Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Do maternity services in New Zealand's public healthcare system deliver on equity? Findings from structural equation modelling of national maternal satisfaction survey data

BACKGROUND

Birthing outcomes in New Zealand are demonstrably inequitable based on governmental reports and research. However, the last Ministry of Health maternal satisfaction survey in 2014 indicated that 77% of women were satisfied or very satisfied with care. This study used data from the maternal satisfaction survey to examine aspects of inequity in reported satisfaction with care.

METHODS

Structural Equation Modelling (SEM) was used to infer latent variables of satisfaction with equity domains from responses to the satisfaction survey. Additional data (residential location and deprivation score), not used in the Ministry of Health primary analysis, were provided and included in this modelling.

RESULTS

SEM showed that satisfaction was not equitably distributed. Younger women, those from areas of high socio-economic deprivation, and remote rural women were most likely to be affected by dissatisfaction associated with physical access, cultural care, information provided, and/or barriers to equity associated with additional costs (all p<0.05). Financial burden of additional costs was also unevenly distributed.

CONCLUSION

While these findings are congruent with other research on the association between social determinants and maternal satisfaction, it is concerning that they remain sources of inequity in New Zealand twenty years after they were first identified as priorities to address. On the basis of this study, urgent attention needs to be paid to removing sources of inequity within the health system and maternity care in particular.

The Triad Mother-Breast Milk-Infant as Predictor of Future Health: A Narrative Review

The benefits of human milk for both mother and infant are widely acknowledged. Human milk could represent a link between maternal and offspring health. The triad mother-breast milk-infant is an interconnected system in which maternal diet and lifestyle might have effects on infant's health outcome. This link could be in part explained by epigenetics, even if the underlining mechanisms have not been fully clarified yet. The aim of this paper is to update the association between maternal diet and human milk, pointing out how maternal diet and lifestyle could be associated with breast-milk composition, hence with offspring's health outcome.

Maternal Mortality Among American Indian/Alaska Native Women: A Scoping Review

Background: Maternal mortality decreased globally by about 38% between 2000 and 2017, yet, it continues to climb in the United States. Gaping disparities exist in U.S. maternal mortality between white (referent group) and minority women. Despite important and appropriate attention to disparities for black women, almost no attention has been given to American Indian/Alaska Native (AI/AN) women. The purpose of this scoping review is to synthesize available literature concerning AI/AN maternal mortality. Methods: Databases were searched using the terms maternal mortality and pregnancy-related death, each paired with American Indian, Native American, Alaska Native, Inuit, and Indigenous. Criteria (e.g., hemorrhage) were paired with initial search terms. Next, pregnancy-associated death was paired with American Indian, Native American, Alaska Native, Inuit, and Indigenous. Criteria in this category were homicide, suicide, and substance use. Results: The three leading causes of AI/AN pregnancy-related maternal mortality are hemorrhage, cardiomyopathies, and hypertensive disorders of pregnancy. AI/AN maternal mortality data for homicide and suicide consistently include small samples and often categorize AI/AN maternal deaths in an "Other" race/ethnicity, which precludes targeted AI/AN data analysis. No studies that reported AI/AN maternal mortality as a result of substance use were found. Health care characteristics such as quality, access, and location also may influence maternal outcomes and maternal mortality. Conclusions: Despite AI/AN maternal mortality being disproportionately high compared to other racial/ethnic groups, relatively little is known about root causes.

Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care

BACKGROUND

Racial disparities in maternal morbidity and mortality remain a pressing public health problem. Variations in cesarean section (C-section) rates among racial and ethnic groups have been well documented, though reasons for these variations remain unknown. In the Department of Veterans Affairs (VA), nearly half of all women Veterans are of reproductive age and >40% of these women are racial and ethnic minorities. Because the VA does not provide obstetrical services, all obstetrical care is provided by community obstetrical providers under the auspices of the VA Community Care Network. However, little is known regarding the rates and correlates of C-sections among women Veterans receiving community obstetrical care.

OBJECTIVE

To examine predictors of C-section deliveries among a cohort of racially diverse pregnant Veterans enrolled in VA care at 15 VA medical facilities nationwide.

RESEARCH DESIGN

Cross-sectional analysis of a longitudinal, prospective, multisite, observational cohort study of pregnant, and postpartum Veterans receiving community-based obstetrical care.

RESULTS

Overall, 659 Veterans delivered babies during the study period, and 35% of the deliveries were C-sections. Predictors of C-section receipt included being a woman of color [adjusted odds ratio (AOR), 1.76; 95% confidence interval (CI), 1.19-2.60], having an Edinburgh Postnatal Depression Scale score ≥10 (AOR, 1.71; 95% CI, 1.11-2.65), having a higher body mass indexes (AOR, 1.07; 95% CI, 1.04-1.11), and women who were older (AOR, 1.08; 95% CI, 1.03-1.13). There was a substantial racial variation in C-section rates across our 15 study sites, with C-section rates meeting or exceeding 50% for WOC in 8 study sites.

CONCLUSIONS

There is substantial racial and geographic variation in C-section rates among pregnant Veterans receiving obstetrical care through VA community care providers. Future research should carefully examine variations in C-sections by the hospital, and which providers and hospitals are included in VA contracts. There should also be an increased focus on the types of providers women Veterans have access to for obstetrical care paid for by the VA and the quality of care delivered by those providers.

The 2014 New York State Medicaid Expansion and Severe Maternal Morbidity During Delivery Hospitalizations

BACKGROUND

Medicaid expansions under the Affordable Care Act have increased insurance coverage and prenatal care utilization in low-income women. However, it is not clear whether they are associated with any measurable improvement in maternal health outcomes. In this study, we compared the changes in the incidence of severe maternal morbidity (SMM) during delivery hospitalizations between low- and high-income women associated with the 2014 Medicaid expansion in New York State.

