Effect of comprehensive care on pregnancy outcomes

Should case management be considered a component of obstetrical interventions for pregnancies at risk of preterm birth?

Preterm birth remains the leading cause of morbidity and mortality among nonanomalous neonates in the United States. Unfortunately, preterm birth rates remain high despite current medical interventions such as progestogen supplementation and cerclage placement. Case management, which encompasses coordinated care aimed at providing a more comprehensive and supportive environment, is a key component in improving health and reducing costs in other areas of medicine. However, it has not made its way into the general lexicon and practice of obstetrical care. Case management intended for decreasing prematurity or ameliorating its consequences may include specialty clinics, social services, coordination of specialty services such as nutrition counseling, home visits or frequent phone calls by specially trained personnel, and other elements described herein. It is not currently included in nor is it advocated for as a recommended prematurity prevention approach in the American College of Obstetricians and Gynecologists or Society for Maternal-Fetal Medicine guidelines for medically indicated or spontaneous preterm birth prevention. Our review of existing evidence finds consistent reductions or trends toward reductions in preterm birth with case management, particularly among individuals with high a priori risk of preterm birth across systematic reviews, metaanalyses, and randomized controlled studies. These findings suggest that case management has substantial potential to improve the environmental, behavioral, social, and psychological factors with patients at risk of preterm birth.

Psychometric Properties of The Persian Version of The Prenatal Attachment Inventory in Pregnant Iranian Women

Background

In 1993, Muller developed the Prenatal Attachment Inventory (PAI) which has been used widely in many studies and translated into several languages. The current study aimed to translate the PAI into Persian, assess the underlying structure of the PAI, and the appropriateness of the one-factor solution proposed by Muller.

Materials and Methods

In this cross-sectional study, we recruited a total of 322 primi- gravidae in their 27^th to 34^th gestational weeks that referred to private and governmental prenatal clinics in Tehran, Iran. All participants completed the Persian versions of the PAI and a demographic questionnaire. Participants were re-tested 2 weeks after the initial test- ing. The following psychometric properties of the PAI were investigated: construct validity by confirmatory factor analysis (CFA), internal consistency reliability with Cronbach’s alpha, and test-retest reliability according to the intraclass correlation coefficient (ICC).

Results

The CFA results indicated that a single-factor model provided good fit to the data, which confirmed the original model by its developer. The Cronbach’s alpha coef- ficient for PAI was 0.856 and the test-retest reliability with ICC was 0.784. Consider- ing the duration between marriage and pregnancy, women with low duration scored significantly higher than women with high duration on PAI (P=0.043).

Conclusion

The Persian version of the PAI showed that one factor structure was ad- equate and could be used for measuring psychological affectionate attachment between Iranian mothers and their fetuses.

A literature update on maternal-fetal attachment

OBJECTIVE

To critically review and synthesize original research published since 2000 designed to measure factors that influence maternal-fetal attachment.

DATA SOURCES

EBSCOhost Research Databases that included PubMed, CINAHL Plus, PsycINFO, and SCOPUS were searched for journal articles published in the past 7 years (2000-2007) that examined variables thought to increase, decrease, or cause no change in level of maternal-fetal attachment. Keyword searches included maternal-fetal attachment, parental attachment, and prenatal attachment.

STUDY SELECTION

Twenty-two studies were selected that met the inclusion criteria of original research, clear delineation of the measurement of maternal-fetal attachment, measurement of maternal-fetal attachment during pregnancy, and inclusion of women or couples, or both.

DATA EXTRACTION

Studies measuring maternal-fetal attachment included a broad range of variables as potential risk or protective factors, or both. Factors associated with higher levels of maternal-fetal attachment included family support, greater psychological well-being, and having an ultrasound performed. Factors such as depression, substance abuse, and higher anxiety levels were associated with lower levels of maternal-fetal attachment.

