Early pregnancy care in North America: A proposal for high-value care that can level health disparities

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services: a scoping review

OBJECTIVE

The objective of this scoping review was to investigate and describe what is reported on the role and scope of practice of midwives and registered nurses providing care for women with pregnancy complications prior to 20 weeks' gestation in acute clinical settings in Australia.

INTRODUCTION

In many high-income countries, women experiencing unexpected complications in early pregnancy attend an acute care service, such as an emergency department, rather than a maternity or obstetric unit. This service structure can impact the care women receive and determine who provides it. Women and their partners, who are often experiencing emotional distress, have reported difficult experiences when accessing acute services, particularly emergency departments, which are not traditionally staffed by midwives. The role and scope of practice of both midwives and registered nurses providing acute early pregnancy care in most high-income countries, including Australia, is poorly reported. Documenting this area of practice is an important first step in facilitating ongoing research in this important aspect of pregnancy care.

INCLUSION CRITERIA

Published and gray literature that described the role and scope of practice of midwives and/or registered nurses providing care in acute early pregnancy settings in Australia were considered for this review.

METHODS

A scoping review of the literature was conducted following JBI methodological guidance and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A 3-step search strategy was conducted to explore evidence from databases and search engines, gray literature sources, and selected reference lists. The search was limited to sources published from 2005 until October 2023. The databases searched included MEDLINE (Ovid), MIDIRS (Ovid), JBI Evidence-based Practice Database (Ovid), CINAHL Ultimate (EBSCOhost), ProQuest Central, Web of Science Core Collection, Scopus, and Cochrane Library. Google and Google Scholar were also used to identify published studies. After screening, data were extracted from records selected for the final review, mapped, and analyzed using content analysis.

RESULTS

A total of 23 sources were selected for inclusion in the review, and these included primary research studies, conference abstracts, and gray literature, such as clinical guidance documents, academic theses, and websites, from January 2008 to October 2023. The most common setting for care provision was the emergency department. Midwives' and registered nurses' role and scope of practice in acute early pregnancy care in Australia can be categorized into 4 areas: physical care, psychosocial support, care coordination, and communication. Women's access to midwifery care at this time in pregnancy appears to be limited. Registered nurses, usually employed in emergency departments, have the most prominent role and scope in the provision of care for women with acute early pregnancy complications. Descriptions of midwives' practice focus more on psychosocial support and follow-up care, particularly in early pregnancy assessment service models.

CONCLUSIONS

This review highlights the inconsistency in midwives' and registered nurses' role and scope in acute early pregnancy in Australia, a finding which is relevant to other international settings. Both professions could further fulfill role and scope capacity in the provision of supportive, individualized, and timely care for women and families accessing a range of acute early pregnancy services. Emergency departments are the usual practice domain of registered nurses who may be limited in terms of the scope of care they can provide to women with early pregnancy complications. Leaders of the midwifery profession should conduct further research into innovative service models that embed a role for midwives in all settings that provide care for pregnant women, regardless of stage of pregnancy.

REVIEW REGISTRATION

Open Science Framework https://osf.io/7zchu/.

Medical management of early pregnancy loss with mifepristone and misoprostol in emergency departments compared to a Complex Family Planning office: Implementation of a COVID-19 institutional policy change

OBJECTIVES

To evaluate the implementation of mifepristone and misoprostol for medical management of early pregnancy loss (EPL) in emergency departments (EDs) by comparing efficacy, complication, and follow-up rates for patients treated in EDs to the Complex Family Planning (CFP) outpatient office.

STUDY DESIGN

In COVID-19's first wave, we expanded medical management of EPL to our EDs. This retrospective study evaluated 72 patients receiving mifepristone and misoprostol for EPL from April 1, 2020 to March 31, 2021, comparing treatment success, safety outcomes, and follow-up rates by location.