METHODS

Data for this retrospective cohort study came from the 2006-2016 New York State Inpatient Database, a census of discharge records from community hospitals. The outcome was SMM during delivery hospitalizations, as defined by the Centers for Disease Control and Prevention. We used regression coefficients (β) from multivariable logistic models: (1) to compare independently in low-income women and in high-income women the changes in slopes in the incidence of SMM before (2006-2013) and after (2014-2016) the expansion, and (2) to compare low- and high-income women for the changes in slopes in the incidence of SMM before and after the expansion.

RESULTS

A total of 2,286,975 delivery hospitalizations were analyzed. The proportion of Medicaid beneficiaries in parturients increased a relative 12.1% (95% confidence interval [CI], 11.8-12.4), from 42.9% in the preexpansion period to 48.1% in the postexpansion period, whereas the proportion of the uninsured decreased a relative 4.8% (95% CI, 2.8-6.8). Multivariable logistic modeling revealed that implementation of the 2014 Medicaid expansion was associated with a decreased slope during the postexpansion period both in low-income women (β = -0.0161 or 1.6% decrease; 95% CI, -0.0190 to -0.0132) and in high-income women (β = -0.0111 or 1.1% decrease; 95% CI, -0.0130 to -0.0091). The decrease in slope during the postexpansion period was greater in low- than in high-income women (β = -0.0042 or 0.42% difference; 95% CI, -0.0076 to -0.0007).

CONCLUSIONS

Implementation of the Medicaid expansion in 2014 in New York State is associated with a small but statistically significant reduction in the incidence of SMM in low-income women compared with high-income women.

Integrated substance use and prenatal care delivery in the era of COVID-19

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Neonatal Morbidity and Mortality in Advanced Aged Mothers-Maternal Age Is Not an Independent Risk Factor for Infants Born Very Preterm

Background: As childbearing is postponed in developed countries, maternal age (MA) has increased over decades with an increasing number of pregnancies between age 35-39 and beyond. The aim of the study was to determine the influence of advanced (AMA) and very advanced maternal age (vAMA) on morbidity and mortality of very preterm (VPT) infants. Methods: This was a population-based cohort study including infants from the "Effective Perinatal Intensive Care in Europe" (EPICE) cohort. The EPICE database contains data of 10329 VPT infants of 8,928 mothers, including stillbirths and terminations of pregnancy. Births occurred in 19 regions in 11 European countries. The study included 7,607 live born infants without severe congenital anomalies. The principal exposure variable was MA at delivery. Infants were divided into three groups [reference 18-34 years, AMA 35-39 years and very(v) AMA ≥40 years]. Infant mortality was defined as in-hospital death before discharge home or into long-term pediatric care. The secondary outcome included a composite of mortality and/or any one of the following major neonatal morbidities: (1) moderate-to-severe bronchopulmonary dysplasia; (2) severe brain injury defined as intraventricular hemorrhage and/or cystic periventricular leukomalacia; (3) severe retinopathy of prematurity; and (4) severe necrotizing enterocolitis. Results: There was no significant difference between MA groups regarding the use of surfactant therapy, postnatal corticosteroids, rate of neonatal sepsis or PDA that needed pharmacological or surgical intervention. Infants of AMA/vAMA mothers required significantly less mechanical ventilation during NICU stay than infants born to non-AMA mothers, but there was no significant difference in length of mechanical ventilation and after stratification by gestational age group. Adverse neonatal outcomes in VPT infants born to AMA/vAMA mothers did not differ from infants born to mothers below the age of 35. Maternal age showed no influence on mortality in live-born VPT infants. Conclusion: Although AMA/vAMA mothers encountered greater pregnancy risk, the mortality and morbidity of VPT infants was independent of maternal age.

Addressing disparities among children with cerebral palsy: Optimizing enablement, functioning, and participation

PURPOSE

Recognizing health disparities among children with cerebral palsy (CP) is necessary for understanding potential risk factors for CP and for implementing early and effective preventative and intervention treatments. However, there is currently little and conflicting evidence regarding the direct impact of contextual factors such as socioeconomic status (SES) for children with CP in the United States. These contextual factors include the complex social determinants of health on prematurity, comprehensive informed obstetric management for minority and vulnerable populations, and cumulative adversity disproportionately experienced by children, by gender, minority status, immigration, poverty, and structural racism.

METHODS

This study presents results from a review of health disparities among children with CP, using registry and population surveillance data from Australia, Canada, Scandinavia, the United Kingdom, Ireland, Turkey, and the United States.

RESULTS

The review confirmed that there are significant health disparities among children with CP, both in terms of prevalence and severity, based on factors such as SES, neighborhood disadvantage, maternal education, gender, and minority status.

CONCLUSION

Strategies need to be implemented in the United States to promote enablement and functioning among children with CP who face additional health disparities. This requires a greater understanding of population groups at increased risk, comprehensive assessment and care for young children with motor delays, and systematic population counts of children and adults with CP using registries and systems of neurodevelopmental surveillance across health, education, and community rehabilitation. These efforts also require sensitivity to structural and persistent racism, stigma, trauma-informed care, and culturally sensitive community engagement. Additional efforts are also required to improve outcomes over the life course for individuals living a life with CP from a framework of enablement, self-direction, equity and social justice.

Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care

INTRODUCTION

Racial and ethnic disparities in rates of maternal morbidity and mortality in the United States are striking and persistent. Despite evidence that variation in the quality of care contributes substantially to these disparities, we do not sufficiently understand how experiences of perinatal care differ by race and ethnicity among women with severe maternal morbidity.

METHODS

We conducted focus groups with women who experienced a severe maternal morbidity event in a New York City hospital during their most recent pregnancy (n = 20). We organized three focus groups by self-identified race/ethnicity ([1] Black, [2] Latina, and [3] White or Asian) to detect any within- and between-group differences. Discussions were audiotaped and transcribed. The research team coded the transcripts and used content analysis to identify key themes and to compare findings across racial and ethnic groups.

