Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes

How Much is too Much? High Utilization of Prenatal Care and Its Impact on Primary Cesarean Birth Among Women in the United States

INTRODUCTION

Nationally, cesarean birth is one of the most performed surgical procedures, yet cesarean births have been linked to an increased risk of delivery complications. Prenatal care (PNC) and education are possible strategies to reduce the number of cesarean births. However, there is scant research assessing the impact of these strategies on safely reducing primary cesarean births. This study evaluates the association between the adequacy of PNC utilization and primary cesarean birth.

METHODS

The analysis used 2018 birth certificate data, and the sample included nulliparous women with no reported pregnancy or delivery complications (N = 729,140). Logistic regression was used to model the association between the adequacy of PNC utilization and delivery method, as well as identify other factors associated with the delivery method.

RESULTS

Among women with a primary cesarean birth, 36.2% had received adequate plus PNC. After adjustment, there was no significant association between women receiving inadequate, intermediate, or adequate PNC and primary cesarean birth. However, women who received adequate plus PNC had an increased odds of having a primary cesarean birth compared to women with no PNC (OR, 1.23; 95% CI, 1.18-1.28).

DISCUSSION

Findings from this study highlight the need to further understand the role of PNC and its potential impact on the delivery method. Within the patient-provider relationship, healthcare providers have the unique opportunity to provide education and inform patients of the risks and benefits of all delivery options. Thus, there is an increased opportunity to safely reduce primary cesarean births.

Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low- and middle-income countries: a review of systematic reviews

BACKGROUND

Maternal mortality in low- and middle-income countries (LMIC) has reduced considerably over the past three decades, but it remains high. Effective interventions are available, but their uptake and coverage remain low. We reviewed and synthesised evidence from systematic reviews on interventions to increase healthcare services utilisation to reduce maternal mortality in LMICs.

METHODS

We searched Medline PubMed and Cochrane Library databases for systematic reviews published between January 2014 and December 2021, investigating interventions to increase healthcare services uptake among pregnant women in LMICs. We used the AMSTAR tool (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the included reviews. We extracted data on the interventions and their effects and grouped them into broad groups based on the outcomes reported in each systematic review.

RESULTS

We retrieved 4,022 articles. After removing duplicates and screening, we included 14 systematic reviews. Male-partner interventions were effective in increasing skilled birth attendance (SBA) postnatal visits and maternal antiretroviral (ART) uptake for HIV-positive pregnant women. However, there was no evidence of their effectiveness on increased early ANC initiation or adequate ANC visits. Mobile health interventions were effective in increasing adequate ANC visits, SBA, facility-based service utilisation, early ANC initiation, and adherence to nutritional supplements. Incentive-based interventions, particularly financial incentives, were effective in increasing the number of ANC visits but not postnatal visits. Facility-based interventions were effective in increasing postnatal visits, maternal ART initiation and uptake, immunisation uptake and follow-up ANC visits. None of the reviews assessed their impact on SBA or adequate ANC visits. Community-based interventions were effective in increasing SBA, ANC service utilisation, ART initiation and uptake, and nutritional supplements and immunisation uptake.

CONCLUSION

Our findings show that the different interventions effectively improved different outcomes on the maternal healthcare continuum. Implementing these interventions in combination has the potential to enhance healthcare service uptake further.

Prenatal care and infant outcomes of teenage births: a Project WATCH study

INTRODUCTION

Infants of teenage births are known to have increased risk of poor infant outcomes. Adequate prenatal care (PNC) is essential to the overall health of infants and their birthing persons. While teenage births continue to be of concern in rural areas, little is known about the association between inadequate PNC and poor infant outcomes in teenage populations.

PURPOSE

To determine the association between inadequate PNC (< 10 visits) and poor infant outcomes neonatal intensive care unit (NICU) stay, low APGAR score, small for gestational age (SGA) and length of stay (LOS).

METHODS

The study used West Virginia (WV) Project WATCH population level data (May 2018-March 2022). Multiple logistic regressions and survival analysis were performed on infant outcomes; NICU stay, APGAR score, infant size, and infant length of stay (LOS) with PNC categories inadequate (< 10 PNC visits) vs adequate (10 or more) adjusting for covariates including maternal race, insurance status, parity, smoking status, substance use status, and diabetes status.