RESULTS

Thirty-three (46%) patients received care in the ED and 39 (54%) at CFP. Treatment success was lower in EDs (23, 70%) compared to CFP (34, 87%), but after adjusting for insurance status and pregnancy type (miscarriage, uncertain viability, unknown location), this was not significant: adjusted odds ratio 0.48 (95% CI 0.13-1.81). More ED patients underwent emergent interventions (3 vs 0) including two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Two cases were attributed to misdiagnosis (cesarean scar and cervical ectopic pregnancies interpreted as incomplete miscarriages) and one to guideline nonadherence. No complications occurred in the CFP group. Follow-up rates were over 80% in both groups. More ED patients engaged in telehealth follow-up (67% vs 18%, p ≤ 0.0001).

CONCLUSIONS

In this small sample, we observed a trend toward less successful treatment in the ED compared to the CFP office. Both correctly making uncommon diagnoses and adhering to new guidelines presented implementation challenges.

IMPLICATIONS

Implementing mifepristone and misoprostol for EPL in our EDs achieved lower rates of pregnancy resolution compared to outpatient management. Complex uncommon diagnoses and implementing new care pathways in EDs may have contributed to complications and highlighted opportunities for improvement. Additional studies are needed to further quantify safety outcomes for EPL management in EDs.

Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis: A Diverse Multicenter Cohort

BACKGROUND AND OBJECTIVES

Racial disparities exist in both neurologic and obstetric populations, underscoring the importance of evaluating pregnancy outcomes in diverse women with multiple sclerosis (MS). The objective of this multicenter retrospective study was to compare pregnancy care and outcomes between Black and Hispanic (underrepresented) and White women with MS.

METHODS

Demographic and clinical data were extracted from medical records of 9 US MS centers for women with MS/clinically isolated syndrome who delivered live births between 2010 and 2021. Sites identified at last 15 consecutive Black/Hispanic women and a matching number of White women. Socioeconomic factors, pregnancy, and MS care/outcomes were compared between groups (underrepresented and White and then Black and Hispanic) using Wilcoxon rank sum (U statistic and effect size r reported), χ2, t tests and logistic regressions as appropriate to data type. Multiple imputation by chained equation was used to account for missing data.

RESULTS

Overall, 294 pregnancies resulting in live births were analyzed ( 81 Black, 67 Hispanic, and 146 White mothers). Relative to underrepresented women, White women lived in areas of higher median (interquartile range [IQR]) Child Opportunity Index (79 [45.8] vs 22 [45.8], U = 3,824, r = 0.56, p < 0.0001) and were more often employed (84.9% vs 75%, odds ratio [OR] 2.57, CI 1.46-4.50, p = 0.0008) and privately insured (93.8% vs 56.8%, OR 11.6, CI 5.5-24.5, p < 0.0001) and more received a 14-week ultrasound (98.6% vs 93.9%, OR 4.66, CI 0.99-21.96, p = 0.027). Mode of delivery was significantly different between the three groups (X2(10,294) = 20.38, p = 0.03); notably, Black women had the highest rates of emergency cesarean deliveries, and Hispanic women highest rates of uncomplicated vaginal deliveries. Babies born to underrepresented women had lower median (IQR) birthweights than babies born to White women (3,198 g [435.3 g] vs 3,275 g [412.5 g], U = 9,255, r = 0.12, p = 0.04) and shorter median (IQR) breastfeeding duration (4.5 [3.3] vs 6.0 [4.2] months, U = 8,184, r = 0.21, p = 0.003). While underrepresented women were younger than White women (mean [SD] 30.9 [4.8] vs 33.8 [4.0], t = 1.97, CI 1.96-3.98, p < 0.0001), their median (Q1-Q3, IQR) Expanded Disability Status Scale was higher (1.5 [1-2.5, 1.5] vs 1 [0-1.5, 1.5], U = 7,260, r = 0.29, p < 0.0001) before pregnancy. Finally, medical records were missing more key data for Black women (19.7% missing vs 8.9% missing, OR 2.54, CI 1.25-5.06, p = 0.008).

DISCUSSION

In this geographically diverse multicenter cohort, underrepresented women entered pregnancy with higher disability and fewer health care resources. Pregnancy represents a pivotal window where structural factors affect maternal and fetal health and neurologic trajectories; it is a critical period to optimize care and health outcomes.