RESULTS

Participants reported distressing experiences and lasting emotional consequences after having a severe childbirth complication. Many women appreciated the life-saving care they received. However, poor continuity of care, communication gaps, and a perceived lack of attentiveness to participants' physical and emotional needs led to substantial concern and disappointment in care. Black and Latina women in particular emphasized these themes.

CONCLUSIONS

This study highlights missed opportunities for improved clinician communication and continuity of care to address emotional trauma when severe obstetric complications occur, particularly for Black and Latina women. Enhancing communication to ensure that women feel heard and informed throughout the birth process and addressing implicit bias, as a part of the more systemic issue of institutionalized racism, could both decrease disparities in obstetric care quality and improve the patient experience for women of all races and ethnicities.

The Biopsychosocial Model and Perinatal Health Care: Determinants of Perinatal Care in a Community Sample

Insufficient care in the perinatal period is associated with poorer maternal health, poorer perinatal outcomes, infant mortality, and health inequalities. Identifying the sources of and reducing the rates of insufficient care is therefore a major clinical and public health objective. We propose a specific application of the biopsychosocial model that conceptualizes prenatal and postpartum care quality as health markers that are influenced by psychological factors and family and social context. Clinic attendance data were abstracted from the electronic medical records of N = 291 participants enrolled in a longitudinal pregnancy cohort study of healthy women who have been followed since the first trimester; the Kotelchuck Index (KI) was calculated as an index of perinatal care utilization. Detailed prenatal psychological, social, and sociodemographic data were collected from self-report questionnaire and interview. Bivariate analyses indicated socio-demographic (e.g., race), psychological (e.g., response to perceived racism, affective symptoms, trauma experience), and social and family context (e.g., social support, family size) significantly influenced pre- and post-natal care utilization. Multivariate logistic regression analyses, adjusting for medical complications, identified social and family context as robust predictors of perinatal care utilization. The findings underscore the need for biopsychosocial models of health care and highlight several potential strategies for improving health care utilization.

A Systematic Review of Racial and Ethnic Disparities in Maternal Health Outcomes among Asians/Pacific Islanders

Efforts to improve women's health and to reduce maternal mortality worldwide have led to a notable reduction in the global maternal mortality ratio (MMR) over the past two decades. However, it is clear that maternal health outcomes are not equitable, especially when analyzing the scope of maternal health disparities across "developed" and "underdeveloped" nations. This study evaluates recent MMR scholarship with a particular focus on the racial and ethnic divisions that impact on maternal health outcomes. The study contributes to MMR research by analyzing the racial and ethnic disparities that exist in the US, especially among Asian and Pacific Islander (API) subgroups. The study applies exclusionary criteria to 710 articles and subsequently identified various maternal health issues that disproportionately affect API women living in the US. In applying PRISMA review guidelines, the study produced 22 peer-reviewed articles that met inclusionary and exclusionary criteria for this review. The data analysis identified several maternal health foci: obstetric outcomes, environmental exposure, obstetric care and quality measures, and pregnancy-related measures. Only eight of the 22 reviewed studies disaggregated API populations by focusing on specific subgroups of APIs, which signals a need to reconceptualize marginalized API communities' inclusion in health care systems, to promote their equitable access to care, and to dissolve health disparities among racial and ethnic divides. Several short- and long-term initiatives are recommended to develop and implement targeted health interventions for API groups, and thus provide the groundwork for future empirically driven research among specific API subgroups in the US.

Timing of Prenatal Care Initiation in the Health Resources and Services Administration Health Center Program in 2017

BACKGROUND

Early prenatal care is vital for improving maternal health outcomes and health behaviors, but medically vulnerable and underserved populations are less likely to begin prenatal care in the first trimester. In 2017, the Health Center Program provided safety-net care to more than 27 million persons, including 573 026 prenatal patients, at approximately 12 000 sites across the United States and U.S. jurisdictions. As part of a mandatory reporting requirement, health centers tracked whether patients initiated prenatal care in their first trimester of pregnancy.

OBJECTIVE

To identify health center characteristics associated with the initiation of prenatal care in the first trimester, as well as actionable steps policymakers, providers, and health centers can take to promote early initiation of prenatal care.

DESIGN

Secondary analysis of cross-sectional data from the 2017 Uniform Data System.

SETTING

The United States and 8 U.S. jurisdictions.

PARTICIPANTS

Health center grantees with prenatal patients (n = 1281).

MEASUREMENTS

Multinomial logistic regression (adjusted for state or jurisdiction clustering) was used to identify health center characteristics associated with achievement of the Healthy People 2020 baseline (77.1%) and target (84.8%) for women receiving prenatal care in the first trimester (Maternal, Infant, and Child Health Objective 10.1).

RESULTS

Overall, 57.4% of health centers met the Healthy People 2020 baseline (mean, 78%; median, 81%), and 37.9% met the Healthy People 2020 target. Several characteristics were positively associated with meeting the baseline (larger proportion of prenatal patients aged 20 to 24 years) and target (more total patients, prenatal care by referral only, a larger proportion of prenatal patients aged 25 to 44 or ≥45 years, and a larger proportion of White or privately insured patients). Other characteristics were negatively associated with the baseline (location outside New England, location in a rural area, and a large proportion of prenatal patients aged <15 years) and target (more prenatal patients, location outside New England, provision of prenatal care to women living with HIV, and more uninsured patients or patients eligible for both Medicare and Medicaid).

LIMITATION

The data set is at the health center grantee level and does not contain information on timing or quality of follow-up prenatal care.

