpartum. Data supports a continuum of care model as best for the health of mother and baby. Despite most women having significant concerns about the postpartum period, these concerns are frequently incompletely addressed by providers. We surveyed prenatal and postpartum patients to understand their concerns and experiences discussing postpartum care with providers.

METHODS

Cross sectional surveys were administered between June 2019 and May 2021. Principal component analysis was used to show higher than average (positive) or lower than average (negative) conversations with providers about postpartum care examined by race, education, and parity. Chi squared tests were conducted to examine the significance of specific postpartum concerns.

RESULTS

421/450 patient surveys were analyzed, based on completion. Most patients were White (193), had post graduate degrees (188), privately insured (236), married (248), first time pregnant (152), and used doctors as their primary provider (267). Patients with lower education, higher parity and Black patients without postgraduate degrees reported higher than average postpartum counseling. Additionally, most patients expressed significant concerns about postpartum exhaustion (65.8%), breastfeeding (62.3%), pain (61.2%), physical activity (54.9%) and the baby blues (50.4%).

CONCLUSIONS

Postpartum concerns are incompletely and inconsistently addressed amongst patients based on race, parity, and education. A continuum of care approach, beginning in the third trimester, through the postpartum period, may provide better counseling to address all patients' concerns.

Disparities in Emergency Department Utilization Among Women with Postpartum Mood Disorders (2006-2016)

INTRODUCTION

Postpartum mood disorders are associated with adverse outcomes for newborns and mothers and may require urgent evaluation. The emergency department is often a healthcare entry point, but factors associated with these emergency department visits are unknown.

METHODS

A longitudinal retrospective analysis using the Nationwide Emergency Department Sample to assess national estimates of emergency department visits by women ages 15-49 with primary diagnosis of a postpartum mood disorder between 2006 and 2016. Emergency department visit rates for postpartum mood disorders per 100,000 live births were calculated.

RESULTS

Emergency department visits related to postpartum mood disorders remained stable from 2006 to 2016 (5153 to 5390 respectively). Two-thirds of visits were by patients younger than 30. Approximately half of visits for postpartum mood disorders were funded by Medicaid (42.4-56.7%) compared to 27.4-41.2% funded by Medicaid for all other age-matched women. Of postpartum mood disorder visits 30.3% were by women from the lowest income quartile. The highest rate of emergency department visits occurred in the youngest patients (ages 15-19: 231 visits versus ages 35-49: 105 visits). Postpartum mood disorder admissions were higher than those for age-matched women with all other diagnoses (19.8% vs. 6.5%).

DISCUSSION

The high rate of women that are young and with public insurance visiting the emergency department for postpartum mood disorders demonstrates an increased risk for these disorders in these populations and an opportunity for targeted intervention by policymakers and providers. Higher admission rates for postpartum mood disorders compared to all other diagnoses reveals a chance to optimize outpatient screening and treatment.

Primary Care Clinician Perspectives on Patient Navigation to Improve Postpartum Care for Patients with Low Income

Background

Birthing individuals experience significant physical and psychosocial transitions during the postpartum period. Despite amplified health needs, many individuals do not successfully transition from obstetric to primary care. Patient navigation provides a patient-centered solution that has been applied to other health care specialties resulting in improved care coordination and patient engagement for populations in greatest need. Our objective was to understand primary care clinician perspectives regarding the role of navigators in improving postpartum care for individuals with low income.

Methods

In this qualitative investigation, we conducted focus groups with primary care clinicians from family and internal medicine specialties. Semistructured interview guides addressed clinician perceptions of navigator roles during the postpartum period and recommendations for navigator training. Focus group discussions were digitally recorded, transcribed, and analyzed via a constant comparative method.

Results

Twenty-eight primary care clinicians, including 26 physicians and 2 advanced practice registered nurses, participated in 8 focus groups. Participants reported favorable attitudes toward implementation of a postpartum patient navigation program. Themes regarding useful navigation services included streamlining obstetric to primary care transition, enhancing visit effectiveness, creating personalized postpartum care, and providing patient- and clinician-focused education. Recommendations for navigator training included education on basic medical concerns that are common in the postpartum period, health information privacy and electronic health record use, health care systems, and community resources.

Clinical Trial Registration number: NCT03922334.

Conclusions

Primary care clinicians were highly receptive to the concept of patient navigation as a process to improve health in the postpartum period through enhanced care coordination and improved patient knowledge, engagement, and self-efficacy.

Screening and Referral for Social Determinants of Health: Maternity Patient and Health Care Team Perspectives

Objective

To identify patient and health care team perspectives on screening and referral for Social Determinants of Health (SDoH) in maternity care.

Methods

This human-centered design study was conducted in a prenatal clinic and in the surrounding community of a university teaching hospital in the Southeastern United States. Qualitative data were collected through semistructured interviews and focus groups between March 2019 and February 2020, with findings shared in-person with participants for feedback.

Results

A total of 19 English- and Spanish-speaking patients and 11 health care team members participated. Participants suggested that all patients should be screened as part of integrated health assessments, early in care and periodically, but only when protocols are in place for addressing needs-immediate or ongoing. They expressed concerns that disclosure of SDoH screening data might exacerbate already existing biases, negatively impact care, or be used to harm them. Patients wanted proactive transparency about the purpose of SDoH screening, and to know who would have access to their data, when and how it would be used, and how long it would be stored. Patients expressed concern about confidentiality and stigma, and wanted their health care team to normalize seeking help, and acknowledge that birthing people's circumstances change over time. Patients and health care team responded that patient-provider communication should be respectful, be antiracist, and demonstrate respect for patient autonomy.