RESULTS

Of births to teenagers, 14% received inadequate PNC. Teens who received inadequate PNC had increased odds of infant admitted to NICU (aOR: 1.84, CI:(1.41, 2.42), p < 0.0001), low 5- minute APGAR score (aOR: 3.26, CI:(2.03,5.22), p < 0.0001), and increased LOS (Est. = -0.33, HR: 0.72, CI:(0.65,0.81), p < 0.0001).

CONCLUSIONS

Results demonstrated that infants of teenagers who received inadequate PNC are at increased risk of requiring a NICU stay, having a low APGAR score and requiring an increased LOS. PNC is particularly important for these groups as they are at increased risk of poor birth outcomes.

Women and health professionals' perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

OBJECTIVES

Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.

DESIGN

Prospective qualitative research.

SETTING

We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.

PARTICIPANTS

26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.

INTERVENTIONS

We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.

RESULTS

Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.

CONCLUSIONS

In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth.

TRIAL REGISTRATION NUMBER

NCT02402855.

Incentives for pregnant mothers during antenatal care for better maternal and neonatal health outcomes in low and middle income countries: A systematic review protocol

Background: Universal access to maternal new-born and child healthcare services (MNCH) is detrimental for attainment of Sustainable Development Goal (SDG) three pertaining to promotion of health at all ages. Incentivization in the form of cash, vouchers, and goods have been used as part of strategies to improve maternal and neonatal health outcomes around the world. However, there exists uncertainties regarding the effectiveness of various incentive-based programmes targeted for pregnant mothers in low- and middle-income countries during their antenatal period.

Methods: We will search six electronic databases, namely the Medical Literature Analysis and Retrieval System Online (Medline), Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science, and Embase in addition to Google Scholar. Manual searching of the reference lists of included studies will also be done. The reporting of this protocol will follow the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 statement [29]. Only interventional studies that follow randomized, quasi randomized, and cluster randomized controlled study designs will be included. A three-stage screening process will be adopted to select articles. Risk of bias for the included studies will be assessed using the tools and criteria specified in the Cochrane handbook. In addition, the GRADE approach will be used to assess the quality of evidence for the maternal and neonatal health outcomes.

Conclusion: This review of trials is essential to inform the effectiveness of incentive-based programmes targeted for pregnant women in low- and middle-income countries. It will help the policy makers to utilise the resources more effectively and to integrate the evidence based public health initiatives into the health system. This can also help build the continuum of care financial packages for all pregnant women.

Equity in antenatal care visits among adolescent mothers: An analysis of 54 country levels trend and projection of coverage from 2000 to 2030

Background

Ensuring utilization of antenatal care (ANC) services by adolescent mothers (ages 10-19) is an enormous challenge in low-and middle-income countries (LMICs). This study provides the first comprehensive analysis of ANC visits among adolescent and adult mothers.

Methods

Using all available Demographic and Health Survey and Multiple Indicator Cluster Surveys between 2000 and 2019 in 54 LMICs, we estimated proportion of ANC visits among women. Bayesian hierarchical regression models were used to estimate trend, projection, and determinants of single and four ANC visits (ANC1 and ANC4) independently. Equity analysis were performed to assess the magnitude of wealth-based and urban-rural inequalities in access to ANC visits.

Results

Compared to women aged 36-49 years, coverage of ANC1 and ANC4 are expected to increase significantly for adolescent mothers and women aged 20-35 years. This increase was observed at the national level, as well as both urban and rural areas in most countries between 2000 and 2030. By 2030, the coverage of ANC1 is predicted to reach 80% or more in all countries except Angola, Central African Republic and Togo, whereas only 16 countries are predicted to reach 80% or more for ANC4. According to wealth quintile, the lowest inequalities with highest coverage of 80% or more ANC4 will be observed in Armenia, Cambodia, Dominican Republic, Ghana, Maldives, Indonesia, and Sao Tome and Principe in 2030. Determinant analysis found increased odds of receiving ANC visits during pregnancy for adolescent mothers with higher educational levels, frequency of listening/watching mass media, and various household socio-economic status factors.