CONCLUSION

Most health centers met the Healthy People 2020 baseline, but opportunities for improvement remain and the Healthy People 2020 target is still a challenge for many health centers. Policymakers, providers, and health centers can learn from high-achieving centers to promote early initiation of prenatal care among medically vulnerable and underserved populations.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

Incarceration Exposure and Barriers to Prenatal Care in the United States: Findings from the Pregnancy Risk Assessment Monitoring System

Previous research demonstrates that exposure to incarceration during pregnancy - either personally or vicariously through a partner - worsens parental care. However, little is known about the specific barriers to parental care that are associated with incarceration exposure. Using data from the Pregnancy Risk Assessment Monitoring System (years 2009-2016), the current study examines the relationship between exposure to incarceration during pregnancy and barriers to prenatal care in the United States. Negative binomial and logistic regression models were used to assess the association between the recent incarceration of a woman or her partner (i.e., incarceration that occurred in the 12 months prior to the focal birth) and several barriers to prenatal care. Findings indicate that exposure to incarceration, either personally or vicariously through a partner, increases the overall number of barriers to prenatal care and this association operates through several specific barriers including a lack of transportation to doctor's appointments, having difficulty finding someone to take care of her children, being too busy, keeping pregnancy a secret, and a woman not knowing she was pregnant. Policies designed to help incarceration exposed women overcome these barriers can potentially yield benefits for enhancing access to parental care.

Perceived Discriminatory Factors that Impact Prenatal Care Satisfaction and Attendance Among Adolescent and Young Adult Couples

OBJECTIVE

To identify possible discriminatory factors that lead to prenatal care dissatisfaction and disengagement from prenatal care among young, expecting couples with a focus on exploring the experiences of Black and Latinx participants.

METHODS

A total of 296 young adolescent couples were recruited. Each couple consisted of an expecting female (ExpF) and an expecting male (ExpM). Participants were asked to give responses to a survey, and data was collected at 3 different time points.

PARTICIPANTS

The sample consisted of 296 expecting young couples.

SETTING

Participants were recruited from obstetrics and gynecology clinics and ultrasound clinics from 4 university-affiliated hospitals in southern Connecticut.

OUTCOME MEASURES

The main outcome measure was prenatal care satisfaction. The secondary outcome was number of prenatal care visits that were attended by each member of the couple dyad. Both of these outcomes were assessed to evaluate whether discriminatory factors that participants experienced in healthcare had an effect on each outcome.

RESULTS

A total of 51 males (17.5%) and 36 females (12.4%) reported a perception of experiencing discrimination in the healthcare system a few times a year or more. Those who believed that race contributed to discrimination in the healthcare system were 2.45 times more likely to have an unpleasant prenatal visit (P = .018). Those who believed that age contributed to discrimination in the healthcare system were 2.74 times more likely to have an unpleasant prenatal visit (P = .001). Participants who believed that physical appearance contributed to discrimination in the healthcare system were 2.83 times more likely to have an unpleasant prenatal visit (P = .01).

CONCLUSION

Black and Latinx young expecting couples are not exempt from discriminatory experiences during prenatal care. Recommendations for quality improvement in prenatal healthcare settings include implementation of standard evaluative measures specific to personal treatment and supportiveness of the medical team.

Screening for Mental Health and Substance Use Disorders in Obstetric Settings

PURPOSE OF REVIEW

The objective of this review is to describe the extent to which (1) obstetric settings are currently screening for mental health and substance use disorders and social determinants of health (SDoH), and (2) screening is followed by systematic approaches for ensuring an adequate response to positive screens. Additionally, clinical and policy implications of current screening practices and recommendations are discussed.

RECENT FINDINGS

Screening for perinatal depression in obstetric settings has increased. Despite their prevalence and negative impact, screening for other mental health and substance use disorders and SDoH is much less common and professional society recommendations are either nonexistent, less consistent, or less prescriptive. To truly address maternal mental health, we need to move beyond focusing solely on depression and address other mental health and substance use disorders and the contextual social determinants in which they occur.

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care

BACKGROUND

Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes.

METHODS

We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features.

RESULTS

We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage.

CONCLUSIONS

Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions.

IMPLICATIONS

Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes.

LEVEL OF EVIDENCE

III.

A Framework for Coordination between Obstetric and Pediatric Providers in Public Health Emergencies: Lessons Learned from the Zika Outbreak in the United States, 2015 to 2017

Emergency response to emerging threats with the potential for vertical transmission, such as the 2015 to 2017 response to Zika virus, presents unique clinical challenges that underscore the need for better communication and care coordination between obstetric and pediatric providers to promote optimal health for women and infants. Published guidelines for routine maternal-infant care during the perinatal period, and models for transitions of care in various health care settings are available, but no broad framework has addressed coordinated multidisciplinary care of the maternal-infant dyad during emergency response. We present a novel framework and strategies to improve care coordination and communication during an emergency response. The proposed framework includes (1) identification and collection of critical information to inform care, (2) key health care touchpoints for the maternal-infant dyad, and (3) primary pathways of communication and modes of transfer across touchpoints, as well as practical strategies. This framework and associated strategies can be modified to address the care coordination needs of pregnant women and their infants with possible exposure to other emerging infectious and noninfectious congenital threats that may require long-term, multidisciplinary management. KEY POINTS: · Emerging congential threats present unique coordination challenges for obstetric and pediatric clinicians during emergency response.. · We present a framework to help coodinate care of pregnant women/infants exposed to congenital threats.. · The framework identifies critical information to inform care, health care touchpoints, and communication/information transfer pathways..