Conclusion

Patients and health care team members recommended that SDoH resource information be accessible to all patients regardless of endorsed needs.

Evaluation of Patient Access to Spanish-Language-Concordant Care on a Postpartum Unit

OBJECTIVE

To evaluate patient access to Spanish-language-concordant care on a postpartum unit and to identify facilitators and barriers to the use of interpretation services.

DESIGN

Mixed-methods research study, comprising a cross-sectional chart review from September to December 2019 and semistructured interviews from June to December 2020.

SETTING/LOCAL PROBLEM

A tertiary academic medical center in the southeastern United States where individuals with limited English proficiency are at risk for poor health outcomes when they are unable to communicate with clinicians in their preferred language.

PARTICIPANTS

We conducted a chart review of 50 randomly selected birthing parent-newborn couplets and interviews with 14 inpatient health care team members.

MEASUREMENTS

The chart review examined patient characteristics, health care team composition including Spanish language proficiency, length of stay, number of interpreter requests, and time between clinician interpreter requests and interpreter arrival on the unit. Interviews evaluated facilitators and barriers to interpreter use.

RESULTS

Access to a clinician certified in medical Spanish or an interpreter was offered to 12 of 50 (24%) couplets upon admission to the unit and to 7 of 50 (14%) of couplets for daily maternal and newborn medical rounds. Clinicians reported long and unpredictable wait times to access interpreters, which led them to rely on hand gestures, broken Spanish, and smartphone apps to "get by" when communicating with patients without certified interpretation services. Participants described low usage of interpreters for "noncritical" encounters.

CONCLUSION

Interpreters and other forms of Spanish-language-concordant care were underused on the postpartum unit. This deviation from national standards may put families at risk for harm. Recommendations from this study include advancing a culture of respectful care, improving the interpreter request workflow, addressing safe staffing, facilitating direct patient access to interpreters, and providing ongoing evaluation and support.

First-Time Mothers' Invisible Presence Using Social Networking Sites

PURPOSE

To describe first-time mothers' experiences with online social networking sites in the early postpartum period, explore how mothers use them to gain support, and to evaluate how their use can aid or hinder maternal role transition.

STUDY DESIGN

Qualitative descriptive study.

METHODS

This qualitative descriptive study, using convenience and snowball sampling, first-time mothers in the early postpartum period were recruited through social media. Semistructured interviews were conducted virtually where mothers were asked to describe their experiences with online social networking. Thematic analysis methods were used to develop themes from participant interviews.

RESULTS

Twelve first-time mothers ranging from 4 to 12 weeks postpartum participated in the study. Thematic analysis revealed four themes: 1) Habits of first-time mom using social networking sites, 2) New purpose online, 3) Taking it to the moms, and 4) Impact on motherhood.

CLINICAL IMPLICATIONS

Maternal child nurses have opportunities to further customize support for first-time mothers online. Awareness of habits, trends, implications of early mothering during COVID-19, and the role social networking sites can play in supporting mothers in the early postpartum period offers new ways for nurses to support and empower the motherhood collective.

A Qualitative Study of Perceptions, Strengths, and Opportunities in Cardiometabolic Risk Management During Pregnancy and Postpartum in a Georgia Safety-Net Hospital, 2021

INTRODUCTION

Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder.

METHODS

We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management.

RESULTS

From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors.

CONCLUSION

Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.

Group-Based Trajectory Analysis for Postpartum Depression Symptoms among Chinese Primiparous Women

Background: Subgroups of individuals sharing similar patterns of postpartum depression (PPD) among Chinese women are unknown thus far. Using a group-based trajectory model, this study aimed to explore the subgroups of Chinese primiparous women that share similar patterns of PPD and to explore the predictors of PPD trajectory membership over the course of the first six months postpartum. Methods: In total, 674 first-time Chinese mothers were recruited, and their depression status was assessed using the Edinburgh Postnatal Depression Scale (EPDS) at four time points. Findings: Around 18.0% of participants belonging to Group 1 labeled as “few or no symptoms” remained stable, with an EPDS score of less than 5 during a six-month postpartum period. Almost one-third of subjects fell within the second trajectory, labeled “subclinical but present symptoms”, and peaked into the range of mild PPD but mostly stayed in the minimal range and had few or no PPD symptoms. Group 3 included 31.2% of women labeled “minor PPD status”, and their mean EPDS scores increased to a peak of 14.66 at six weeks postpartum. Group 4, with “major PPD status”, comprised 19.2% of the population, and the mean EPDS scores dramatically increased, reaching a peak of 19.59 at 12 weeks postpartum. Fewer types of support and not attending parenting training were associated with membership in the minor and major PPD status trajectories. Conclusions: Almost half of the Chinese new mothers in the study were found to fall into the two groups with minor or major PPD status trajectories, who should be given more attention and awareness from health professionals and researchers. Understanding predictors of group membership could help health providers to identify folks to prioritize getting connected to care as well as forming targeted interventions. Less degree of received support and not attending parenting training were identified to predict PPD trajectory membership. The regular, routine screening of PPD should be conducted at least 12 weeks postpartum, especially for new mothers in the major PPD status trajectory.