Conclusions

This study calls for advanced, innovative and cost-effective approaches to increase ANC coverage among adolescent mothers, particularly in rural areas and/or in low socioeconomic groups.

"First Five" Quality Improvement Program Increases Adherence and Continuity with Well-child Care

The American Academy of Pediatrics Bright Futures recommends routine well-child care as optimal care for children. This quality improvement project aimed to increase adherence to the "First Five" visits after newborn follow-up at 2, 4, 6, 9, and 12 months-by 25% (50% or higher) and continuity with providers by 20% (64% or higher) between 2013 and 2016.

METHODS

Retrospective data collection identified a quality gap, in which only 25% had the required well-child visits by the first year. We interviewed parents/caregivers of 12- to 15-month-old children for their perspectives on access to care, scheduling, and the medical home concept. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives. We then piloted interventions in one of our clinic's pod/subgroup. Process and outcome measures were analyzed using descriptive statistics, a run chart, and a 2-sample % Defective Test.

RESULTS

Parent/caregiver interviews revealed that only 6% knew what a medical home was, and only 40% "almost always saw the same provider for care." At baseline in 2012, we documented completion of all 5 visits in only 25% of the children; <10% of those children had consecutive visits with the same provider. After multiple Plan-Do-Study-Act cycles and pilot, our "First Five" well-child care adherence rose to 78%, and continuity increased to 74% in 2018 (P < 0.001 for adherence, P < 0.001 for continuity).

CONCLUSION

A multifaceted, evidence-based approach improved both well-child care adherence and provider continuity.

Understanding racial disparities in severe maternal morbidity using Bayesian network analysis

Previous studies have evaluated the marginal effect of various factors on the risk of severe maternal morbidity (SMM) using regression approaches. We add to this literature by utilizing a Bayesian network (BN) approach to understand the joint effects of clinical, demographic, and area-level factors. We conducted a retrospective observational study using linked birth certificate and insurance claims data from the Arkansas All-Payer Claims Database (APCD), for the years 2013 through 2017. We used various learning algorithms and measures of arc strength to choose the most robust network structure. We then performed various conditional probabilistic queries using Monte Carlo simulation to understand disparities in SMM. We found that anemia and hypertensive disorder of pregnancy may be important clinical comorbidities to target in order to reduce SMM overall as well as racial disparities in SMM.

A cross-sectional study to evaluate antenatal care service provision in 3 hospitals in Nepal

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Pregnancy complications, substance abuse, and prenatal care predict birthweight in adolescent mothers

BACKGROUND

Reduced birthweight is associated with adverse physical and mental health outcomes later in life. Children of adolescent mothers are at higher risk for reduced birthweight. The current study aimed to identify the key risk factors affecting birthweight in a well-characterized sample of adolescent mothers to inform preventive public health efforts.

METHODS

Sixty-four adolescent mothers (≤ 21 years of age) provided detailed data on pregnancy, birth and psychosocial risk. Separate regression analyses with (1) birthweight and (2) low birthweight (LBW) as outcomes, and pregnancy complications, prenatal care, maternal age, substance abuse during pregnancy, socioeconomic risk, stressful life events and the child's sex as independent variables were conducted. Exploratively, a receiver operating characteristic (ROC) analysis was performed to investigate the quality of the discriminatory power of the risk factors.

RESULTS

The following variables explained variance in birthweight significantly: prenatal care attendance (p = .006), pregnancy complications (p = .006), and maternal substance abuse during pregnancy (p = .044). Prenatal care attendance (p = .023) and complications during pregnancy (p = .027) were identified as significant contributors to LBW. Substance abuse (p = .013), pregnancy complications (p = .022), and prenatal care attendance (p = .044) showed reasonable accuracy in predicting low birthweight in the ROC analysis.