Future Directions: Analyzing Health Disparities Related to Maternal Hypertensive Disorders

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, constituting one of the most significant causes of maternal morbidity and mortality. Hypertensive disorders, specifically gestational hypertension, chronic hypertension, and preeclampsia, throughout pregnancy are contributors to the top causes of maternal mortality in the United States. Diagnosis of hypertensive disorders throughout pregnancy is challenging, with many disorders often remaining unrecognized or poorly managed during and after pregnancy. Moreover, the research has identified a strong link between the prevalence of maternal hypertensive disorders and racial and ethnic disparities. Factors that influence the prevalence of maternal hypertensive disorders among racially and ethnically diverse women include maternal age, level of education, United States-born status, nonmetropolitan residence, prepregnancy obesity, excess weight gain during pregnancy, and gestational diabetes. Examination of the factors that increase the risk for maternal hypertensive disorders along with the current interventions utilized to manage hypertensive disorders will assist in the identification of gaps in prevention and treatment strategies and implications for future practice. Specific focus will be placed on disparities among racially and ethnically diverse women that increase the risk for maternal hypertensive disorders. This review will serve to promote the development of interventions and strategies that better address and prevent hypertensive disorders throughout a pregnant woman's continuum of care.

A Novel Model for a Free Clinic for Prenatal and Infant Care in Detroit

PURPOSE

Detroit experiences the highest preterm birth rate and some of the worst birth outcomes in the country. Women and children have extremely high levels of poverty and face numerous barriers to care including lack of trust and racial disparities in care and concrete barriers such as limited transportation and childcare, work hour conflicts, and lack of insurance.

DESCRIPTION

We report on a unique model of patient care focused on providing patient-centered care and building trusting relationships. This model is encompassed in a new free, volunteer-run, faith-based clinic which offers prenatal, postpartum, and infant care.

ASSESSMENT

In the first 2 years of operation, demand for services rose rapidly and there were stellar clinical outcomes, despite the fact that Luke patients are among the medically and socially highest risk populations in the nation.

CONCLUSION

While marginalized populations have worse birth outcomes and far more infant deaths, making care accessible and responsive to patient needs while focusing on building patient relationships is an important strategy to improve outcomes.

Predicting Postpartum Hemorrhage After Vaginal Birth by Labor Phenotype

INTRODUCTION

Postpartum hemorrhage (PPH) is an important contributor to maternal morbidity and mortality. Predicting which laboring women are likely to have a PPH is an active area of research and a component of quality improvement bundles. The purpose of this study was to identify phenotypes of labor processes (ie, labors that have similar features, such as duration and type of interventions) in a cohort of women who had vaginal births, estimate the likelihood of PPH by phenotype, and analyze how maternal and fetal characteristics relate to PPH risk by phenotype.

METHODS

This study utilized the Consortium for Safe Labor dataset (2002-2008) and examined term, singleton, vaginal births. Using 16 variables describing the labor and birth processes, a latent class analysis was performed to describe distinct labor process phenotypes.

RESULTS

Of 24,729 births, 1167 (4.72%) women experienced PPH. Five phenotypes best fit the data, reflecting labor interventions, duration, and complications. Women who had shorter duration of admission after spontaneous labor onset (admitted in latent or active labor) had the lowest rate of PPH (3.8%-3.9%). The 2 phenotypes of labor progress characterized by women who had complicated prolonged labors (spontaneous or induced) had the highest rate of PPH (8.0% and 12.0%, respectively). However, the majority of PPH (n = 881, 75%) occurred in the phenotypes with fewer complications. Prepregnancy body mass index did not predict PPH. Overall, the odds of PPH were highest among nulliparous women (odds ratio [OR], 1.52; 95% CI, 1.30-1.77), as well as Black women (OR, 1.39; 95% CI, 1.13-1.73) and Hispanic women (OR, 1.85; 95% CI, 1.56-2.20). Within phenotypes, maternal race and ethnicity, nulliparity, macrosomia, hypertension, and depression were associated with increased odds of PPH.

DISCUSSION

Women who were classified into a lower-risk labor phenotype and still experienced PPH were more likely to be nulliparous, a person of color, or diagnosed with hypertension.

Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review

OBJECTIVE

To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the United States and to highlight opportunities for intervention and future research.

DATA SOURCES

We performed a systematic search using Ovid MEDLINE, CINAHL, Popline, Scopus, and ClinicalTrials.gov (1990-2018) using MeSH terms related to maternal mortality, morbidity, and social determinants of health, and limited to the United States.

METHODS OF STUDY SELECTION

Selection criteria included studies examining associations between social determinants and adverse maternal outcomes including pregnancy-related death, severe maternal morbidity, and emergency hospitalizations or readmissions. Using Covidence, three authors screened abstracts and two screened full articles for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Two authors extracted data from each article and the data were analyzed using a descriptive approach. A total of 83 studies met inclusion criteria and were analyzed. Seventy-eight of 83 studies examined socioeconomic position or individual factors as predictors, demonstrating evidence of associations between minority race and ethnicity (58/67 studies with positive findings), public or no insurance coverage (21/30), and lower education levels (8/12), and increased incidence of maternal death and severe maternal morbidity. Only 2 of 83 studies investigated associations between these outcomes and socioeconomic, political, and cultural context (eg, public policy), and 20 of 83 studies investigated material and physical circumstances (eg, neighborhood environment, segregation), limiting the diversity of social determinants of health studied as well as evaluation of such evidence.

CONCLUSION

Empirical studies provide evidence for the role of race and ethnicity, insurance, and education in pregnancy-related mortality and severe maternal morbidity risk, although many other important social determinants, including mechanisms of effect, remain to be studied in greater depth.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018102415.