Prevalence and Predictors of Integrated Care Among Teen Mothers and Their Infants

PURPOSE

Integrated models of primary care for parenting teens, in which teens and infants are cared for by the same clinical team on the same day, are associated with reduced repeated pregnancies and increased uptake of contraception and immunization. Our purpose was to determine how frequently teen-infant dyads receive integrated care.

METHODS

This study used Medicaid Analytic eXtract data to create a retrospective cohort of mothers aged 12-17 linked with infants born from 2007-2012 in 12 states. Teen-infant dyads were enrolled in Medicaid throughout the year after birth. The primary outcome was integrated care in the year after birth, defined as ≥ 1 instance when teen and infant had visits on the same day, billed to the same clinician identifier. Logistic regression assessed the relationship between integrated care and maternal demographics, dyad health, clinician specialty, and community factors.

RESULTS

Of 20,203 dyads, 3,371 (16.7%) had integrated care in the year after birth. Dyads with integrated care had a mean of 1.2 (SD 1.3) integrated visits. Dyads with integrated care had more visits (14.9, SD 10.6 vs. 11.7, SD 8.3), including more preventive visits for teens and more acute visits for both teens and infants. In regression, integrated care was associated with maternal factors (younger age, non-Latinx white race, and maternal health risks), residence in rural or high-poverty areas, and ever visiting Family Medicine clinicians.

DISCUSSION

Though uncommon, integrated care was associated with greater engagement in health care. Implementation of integrated care may support increased preventive care for parenting teens.

'Torn in two': Experiences of Mothers Who Are Pregnant when Their Child Is Diagnosed With Cancer

Mothers of children diagnosed with cancer have been shown to experience high rates of psychological distress and poor physical health. Pregnancy further increases the healthcare needs of mothers due to the marked physiological changes and psychological adaptations. Our study aimed to explore the experiences of mothers who were pregnant and/or had a baby while their older child was receiving treatment for cancer. Our study employed a qualitative description methodology using semi-structured interviews. Participants were recruited from across Australia via notices on social media sites and the distribution of flyers. The sample comprised 13 mothers who were pregnant and/or had a baby and had a child diagnosed with cancer who was under 17 years old. Thematic analysis was used to analyse the data from which six themes were identified: (1) an impossible balancing act, (2) mother's health and well-being, (3) creating certainty: birthing plans, (4) a bit of sunshine and a time to rest, (5) challenges of caring for the baby and (6) an unenviable position: doing my best versus feeling guilty. Our study demonstrates the additional challenges faced by mothers who are pregnant while their child is receiving cancer treatment. There is a need for a comprehensive and coordinated program that provides pregnant mothers with practical and psychological support. The implementation of such a program has the potential to improve health outcomes for all family members, particularly the mother and their newborn.

Investigating women’s health issues and help-seeking intentions in primary care in Japan: a cross-sectional study

Background

Many women face a variety of barriers to seeing obstetricians and gynecologists (OB/GYNs). Primary care physicians (PCPs) in Japan are not well equipped to address and adequately handle women’s health issues. Hence, opportunities for women to consult PCPs about women’s health issues are often limited during busy outpatient encounters. It is essential to explore PCP’s roles in women’s health care by examining women’s health needs in a primary care setting. The aim of the study is to describe the prevalence and distribution of women’s health issues and help-seeking intentions among women visiting a primary care clinic.

Methods

This was a cross-sectional study using a questionnaire. We included women aged 20–60 years who visited a primary care clinic for any reason. The questionnaire comprised a list of women’s health issues, the General Help Seeking Questionnaire to assess help-seeking intentions, and participants’ demographics including their reasons for visiting and regularity of OB/GYN visits.

Results

We distributed the questionnaire to 294 women and analyzed 260 valid responses. The average age of the respondents was 40.5 years old, and they had an average of 5.2 clinic visits a year. Approximately half of them (50.4%) visited for their own care. One hundred thirty-nine (53.9%) reported at least one women’s health issue, and 73.9% of them had no regular visit to an OB/GYN. The major concerns of women’s health issues included gynecological cancer screenings and menstrual problems. The distribution of help-seeking intentions for each source of care appeared to be classified into three patterns. One fifth of the women indicated high help-seeking intentions for PCPs, and a greater number of women expressed higher help-seeking intentions for PCPs when they did not regularly see an OB/GYN.

Conclusions

A significant number of women who visited a primary care clinic had a specific concern about women’s health issues, and a majority of them had not regularly visited their OB/GYN. PCPs may have an important role in providing an opportunity for women to discuss their concerns about women’s health issues as part of comprehensive care during a daily clinical encounter.

Medicaid expansion in Oregon and postpartum healthcare among people with and without prenatal substance use disorder

Background

People with a maternal substance use disorder (SUD) may experience a lack of access to necessary healthcare and more specifically, postpartum healthcare. It is not known whether increased insurance coverage introduced by Medicaid expansion has improved postpartum healthcare utilization among this population.

Methods

Oregon 2008-2016 birth certificates and Medicaid claims were used to examine whether continuous insurance enrollment and postpartum healthcare utilization increased post-Medicaid expansion in a population with and without SUD (n = 9,337). International Classification of Diseases codes were used to identify deliveries, SUD, and postpartum healthcare. Univariable and multivariable generalized linear regression with standard errors clustered by individual were used to estimate the association between Medicaid expansion and postpartum healthcare utilization, stratified by maternal SUD.

