Development of the person-centered prenatal care scale for people of color

Person-centered abortion care scale: Validation for medication abortion in the United States

OBJECTIVE

Medication abortions now make up the majority of abortions in the US, with new service delivery models such as telehealth; however, it is unclear how this may impact patient experiences. The objective of the study is to adapt and validate a person-centered abortion care (PCAC) scale for medication abortions that was developed in a global South context (Kenya) for use in the United States.

STUDY DESIGN

This study includes medication abortion patients from a hospital-based clinic who had one of two modes of service delivery: (1) telemedicine with no physical exam or ultrasound; or (2) in-person with clinic-based exams and ultrasounds. We conducted a sequential approach to scale development including: (1) defining constructs and item generation; (2) expert reviews; (3) cognitive interviews (n = 12); (4) survey development and online survey data collection (N = 182, including 45 telemedicine patients and 137 in-person patients); and (5) psychometric analyses.

RESULTS

Exploratory factor analyses identified 29-items for the US-PCAC scale with three subscales: (1) Respect and Dignity (10 items), (2) Responsive and Supportive Care (nine items for the full scale, one additional mode-specific item each for in-person and telemedicine), and (3) Communication and Autonomy (10 items for the full scale, one additional item for telemedicine). The US-PCAC had high content, construct, and criterion validity. It also had high reliability, with a standardized alpha for the full 29-item US-PCAC scale of 0.95. The US-PCAC score was associated with overall satisfaction.

CONCLUSION

This study found high validity and reliability of a newly-developed person-centered abortion care scale for use in the US. As medication abortion provision expands, this scale can be used in quality improvement efforts.

IMPLICATIONS

This study found high validity and reliability of a newly-developed person-centered care scale for use in the United States for in-person and telemedicine medication abortion.

A randomized comparative-effectiveness study of two enhanced prenatal care models for low-income pregnant people: Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE)

BACKGROUND

Improving perinatal mental health and care experiences and preventing adverse maternal and infant outcomes are essential prenatal care components, yet existing services often miss the mark, particularly for low-income populations. An enhanced group prenatal care program, "Glow! Group Prenatal Care and Support," was developed in California's Central Valley in response to poor perinatal mental health, disrespectful care experiences, and high rates of adverse birth outcomes among families with low incomes.

METHODS

Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) is a pragmatic, two-arm, randomized, comparative-effectiveness study designed to assess depression (primary outcome), the experience of care (secondary outcome), and preterm birth (exploratory outcome) among Medi-Cal (California's Medicaid program)-eligible pregnant and birthing people, comparing those assigned to Glow! Group Prenatal Care and Support (Glow/GC) with those assigned to enhanced, individual prenatal care through the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP/IC). Participating clinical practices offer the two comparators, alternating between comparators every 6 weeks, with the starting comparator randomized at the practice level. Participant-reported outcomes are assessed through interviewer-administered surveys at study entry, during the participant's third trimester, and at 3 months postpartum; preterm birth and other clinical outcomes are abstracted from labor and delivery records. Patient care experiences are further assessed in qualitative interviews. The protocol complies with the Standard Protocol Items for Randomized Trials.

CONCLUSIONS

This comparative-effectiveness study will be used to determine which of two forms of enhanced prenatal care is more effective, informing future decisions regarding their use.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04154423.

Parent and staff focus groups to address NICU racial inequities: "There's radical optimism in that we're in a different time and we're not doing it alone"

OBJECTIVES

To understand local mechanisms of racial inequities and generate recommendations from community members regarding how to promote racial equity in the Neonatal Intensive Care Unit (NICU).

METHODS

In an urban tertiary care NICU, 4 semi-structured in-person focus groups with follow-up audio diaries were conducted with NICU parents and staff from 2022-2023 with support from interpreters, a psychologist, and a family advocate. Researchers coded transcripts independently and thematic analysis was utilized to generate and refine themes.

