Maternal Psychological Well-Being and Infant Emergency Department Utilization

Maternal Mental Health Diagnoses and Infant Emergency Department Use, Hospitalizations, and Death

BACKGROUND

The period surrounding childbirth is a uniquely vulnerable time for women and their mental health. We sought to describe the association between maternal mental health diagnoses in the year prior and after birth and infant Emergency Department (ED) utilization, hospitalization, and death.

METHODS

We studied mothers who gave singleton live birth in California (2011-2017) and their infants using linked infant birth and death certificates and maternal and infant discharge records. Maternal mental health diagnoses in the year before and after birth were identified using International Classification of Diseases (ICD) codes. We abstracted infant ED visits, hospitalizations, discharge diagnoses, deaths, and causes of death. Log-linear regression was used to compare relative risks of infant outcomes between mothers with and without mental health diagnoses, adjusting for maternal variables.

RESULTS

Of the 3,067,069 mother-infant pairs, 85,047 (2.8%) mothers had at least one mental health diagnosis in the year before and after birth. Infants of mothers with mental health diagnoses were more likely to visit the ED (aRR 1.2, CI:1.1-1.2), have three or more ED visits (aRR 1.4, CI:1.3-1.4), be hospitalized (aRR 1.1, CI:1.04-1.1), and die (aRR 1.7, CI:1.6-1.8) in the first year of life. These infants were also more likely to be diagnosed with accidental injuries, nonaccidental trauma, and non-specific descriptive diagnosis (fussiness/fatigue/brief resolved unexplained event).

CONCLUSION

This large administrative cohort study showed associations between maternal mental health diagnoses and infant acute ED visits, hospitalization, and death. This study underscores the urgent need to understand what is driving these findings and how to mitigate this risk.

Perinatal Depression Associated With Increased Pediatric Emergency Department Use And Charges In The First Year Of Life

In New Jersey, universal screening for perinatal depression at the time of delivery has resulted in a 95 percent screening rate. The widespread availability of screening data allowed me to investigate the association between perinatal depression severity and infant emergency department (ED) use and charges in the first year of life. I used birth records linked to hospital discharge records for the period 2016-19. Compared with infants who had mothers with no symptoms, infants with mothers with mild or moderate/severe depressive symptoms had significantly higher overall and nonemergent ED use, but not significantly higher emergent ED use. The positive associations between depressive symptoms and ED charges were particularly striking for infants with Medicaid, which pays for a disproportionate share of pediatric ED care in the United States. This study contributes to the evidence base linking perinatal depression screening and pediatric ED use. Opportunities may exist within Medicaid to optimize screening and referrals for perinatal depression, with potential cost-saving benefits for reducing nonemergent pediatric ED visits.

Development and validation of a parental competence questionnaire in the paediatric hospital emergency setting (ECP-U)

OBJECTIVE

To develop and validate a parental competence questionnaire for parents of children seeking care in hospital emergency departments.

METHODS

An instrumental study of the development of an assessment questionnaire was carried out in three phases: 1) review of relevant measures and item generation, 2) content validity evaluation, 3) psychometric evaluation. Exploratory factor analysis was performed to examine the factorial structure. Internal consistency was evaluated using ordinal alpha. Hypothesis testing was determined between the resulting factors, the Parental Stress Scale and the State-Trait Anxiety Inventory.

RESULTS

The participants were 270 parents of children aged 0-14 years old from a referral hospital in Valencia (Spain). An 18-item questionnaire was developed, comprising five factors that explain 53.0% of the variance: 1) "emotional management and expression", 2) "passive social support", 3) "parental agency", 4) "basic needs and care" and 5) "active social support". The internal consistency for the different factors was modest (>0.70). A negative correlation between the Parental Stress Scale and the parental competence questionnaire was found for most of the factors.

CONCLUSIONS

This questionnaire on parental competence in the hospital emergency department (ECP-U) is a useful and simple self-report instrument for assessing the parental competence of parents with children in the emergency department.

PRACTICAL IMPLICATIONS

The resulting questionnaire is of practical value to both healthcare professionals and researchers in this field. It can be administered quickly in clinical practice and used to identify parents' levels of parental competence and refer those with difficulties to appropriate support services.

Factor structure and validity of the Parental Competence Questionnaire in the Paediatric Hospital Emergency Setting (ECP-U)

OBJECTIVE

To confirm the structure and examine the psychometric properties of the Parental Competence Questionnaire in the Paediatric Hospital Emergency Setting (ECP-U).