DATA SYNTHESIS

The large majority of studies reviewed were limited by small, homogenous samples deemed insufficient to detect significant differences, inconsistent measurement of maternal-fetal attachment during gestational periods, and cross-sectional designs.

CONCLUSIONS

Further research is essential to identify factors influencing maternal-fetal attachment. Specifically, research needs to be conducted on larger sample sizes of greater racial and ethnic diversity.

Testing the Health Practices in Pregnancy Questionnaire-II

OBJECTIVE

To revise and test a 34-item self-administered questionnaire that measures health practices important to pregnancy outcome.

DESIGN

Three studies were conducted: a content validity study with nurse experts, a content validity study with pregnant women, and a cross-sectional study using mailed surveys to test the reliability and construct validity of the Health Practices in Pregnancy Questionnaire-II (HPQ-II).

SETTINGS

Nurse-midwifery and obstetric physician practices.

PARTICIPANTS

Clinical experts (n = 8) and pregnant women (n = 10 for Study 2; n = 312 for Study 3).

MAIN OUTCOME MEASURE

The HPQ-II, a self-report instrument that measures pregnancy health practices.

RESULTS

Content validity was established with two reviews of the HPQ-II conducted by clinical experts and pregnant women and by a satisfactory Content Validity Index. Construct validity was supported by statistically significant correlations with a measure of prepregnancy health practices, scores on individual prepregnancy health practice items, and a theoretically related measure of women's attitudes toward their pregnancies and babies. Reliability (internal consistency) was satisfactory.

CONCLUSIONS

This instrument promises to be useful in research and practice involving health practices during pregnancy.

Lifestyle practices of Jordanian pregnant women

BACKGROUND

Although many improvements have been made in the area of women's health in Jordan, women during pregnancy still face many health problems that put their lives at risk. This is evident in the relatively high Maternal Mortality Rate, anaemia, low birth weight and other problems related to their lifestyle practices during pregnancy (Jordanian Ministry of Health 1998).

PURPOSE

To describe the health-promoting lifestyle behaviours of Jordanian pregnant women. The Maternal Health Promoting Lifestyle Profile (MHPLP), based on the Health Promotion Model, was modified to measure maternal practices. A representative sample of 400 Jordanian pregnant women in their 20th week of gestation or beyond were recruited from five public Maternal and Child Health Centres in the city of Irbid, in the northern part of Jordan. The MHPLP measures six dimensions: physical activity, stress management, self-actualization, nutrition, health responsibility and interpersonal support. Data were analysed by using descriptive analysis.

RESULTS

The women reported high scores on health responsibility and self-actualization, moderate scores on interpersonal support and nutrition, and low scores on physical activity and stress management behaviours. CONCLUSIONS AND IMPLICATIONS FOR POLICY, PRACTICE AND RESEARCH: The findings have implications for the quality of care delivered through the maternal and child health services. Health promotion and healthy lifestyle need to be an integral part of health services provided for pregnant women. Further research is needed to develop an instrument that integrates the cultural beliefs relating to lifestyle practices of Jordanian pregnant women mainly in the areas of physical activities and stress management. Policy implications of the findings are discussed.

Demonstrating a positive return on investment for a prenatal program at a managed care organization. An economic analysis

Healthcare providers need information to guide the management of patient health while administrators focus on resource management. The underpinning of economic analysis, in the clinical setting, is that resources are scarce. The allocation of resources requires delivered services to provide more benefits than cost and hence, the need to demonstrate a return on investment (ROI) for disease management programs. This article describes the ROI for a prenatal program developed at a Western New York Managed Care Organization (MCO). A positive ROI for the program under study will be demonstrated using a model of economic analysis.

Determinants of late prenatal care initiation by African American women in Washington, DC

OBJECTIVES

The objective of this study was to identify the determinants of late prenatal care (PNC) initiation among minority women in Washington, DC.