CONCLUSIONS

Among high-risk adolescent mothers, both biological factors, such as pregnancy complications, and behavioural factors amenable to intervention, such as substance abuse and insufficient prenatal care, seem to contribute to reduced birthweight in their children, a predisposing factor for poorer health outcomes later in life. More tailored intervention programmes targeting the specific needs of this high-risk group are needed.

Accelerating progress towards the elimination of mother-to-child transmission of HIV: a narrative review

INTRODUCTION

Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT).

METHODS

We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.

RESULTS AND DISCUSSION

From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.

CONCLUSIONS

A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

Latest-Late Fertility? Decline and Resurgence of Late Parenthood Across the Low-Fertility Countries

After decades of fertility postponement, we investigate recent changes in late parenthood across low-fertility countries in the light of observations from the past. We use long series of age-specific fertility rates from the Human Fertility Database (1950-2016) for women, and new data covering the period 1990-2016 for men. In 1950, the contribution of births at age 40 and over to female fertility rates ranged from 2.5 to 9 percent, but then fell sharply until the 1980s. From the 1990s, however, the prevalence of late first births increased rapidly, especially so in countries where it was initially lowest. This has produced a late fertility rebound in the last two decades, occurring much faster for women than for men. Comparisons between recent and past extremely late (age 48+) fertility levels confirm that people are now challenging the natural fertility barriers, particularly for a first child.

Social determinants of health and disparities in prenatal care utilization during the Great Recession period 2005-2010

BACKGROUND

Early, regular prenatal care utilization is an important strategy for improving maternal and infant health outcomes. The purpose of this study is to better understand contributing factors to disparate prenatal care utilization outcomes among women of different racial/ethnic and social status groups before, during, and after the Great Recession (December 2007-June 2009).

METHODS

Data from 678,235 Washington (WA) and Florida (FL) birth certificates were linked to community and state characteristic data to carry out cross-sectional pooled time series analyses with institutional review board approval for human subjects' research. Predictors of on-time as compared to late or non-entry to prenatal care utilization (late/no prenatal care utilization) were identified and compared among pregnant women. Also explored was a simulated triadic relationship among time (within recession-related periods), social characteristics, and prenatal care utilization by clustering individual predictors into three scenarios representing low, average, and high degrees of social disadvantage.

RESULTS

Individual and community indicators of need (e.g., maternal Medicaid enrollment, unemployment rate) increased during the Recession. Associations between late/no prenatal care utilization and individual-level characteristics (including disparate associations among race/ethnicity groups) did not shift greatly with young maternal age and having less than a high school education remaining the largest contributors to late/no prenatal care utilization. In contrast, individual maternal enrollment in a supplemental nutrition program for women, infants, and children (WIC) exhibited a protective association against late/no prenatal care utilization. The magnitude of association between community-level partisan voting patterns and expenditures on some maternal child health programs increased in non-beneficial directions. Simulated scenarios show a high combined impact on prenatal care utilization among women who have multiple disadvantages.

CONCLUSIONS

Our findings provide a compelling picture of the important roles that individual characteristics-particularly low education and young age-play in late/no prenatal care utilization among pregnant women. Targeted outreach to individuals with high disadvantage characteristics, particularly those with multiple disadvantages, may help to increase first trimester entry to utilization of prenatal care. Finally, WIC may have played a valuable role in reducing late/no prenatal care utilization, and its effectiveness during the Great Recession as a policy-based approach to reducing late/no prenatal care utilization should be further explored.

Program Impact Pathway Analysis Reveals Implementation Challenges that Limited the Incentive Value of Conditional Cash Transfers Aimed at Improving Maternal and Child Health Care Use in Mali

BACKGROUND

The program "Santé Nutritionnelle à Assise Communautaire à Kayes" (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child's second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs).

OBJECTIVES

The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance.

METHODS

We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey.

RESULTS

FLWs' knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit.

CONCLUSION

Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.

Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015

OBJECTIVE

In Ghana, intermittent preventive treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended for the prevention of malaria-related adverse outcomes. This study demonstrates the coverage of IPTp-SP use among pregnant women over a period (2011-2015) and the impact of various sociodemographic groups on the uptake of IPTp-SP.