RESULTS

16 racially diverse and multidisciplinary staff and parents participated, and six themes emerged from the data. Mechanisms of racial inequities included power dynamics, interpersonal and institutional dehumanization, and societal inequities. Recommendations included redistributing power, transforming space and staff to promote humanism, and mitigating harm through peer support and resource allocation.

CONCLUSION

Focus groups are a promising strategy to identify interventions to address racial inequities. Future research should focus on intervention implementation and evaluation.

A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol

Background

Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities.

Methods

The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness.

Discussion

This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Communication Between Pregnant People of Color and Prenatal Care Providers in the United States: An Integrative Review

INTRODUCTION

Racism and discrimination negatively affect patient-provider communication. Yet, pregnant people of color consistently report being discriminated against, disrespected, and ignored. The purpose of this integrated review was to identify studies that examined communication between pregnant people of color and their prenatal care providers and evaluate the factors and outcomes arising from communication.

METHODS

We searched the PubMed, Embase, CINAHL, and PsychINFO databases for studies published between 2001 and 2023. Articles were eligible for inclusion if they reported on primary research conducted in the United States, were written in English, and focused on patient-provider communication with a sample that included pregnant people of color, defined as those who self-identified as Black, African American, Hispanic, Latina/x/e, Indigenous, American Indian, Asian, Asian American, Native Hawaiian, and/or Pacific Islander American. Twenty-six articles were included in the review. Relevant data were extracted and compiled into an evidence table. We then applied the rating scale of the Johns Hopkins Evidence-Based Practice model to assess the level of evidence and quality of the studies. Themes were identified using a memoing technique and organized into 3 a priori categories: factors, outcomes, and recommendations.

RESULTS

Two overarching themes emerged from our analysis: racism/discrimination and unmet information needs. Subthemes were then identified as factors, outcomes, or recommendations. Factors included provider behaviors, language barriers, structural barriers, provider type, continuity of care, and fear. Outcome themes were disrespect, trust, decision-making power, missed appointments, and satisfaction with care. Lastly, culturally congruent care, provider training, and workforce development were categorized as recommendations.

DISCUSSION

Inadequate communication between prenatal care providers and pregnant people of color continues to exist. Improving access to midwifery education for people of color can contribute to delivering perinatal care that is culturally and linguistically aligned. Further research about digital prenatal health communication is necessary to ensure equitable prenatal care.

Obstetric violence is a misnomer

The term "obstetric violence" has been used in the legislative language of several countries to protect mothers from abuse during pregnancy. Subsequently, it has been expanded to include a spectrum of obstetric procedures, such as induction of labor, episiotomy, and cesarean delivery, and has surfaced in the peer-reviewed literature. The term "obstetric violence" can be seen as quite strong and emotionally charged, which may lead to misunderstandings or misconceptions. It might be interpreted as implying a deliberate act of violence by healthcare providers when mistreatment can sometimes result from systemic issues, lack of training, or misunderstandings rather than intentional violence. "Obstetric mistreatment" is a more comprehensive term that can encompass a broader range of behaviors and actions. "Violence" generally refers to the intentional use of physical force to cause harm, injury, or damage to another person (eg, physical assault, domestic violence, street fights, or acts of terrorism), whereas "mistreatment" is a more general term and refers to the abuse, harm, or control exerted over another person (such as nonconsensual medical procedures, verbal abuse, disrespect, discrimination and stigmatization, or neglect, to name a few examples). There may be cases where unprofessional personnel may commit mistreatment and violence against pregnant patients, but as obstetrics is dedicated to the health and well-being of pregnant and fetal patients, mistreatment of obstetric patients should never be an intended component of professional obstetric care. It is necessary to move beyond the term "obstetric violence" in discourse and acknowledge and address the structural dimensions of abusive reproductive practices. Similarly, we do not use the term "psychiatric violence" for appropriately used professional procedures in psychiatry, such as electroshock therapy, or use the term "neurosurgical violence" when drilling a burr hole. There is an ongoing need to raise awareness about the potential mistreatment of obstetric patients within the context of abuse against women in general. Using the term "mistreatment in healthcare" instead of the more limited term "obstetric violence" is more appropriate and applies to all specialties when there is unprofessional abuse and mistreatment, such as biased care, neglect, emotional abuse (verbal), or physical abuse, including performing procedures that are unnecessary, unindicated, or without informed patient consent. Healthcare providers must promote unbiased, respectful, and patient-centered professional care; provide an ethical framework for all healthcare personnel; and work toward systemic change to prevent any mistreatment or abuse in our specialty.