METHODS

DC-resident, African American women (n = 303) were recruited at 14 PNC facilities, representing the various types of PNC facilities located in DC: 4 hospital-based clinics, 5 community-based clinics, and 5 private practices. The women were interviewed at their first prenatal care visits to determine their perceptions of 63 barriers, motivators and facilitators influencing PNC initiation; substance use; and sociodemographic background. PNC initiation was classified as early (prior to the 20th week of gestation) or late (after the 20th week of gestation). The responses of women who initiated PNC early versus late were compared using bivariate and multivariate statistical procedures. Classification and Regression Trees analysis was used to identify groups at risk of late initiation.

RESULTS

Variables contributing to late PNC initiation included maternal age not between 20 and 29 years, unemployment, no history of previous abortions, consideration of abortion, lack of money to pay for PNC, and no motivation to learn how to protect ones health. Three risk groups for late PNC initiation included 1) women consideringabortion and not employed outside their homes; 2) women not considering abortion who had no previous abortion experience; and 3) teenagers not considering abortion and with no previous abortions.

CONCLUSIONS

The results of this study indicate that psychosocial barriers are more important than structural barriers. Of the psychosocial barriers, the major determinants of late PNC initiation were consideration of abortion and previous abortion experience.

A comparison of pregnancy health practices of women in inner-city and small urban communities

OBJECTIVE

To examine whether the relationships among pregnancy health practices, maternal-fetal attachment, and prenatal depression differ between women living in the inner city and women living in a smaller urban community.

DESIGN

Cross-sectional, descriptive survey.

SETTING

Clinics in inner-city and small urban communities in the Midwest.

PARTICIPANTS

Fifty-five pregnant women living in the inner city and 197 pregnant women living in a smaller urban setting.

MAIN OUTCOME MEASURES

Health Practices Questionnaire, a self-report instrument that measures pregnancy health practices.

RESULTS

Women living in the inner city reported lower levels of health practices than women in urban settings, but this was moderated by maternal-fetal attachment. Inner-city women with lower levels of maternal-fetal attachment had poorer health practices than inner-city women with higher levels of maternal-fetal attachment; there was no relationship for women residing in the small urban area. Depression was negatively associated with health practices for all women; however, there was no difference by residence.

CONCLUSION

Maternal-fetal attachment contributed differently to health practices in women from the inner city compared with women from small urban communities. Nurses can use this information to help identify women at risk for poor pregnancy health practices. More research is needed to identify the interventions that most effectively improve health practices.

Does public health nurse home visitation make a difference in the health outcomes of pregnant clients and their offspring?

Public health nurses (PHNs) at Lincoln-Lancaster County Health Department have used the Care Pathway tool to track client progress. Conceptually similar to critical pathways used in hospital settings, the Care Pathway is used by the PHN to document milestones of progress by trimester of pregnancy. Data for this research was gathered from chart review of 55 prenatal clients. Study results demonstrate that subjects who had from five to nine home visits by a PHN during pregnancy showed a higher average hemoglobin for the mothers and a higher average birthweight for the babies than those visited four or fewer times. None of the low birthweight babies was born to mothers in the "more visits" category. Furthermore, more breastfeeding was recorded for those who had received more PHN visits. This documentation enabled us to describe better the referent population and to begin to estimate the effect of PHN home visitation on the health outcomes of clients. In essence, we addressed the questions: (1) "Does PHN home visitation make a difference in health outcomes of clients and their families?" and (2) "If so, how can effects be measured?"

Quality measurement in nursing: an update of where we are now

This article summarizes the findings of the third review of nursing quality measurement literature commissioned by the American Nurses' Association, discusses implications of the current state of the art of nursing measurement, and suggests directions based upon lessons learned from all 3 reviews. Using both computer and hand searching methods, 326 articles describing measurement of nursing care quality were abstracted. Recommendations based on the analysis of Literature include incorporating the Nursing Minimum Data Set into databases; documenting nursing hours and nursing educational preparation; determining appropriate patient outcomes within different settings; continued research identifying nurse-sensitive outcomes; and continued nursing leadership in quality improvement efforts for health care.