DESIGN

Retrospective analysis using data from all pregnant women in the Kintampo Health and Demographic Surveillance System area on the uptake of IPTp-SP.

SETTING

Kintampo North Municipality and Kintampo South District of Ghana.

PARTICIPANTS

All pregnant women in the Kintampo Health and Demographic Surveillance System area.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number of doses of IPTp-SP taken by pregnant women were examined. Logistic regression was used to assess the determinant of uptake of IPTp-SP while adjusting for within-subject correlation from women with multiple pregnancies.

RESULTS

Data from 2011 to 2015 with a total of 17 484 pregnant women were used. The coverage of the recommended three or more doses of IPTp-SP among all pregnant women was 40.6%, 44.0%, 45.9%, 20.9% and 32.4% in 2011, 2012, 2013, 2014 and 2015, respectively. In the adjusted analysis, age, household size, education, religion, number of antenatal care visits, ethnicity, marital status, wealth index and place of residence were significantly associated with the uptake of three or more doses of IPTp-SP. Having middle school education or higher, aged 20 years and above, visiting antenatal care five times or more (OR 2.83, 95% CI 2.64 to 3.03), being married (OR 1.10, 95% CI 1.02 to 1.19) and those in higher wealth quintiles were significantly more likely to take three or more doses of IPTp-SP.

CONCLUSION

The uptake of the recommended three or more doses of IPTp-SP is low in the study area. We recommend a community-based approach to identify women during early pregnancy and to administer IPTp-SP.

Provision and uptake of routine antenatal services: a qualitative evidence synthesis

BACKGROUND

Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future.

OBJECTIVES

To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers.

SEARCH METHODS

To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase.

SELECTION CRITERIA

We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education.

DATA COLLECTION AND ANALYSIS

Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour.

MAIN RESULTS

We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies.

AUTHORS' CONCLUSIONS

This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

Maternal healthcare insurance ownership and service utilisation in Ghana: Analysis of Ghana Demographic and Health Survey

Objectives

Previous studies have attempted to assess the role of health insurance on health care utilization in African settings. However, there is limited evidence on the effects of health insurance on use of maternal health care. In the present study our objective was to measure the prevalence of insurance ownership, types of services covered by the insurance and the association of insurance ownership with the utilization of respective maternal health services in Ghana.

Methods

This study was based on nationally representative Demographic and Health Survey in Ghana (GDHS 2014) encompassing 4,293 mothers aged 15–49 years. Outcome variables were use of early antenatal care (ANC), facility delivery, and postnatal care (PNC) for mothers and children, and the explanatory variables were insurance coverage for these services. Associations were analysed using logistic regression models whilst controlling for potentially confounding variables.

Results

Prevalence of health insurance ownership was 66.8% (95%CI = 64.5–68.9) with significant socioeconomic disparities. The prevalence was higher particularly among women who were urban residents, had higher educational and wealth status. In general, insurance coverage for services such as ANC, childbirth and postnatal care was higher in rural areas, but that of cash benefit was higher in urban areas. Findings of multivariate analysis indicated that women who had their ANC services covered had significantly higher odds of attending at least one and four ANC visits, as well as receiving PNC for child. Insurance coverage for childbirth services showed significant association with the PNC for child, not with choice of health facility delivery. Women who had cash benefit were twice as likely to use early ANC visit (OR = 2.046, p<0.05), facility delivery (OR = 1.449, p<0.05), and PNC for mother (OR = 1.290, p<0.05).

Conclusion

Overall prevalence of health insurance coverage has increased since 2008, with significant disparities across demographic and socioeconomic groups. Insurance ownership for different types of maternal health services showed positive association with service uptake, with exceptions for place of delivery, indicating that insurance coverage alone may not be able to promote facility delivery. More studies are required to measure the progress in maternal healthcare utilisation through the insurance programmes.

Maternal Depression Scale: Do "Drop-In" Laborist Patients Have Increased Postpartum Screening Risks Compared to Patients with Adequate Prenatal Care?