Shared Decision Making in Perinatal Care

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Development and Validation of a Scale to Measure Person-Centered Care in Fetal Care Centers

INTRODUCTION

Fetal care centers (FCCs) in the USA lack a standardized instrument to measure person-centered care. This study aimed to develop and validate the Person-Centered Care in Fetal Care Centers (PCC-FCC) Scale.

METHODS

Initial items were developed based on literature and input from clinicians and former patients. A Delphi study involving 16 experts was conducted to validate the content and construct. Through three rounds of online questionnaires using open-ended questions and Likert scales, consensus on item clarity and relevancy was established. The resulting items were then piloted with former fetal care center patients via a web-based survey. The instrument's reliability and validity were validated using Cronbach's α and exploratory factor analysis, respectively. Concurrent validity was assessed by comparing scores with the Revised Patient Perception of Patient-Centeredness (PPPC-R) Questionnaire.

RESULTS

258 participants completed the 48-item pilot PCC-FCC survey, categorized into six domains. Factor analysis yielded a 2-factor, 28-item scale. Internal consistency of the final scale had good reliability (α = 0.969). Data supported content, construct, and concurrent validity.

CONCLUSION

The PCC-FCC Scale is a reliable and valid measure of person-centered care in U.S. FCCs. It can be used to enhance services and begin connecting person-centered care to maternal-child health outcomes.

Psychometric assessment of the US person-centered prenatal and maternity care scales in a low-income predominantly Latinx population in California

OBJECTIVES

To assess psychometric properties of two scales developed to measure the quality of person-centered care during pregnancy and childbirth in the United States-the Person-Centered Prenatal Care (PCPC-US) and Person-Centered Maternity Care (PCMC-US) scales-in a low-income predominantly Latinx population in California.

METHODS

Data were collected from July 2020 to June 2023 from surveys of low-income pregnant and birthing people in Fresno, California, participating in the "Engaging Mothers and Babies; Reimagining Antenatal Care for Everyone" (EMBRACE) trial. Research staff administered the 26-item PCPC-US scale at 30-34 weeks' gestation (n = 315) and the 35-item PCMC-US scale at 10-14 weeks after birth (n = 286), using the language preferred by the participant (English or Spanish). We assessed construct, criterion, and known group validity and internal consistency of the scales.

RESULTS

78% of respondents identified as Latinx. Factor analysis identified one dominant factor for each scale that accounted for over 60% of the cumulative variance, with most items loading at > 0.3. The items also loaded adequately on sub-scales for "dignity and respect," "communication and autonomy," and "responsive and supportive care." Cronbach's alpha for the full scales were > 0.9 and between 0.70 and 0.87 for the sub-scales. Summative scores range from 0 to 100, with higher scores indicating higher person-centered care. Correlations with scores on scales measuring prenatal care quality and birth experience provided evidence for criterion validity, while associations with known predictors provided evidence for known-group validity.

CONCLUSIONS

The PCPC-US and PCMC-US scales, which were developed using a community-engaged process and found to have good psychometric properties in a largely high-income sample of Black women, were shown to also have good psychometric properties in a sample of low-income primarily Latinx women. Both scales provide valid and reliable tools to measure person-centered care experiences among minoritized communities to support efforts to reduce existing birth inequities.