Results

Among the 10.3% with SUD, expansion was not associated with increased continuous enrollment or postpartum healthcare utilization. Among those without SUD, post-expansion deliveries were associated with increased continuous enrollment (+105.0 days; 95% CI=96.9-113.2), total (+4.4; 95% CI=2.9-6.0), postpartum (+0.3; 95% CI=0.2-0.4), inpatient (+0.9; 95% CI=0.7-1.1), outpatient (+2.3; 95% CI=1.4-3.3), office (+0.9; 95% CI=0.2-1.6), and emergency department (+0.3; 95% CI=0.1-0.5) visits. Among deliveries to postpartum people with SUD, 27.2% had opioid use disorder (OUD); expansion was associated with increased OUD medication use (12.0% vs 18.3%) and number of fills (6.7 vs 16.6).

Conclusions

Medicaid expansion in Oregon was only associated with increased Medicaid-financed healthcare utilization for postpartum people without SUD, with the exception of those with OUD, demonstrating the need for assessing various strategies to improve postpartum healthcare utilization.

Trajectories of Postpartum Recovery: What is Known and Not Known

Women's postpartum health is a public health issue that has lifelong consequences. Timely recognition and treatment of physical and mental health issues can have positive health consequences while lack of access to effective treatments or health care services can lead to long-term health problems. To advance knowledge of priority health symptoms and trajectories of postpartum recovery from women's health perspectives, we share findings from the Maternal health And Maternal Morbidity in Ireland (MAMMI) study. Data from 3047 first-time mothers recruited to a longitudinal maternal health study in Ireland from 2012 to 2017 reveal the trajectories of maternal health and health problems experienced up to 12 months postpartum. Morbidities explored include urinary incontinence, pelvic girdle pain, and sexual and mental health issues. Viewed together, and over time, the scale and persistent nature of many physical and mental health problems become apparent, yet considerable proportions of women were not asked directly about health problems by health care professionals. When women do not know what is and is not normal postpartum, they may suffer in silence and the consequence is that health problems/issues that are preventable, and treatable, are likely to become chronic. To make positive contributions to women's health, maternity care systems must be truly woman-centered and structured in ways that place emphasis on women's own health needs. In systems where women's voices and concerns are acknowledged and central, women are likely to thrive and flourish in motherhood.

Operationalizing Whole-Person Postpartum Care: Health Care Provider-Level Strategies

Postpartum mothers report feeling unsupported and unprepared by their health care providers to meet the challenges of the postpartum period. This gap perpetuates a cycle of disappointment with and disengagement from postpartum care services. The need to revamp postpartum care has been recognized at the population level but implementing changes at the health care provider level is challenging without practical guidance. The needs of new mothers are broad in scope and variable between individuals, requiring a whole-person care approach that is comprehensive yet nimble. Presented here are provider-level strategies to promote care that both elicits and is responsive to the unique care goals of this population.

Postnatal Unit Care and Safe Transition Home

The United States has the highest maternal mortality rate among developed nations with 60% of deaths occurring during the postpartum period. This chapter presents the case study of Maya Howard. Maya represents of composite of qualitative research studies that reveals missteps, gaps, and oversights of Black mothers and birthing people during birth and the postpartum period. Using a Black feminist framework, the chapter offers solutions to improve postnatal unit care and the transition home, a critical step in improving care and saving lives for all mothers and birthing people.

A qualitative research study of primary care physicians' views of telehealth in delivering postnatal care to women

BACKGROUND

The postpartum period is a critical time for women to optimise their physical and mental health. Primary care physicians (PCP) often manage postpartum women in the community setting after uneventful births. However, women encounter difficulties accessing care before and after their conventional 6-week physical review. Telehealth-based interventional studies have demonstrated their successful applications in several areas of postpartum care but is not widely adopted. The study aimed to explore the PCPs' views on their acceptability and perceived barriers of telehealth in delivering postpartum care to women in primary care.

METHODS

Twenty-nine PCPs participated in eleven in-depth interviews and four focus group discussions for this qualitative study conducted in Singapore. The purposively sampled PCPs had varied demographic background and medical training. Two investigators independently coded the audited transcripts. Thematic content analysis was performed using the codes to identify issues in the pertaining to the perceived usefulness, ease of use and attitudes towards telehealth in postpartum care as described in the "Telehealth Acceptance Model" framework.

RESULTS

Most PCPs perceived usefulness and ease of use of video consultation in delivering postpartum care. They recognised telehealth service to complement and support the current face-to-face postpartum care amidst the pandemic. However, training, leadership support, organizational infrastructure, healthcare financial policy and personal demographic profile influence their acceptance of a new care model for postnatal mothers.

CONCLUSION

Addressing the barriers and strengthening the facilitators will enhance PCPs' acceptance and utilisation of the proposed hybrid (telehealth and in-person) postnatal care model for mothers.

Factors that influence uptake of routine postnatal care: Findings on women's perspectives from a qualitative evidence synthesis

BACKGROUND

Effective postnatal care is important for optimal care of women and newborns-to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care.

METHODS

We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach.

FINDINGS

Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women's desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care.

CONCLUSIONS

Factors that influence women's utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings.

REGISTRATION

This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Perinatal care for women with refugee backgrounds from African countries: a qualitative study of intersections with psychological wellbeing

Background

Experiences with healthcare services, including perinatal healthcare services, contribute to psychological wellbeing for refugees post-resettlement. To address the paucity of literature examining the relationship between perinatal healthcare and psychological wellbeing in women with refugee backgrounds from African countries this study aimed to: (1) understand the relationship between psychological wellbeing and perinatal care amongst this population, and; (2) identify areas for improved perinatal healthcare services to ensure positive wellbeing outcomes in this population.