Objectives The Edinburgh Postnatal Depression Scale (EPDS) identifies women with depressive symptoms in pregnancy. Our primary objective was to determine the prevalence of EPDS screen-positive women delivering on our no prenatal care (laborist) service and to compare these patients to private patients delivering with prenatal care. Methods Retrospective cohort analysis of EPDS scores during January 1, 2015 to June 18, 2015 was conducted. Scores ≥ 10 were considered at-risk. Results were analyzed as an aggregate and then as no prenatal care versus prenatal care. Characteristics for patients with at-risk scores (EPDS ≥ 10) versus low-risk scores (EPDS < 10) were quantified. Results Analysis occurred on 970 women. EPDS ≥ 10 occurred in 12.4% (n = 120/970). Positive EPDS score was 21.1% without prenatal care versus 10.9% with adequate prenatal care (P = 0.003). Maternal demographics and delivery characteristics were clinically similar in patients with prenatal care compared to no prenatal care. Private insurance was more common in patients with prenatal care compared to no prenatal care (23.5 versus 8.1%, P = 0.0001). However, analysis of patients with EPDS > 10 showed non-significant distributions of ethnicity, private insurance, Medicaid, or no insurance compared to patients with EPDS < 10. Conclusion for Practice Patients without prenatal care who arrive solely for urgent "drop-in" delivery have a measurable increased risk factor for postpartum depressive symptoms. Ethnicity and payor status were related to adequacy of prenatal care but were not significant variables when analyzing patients with EPDS > 10. Laborist services providing care to "drop-in" patients should recognize this increased risk and develop policies for screening, referral and follow-up of at-risk patients.

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.

MEDICAL GENETIC COUNSELING OF WOMEN WITH CONGENITAL HEART DISEASES OF FETUS

Aim of the work. Determine the effectiveness of prenatal diagnosis of congenital heart defects in the fetus and the informativeness of different markers used in the medical-genetic counseling of pregnant women.. Materials and methods. The analysis of the results of medical genetic counseling of pregnant women with fetal heart diseases was carried out. The effectiveness of using different methods of prenatal diagnosis in 67 pregnant women is estimated. The data of somatic, genealogical and reproductive anamnesis, biochemical markers of chromosomal pathology of the 1st and 2nd trimester of pregnancy, and the spectrum of the detected fetal heart disease were studied. Results of the research. It was found that 46 (68.7 %) women had somatic diseases: pathology of the cardiovascular system (11.9 %); endocrine system - at 8 (11,9 %); respiratory disease – 3 (4.5 %) and urinary system – 2 (3.0 %). 13 (19.4 %) out of 67 women had acute respiratory viral infections in the first trimester of pregnancy. In 4 (6 %) cases - bad habits. The first time pregnant were 31 (46.3 %) women, 21 (31.3 %) – the second time, 10 (14.9 %) in the third, and 5 (7.5 %) in the fourth or more times. In history, 58 (86.6 %) women did not have reproductive function disorders, 8 (11.9 %) had unauthorized miscarriages and frozen pregnancy. The burden of gynecological anamnesis was observed in 12 (17.9 %) women, and hereditary - in 6 (9.0 %) women. In the structure of congenital defects of the heart, false anatomical anomalies were found more often: hypoplasia of the left heart organs – 14 (20.9 %), tetralogy of Fallot - 9 (13.3 %). Biochemical markers of chromosomal pathology in the first trimester in 11 (16.4 %) women recorded indicators that are characteristic of the risk of chromosomal pathology, and in the second trimester – in 9 (13.4 %). Two pregnant women used a NIPT (non-invasive prenatal test) test that did not detect chromosomal abnormalities in the fetus. In 8 cases, invasive prenatal diagnosis of the fetus was recommended, which was carried out by three women, and five refused. Conclusions. The peculiarities of somatic (in 46–68.7 % of women), reproductive (in 8-11.9 % of women) gynecological anamnesis (in 12–17.9 % of women), which can be the risk factors of congenital fetal heart disease, are revealed. In the structure of congenital defects of the heart of the fetus more often revealed hypoplasia of the left heart organs – 14 (20.9 %), tetralogy of Fallot – 9 (13.3 %). In 11 (16.4 %) women recorded indicators of biochemical markers, characteristic for the risk of chromosomal pathology, in the first trimester, and – in 9 (13.4 %) pregnant women – in the second trimester. Comparative data on prenatal diagnosis of congenital heart defects in the fetus of chromosomal, monogenic and multifactorial etiology are given. On the basis of the obtained results an algorithm of medical-genetic counseling of this contingent of patients was offered.

Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the Quality of Prenatal Care Questionnaire (QPCQ)

OBJECTIVE

To translate and to observe the psychometric measures of the Brazilian version of the Quality of Prenatal Care Questionnaire.

METHODS

The translation protocol followed the standards of the International Society for Pharmacoeconomics and Outcomes Research. Descriptive statistics were performed to identify characteristics of 280 literate postpartum women in a public hospital. We examined the internal consistency using Cronbach's alfa. To determine the test-retest reproducibility and the instrument's stability, we performed the intraclass correlation coefficient and Bland and Altman plot between two applications. We investigated the item's properties using the item response theory.

RESULTS

The overall Cronbach's alpha index was 0.975. The intraclass correlation coefficient was 0.995 (95%CI 0.993-0.996) and a uniform distribution was visualized at the Bland and Altman plot. The item response theory identified the discriminatory power and the difficulty level of the instrument and of each item. The instrument showed acute angulation of the expected total score, and good concentrate information and good standard error curves, preserving the latent construct and its original items.

CONCLUSIONS

This analysis concluded that the Brazilian version of the Quality of Prenatal Care Questionnaire is a high-quality, reliable and valid questionnaire to determine the quality of prenatal care among Brazilian women. The questionnaire is suitable for the cultural context represented.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews

BACKGROUND

Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB.

OBJECTIVES

We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update.

METHODS

We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI.

MAIN RESULTS

We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB.

OUTCOME

preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions.

OUTCOME

perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources.

OUTCOMES

preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm.

AUTHORS' CONCLUSIONS

Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

Maternal Behavioral Health: Fertile Ground for Behavior Analysis

The World Health Organization has identified four behavioral health priorities as risk factors for noncommunicable diseases in maternal populations: tobacco use, harmful alcohol use, poor nutrition, and lack of physical activity. These risk factors also significantly affect pregnant and immediately postpartum mothers, doubling the health risk and economic burden by adversely affecting maternal and birth or infant outcomes. Psychosocial and behavioral interventions are ideal for pregnant and immediately postpartum women as opposed to pharmacotherapy. Among other behavioral interventions, the use of incentives based on the principles of reinforcement has been a successful yet controversial way to change health behaviors. Implementing an incentive-based intervention in maternal health often brings up social validity concerns. The existing guideline on how to develop and conduct research in incentive-based interventions for maternal health lacks enough information on the specific variables to control for to maintain the intervention's effectiveness. This article outlines some of the critical variables in implementing an effective behavior-analytic intervention and addressing social validity concerns to change maternal behaviors in a sustainable manner, along with specific research topics needed in the field to prevent adverse maternal, birth, and infant outcomes.

Associations between introduction and withdrawal of a financial incentive and timing of attendance for antenatal care and incidence of small for gestational age: natural experimental evaluation using interrupted time series methods

OBJECTIVES

To determine whether introduction or withdrawal of a maternal financial incentive was associated with changes in timing of first attendance for antenatal care ('booking'), or incidence of small for gestational age.

DESIGN

A natural experimental evaluation using interrupted time series analysis.

SETTING

A hospital-based maternity unit in the north of England.

PARTICIPANTS

34 589 women (and their live-born babies) who delivered at the study hospital and completed the 25th week of pregnancy in the 75 months before (January 2003 to March 2009), 21 months during (April 2009 to December 2010) and 36 months after (January 2011 to December 2013) the incentive was available.

INTERVENTION

The Health in Pregnancy Grant was a financial incentive of £190 ($235; €211) payable to pregnant women in the UK from the 25th week of pregnancy, contingent on them receiving routine antenatal care.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mean gestational age at booking. Secondary outcomes were proportion of women booking by 10, 18 and 25 weeks' gestation; and proportion of babies that were small for gestational age.