Measuring women's experiences during antenatal care (ANC): scoping review of measurement tools

BACKGROUND

The new WHO model for antenatal care (ANC) focuses on improving practice, organisation and delivery of ANC within health systems, which includes both clinical care and women's experiences of care. The goal of this review is to identify tools and measures on women's experiences of ANC.

METHODS

We conducted a scoping review to identify tools and measures on women's experiences of ANC. An iterative approach was used to review all tools in a series of four steps: (1) identify papers between 2007 and 2023; (2) identify the tools from these papers; (3) map relevant measures to conceptualizations of experiences of care, notably mistreatment of women and respectful maternity care and (4) identify gaps and opportunities to improve measures.

RESULTS

Across the 36 tools identified, a total of 591 measures were identified. Of these, 292/591 (49.4%) measures were included and mapped to the typology of mistreatment of women used as a definition for women's experiences care during ANC in this review, while 299/591 (44.9%) irrelevant measures were excluded. Across the included measures, the highest concentration was across the domains of poor rapport between women and providers (49.8%) followed by failure to meet professional standards of care (23.3%). Approximately, 13.9% of measures were around overall respectful care, followed by health systems (6.3%), and any  physical or verbal abuse, stigma and/or discrimination (4.8%) .

CONCLUSION

This analysis provides an overview of the existing tools, gaps and opportunities to measure women's experiences during ANC. Expanding beyond the childbirth period, these findings can be used to inform existing and future tools for research and monitoring measuring women's experiences of ANC.

Development, woman-centricity and psychometric properties of maternity patient-reported experience measures: a systematic review

OBJECTIVE

Valid and reliable maternity patient-reported experience measures are critical to understanding women's experiences of care. They can support clinical practice, health service and system performance measurement, and research. The aim of this review is to identify and critically appraise the risk of bias, woman-centricity (content validity), and psychometric properties of maternity patient-reported experience measures published in the scientific literature.

DATA SOURCES

MEDLINE, CINAHL Plus, PsycINFO, and Embase were systematically searched for relevant records between January 1, 2010 and July 10, 2021.

STUDY ELIGIBILITY CRITERIA

We searched for articles describing the instrument development of maternity patient-reported experience measures and measurement properties associated with instrument validity and reliability testing. Articles that described patient-reported experience measures developed outside of the maternity context and articles that did not contribute to the instruments' development, content validation, and/or psychometric evaluation were excluded.

METHODS

Included articles underwent risk of bias, content validity, and psychometric properties assessments in line with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidance. Patient-reported experience measure results were summarized according to language subgroups. An overall recommendation for use was determined for each patient-reported experience measure language subgroup.

RESULTS

A total of 54 studies reported on the development and psychometric evaluation of 25 maternity patient-reported experience measures, grouped into 45 language subgroups. The quality of evidence underpinning the instruments' development was generally poor. Only 2 (4.4%) patient-reported experience measures reported sufficient content validity, and only 1 (2.2%) received a level "A" recommendation, required for real-world use.

CONCLUSION

Maternity patient-reported experience measures demonstrated poor-quality evidence for their measurement properties and insufficient detail about content validity. Future maternity patient-reported experience measure development needs to prioritize women's involvement in deciding what is relevant, comprehensive, and comprehensible to measure. Improving the content validity of maternity patient-reported experience measures will improve overall validity and reliability and facilitate real-world practice improvements. Standardized patient-reported experience measure implementation also needs to be prioritized to support advancements in clinical practice for women.

Person-centred sexual and reproductive health: A call for standardized measurement

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

Birth includes us: Development of a community-led survey to capture experiences of pregnancy care among LGBTQ2S+ families

BACKGROUND

Limited research captures the intersectional and nuanced experiences of lesbian, gay, bisexual, transgender, queer, two-spirit, and other sexual and gender-minoritized (LGBTQ2S+) people when accessing perinatal care services, including care for pregnancy, birth, abortion, and/or pregnancy loss.

