Increasing Prenatal Care Compliance in At-Risk Black Women: Findings from a RCT of Patient Navigation and Behavioral Incentives

Factors associated with loss to follow up after abnormal cervical cancer screening in pregnancy

OBJECTIVE

To assess risk factors associated with loss to follow up in patients referred for colposcopy after abnormal cervical cytology during pregnancy in a Southern safety net hospital population.

METHODS

An urban colposcopy center was queried for patients referred for follow up of abnormal cervical cytology during pregnancy and the postpartum period. Patients were identified through a standardized referral code in the electronic medical record. Multivariable logistic regression was used to compare patient characteristics between those who followed up for colposcopy and those lost to follow up. Independent risk factors assessed included age, parity, race, insurance, HIV status, history of mental illness, BMI, gestational age and trimester at screening, cytology at colposcopy referral, interval days until colposcopy, and biopsy histology.

RESULTS

1063 patients were identified, with 40.8% of patients who completed referred colposcopy. Patient characteristics predictive for colposcopy follow up included: maternal age at referral cervical cytology >30 years (1.67; 1.27-2.20; < 0.003), gestational age < 18 weeks at abnormal cervical cytology (1.57; 1.23-2.01; <0.0002), maternal race non-African American (2.20; 1.32-3.65; <0.0024) and with high grade cervical cytology (2.42; 1.81-3.24; <0.0001).

CONCLUSION

In this population, inadequate follow up for abnormal cervical cytology during pregnancy is prominent, especially among those with younger maternal age, African American (AA) race, cervical cytology completed at later gestational ages of pregnancy, and low-grade initial cytology. Higher no-show rate among AA patients supports well-documented health disparities and need for further investigation and protocols to identify those at risk for loss to follow up.

Philadelphia Latine Immigrant Birthing People's Perspectives on Mitigating the Chilling Effect on Prenatal Care Utilization

RESEARCH DESIGN

Community-engaged qualitative study using inductive thematic analysis of semistructured interviews.

OBJECTIVE

To understand Latine immigrants' recent prenatal care experiences and develop community-informed strategies to mitigate policy-related chilling effects on prenatal care utilization.

BACKGROUND

Decreased health care utilization among immigrants due to punitive immigration policies (ie, the "chilling effect") has been well-documented among Latine birthing people both pre and postnatally.

PATIENTS AND METHODS

Currently or recently pregnant immigrant Latine people in greater Philadelphia were recruited from an obstetric clinic, 2 pediatric primary care clinics, and 2 community-based organization client pools. Thematic saturation was achieved with 24 people. Participants' pregnancy narratives and their perspectives on how health care providers and systems could make prenatal care feel safer and more comfortable for immigrants.

RESULTS

Participants' recommendations for mitigating the chilling effect during the prenatal period included training prenatal health care providers to sensitively initiate discussions about immigrants' rights and reaffirm confidentiality around immigration status. Participants suggested that health care systems should expand sources of information for pregnant immigrants, either by partnering with community organizations to disseminate information or by increasing access to trusted individuals knowledgeable about immigrants' rights to health care. Participants also suggested training non-medical office staff in the use of interpreters.

CONCLUSION

Immigrant Latine pregnant and birthing people in greater Philadelphia described ongoing fear and confusion regarding the utilization of prenatal care, as well as experiences of discrimination. Participants' suggestions for mitigating immigration-related chilling effects can be translated into potential policy and programmatic interventions which could be implemented locally and evaluated for broader applicability.

Patient navigation in women's health care for maternal health and noncancerous gynecologic conditions: a scoping review

PURPOSE

This study investigated the scope of patient navigation studies on women's health care for maternal health and noncancerous gynecologic conditions and aimed to report the characteristics of the identified patient navigation programs.

METHODS

A scoping review was conducted following Arksey and O'Malley's framework. Five electronic databases were searched for relevant studies published in English: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo. There were no restrictions on the publication date and the search was completed in July 2023.

RESULTS

This scoping review included 14 studies, which collectively examined seven patient navigation programs. All selected studies were related to maternal health issues (e.g., perinatal health problems and contraception for birth spacing). Close to two-thirds of the patient navigation services were provided by women (n=9, 64.3%) and half by lay navigators (n=7, 50.0%). The majority incorporated the use of mobile health technologies (n=11, 78.6%). All of the patient navigation programs included in the review coordinated the necessary clinical and social support services to improve women's access to care.

CONCLUSION

Patient navigation appears to be in its nascent phase in the field of maternal health. The results of this study suggest that the implementation of patient navigation services could potentially improve access to care for socially disadvantaged women and families. Furthermore, providing patient navigation services that are specifically tailored to meet women's needs could improve the quality of maternity care.

Improving Peripartum Care Engagement Among Black Women at Risk for Low Prenatal Care Attendance: A Secondary Analysis of Predictors of Attendance and Sample Representativeness

Background: The United States has unacceptably high rates of maternal and infant mortality, especially among Black women and their infants. Prenatal and postpartum care help reduce maternal and infant morbidity and mortality; however, Black women are less likely to access and utilize peripartum care largely due to structural racism. Identifying factors that buffer against the systemic barriers disproportionately impacting this community is an important step in addressing racial health disparities. Using existing data from a randomized controlled trial (RCT) targeting maternal and infant health disparities, this study aims to (1) explore predictors of peripartum care attendance and (2) examine clinical trial sample representativeness. Methods: The analyses addressing the primary aim of the study included Black women at risk for low prenatal care (PNC) engagement who consented to RCT participation and had a documented live birth (n = 123). For the secondary study aim, comparisons between women who consented to the RCT (Consenters; n = 149) and those who did not (Non-consenters; n = 122) were made using chi-square and t-tests. Results: Hierarchical linear and logistic regression identified predictors of prenatal and postpartum care attendance, respectively. After controlling for multiple comparisons, no significant differences were identified between characteristics of Consenters and Non-consenters. Older age (p = 0.038), high-risk pregnancy (p < 0.001), and no past week substance use (p = 0.033) predicted better PNC attendance. PNC attendance predicted postpartum visit attendance (p < 0.001). Conclusions: This study provides benchmark data on predictors of peripartum care and sample representativeness in RCTs. Findings have important implications for health care system changes and development of culturally informed interventions.

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery-Addressing systemic racism and other social determinants of health as causes of obstetrical disparities

The Centers for Disease Control and Prevention define social determinants of health as "the conditions in the places where people live, learn, work, and play" that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.