Methods

A total of 39 participants were included in the study. Nineteen women from seven African countries participated in interviews – seven both prior to and after having their babies, two only while pregnant and ten only after their baby had been born. In addition, interviews were conducted with 20 service providers. Interviews were thematically analysed.

Results

Four key themes were identified, covering continuity of care, cultural safety of care, agency in decision making, and ongoing impacts of perinatal care experiences.

Conclusions

The results highlighted the need for changes to perinatal healthcare provision at the systems level, including implementing a continuity of care model, and ensuring women’s access to individualised, trauma-informed perinatal services which attend to the cultural and psychosocial resettlement needs of this population. These findings informed recommendations for improving perinatal healthcare services and better psychological outcomes – and in turn broader health outcomes – for African-background refugee mothers.

Scoping Review of Postpartum Discharge Education Provided by Nurses

OBJECTIVE

To determine what is known about postpartum education provided by nurses to women before discharge from the hospital after birth and whether current nursing practices are effective to prepare women to identify warning signs of complications, perform self-care (physical and emotional), prepare for parenting a newborn, and establish infant feeding.

DATA SOURCES

We conducted a systematic search of CINAHL Plus and MEDLINE for relevant sources, including peer-reviewed articles, conference presentations, and guidelines from professional organizations, that were published in English from January 2010 through November 30, 2020.

STUDY SELECTION

We included sources if participants were women who had given birth to a healthy, liveborn, term infant and were receiving education in whole or in part by a nurse during the maternity hospitalization. We excluded sources with samples of high-risk women or those who gave birth to high-risk infants (preterm, congenital anomalies, neonatal abstinence syndrome). Forty-six of the sources met the inclusion criteria.

DATA EXTRACTION

We extracted citation, type of document, country of origin, context (prenatal/postpartum or both and inpatient/outpatient or both), aim, participants (mother/father or both, sample characteristics), content of education and who provided it, outcomes or key themes, and main results.

DATA SYNTHESIS

Infant topics included breastfeeding and safe sleep, and maternal topics included breastfeeding, postpartum mood, and self-care after birth. Nurses prioritized safety, including safe sleep; preventing infant falls; decreasing infection; screening for postpartum depression; and avoiding adverse outcomes after discharge. Women focused on self-care, pain management, infant care, and parenting. Women and nurses prioritized breastfeeding. Authors of the included sources measured effectiveness by patient satisfaction, chart audit, pre- and posttests of nurses' knowledge, and breastfeeding duration. Women reported barriers to postpartum education such as limited nursing time or conflicting information.

CONCLUSION

Postpartum education is a priority, but its effectiveness is not well studied. Few maternal or infant health-centered outcomes have been measured beyond breastfeeding duration. Nursing care and nurse expertise are not easily quantified or measured. Research is needed to inform best practices for postpartum education.

Systematic Review of Health Promotion Frameworks Focused on Health in the Postpartum Period

OBJECTIVE

To systematically review the scope and development of frameworks to promote health during the postpartum period.

DATA SOURCES

We searched PubMed, CINAHL, and American Psychological Association PsycInfo during May 2021.

STUDY SELECTION

We included English-language, peer-reviewed articles focused on frameworks for health promotion in the postpartum period. We placed no time limit on publication date. Our search resulted in 2,355 articles after we removed duplicates. After excluding articles based on titles and abstracts, we conducted full-text reviews of 23 articles. Three articles met inclusion criteria and addressed the following frameworks: Integrated Perinatal Health Framework, Perinatal Maternal Health Promotion Model, and Maternal Self-Care Framework.

DATA EXTRACTION

We extracted data into analytic tables that included categories for the scope, such as time frame, and criteria for the level of development of the frameworks, including the origins, concept definitions and theoretical linkages among concepts, and evidence of application in research or practice.

DATA SYNTHESIS

The three frameworks described in the articles included in our review covered various periods, including the reproductive life span, the first year after birth, and the first 6 weeks after birth. Overall, the frameworks were comprehensive. Most key concepts in the frameworks were defined, and some degree of relationships linking concepts was specified. Empirical referents were provided for most but not all concepts in the frameworks. Developers of the three frameworks elaborated on application in practice or health services, but only the developers of the Maternal Self-Care Framework indicated how their framework might be used in research. The Integrated Perinatal Health Framework and Maternal Self-Care Framework were partially derived from existing general theories; the methods used to develop the Perinatal Maternal Health Promotion Model were less clear.

CONCLUSION

The frameworks met most criteria and together provided a comprehensive strategy for health promotion during the postpartum period. Elaboration of the frameworks for application in research is needed.