Violence As a Direct Cause of and Indirect Contributor to Maternal Death

Background: Death during pregnancy and postpartum in the United States is an issue of urgent and growing concern. Mortality from obstetric-related causes is on the rise, and pregnancy-associated homicide remains a leading cause of death. It is unknown how the context in which women live contributes to their risk of obstetric or violent death during pregnancy and the postpartum period. This study aimed to quantify incidence of mortality from obstetric-related causes and violent death during pregnancy and up to 1-year postpartum, and to identify associations between state-level violent crime rates and incidence of pregnancy-related mortality and pregnancy-associated homicide. Materials and Methods: We conducted a retrospective, ecologic analysis of all pregnancy-associated homicides in 17 states participating in the National Violent Death Reporting System from 2011 to 2015. Pregnancy-related mortality was identified by International Classification of Diseases-10 code for underlying cause of death in death records issued in the same states and years, data provided by the National Center for Health Statistics. We characterized decedents of both violent and nonviolent maternal death (n = 174 and 1,617, respectively). Five-year mortality ratios (deaths per 100,000 live births) were estimated for both pregnancy-related mortality and pregnancy-associated homicide in every state. Poisson regression models estimated associations between violent crime and maternal death, adjusting for area-level socioeconomic conditions. Results: Both pregnancy-related mortality and pregnancy-associated homicide ratios were higher in states with higher rates of violent crime (relative risk [RR] = 1.05, 95% confidence interval [CI] = 1.01-1.12; RR = 1.17, 95% CI = 1.01-1.34, respectively). Conclusion: Broad population-wide violence prevention efforts may help reduce incidence of maternal mortality from both obstetric and violent causes.

Different levels of associations between medical co-morbidities and preterm birth outcomes among racial/ethnic women enrolled in Medicaid 2014-2015: retrospective analysis

Background

The causes of preterm birth are multi-dimensional, including delayed and inadequate prenatal services as well as other medical and socioeconomic factors. This study aimed to examine the different levels of association between preterm birth and major medical co-morbidities among various racial/ethnic women enrolled in Medicaid.

Methods

This is a retrospective analysis of 457,200 women aged between 15 and 44 with a single live birth from the IBM® MarketScan® Multi-State Medicaid Database from 2014 to 2015. Preterm birth, defined by delivery before 37 completed weeks of gestation, was the primary dependent variable. All births were dichotomously categorized as either preterm or full-term birth using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Independent variables included race/ethnicity, categorized as non-Hispanic white, non-Hispanic black, Hispanic, or other. Medical co-morbidities included smoking, drug dependence, alcohol dependence, diabetes, and hypertension. Total healthy prenatal visit count and high-risk prenatal visit encounters identified during 30 weeks prior to the delivery date were included in the analysis.

Results

A significantly higher preterm birth rate was found in black women after controlled for medical co-morbidities, age, prenatal visit count, and high-risk pregnancy. Different levels of association between preterm birth outcome and major medical co-morbidities were examined among various racial/ethnic women enrolled in Medicaid. Drug dependence was associated with higher odds of preterm birth in black (OR = 2.56, 95% CI [1.92–3.41]) and white women (OR = 2.12, 95% CI [1.91–2.34]), when controlled for other variables. In Hispanic women, diabetes (OR=1.44, 95% CI [1.27, 1.64]) and hypertension (OR=1.98, 95% CI [1.74, 2.26]) were associated with higher odds of preterm birth. White women diagnosed with drug dependence had a 14.0% predicted probability of preterm birth, whereas black women diagnosed with drug dependence had a predicted probability of preterm birth of 21.5%.

Conclusions

The associations of medical co-morbidities and preterm births varied across racial and ethnic groups of women enrolled in Medicaid. This report calls for future research on racial/ethnic disparity in preterm birth to apply integrative and qualitative approaches to understand the disparity from a contextual perspective, especially for vulnerable pregnant women like Medicaid enrollees.

Sociodemographic Characteristics and Clinical Outcomes of People Receiving Inadequate Prenatal Care: A Retrospective Cohort Study

OBJECTIVE

This study sought to describe the incidence inadequate prenatal care (IPNC) at an urban level II hospital in Hamilton, Ontario, and to compare the characteristics and outcomes of mothers who received IPNC and their newborns with those who received adequate prenatal care (APNC). This study is the first part of a mixed-methods research program aimed at informing the development of an interdisciplinary, patient-centred, prenatal care program for people who struggle to access conventional modes of care.

METHODS

This retrospective cohort study compared mothers and neonates born at St. Joseph's Health Care Hamilton in 2016 with IPNC (fewer than or equal to four antenatal visits, or first visit in third trimester) with those born with APNC (five or more prenatal visits and initial visit before the third trimester). Cases and controls matched 3:1 for age and parity were identified through a retrospective chart review.

RESULTS

In total 3235 charts were reviewed, and 69 cases of IPNC were identified (2.1%). The IPNC group had lower education and higher unemployment levels, as well as higher rates of smoking and drug use. Our primary and secondary outcomes of newborn custody loss, neonatal intensive care unit admission, and neonatal length of stay were significantly higher in the IPNC group.

CONCLUSION

Patients delivering with IPNC represent a high-risk group with increased rates of adverse neonatal outcomes and newborn custody loss. This quantitative study will inform future research and innovative interdisciplinary program development aimed at increasing access to prenatal care in an effort to improve maternal and neonatal outcomes.

Changing the conversation: applying a health equity framework to maternal mortality reviews

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Wise Women's Provision of Maternal-Child Health Information and Support for Urban, African American Women

Introduction: The United States is experiencing a maternal-child health (MCH) crisis including racial inequalities in mortality. This study explored the roles of lay experts who provide information and support to women of childbearing age (i.e., Wise Women) and cultural norms for sharing MCH information and support in an urban, predominantly African American community. Methodology: This qualitative community-engaged study (N = 49) of social networks utilized a semistructured guide and brainstorming activities with eight focus groups (three community leader, three community women, and two Wise Women). Results: Although several sources of MCH information and support were noted, Wise Women were the most frequently reported culturally normative sources. Emergent themes included positive affirmations for informal exchange of MCH information among women and roadblocks to MCH information exchange and support. Discussion: Results suggest a need for culturally relevant interventions that would strengthen lines of communication and social connectedness among African American women.

