Abuse and psychosocial stress as factors in high utilization of medical services during pregnancy

Frequency of unscheduled visits to the Obstetrical Triage Assessment unit by pregnant adolescents in an urban Canadian Center compared to a matched cohort of pregnant women

OBJECTIVES

People from marginalized and vulnerable populations present more frequently for unscheduled, emergency obstetrical services at labour and delivery triage units. Based on our clinical experience, pregnant adolescents visit the obstetrical triage assessment units (OTAU) more often than adults do. This study was designed to assess this phenomenon by quantifying and describing the frequency of unscheduled visits to the OTAU by pregnant adolescents (age <20 y) compared with a matched cohort of adult pregnant patients (age ≥20 y).

METHODS

A retrospective database review was performed for data on all adolescent patients that delivered at our institution at ≥20 weeks gestation between January 1, 2013, and December 31, 2017. Adolescent pregnant patients were matched in a 1:1 ratio with adult pregnant patients. Demographic and clinical characteristics as well as the number of visits to the OTAU were recorded.

RESULTS

A total of 160 adolescent pregnant patients visited the OTAU during the study period. The mean number of visits to the OTAU by adolescents was 2.77 ± 2.40 compared with 1.96 ± 1.80 visits in the adult cohort (P = 0.0001). Adolescents were 63% more likely than adults to access triage services (incidence rate ratio [IRR] 1.63; 95% CI 1.09-2.44, P = 0.017). Diagnosis of a mental health condition was the only identified risk factor for accessing OTAU, irrespective of age (IRR 1.64; 95% CI 1.05, 2.55, P = 0.029).

CONCLUSIONS

Adolescent pregnant patients tend to visit the OTAU on an unscheduled basis more often than do adult patients. The presence of a mental health condition was identified as an important predictor of unscheduled visits to OTAUs for adolescent patients.

Assessment of significant psychological distress at the end of pregnancy and associated factors

The aim of this study is to study the prevalence of mental distress at the end of pregnancy and after birth and the impact of selected socio-demographic and obstetric factors. This is a cross-sectional study. The sample is consisted of 351 puerperal women at the age of 18 and over. Sociodemographic, obstetric variables were collected to detect significant psychological distress; the instrument used was General Health Questionnaire (GHQ-28). Logistic multivariable regressions were used to investigate associations. The prevalence of significant mental distress amounted to 81.2%, mostly related to social relationship and anxiety. The women who affirmed having more stress during pregnancy had too significantly increased emotional distress before the birth as well as during early puerperium, increasing somatic symptoms (p < 0.001; OR 2.685; CI 95% 1.583-4.553), anxiety (p < 0.001; OR 4.676; CI 95% 2.846-7.684), and depressive symptoms (p < 0.01). Somatic symptoms (p < 0.05; OR 2.466; CI 95% 1.100-5.528) and social dysfunction (p < 0.001; OR 1.672; CI 95% 0.711-3.932) occur most frequently in women who already had children. Regarding socio-demographic data, being an immigrant is the only protective factor reducing the social dysfunction in the last weeks of pregnancy (p < 0.01; OR 0.478; CI 95% 0.274-0.832). Psychological distress at the end of a full-term pregnancy and in the postpartum period occurs frequently and was associated mainly with stress experienced during pregnancy and parity. It is advisable to perform proper assessment of stress and significant psychological distress at the early stage of pregnancy and repeatedly later on until delivery. Information and support from professionals can help to decrease and prevent their negative impact on maternal and fetal health, as observed in the current evidence.

Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status

BACKGROUND

Pregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes, but the drivers of this association have not been explored from the patient perspective.

PURPOSE

We sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy.

METHODS

We conducted a comparative qualitative analysis of in-depth semistructured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as either high or low utilizers of unscheduled care, and interviewed about challenges faced in obtaining pregnancy care and reasons for choosing between unscheduled versus scheduled care delivery.

RESULTS

Demographically, high utilizers were similar to low utilizers, but were more likely to report adverse childhood experiences (p = .01). All 40 participants reported resource constraints and perceived hospital-based unscheduled obstetric care to be more accessible than outpatient prenatal care. Beyond this, high (n = 20) and low (n = 20) utilizer narratives differed significantly. Two distinct high utilizer profiles emerged. Some high utilizers repetitively used unscheduled hospital-based services owing to psychosocial determinants. Other high utilizing participants were driven by severe experiences of illness insufficiently addressed by outpatient prenatal care. Low utilizer narratives demonstrated high self-efficacy and social support compared with high utilizers.

CONCLUSIONS

Low-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need.

IMPLICATIONS FOR POLICY AND/OR PRACTICE

Tailored community-focused innovations that use unscheduled visits as signals of risk may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.

Effects of Maternal Mental Health on Engagement in Favorable Health Practices During Pregnancy

INTRODUCTION

A woman's health practices during pregnancy are associated with maternal and neonatal outcomes. Yet limited research has examined predictors of a woman's engagement in favorable health practices, particularly in pregnant women at greatest risk for adverse outcomes. We examined the role of mental health on engagement in favorable health practices during pregnancy in a sample of pregnant, low-income, predominantly African American women.