Vaginal Bleeding Before 20 Weeks Gestation

Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.

The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs

BACKGROUND

Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss.

OBJECTIVE

This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions.

STUDY DESIGN

From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care.

RESULTS

Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9).

CONCLUSION

In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

Effect of a family planning program on documented emotional support and reproductive goals counseling after previable pregnancy loss

OBJECTIVES

To evaluate the effect of the Ryan Program for family planning training on patient counseling surrounding previable pregnancy loss.

METHODS

We conducted a retrospective cohort study of patients with first- and second-trimester miscarriages, therapeutic abortions, ectopic and molar pregnancies, from years before and after establishing a Ryan Program. We compared documentation of coping and future reproductive goals by patient factors, using chi square testing and logistic regression.

RESULTS

We included 285 pregnancies: 138 pre-Ryan, 147 post-Ryan. Documentation of coping and future goals was greater post-Ryan than pre-Ryan (57.8% vs. 26.8% for coping, 72.8% vs. 50.7% for goals; both p < 0.001). Coping was less likely to be documented for adolescents (aOR 0.02), patients of Asian race (aOR 0.08), those diagnosed in the emergency department (aOR 0.22), and those with ectopic or molar pregnancy (aOR 0.14) (all p < 0.005). Coping documentation increased with second-trimester loss (aOR 6.19) and outpatient follow-up (aOR 3.41) (all p < 0.005).

CONCLUSIONS

Establishment of a Ryan Program was associated with greater attention to patient coping and goals after previable pregnancy loss. Patients experiencing medically-dangerous pregnancy losses receive less attention to their coping.

PRACTICE IMPLICATIONS

Comprehensive family planning training and outpatient access may improve patient-centeredness of care for previable pregnancy loss.

Pregnancies lost and found: a quality improvement project to increase follow-up for early pregnancy complications

Pregnancy of unknown location (PUL) and medically managed ectopic pregnancy (EP) require longitudinal surveillance to avoid adverse outcomes; however, patients with PUL/EP in the United States (U.S.) are often unable to adhere to recommended treatment plans. This quality improvement (QI) project sought to improve PUL/EP follow-up using a three-pronged intervention: standardised recall procedures, direct patient-provider communication and electronic medical record (EMR) documentation templates and tracking. We compared patients with PUL/EP managed before and after the QI project. Our primary outcome was completion of PUL/EP clinical care. Demographics, initial diagnoses and adverse outcomes were similar between 87 pre-QI and 81 post-QI patients. Significantly more patients completed PUL/EP clinical care post-QI (80.2 vs. 65.5% p = .03). Post-QI, more providers contacted patients at standard intervals (100 vs. 57.1%, p < .0001), and EMR documentation was improved (100 vs. 69.0%, p < .001). Simple changes to PUL/EP management improved completion of clinical care and compliance with standardised recall and documentation.IMPACT STATEMENTWhat is already known on this subject? Pregnancy of unknown location (PUL) and medically managed ectopic pregnancy (EP) require longitudinal surveillance to avoid adverse outcomes; however, patients with PUL/EP in the United States (U.S.) are often unable to adhere to recommended treatment plans.What do the results of this study add? By standardising recall procedures, ensuring direct communication between patients and providers using a dedicated cell phone, and integrating case tracking and documentation into the electronic medical record (EMR), this quality improvement (QI) project improved completion of clinical follow-up for patients with PUL/EP (overall, 80.2 vs. 65.5% pre-QI, p=.03) and for the subgroup with medically managed EP not requiring surgery (76.5 vs. 36.4% pre-QI, p= .05). We also improved providers' compliance with standardised recall procedures and EMR documentation post-QI (p < .0001). There was no difference in the number of attempts to contact patients, or in the number of surveillance blood draws actually performed. Post-QI, survey responses indicated that patients were easily able to contact their provider and understood the importance of follow-up processes.What are the implications of these findings for clinical practice and/or research? Early pregnancy care providers can utilise simple strategies to improve follow-up of patients with PUL and medically managed EP, without increasing burdens to their health systems. Patients' favourable experiences with this management support its implementation.