Maternal Medical Complexity: Impact on Prenatal Health Care Spending among Women at Low Risk for Cesarean Section

The development of a core outcome set for studies of pregnant women with multimorbidity

BACKGROUND

Heterogeneity in reported outcomes can limit the synthesis of research evidence. A core outcome set informs what outcomes are important and should be measured as a minimum in all future studies. We report the development of a core outcome set applicable to observational and interventional studies of pregnant women with multimorbidity.

METHODS

We developed the core outcome set in four stages: (i) a systematic literature search, (ii) three focus groups with UK stakeholders, (iii) two rounds of Delphi surveys with international stakeholders and (iv) two international virtual consensus meetings. Stakeholders included women with multimorbidity and experience of pregnancy in the last 5 years, or are planning a pregnancy, their partners, health or social care professionals and researchers. Study adverts were shared through stakeholder charities and organisations.

RESULTS

Twenty-six studies were included in the systematic literature search (2017 to 2021) reporting 185 outcomes. Thematic analysis of the focus groups added a further 28 outcomes. Two hundred and nine stakeholders completed the first Delphi survey. One hundred and sixteen stakeholders completed the second Delphi survey where 45 outcomes reached Consensus In (≥70% of all participants rating an outcome as Critically Important). Thirteen stakeholders reviewed 15 Borderline outcomes in the first consensus meeting and included seven additional outcomes. Seventeen stakeholders reviewed these 52 outcomes in a second consensus meeting, the threshold was ≥80% of all participants voting for inclusion. The final core outcome set included 11 outcomes. The five maternal outcomes were as follows: maternal death, severe maternal morbidity, change in existing long-term conditions (physical and mental), quality and experience of care and development of new mental health conditions. The six child outcomes were as follows: survival of baby, gestational age at birth, neurodevelopmental conditions/impairment, quality of life, birth weight and separation of baby from mother for health care needs.

CONCLUSIONS

Multimorbidity in pregnancy is a new and complex clinical research area. Following a rigorous process, this complexity was meaningfully reduced to a core outcome set that balances the views of a diverse stakeholder group.

Key outcomes for reporting in studies of pregnant women with multiple long-term conditions: a qualitative study

BACKGROUND

Maternal multiple long-term conditions are associated with adverse outcomes for mother and child. We conducted a qualitative study to inform a core outcome set for studies of pregnant women with multiple long-term conditions.

METHODS

Women with two or more pre-existing long-term physical or mental health conditions, who had been pregnant in the last five years or planning a pregnancy, their partners and health care professionals were eligible. Recruitment was through social media, patients and health care professionals' organisations and personal contacts. Participants who contacted the study team were purposively sampled for maximum variation. Three virtual focus groups were conducted from December 2021 to March 2022 in the United Kingdom: (i) health care professionals (n = 8), (ii) women with multiple long-term conditions (n = 6), and (iii) women with multiple long-term conditions (n = 6) and partners (n = 2). There was representation from women with 20 different physical health conditions and four mental health conditions; health care professionals from obstetrics, obstetric/maternal medicine, midwifery, neonatology, perinatal psychiatry, and general practice. Participants were asked what outcomes should be reported in all studies of pregnant women with multiple long-term conditions. Inductive thematic analysis was conducted. Outcomes identified in the focus groups were mapped to those identified in a systematic literature search in the core outcome set development.

RESULTS

The focus groups identified 63 outcomes, including maternal (n = 43), children's (n = 16) and health care utilisation (n = 4) outcomes. Twenty-eight outcomes were new when mapped to the systematic literature search. Outcomes considered important were generally similar across stakeholder groups. Women emphasised outcomes related to care processes, such as information sharing when transitioning between health care teams and stages of pregnancy (continuity of care). Both women and partners wanted to be involved in care decisions and to feel informed of the risks to the pregnancy and baby. Health care professionals additionally prioritised non-clinical outcomes, including quality of life and financial implications for the women; and longer-term outcomes, such as children's developmental outcomes.

CONCLUSIONS

The findings will inform the design of a core outcome set. Participants' experiences provided useful insights of how maternity care for pregnant women with multiple long-term conditions can be improved.