Population-attributable fraction of risk factors for severe maternal morbidity

Background

Severe maternal morbidity is an important proxy for maternal mortality. Population attributable fraction is the proportion of a disease that is attributable to a given risk factor and can be used to estimate the reduction in the disease that would be anticipated if a risk factor was reduced or eliminated.

Objective

We sought to determine the population-attributable fraction (PAF) of potentially modifiable risk factors for severe maternal morbidity.

Study Design

We used a retrospective cohort of 86,260 delivery hospitalizations from Magee-Womens Hospital, Pittsburgh, PA for this analysis (2003-2012). Severe maternal morbidity was defined as any of the following: Centers for Disease Control and Prevention International Classification of Diseases 9^th Revision diagnosis and procedure codes for the identification of maternal morbidity; prolonged postpartum length of stay (defined as >3 standard deviations beyond the mean length of stay: >3 days for vaginal deliveries and >5 days for Cesarean deliveries); or maternal intensive care unit admission. We used multivariable logistic regression with generalized estimating equations to estimate the association of prepregnancy overweight or obesity, maternal age ≥35 years, preexisting hypertension, preexisting diabetes, excessive gestational weight gain, smoking, education, and marital status with severe maternal morbidity. We then calculated the PAF for each risk factor. We also examined the impact of modest reductions and elimination of risk factors on the PAF of severe maternal morbidity.

Results

The overall rate of severe maternal morbidity was 2.0%. Overweight and obesity, maternal age ≥35 years, preexisting hypertension, excessive gestational weight gain, and lack of a college degree had PAF ranging from 4.5% to 13%. If all risk factors were eliminated, 36% of cases could have been prevented. Modest reductions in the prevalence of excessive BMI and advanced maternal age had minimal impact on preventing severe maternal morbidity. Smoking during pregnancy and marital status were not associated with severe maternal morbidity.

Conclusions

Our data suggest maternal morbidity can be reduced by modifying common, individual-level risk factors. Nevertheless, the majority of cases were not attributable to the patient level risk factors we examined. These data support the need for large studies of patient-, provider-, system- and population-level factors to identify high-impact interventions to reduce maternal morbidity.

Preference, knowledge and utilization of midwives, childbirth education classes and doulas among U.S. black and white women: implications for pregnancy and childbirth outcomes

This secondary analysis explored preference, knowledge and utilization of midwifery care, childbirth education and doula care among 627 black and white women at three Midwestern U.S. health clinics. Women who were white, more educated, not living in a high crime neighborhood, and privately insured were more likely to attend childbirth classes. Sociodemographic factors that predicted having heard about doula care included being more educated and having a partner. None of the sociodemographic variables predicted midwifery care. Education about existing childbearing resources and availability of low-cost options should be expanded, particularly for black women and those with low resources.

Positive Deviance to Address Health Equity in Quality and Safety in Obstetrics

Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.

Skin Tone Matters: Racial Microaggressions and Delayed Prenatal Care

INTRODUCTION

Literature posits that discrimination can be a barrier to racial and ethnic minorities' healthcare use. This study examines the relationship between perceived discrimination in the form of racial microaggressions and delayed prenatal care in African American women. It also investigates whether this relationship is modified by women's shade of skin color owing to societal attitudes and beliefs tied to colorism (also known as skin-tone bias).

METHODS

Data were collected from a cohort of 1,410 black, African American women in metropolitan Detroit, Michigan, enrolled in 2009-2011 (analyzed between August 2017 and July 2018). Perceived racial microaggressions were assessed using the 20-item Daily Life Experiences of Racism and Bother scale. Logistic regression modeled the relationship between the Daily Life Experiences of Racism and Bother scale and delayed prenatal care, defined as third trimester or no prenatal care entry.

RESULTS

Nearly a quarter (24.8%) of women had delayed prenatal care. Logistic regression models showed that a Daily Life Experiences of Racism and Bother score above the median was associated with delayed prenatal care (AOR=1.31, 95% CI=1.00, 1.71). This association was moderated by self-reported maternal skin tone (interaction p=0.03). A higher Daily Life Experiences of Racism and Bother score was associated with delayed prenatal care among African-American women at either end of the color continuum (light brown: AOR=1.64, 95% CI=1.02, 2.65; dark brown: AOR=2.30, 95% CI=1.20, 4.41) but not in the middle (medium brown women).

CONCLUSIONS

Skin tone-based mistreatment in tandem with racial discrimination in the form of racial microaggressions may influence African American women's use of prenatal care. These findings have implications related to the engagement of women of color, particularly African American women, in healthcare systems and maternal and child health programs.

The Impact of Racism on Child and Adolescent Health

The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. By acknowledging the role of racism in child and adolescent health, pediatricians and other pediatric health professionals will be able to proactively engage in strategies to optimize clinical care, workforce development, professional education, systems engagement, and research in a manner designed to reduce the health effects of structural, personally mediated, and internalized racism and improve the health and well-being of all children, adolescents, emerging adults, and their families.

Risk factors for alcohol use among pregnant women, ages 15-44, in the United States, 2002 to 2017

Fetal alcohol exposure can lead to severe birth and developmental defects. Determining which pregnant women are most likely to drink is essential for targeting interventions. In National Survey on Drug Use and Health data on pregnant women from 2002 to 2017 (N = 13,488), logistic regression was used to produce adjusted odds ratios (aOR) indicating characteristics associated with two past-month outcomes: any alcohol use and binge drinking. Risk factors were sociodemographic (age, race/ethnicity, marital status, education level, income) and clinical (trimester, substance use, alcohol use disorder, major depression). Where associations differed by pregnancy stage (trimester 1 vs. trimesters 2 and 3), association was evaluated by stage. Overall, higher risk for any and binge drinking was observed among those with other substance use (aORs 2.9-25.9), alcohol use disorder (aORs 4.5-7.5), depression (aORs = 1.6), and unmarried women (aORs 1.6-3.2). For any drinking, overall, higher risk was observed in adolescents (aOR = 1.5) and those with higher education (aOR = 1.4), while lower risk was observed in those with lower income (aORs = 0.7). For binge drinking, associations differed by pregnancy stage. In trimester 1, lower risk was observed in middle ages (aOR = 0.4). In trimesters 2/3, higher risk was observed in Blacks (aOR = 3.3) and those with lower income (aORs 3.5-3.9), while lower risk was observed in those with higher education (aOR = 0.3). To prevent severe prenatal harm, health care providers should focus on women at higher risk for binge drinking during pregnancy: women with tobacco or drug use, alcohol use disorder, or depression, and women who are unmarried, Black, or of lower socioeconomic status.