METHODS

An instrumental validation study of the ECP-U questionnaire and an examination of its psychometric properties were carried out.

RESULTS

The participants were 260 mothers and fathers seeking care in the paediatric emergency department of a hospital in Valencia (Spain) with children aged 0 to 14 years old. The five-factor structure of the ECP-U was confirmed with excellent statistical fits. Second-order models and a more parsimonious four-factor structure with adequate but marginal fits are proposed. With the exception of the "parental agency" factor (in both models examined) and the "active social support" factor (in the original five-factor structure), the internal consistency of the different factors was modest (≥ 0.70). A negative correlation was found between the Parental Stress Scale and the ECP-U for most factors.

CONCLUSIONS

Validity and reliability analyses indicate that the ECP-U is an instrument with modest psychometric properties.

IMPLICATIONS FOR PRACTICE

The ECP-U is an instrument that can be used by future researchers to identify different levels of parental competence in paediatric hospital emergency departments. This will enable help to be given to families with parenting issues and problems. The underlying concern is to reduce the number of frequent users and "Non-Urgent Presentations" to paediatric emergency departments due to low parental competence.

Developing a multimodal maternal infant perinatal outpatient delivery system: the MOMI PODS program

Progress in maternal child health has been hampered by poor rates of outpatient follow up for postpartum individuals. Primary care after delivery can effectively detect and treat several pregnancy-related complications and comorbidities, but postpartum linkage to primary care remains low. In this manuscript, we share the experience of implementing a novel mother-infant dyad program, the Multimodal Maternal Infant Perinatal Outpatient Delivery System (MOMI PODS), to improve primary care linkage and community resource access postpartum via integration into pediatric care structures. With a focus on providing care for people who are publicly insured, we designed a program to mitigate maternal morbidity risk factors in postpartum individuals with chronic disease or pregnancy complications. We discuss the systematic process of designing, executing, and evaluating a collaborative clinical program with involvement of internal medicine/pediatric, family medicine, and obstetric clinicians via establishing stakeholders, identifying best practices, drawing from the evidence base, designing training and promotional materials, training partners and providers, and evaluating clinic enrollment. We share the challenges encountered such as in achieving sufficient provider capacity, consistent provision of care, scheduling, and data tracking, as well as mitigation strategies to overcome these barriers. Overall, MOMI PODS is an innovative approach that integrates outpatient postpartum care into traditional pediatric structures to increase access, showing significant promise to improve healthcare utilization and promote postpartum health.

Health Care Utilization During the COVID-19 Pandemic Among Individuals Born Preterm

Importance

Limited data exist on pediatric health care utilization during the COVID-19 pandemic among children and young adults born preterm.

Objective

To investigate differences in health care use related to COVID-19 concerns during the pandemic among children and young adults born preterm vs those born at term.

Design, Setting, and Participants

In this cohort study, questionnaires regarding COVID-19 and health care utilization were completed by 1691 mother-offspring pairs from 42 pediatric cohorts in the National Institutes of Health Environmental Influences on Child Health Outcomes Program. Children and young adults (ages 1-18 years) in these analyses were born between 2003 and 2021. Data were recorded by the August 31, 2021, data-lock date and were analyzed between October 2021 and October 2022.

Exposures

Premature birth (<37 weeks' gestation).

Main Outcomes and Measures

The main outcome was health care utilization related to COVID-19 concerns (hospitalization, in-person clinic or emergency department visit, phone or telehealth evaluations). Individuals born preterm vs term (≥37 weeks' gestation) and differences among preterm subgroups of individuals (<28 weeks', 28-36 weeks' vs ≥37 weeks' gestation) were assessed. Generalized estimating equations assessed population odds for health care used and related symptoms, controlling for maternal age, education, and psychiatric disorder; offspring history of bronchopulmonary dysplasia (BPD) or asthma; and timing and age at COVID-19 questionnaire completion.

Results

Data from 1691 children and young adults were analyzed; among 270 individuals born preterm, the mean (SD) age at survey completion was 8.8 (4.4) years, 151 (55.9%) were male, and 193 (71.5%) had a history of BPD or asthma diagnosis. Among 1421 comparison individuals with term birth, the mean (SD) age at survey completion was 8.4 (2.4) years, 749 (52.7%) were male, and 233 (16.4%) had a history of BPD or asthma. Preterm subgroups included 159 individuals (58.5%) born at less than 28 weeks' gestation. In adjusted analyses, individuals born preterm had a significantly higher odds of health care utilization related to COVID-19 concerns (adjusted odds ratio [aOR], 1.70; 95% CI, 1.21-2.38) compared with term-born individuals; similar differences were also seen for the subgroup of individuals born at less than 28 weeks' gestation (aOR, 2.15; 95% CI, 1.40-3.29). Maternal history of a psychiatric disorder was a significant covariate associated with health care utilization for all individuals (aOR, 1.44; 95% CI, 1.17-1.78).