METHODS

We describe the participatory research methods used to develop the Birth Includes Us survey, an online survey study to capture experiences of respectful perinatal care for LGBTQ2S+ individuals. From 2019 to 2021, our research team in collaboration with a multi-stakeholder Community Steering Council identified, adapted, and/or designed survey items which were reviewed and then content validated by community members with lived experience.

RESULTS

The final survey instrument spans the perinatal care experience, from preconception to early parenthood, and includes items to capture experiences of care across different pregnancy roles (eg, pregnant person, partner/co-parent, intended parent using surrogacy) and pregnancy outcomes (eg, live birth, stillbirth, miscarriage, and abortion). Three validated measures of respectful perinatal care are included, as well as measures to assess experiences of racism, discrimination, and bias across intersections of identity.

DISCUSSION AND CONCLUSIONS

By centering diverse perspectives in the review process, the Birth Includes Us instrument is the first survey to assess the range of experiences within LGBTQ2S+ communities. This instrument is ready for implementation in studies that seek to examine geographic and identity-based perinatal health outcomes and care experiences among LGBTQ2S+ people.

Summary of neonatal and maternal transport and reimbursement policies-a 5-year update

OBJECTIVE

To examine the number of states with neonatal and maternal transport and reimbursement policies in 2019, compared with 2014.

STUDY DESIGN

We conducted a systematic review of web-based, publicly available information on neonatal and maternal transport policies for each state in 2019. Information was abstracted from rules, codes, licensure regulations, and planning and program documents, then summarized within two categories: transport and reimbursement policies.

RESULT

In 2019, 42 states had a policy for neonatal transport and 37 states had a policy for maternal transport, increasing by 8 and 7 states respectively. Further, 31 states had a reimbursement policy for neonatal transport and 11 states for maternal transport, increases of 1 state per category. Overall, the number of states with policies increased from 2014 to 2019.

CONCLUSION

The number of state neonatal and maternal transport policies increased; these policies may support provision of care at the most risk-appropriate facilities.

Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum

Objectives: Person-centered care has been increasingly recognized as an important aspect of health care quality, including in maternity care. Little is known about correlates and outcomes of person-centered care in maternity care in the United States. Materials and Methods: Data were from a prospective cohort of more than 3000 individuals who gave birth to a first baby in a Pennsylvania hospital. Person-centered maternity care was measured via a 13-item rating scale administered 1-month postpartum. Content validity was established through exploratory factor analysis. The resulting scale had scores ranging from 13 to 54, with Cronbach's alpha of 0.86. Using linear and logistic regression models to control for covariates, we examined associations between participants' characteristics and person-centered maternity care and between person-centered maternity care and postpartum outcomes. Results: Participants had a mean total score of 47.80 on the person-centered maternity care scale. Patient factors independently associated with more person-centered maternity care included older age, more positive attitude toward vaginal birth during pregnancy, and spontaneous vaginal birth. In adjusted models, higher person-centered maternity scale scores were strongly associated with many positive physical and mental health outcomes at 1 and 6 months postpartum. Conclusions: Our findings underscore the importance of person-centered maternity not just due to its intrinsic value but also because it may be associated with both mental and physical health outcomes through the postpartum period. Results suggest that policy efforts are necessary to ensure person-centered maternity care, especially for delivery hospitalization experience.

Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure

BACKGROUND

Patient agency in contraceptive decision-making is an essential component of reproductive autonomy.

OBJECTIVE

We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist.

DESIGN

For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory-based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale.

PARTICIPANTS

A racially/ethnically diverse sample of 338 individuals, aged 15-34 years, receiving contraceptive care across nine California clinics in 2019-2020.

MAIN MEASURES

Contraceptive Agency Scale (CAS) of patient agency in preventive care.