Dinámicas sociales en salud materna con énfasis en la Morbilidad Materna Extrema y aportes de la bioética en su comprensión

El propósito del presente artículo es analizar las dinámicas sociales en salud materna y los aportes de la bioética en su comprensión, haciendo énfasis en la Morbilidad Materna Extrema. Para ello, se llevó a cabo una revisión narrativa realizada en las bases de datos Scopus, Pubmed, Web of Science, Lilacs, Scielo y Google Scholar con la estrategia “Maternal Health” AND “Bioethics” OR “Social Justice”; incluyendo artículos en español, inglés y portugués, publicados en los últimos 25 años. En los resultados se incluyeron 79 manuscritos originales y 21 manuscritos de reflexión y revisión, que surtieron el análisis descriptivo al generar las siguientes categorías temáticas: 1. Necesidades de atención en salud y de cuidado; 2. Determinantes sociales, factores de riesgo y protectores; 3. Calidad de la atención, experiencias en el tratamiento y barreras de acceso; y 4. Perspectivas éticas y bioéticas de la salud materna. Como conclusión, se pudo afirmar que el abordaje bioético de la salud materna propone categorías de análisis como la justicia, la equidad, la autonomía y el acceso. Además de las condiciones de vida desde la pluralidad cultural y las consideraciones en cuanto a la comunicación y el lenguaje. Lo anterior, implica que desde los sistemas de salud se deben rediseñar los enfoques de atención en salud materna para abordar las vulnerabilidades y potenciar las capacidades de las mujeres.

A Trauma-informed Approach to Postpartum Care

Distressing or traumatic perinatal experiences and adverse health outcomes can lead to particularly challenging postpartum experiences for patients and families. By adopting a trauma-informed care approach, the health care team can provide much-needed support, prevent additional harm, and promote healing. We propose practical communication, behavioral, and procedural considerations for integrating trauma-informed care principles into routine postpartum care, with attention to populations that have been marginalized. We see postpartum care as a critical component of holistic patient recovery and an opportunity to facilitate posttraumatic growth so that all families can thrive.

Effectiveness of Fertility Awareness-Based Methods for Pregnancy Prevention During the Postpartum Period

OBJECTIVES

To summarize the evidence on typical and perfect-use effectiveness of fertility awareness-based methods for avoiding pregnancy during the postpartum period, whether breastfeeding or not.

STUDY

Design We conducted a systematic review of studies published in English, Spanish, French, or German by November 2021 in MEDLINE, EMBASE, CINAHL, Web of Science, and ClinicalTrials.gov. Abstract and full text review were completed by two independent reviewers. Study inclusion: at least 50 subjects who enrolled prior to experiencing three cycles after childbirth and were using a specific fertility awareness-based method to avoid pregnancy; unintended pregnancy rate or probability calculated; postpartum amenorrheic and postpartum cycling individuals analyzed separately; and prospectively measured pregnancy intentions and outcomes. Outcomes were abstracted and study quality was systematically assessed by two independent investigators.

RESULTS

Four studies provided effectiveness data for one specific fertility awareness-based method among postpartum individuals. Of these, there were zero high quality, one moderate quality, and three low quality for our question of interest. Typical-use pregnancy probability for the first six cycles postpartum for Marquette Method users was 12.0 per 100 women years (standard error [SE] not reported) and for Billings Ovulation Method users ranged from 9.1 (SE 3.9) for non-lactating women <30 years old to 26.8 (SE 4.6) for lactating women <30 years old. Typical-use pregnancy probabilities for the first six months post-first menses for the Postpartum Bridge to Standard Days Method users was 11.8 (95% confidence interval 6.01-17.16) and for Billings Ovulation Method users was 8.5 per 100 women (SE 1.7).

CONCLUSIONS

The current evidence on the effectiveness of each fertility awareness-based method for postpartum persons is very limited and of mostly low quality. More high quality studies on the effectiveness of fertility awareness-based method in postpartum persons are needed to inform clinical counseling and patient-centered decision-making.

Source of Prenatal Care and Nonreceipt of Postpartum Health Care in the United States

Background: Prior work finds that receiving prenatal care is positively associated with receiving postpartum health care. However, less is known about whether postpartum health care receipt varies by the source of prenatal care. Materials and Methods: This study analyzed data from the 2011-2017 U.S. National Survey of Family Growth to examine associations between the source of prenatal care (private care facility, public/community health facility, other source, or no prenatal care) and nonreceipt of postpartum health care using weighted multivariable logistic regression models. This analysis did not require institutional review board approval. Results: Of the total estimation sample (N = 1,190), 10.8% of respondents reported not receiving postpartum health care. There were no statistically significant differences in nonreceipt of postpartum health care between women who received prenatal care from a public/community health facility or other source and those who attended a private facility. However, women who received no prenatal care had a higher likelihood of not receiving postpartum health care compared with those who attended a private facility (adjusted odds ratio 8.7, 95% confidence interval 4.3-17.5). Conclusions: Receiving prenatal care, regardless of the source, reduced the likelihood of a woman not receiving postpartum health care within a year after delivery. Interventions aimed at women who did not receive any prenatal care may be critical for improving postpartum health care use and subsequently preventing adverse maternal outcomes.

Does Parental Reflective Functioning Mediate the Associations between the Maternal Antenatal and Postnatal Bond with the Child in a Community Sample?

Although establishing an affective tie with a child during perinatality is considered one of the most important maternal tasks, little is still known about the mediators of the association between maternal antenatal and postnatal bonding with the infant. This prospective study addresses this gap by evaluating a community sample of 110 Italian women to assess whether maternal pre- and postnatal bonds with the infant are mediated by parental reflective functioning (PRF), as assessed at the third trimester of pregnancy and three months postpartum. Controlling for confounding variables, the hierarchical regression analyses show the maternal prenatal quality of attachment to the fetus as the main predictor of maternal postnatal attachment to the child (β = 0.315; t = 0.2.86; p = 0.005). The mediation analyses show that mothers’ PRF (b = 0.245; SE = 0.119; 95% CI = 0.071, 0.531) explains 39% of the relationship between maternal pre- and postnatal bonding with the child. The findings of this study contribute to research on the association between prenatal and mother-to-infant bonding by additionally investigating the importance of taking into account maternal PRF as a mediating variable. This provides support for the clinical utility of interventions focused on maternal PRF.

Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery

The American Rescue Plan provides a pathway for states to expand postpartum Medicaid coverage for low-income mothers through 12 months after delivery. Data suggests that extension of post-partum Medicaid coverage should improve access to outpatient health care services, increase healthcare utilization, improve chronic disease management for at-risk mothers, and reduce disparities in care for racial/ethnic groups over-represented in Medicaid. Opportunities to provide increased preventive care for perinatal mood disorders and smoking cessation also exist. Further, this policy may reduce the burden of late maternal mortality. While improved access to contraceptive service postpartum provides a potential mechanism by which birth outcomes may improve, the effect of this policy on NICU admission, low birth weight (LBW) infants, and preterm birth is unknown. We discuss possible birth, infant and maternal health outcomes which may result from this expansion, drawing on data from the 2010 Medicaid Expansion via the Affordable Care Act.

Interconception Preventive Care and Recurrence of Pregnancy Complications for Medicaid-Insured Women

Background: Pregnancy complications may recur and are associated with potentially modifiable risks. The role of interconception preventive care in reducing repeat pregnancy complications is understudied. Materials and Methods: This retrospective cohort used 2007-2012 Medicaid claims from 12 states. Included women who had an index birth complicated by prematurity, hypertension, or diabetes, a subsequent birth within 36 months, and Medicaid eligibility for ≥11 of 12 months after index birth. Logistic regression assessed for an association between the exposure of preventive visits in the year after index birth and primary outcomes of prematurity, hypertension, or diabetes in the subsequent pregnancy. Regression adjusted for confounders including demographics (age, race and ethnicity, rural residence, state), index pregnancy features (complications, prenatal visits, multiple gestation, maternal and infant length of stay, year), visits to address complications in the index birth, and interpregnancy interval. Results: Of 17,372 women, mean age was 24.3 ± 5.3 years, and race/ethnicity was 50.3% non-Hispanic White, 27.2% non-Hispanic Black, and 11.9% Hispanic. In the index pregnancy 43.3% experienced prematurity, 39.2% experienced hypertension, and 34.2% experienced diabetes. In the year after the index pregnancy, 54.7% had at least one preventive visit. In the second pregnancy, 47.7% experienced prematurity, hypertension, or diabetes. Recurrence rates were 28.1% for preterm birth, 38.0% for hypertension, and 48.3% for diabetes. Preventive visits were associated with reduced hypertension in the subsequent pregnancy (OR 0.88, 95% CI 0.82-0.97) but not reduced preterm birth or diabetes. Conclusions: Preventive visits after an index birth complicated by prematurity, hypertension, or diabetes were associated with 10% lower odds of hypertension in a subsequent pregnancy, but not with reductions in diabetes or prematurity. Some complications may be more amenable to interconception preventive services than others.

"There's a Lot of Like, Contradicting Stuff"-Views on Healthy Living during Pregnancy and Postpartum

The transition from pregnancy through early postpartum can be a particularly vulnerable time for women as they adjust to the changes of motherhood. This study aimed to provide a detailed account of additional health challenges that mothers are facing throughout motherhood during the pandemic. Data obtained can be utilized to create tailored interventions to aid women during their reproductive years. A sequential approach was utilized, collecting health-related information via survey and subsequent focus groups or interviews to further examine health experiences during pregnancy or postpartum. Fifty-seven participants completed the online survey, 73.5% were postpartum. The healthy eating index of the cohort was low, 50.5 ± 10.3%. Prior to pregnancy, 54.5% were classified as overweight/obese. Following pregnancy, 71.1% were classified as overweight or obese. Emergent qualitative themes from focus groups (n = 3) and interviews (n = 6) included (1) value and desire for healthy eating, (2) desire to make well-informed health-based decisions, and (3) role of social networks during pregnancy and postpartum. Pregnant/postpartum women desire to lead a healthy lifestyle but experience barriers to accomplishing intended goals. Upstream resources and policies that promote healthy living for pregnant/postpartum women can reduce chronic disease throughout the lifespan following childbirth.

Postnatal Unit Experiences Associated With Exclusive Breastfeeding During the Inpatient Stay: A Cross-Sectional Online Survey

BACKGROUND

Efforts to provide accessible and effective infant feeding support are advancing to set up new families to meeting their goals. However, data continue to be limited for understanding how inpatient postpartum support and experiences contribute to exclusive breastfeeding during hospitalization.

RESEARCH AIMS

To explore postnatal unit experiences including skin-to-skin contact, overnight support, rooming-in, responsive clinicians, and understandable communication that correlate with early infant feeding outcomes among a sample of mothers who intended to breastfeed.

METHODS

This was a prospective cross-sectional survey study. Through secure online survey, participants submitted (N = 2,401) responses from November 2016 to May 2017 about their experiences with maternity healthcare and offered thoughts on the postnatal unit environment. Descriptive statistics were used to examine distributions of maternal characteristics, postpartum experience, and birthing facility characteristics.

RESULTS

Exclusive breastfeeding was positively correlated with the following postnatal unit experiences: mother did not ask that her infant be taken out of the postnatal unit room; infant staying in postnatal unit room except for treatment(s); mother got help from clinical staff when needed after pressing the call button; and nurse, midwife, and/or doctor always explained information to mother in ways that they understood.