Conclusions and Relevance

These findings suggest that during the COVID-19 pandemic, children and young adults born preterm were more likely to have used health care related to COVID-19 concerns compared with their term-born peers, independent of a history of BPD or asthma. Further exploration of factors associated with COVID-19-related health care use may facilitate refinement of care models.

Maternal Emergency Department Use Before Pregnancy and Infant Emergency Department Use After Birth

IMPORTANCE

Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant.

OBJECTIVE

To study the association between maternal prepregnancy ED use and risk of infant ED use in the first year of life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included all singleton livebirths in all of Ontario, Canada, from June 2003 to January 2020.

EXPOSURES

Any maternal ED encounter within 90 days preceding the start of the index pregnancy.

MAIN OUTCOMES AND MEASURES

Any infant ED visit up to 365 days after the index birth hospitalization discharge date. Relative risks (RR) and absolute risk differences (ARD) were adjusted for maternal age, income, rural residence, immigrant status, parity, having a primary care clinician, and number of prepregnancy comorbidities.

RESULTS

There were 2 088 111 singleton livebirths; the mean (SD) maternal age was 29.5 (5.4) years, 208 356 (10.0%) were rural dwelling, and 487 773 (23.4%) had 3 or more comorbidities. Among singleton livebirths, 206 539 mothers (9.9%) had an ED visit within 90 days before the index pregnancy. ED use in the first year of life was higher among infants whose mother had visited the ED before pregnancy (570 per 1000) vs those whose mother had not (388 per 1000) (RR, 1.19 [95% CI, 1.18-1.20]; ARD, 91.1 per 1000 [95% CI, 88.6-93.6 per 1000]). Compared with mothers without a prepregnancy ED visit, the RR of infant ED use in the first year was 1.19 (95% CI, 1.18-1.20) if its mother had 1 prepregnancy ED visit, 1.18 (95% CI, 1.17-1.20) following 2 visits, and 1.22 (95% CI, 1.20-1.23) after at least 3 maternal visits. A low-acuity maternal prepregnancy ED visit was associated with an adjusted odds ratio (aOR) of 5.52 (95% CI, 5.16-5.90) for a low-acuity infant ED visit, which was numerically higher than the pairing of a high-acuity ED use between mother and infant (aOR, 1.43, 95% CI, 1.38-1.49).

CONCLUSIONS AND RELEVANCE

In this cohort study of singleton livebirths, prepregnancy maternal ED use was associated with a higher rate of ED use by the infant in the first year of life, especially for low-acuity ED use. This study's results may suggest a useful trigger for health system interventions aimed at reducing some ED use in infancy.

Factors associated with the inappropriate use of the pediatric emergency department. A systematic review

BACKGROUND

Pediatric emergency department (PED) admissions have risen in recent years, a trend not justified by the severity of the pathologies presented. The aim of this study is to analyse factors related to the inappropriate use of pediatric emergency departments.

METHODS

This is a systematic review reported in accordance with the PRISMA statement. We searched the PubMed, Web of Science and Science Direct databases, using keywords extracted from MeSH, and conducted a reverse search using Google Scholar and Open Grey, for the period January 2017 to August 2022. The quality of the papers was assessed using STROBE, CASPe, AMSTAR-2, GRADE, Levels Of Evidence and Grades Of Recommendation.

RESULTS

A total of 20 studies were selected. Factors related to inappropriate use included the younger age of children, black caregivers, lower socioeconomic status, lower parental educational attainment, perceived urgent demand for care, parental emotions in response to their children's health problems, psychological distress, the ineffective exercise of the parental role, the advantages of the PED and the nature of health insurance.

CONCLUSIONS AND IMPLICATIONS

The results illustrate the heterogeneous nature of the phenomenon under investigation. Gaining an understanding of the factors related to the inappropriate demand of PEDs, from the perspective of health professionals, can help in developing interventions to reduce unnecessary consultations and relieve pressure on these healthcare services.