RESULTS

By 21 months after introduction of the grant (ie, immediately prior to withdrawal), compared with what was predicted given prior trends, there was an reduction in mean gestational age at booking of 4.8 days (95% CI 2.3 to 8.2). The comparable figure for 24 months after withdrawal was an increase of 14.0 days (95% CI 2.8 to 16.8). No changes in incidence of small for gestational age babies were seen.

CONCLUSIONS

The introduction of a universal financial incentive for timely attendance at antenatal care was associated with a reduction in mean gestational age at first attendance, but not the proportion of babies that were small for gestational age. Future research should explore the effects of incentives offered at different times in pregnancy and of differing values; and how stakeholders view such incentives.

NAITRE study on the impact of conditional cash transfer on poor pregnancy outcomes in underprivileged women: protocol for a nationwide pragmatic cluster-randomised superiority clinical trial in France

INTRODUCTION

Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country.

METHODS AND ANALYSIS

This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group.

ETHICS AND DISSEMINATION

Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02402855; pre-results.

Timing and adequate attendance of antenatal care visits among women in Ethiopia

Introduction

Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia.

Methods

Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population.

Results

Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of delayed initiation of ANC visits (OR = 1.65; 95%CI: 1.26–2.18). However, rural women had 44% reduction in the odds of having inadequate ANC visits. In addition, multi-parity showed higher odds of delayed initiation of ANC visit when compared to the primigravida (OR = 2.20; 95%CI: 1.07–2.69). On the contrary, there was 36% reduction in the odds of multigravida having inadequate ANC visits when compared to the women who were primigravida. There were higher odds of inadequacy in ANC visits among women who engaged in sales/business, agriculture, skilled manual and other jobs when compared to women who currently do not work, after adjusting for covariates. From the predictive margins, assuming the distribution of all covariates remained the same among respondents, but everyone was aged 15–19 years, we would expect 71.8% delayed initiation of ANC visit. If everyone was aged 20-24years, 73.4%; 25-29years, 66.5%; 30-34years, 64.8%; 35-39years, 65.6%; 40-44years, 59.6% and 45-49years, we would expect 70.1% delayed initiation of ANC visit. If instead the distribution of age was as observed and for other covariates remained the same among respondents, but no respondent lived in the rural, we would expect about 61.4% delayed initiation of ANC visit; if however, everyone lived in the rural, and we would expect 71.6% delayed initiation in ANC visit. Model III revealed the predictive margins of all factors examined for delayed initiation for ANC visits, while Model IV presented the predictive marginal effects of the determinants of adequacy of ANC visits.

Conclusion

The precise mechanism by which these factors affect ANC visits remain blurred at best. There may be factors on the demand side like the women’s empowerment, financial support of the husband, knowledge of ANC visits in the context of timing, frequency and the expectations of ANC visits might be mediating the effects through the factors found associated in this study. Supply side factors like the quality of ANC services, skilled staff, and geographic location of the health centers also mediate their effects through the highlighted factors. Irrespective of the knowledge about the precise mechanism of action, policy makers could focus on improving women’s empowerment, improving women’s education, reducing wealth inequity and facilitating improved utilization of ANC through modifications on the supply side factors such as geographic location and focus on hard to reach women.

Beyond "Back to Sleep": Ways to Further Reduce the Risk of Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) remains the leading cause of postneonatal mortality in the United States, despite reduction in rates of more than 50% since the initiation of the "Back to Sleep" (now called "Safe to Sleep") campaign in 1994. In recent years, the rate of decline in SIDS deaths has plateaued, even with the ongoing educational efforts that promote safe sleep and other risk reduction measures. The 2016 American Academy of Pediatrics guidelines for reducing the risk of SIDS focus heavily on sleep practices, bedding, and location, but also include factors that often receive less attention (ie, prenatal care, maternal smoking, alcohol and drug use, and childhood vaccinations). This review describes these factors that are less often addressed and identifies interventions that have resulted in positive behavioral changes that not only benefit infants, but also promote the health and well-being of their mothers. [Pediatr Ann. 2017;46(8):e284-e290.].