Effects of an 8-week pelvic core stability and nutrition community programme on maternal health outcomes

INTRODUCTION

Women, during the antenatal and post-partum period, report pelvic, low back pain, stress and urge urinary incontinence, colorectal dysfunction, and other co-morbidities that negatively affect health-related quality of life. Exercise and nutrition are important considerations for improving maternal health in this period.

PURPOSE

The purpose of this study was to examine the effects of a community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling over an 8-week period on pelvic floor and urinary distress (UDI), prolapse and colorectal distress for antenatal and post-partum women with limited access to health care, and low socio-economic resources from a Midwestern Region of the United States.

MATERIALS AND METHODS

Purposive sample of 35 females, ages 18-44, were recruited for this prospective, preintervention to postintervention study, following ethical approval from Institutional Review Board and voluntary written consent from participants. The Health History Questionnaire, SF-36, Food Frequency Questionnaire, report of pelvic organ prolapse dysfunction (POPDI), colorectal-anal dysfunction (CRADI), and UDI as measured by the Pelvic Floor Distress Inventory (PFDI) were completed before and after intervention.

RESULTS

Thirty-five women (n = 35) 18 to 44 years old (mean age of 22.72 ± 3.45 years) completed the study. A significant difference was found from preintervention to postintervention scores means for PFDI total scores, CRADI individual scores, and UDI individual scores (p < .05). POPDI scores decreased preintervention to postintervention but were not significant. A significant improvement in healthy nutrition and breastfeeding postintervention was also found (z = 3.21, p = .001). Further analysis showed significant, but weak, correlation between parity and POPDI (r = .366, p = .033); between parity and UDI (r = .384, p = .03); and between parity and PFDI (r = .419, p = .014).

DISCUSSION

Our study found a significant reduction in pelvic floor dysfunction, urinary, and colorectal-anal distress symptoms and improvement in breastfeeding and healthy nutrition following an 8-week community-driven nutrition and exercise programme focused on pelvic floor and core stability, healthy nutrition, and breastfeeding counselling.

Reducing Disparities in Severe Maternal Morbidity and Mortality

Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as compared with white women. Growing research indicates that quality of health care, from preconception through postpartum care, may be a critical lever for improving outcomes for racial and ethnic minority women. This article reviews racial and ethnic disparities in severe maternal morbidities and mortality, underlying drivers of these disparities, and potential levers to reduce their occurrence.

Understanding how the concentration of neighborhood advantage and disadvantage affects spina bifida risk among births to non-Hispanic white and Hispanic women, Texas, 1999-2014

BACKGROUND

This is the first study to utilize the index of concentration at the extremes (ICE) to examine risk factors for spina bifida in Texas. The ICE is a useful measure for providing the degree to which residents in a certain area are concentrated into groups at the extremes of disadvantage and privilege. We introduce two novel ICE measures (language and nativity), and three existing ICE measures (race/ethnicity, income, and education), which we applied specifically to Texas residents.

METHODS

We used multivariable mixed-model Poisson regression analyses to estimate spina bifida birth prevalence and prevalence ratios among singleton live births in Texas, 1999-2014, for each of our ICE measures. Maternal census tract at delivery was included in the models as a random effect. Analyses were stratified by maternal race/ethnicity (Hispanics and non-Hispanic whites). Live births served as denominators for each category.

RESULTS

Among non-Hispanic white women, those in the most disadvantaged versus the advantaged census tract quintile had adjusted relative risk between 1.6 and 8.5 for having a baby affected by spina bifida. However, Hispanic women in the most disadvantaged versus advantaged census tract quintile for four ICE measures had a 33% to 87% lower risk of having an affected pregnancy.

CONCLUSIONS

Findings suggest spina bifida risk is associated with neighborhood disadvantage or advantage, and that relationship seems to vary by race-ethnicity. The varied associations between ICE measures and spina bifida by race/ethnicity highlights the importance of using targeted interventions in the prevention of spina bifida.

Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status

BACKGROUND

Pregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes, but the drivers of this association have not been explored from the patient perspective.

PURPOSE

We sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy.

METHODS

We conducted a comparative qualitative analysis of in-depth semistructured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as either high or low utilizers of unscheduled care, and interviewed about challenges faced in obtaining pregnancy care and reasons for choosing between unscheduled versus scheduled care delivery.

RESULTS

Demographically, high utilizers were similar to low utilizers, but were more likely to report adverse childhood experiences (p = .01). All 40 participants reported resource constraints and perceived hospital-based unscheduled obstetric care to be more accessible than outpatient prenatal care. Beyond this, high (n = 20) and low (n = 20) utilizer narratives differed significantly. Two distinct high utilizer profiles emerged. Some high utilizers repetitively used unscheduled hospital-based services owing to psychosocial determinants. Other high utilizing participants were driven by severe experiences of illness insufficiently addressed by outpatient prenatal care. Low utilizer narratives demonstrated high self-efficacy and social support compared with high utilizers.

CONCLUSIONS

Low-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need.

IMPLICATIONS FOR POLICY AND/OR PRACTICE

Tailored community-focused innovations that use unscheduled visits as signals of risk may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.