CONCLUSION

Postnatal unit experiences associated with exclusive breastfeeding during postpartum hospitalization were rooming in; parents who did not ask for their infant to be taken out of the unit room; whether mothers received timely help from clinical staff; and information was explained in a way they could understand.

Quality Improvement Project to Increase Postpartum Clinic Visits for Publicly Insured Women

OBJECTIVE

To increase the percentage of women who attend postpartum visits and decrease the number of days to the first postpartum visit by implementing a scheduling change.

DESIGN

Quality improvement project.

SETTING/LOCAL PROBLEM

A small nurse practitioner maternity care clinic in an academic health center at which only 74% of the women who attended two or more prenatal visits attended postpartum clinic visits.

PARTICIPANTS

A diverse sample of 25 publicly insured women who gave birth during the 5-month implementation period.

INTERVENTION/MEASUREMENTS

We added a 2- to 3-week postpartum appointment to our standard 6-week postpartum appointment. The measurable outcomes were the percentage of women who attended postpartum clinic visits and the number of days to the first postpartum visit.

RESULTS

During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation.

CONCLUSION

Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings.

Systematic Review of the Effect of Technology-Mediated Education Intervention on Maternal Outcomes in the First Year After Birth

OBJECTIVE

To synthesize the findings on the effect of technology-mediated education intervention in the first year after birth on maternal health outcomes and to evaluate interventions for participant perspectives and health equity.

DATA SOURCES

We conducted a systematic review of the literature using the electronic databases PubMed, Embase, and CINAHL for articles published between 2010 and 2020. The search strategy was developed by a health sciences librarian.

STUDY SELECTION

We included articles if the following criteria were met: they reported studies conducted in the United States or a resource-similar nation on the evaluation of a technology-mediated education intervention within the first year after birth and they included the assessment of at least one maternal health outcome.

DATA EXTRACTION

The lead author extracted data from the full-text articles and entered them into Microsoft Excel. We assessed the quality and risk of bias using the Cochrane Collaboration's tool for examining the potential risk of bias.

DATA SYNTHESIS

We identified 21 articles that met the inclusion criteria. Videos were the most commonly reported technology-mediated education intervention, followed by text messages, phone calls, and websites. Maternal health outcomes addressed in the included articles were mental health, weight loss, breastfeeding, general postpartum education, perineal care, and substance use. Technology-mediated education interventions positively affected mental health, weight loss, and breastfeeding outcomes.

CONCLUSION

The current evidence suggests that technology-mediated education intervention is beneficial for the physical and mental health outcomes of women during the first year after birth. Future work may benefit from more attention to health equity and design in collaboration with women to gain a better understanding of the information needs and desired technology features.

Seizing the Window of Opportunity Within 1 Year Postpartum: Early Cardiovascular Screening

Background Our objective was to assess new chronic hypertension 6 to 12 months postpartum for those with hypertensive disorder of pregnancy (HDP) compared with normotensive participants. Methods and Results We performed a prospective cohort study of participants with singleton gestations and no known preexisting medical conditions who were diagnosed with HDP compared with normotensive women with no pregnancy complications (non-HDP). Participants underwent cardiovascular risk assessment 6 to 12 months after delivery. Primary outcome was onset of new chronic hypertension at 6 to 12 months postpartum. We also examined lipid values, metabolic syndrome, prediabetes, diabetes, and 30-year cardiovascular disease (CVD) risk. Multivariable logistic regression was performed to assess the association between HDP and odds of a postpartum diagnosis of chronic hypertension while adjusting for parity, body mass index, insurance, and family history of CVD. There were 58 participants in the HDP group and 51 participants in the non-HDP group. Baseline characteristics between groups were not statistically different. Participants in the HDP group had 4-fold adjusted odds of developing a new diagnosis of chronic hypertension 6 to 12 months after delivery, compared with those in the non-HDP group (adjusted odds ratio, 4.60 [95% CI, 1.65-12.81]), when adjusting for body mass index, parity, family history of CVD, and insurance. Of the HDP group, 58.6% (n=34) developed new chronic hypertension. Participants in the HDP group had increased estimated 30-year CVD risk and were more likely to have metabolic syndrome, a higher fasting blood glucose, and higher low-density lipoprotein cholesterol. Conclusions Participants without known underlying medical conditions who develop HDP have 4-fold increased odds of new diagnosis of chronic hypertension by 6 to 12 months postpartum as well as increased 30-year CVD risk scores. Implementation of multidisciplinary care models focused on CVD screening, patient education, and lifestyle interventions during the first year postpartum may serve as an effective primary prevention strategy for the development of CVD.

Exploring the Unmet Needs of Postpartum Mothers: A Qualitative Study

This study aimed to identify unmet needs of mothers in the postpartum period. Semi-structured telephone interviews were conducted two weeks postpartum with a convenience sample of 26 mothers who gave birth at an academic medical center. Topics included mothers’ concerns, levels of preparedness, educational needs and preferences during antepartum, labor and birth, and postpartum periods. Data were qualitatively analyzed using NVivo and a combination of open coding and theoretical coding, based on the Perinatal Maternal Health Promotion Model. Three major themes emerged: concerns, expectations, and positive coping strategies, with variations by previous maternal experience. Findings suggest the need for different models of care with more anticipatory, mother-centered care to better meet mothers’ needs and enhance postpartum outcomes and breastfeeding success.