KEY RESULTS

Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black, 10% Asian/Native Hawaiian/Pacific Islander. Scale items covered the domains of freedom from coercion, non-judgmental care, and active decision-making, and loaded on to a single factor, with a Cronbach's α of 0.80. Item responses fit a unidimensional partial credit item response model (weighted mean square statistic within 0.75-1.33 for each item), met criteria for internal structure validity, and showed no meaningful differential item functioning. Most participants expressed high agency in their contraceptive visit (mean score 9.6 out of 14). One-fifth, however, experienced low agency or coercion, with the provider wanting them to use a specific method or to make decisions for them. Agency scores were lowest among Asian/Native Hawaiian/Pacific Islander participants (adjusted coefficient: -1.5 [-2.9, -0.1] vs. White) and among those whose mothers had less than a high school education (adjusted coefficient; -2.1 [-3.3, -0.8] vs. college degree or more).

CONCLUSIONS

The Contraceptive Agency Scale can be used in research and clinical care to reinforce non-coercive service provision as a standard of care.

Factors associated with person-centered care during pregnancy and birth for Black women and birthing people in California

INTRODUCTION

In the United States, adverse birth outcomes are most prevalent among Black women and birthing people, who are known to experience increased mistreatment and disrespect in care. The purpose of this paper is to describe findings from a study that used two validated scales to examine factors associated with experiences of person-centered care during pregnancy and birth among Black birthing people in California.

METHODS

We used data from 234 Black women and birthing people who were recruited between January and September 2020 as part of a validation study for the Person-Centered Prenatal Care (PCPC) and the Person-Centered Maternity Care (PCMC-US) scales. Bivariate and multivariate analyses were conducted to examine the associations between PCPC and PCMC-US scores and sociodemographic, health-related, and care-related factors.

RESULTS

The factors associated with lower PCPC scores were having foreign-born parents, having public or no insurance, part-time employment, unstable housing, late start of prenatal care (in the second or third trimester), poorer self-rated health (less than very good), and lack of continuity of care with prenatal providers. Factors associated with lower PCMC-US scores were having public insurance, late start of prenatal care, longer length of stay in facility following birth, poorer self-rated health, lack of continuity of care between prenatal care and birth providers, and racial discordance with birth provider.

CONCLUSIONS

Our analysis highlights the contributions of intersecting identities as well as health-related and care-related factors to Black birthing people's experiences of care in California. Continuity of care and provider racial concordance, in particular, were shown to improve pregnancy and birth experiences.

Adaptation of the Person-Centered Maternity Care Scale in the United States: Prioritizing the Experiences of Black Women and Birthing People

INTRODUCTION

Mistreatment by health care providers disproportionately affects Black, Indigenous, and other people of color in the United States. The goal of this study is to adapt the global Person-Centered Maternity Care (PCMC) scale for use in the United States, with particular attention to the experiences of Black women and birthing people.

METHODS

We used a community-engaged approach including expert reviews and cognitive interviews to assess content validity, relevance, comprehension, and comprehensiveness of the PCMC items. Surveys of 297 postpartum people, 82% of whom identified as Black, were used for psychometric analysis in which we assessed construct and criterion validity and reliability. The University of California, San Francisco, California Preterm Birth Initiative's Community Advisory Board, which consists of community members, community-based health workers, and social service providers in Northern California, provided input during all stages of the project.

RESULTS

Through an iterative process of factor analysis, discussions with the Community Advisory Board, and a prioritization survey, we eliminated items that performed poorly in psychometric analysis, yielding a 35-item PCMC-U.S. scale with subscales for dignity and respect, communication and autonomy, and responsive and supportive care. The Cronbach's alpha for the full scale is 0.95 and for the subscales is 0.87. Standardized summative scores range from 0 to 100, with higher scores indicating more PCMC. Correlations with related measures indicated high criterion validity.

CONCLUSIONS

The 35-item PCMC-U.S. scale and its subscales have high validity and reliability in a sample of predominantly Black women. This scale provides a tool to support efforts to reduce the inequities in birth outcomes experienced by Black, Indigenous, and other people of color.

Variation in guideline-based prenatal care in a commercially insured population

BACKGROUND

Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied.

OBJECTIVE

This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics.

STUDY DESIGN

This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment.

RESULTS

The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income.

CONCLUSION

In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.