Non-communicable diseases and maternal health: a scoping review

BACKGROUND

Non-communicable diseases [NCDs] are leading causes of ill health among women of reproductive age and an increasingly important cause of maternal morbidity and mortality worldwide. Reliable data on NCDs is necessary for accurate measurement and response. However, inconsistent definitions of NCDs make reliable data collection challenging. We aimed to map the current global literature to understand how NCDs are defined, operationalized and discussed during pregnancy, childbirth and the postnatal period.  METHODS: For this scoping review, we conducted a comprehensive global literature search for NCDs and maternal health covering the years 2000 to 2020 in eleven electronic databases, five regional WHO databases and an exhaustive grey literature search without language restrictions. We used a charting approach to synthesize and interpret the data.  RESULTS: Only seven of the 172 included sources defined NCDs. NCDs are often defined as chronic but with varying temporality. There is a broad spectrum of conditions that is included under NCDs including pregnancy-specific conditions and infectious diseases. The most commonly included conditions are hypertension, diabetes, epilepsy, asthma, mental health conditions and malignancy. Most publications are from academic institutions in high-income countries [HICs] and focus on the pre-conception period and pregnancy. Publications from HICs discuss NCDs in the context of pre-conception care, medications, contraception, health disparities and quality of care. In contrast, publications focused on low- and middle-income countries discuss NCDs in the context of NCD prevention. They take a life cycle approach and advocate for integration of NCD and maternal health services.

CONCLUSION

Standardising the definition and improving the articulation of care for NCDs in the maternal health setting would help to improve data collection and facilitate monitoring. It would inform the development of improved care for NCDs at the intersection with maternal health as well as through a woman's life course. Such an approach could lead to significant policy and programmatic changes with the potential corresponding impact on resource allocation.

Outpatient Foley catheter induction protocol provides clinical and cost benefits

BACKGROUND

Obstetric induction procedures are expensive, and little is known of the specific difference in cost between inpatient and outpatient protocols for these procedures.

OBJECTIVE

The objective of this study was to examine the difference in health care costs, maternal and neonatal morbidity, and cesarean birth rates for inpatient versus outpatient Foley induction protocols.

MATERIAL AND METHODS

We conducted a retrospective study using deliveries from 2013 to 2015 that received an outpatient or inpatient Foley catheter induction. Inductions were matched by race, parity, and maternal age. We used univariate and multivariate logistic regression to test the association between type of induction, length of stay, and cost. Maternal and neonatal factors and cesarean rates were also considered.

RESULTS

A total of 163 outpatient Foley inductions were matched 1:1 to inpatient inductions. Outpatient inductions were more likely to have a shorter length of hospitalization from admission to discharge (a 7.17-hour difference, 95% CI, 71.00, 77.59) and lower costs of hospitalization ($408 per patient, 95% CI, 4305, 4714). In the univariate analysis, there was no difference in rate of cesarean birth (OR 0.95, 95% CI, 0.61, 1.48). However, in the multivariate analysis, there was a decreased rate of cesarean for outpatient inductions (OR 0.5, 95% CI, 0.26, 0.97).

CONCLUSIONS

Outpatient Foley catheter induction appears to be a safe, cost-effective method for induction of labor. Generating protocols allowing patients to receive quality care in an outpatient setting is increasingly important in current health care environments.

A Labor Support Workshop to Improve Undergraduate Nursing Students' Understanding of the Importance of High Touch in a High-Tech World

This article presents the development and evaluation of a labor support workshop aimed at providing senior undergraduate nursing students with education on the provision of labor support. In collaboration with a Lamaze educator, a two and half hour interactive educational session was developed. The workshop included both a didactic and a hands-on component which included physical labor support strategies, which could be utilized in the clinical setting. Pre-and postintervention data was collected on students' knowledge and self-efficacy in the provision of labor support, as well as, data on their use of these strategies while in the clinical setting. The labor support workshop was well received by students (4.9/5) and increased their self-reported knowledge (p = <.001) and self-efficacy (p = <.001) in the provision of labor support.

Area-level deprivation and preterm birth: results from a national, commercially-insured population

BACKGROUND

Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors.

METHODS

We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects.

RESULTS

In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association.

CONCLUSIONS

Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.