METHODS

A convenience sample of pregnant women was obtained from 3 obstetric clinics within a large Mid-Atlantic academic health system. Pregnant women (N = 166) completed measures of depression, social support, and engagement in favorable health practices during their second trimester. Six domains of health practices (ie, balance of rest and exercise, safety measures, nutrition, substance use, health care access, access to pregnancy-related information) were assessed by the Health Practices in Pregnancy Questionnaire-II. Multiple linear regression was used to examine predictors of engagement in favorable health practices.

RESULTS

Fifty-nine percent of the study participants experienced depressive symptomatology during pregnancy. Multivariate linear regression modeling demonstrated that increased depressive symptoms, decreased social support, young age, and prepregnancy overweight or obesity were significant predictors of nonengagement in favorable health practices during pregnancy.

DISCUSSION

Findings suggest that pregnant women with poor mental health (eg, depressive symptomatology, poor social support) and specific sociodemographic characteristics (eg, young age, prepregnancy overweight or obesity) were less likely to engage in favorable health practices during pregnancy. Health care providers are uniquely positioned to assess a woman's mental health and related indicators to optimize pregnancy and neonatal outcomes.

MENTAL HEALTH DISORDERS SUBSEQUENT TO GESTATIONAL DIABETES MELLITUS DIFFER BY RACE/ETHNICITY

INTRODUCTION

The relationship between gestational diabetes mellitus (GDM) and postpregnancy mental health disorders has been inconsistently reported. Additionally, race/ethnicity data are limited. We sought to elucidate the intersection of these relationships.

METHODS

We analyzed 18,109 women aged 18-40 with self-reported race/ethnicity. Women with (n = 659) and without (n = 14,461) GDM were followed for a median of 4.4 (interquartile range 1.4-6.8) and 4.0 (1.5-6.4) years, respectively, for incident mental health disorders. Multivariable repeated measures analyses were conducted to examine associations between GDM and postpregnancy mental health disorders, race/ethnicity, and the interaction of these factors.

RESULTS

Women with compared to women without GDM were older (mean ± standard deviation, 32 ± 5 vs. 30 ± 5 years; P < .001) and had higher body mass index (29.0 ± 7.2 vs. 25.3 ± 5.2 kg/m(2) ; P < .001). GDM was associated with increased risk for depression and anxiety after adjusting for age and pregnancy complications; however, loss of significance in the fully adjusted model for depression (odds ratio [95% CI]: 1.29 [0.98, 1.70]; P = .064) and anxiety (1.14 [0.83, 1.57], P = .421) suggested that clinical and socioeconomic factors influence this relationship. Hispanic compared to white women had a greater risk for depression (1.40 [1.15, 1.72]; P = .001), even after multivariable adjustment. The interaction between GDM and race was evident in complication-adjusted but not fully adjusted models.

CONCLUSIONS

The incidence of mental health disorders subsequent to GDM was attenuated after adjustment for clinical and socioeconomic factors. Moreover, race/ethnicity influenced this relationship. Further investigation is warranted to clarify potential underlying mechanisms.

Prevalence of abuse and violence before, during, and after pregnancy in a national sample of Canadian women

OBJECTIVES

We describe the prevalence of abuse before, during, and after pregnancy among a national population-based sample of Canadian new mothers.

METHODS

We estimated prevalence, frequency, and timing of physical and sexual abuse, identified category of perpetrator, and examined the distribution of abuse by social and demographic characteristics in a weighted sample of 76,500 (unweighted sample = 6421) Canadian mothers interviewed postpartum for the Maternity Experiences Survey (2006-2007).

RESULTS

Prevalence of any abuse in the 2 years before the interviews was 10.9% (6% before pregnancy only, 1.4% during pregnancy only, 1% postpartum only, and 2.5% in any combination of these times). The prevalence of any abuse was higher among low-income mothers (21.2%), lone mothers (35.3%), and Aboriginal mothers (30.6%). In 52% of the cases, abuse was perpetrated by an intimate partner. Receiving information on what to do was reported by 61% of the abused mothers.

CONCLUSIONS

Large population-based studies on abuse around pregnancy can facilitate the identification of patterns of abuse and women at high risk for abuse. Before and after pregnancy may be particularly important times to monitor risk of abuse.

Predicting pregnancy from pregnancy intentions: prospective findings from the Central Pennsylvania Womens's Heath Study (CePAWHS)

OBJECTIVE

We examined whether adult women's intention for future pregnancy predicted actual pregnancies occurring in a 2-year follow-up study.

METHODS

Data are from the Central Pennsylvania Women's Health Study population-based longitudinal survey of women ages 18-45 (n = 1,420). The analytic sample consists of 889 nonpregnant women who had reproductive capacity. Intention for future pregnancy was ascertained at baseline, and women were re-interviewed 2 years later to document interval pregnancies. The impact of pregnancy intention on subsequent pregnancy was analyzed using multiple logistic regression adjusting for relevant covariates.

RESULTS

At baseline, 46% of women were considering a future pregnancy. One hundred thirty-seven women became pregnant during the 2-year study; of these pregnancies, 83% were intended (occurring in women considering a future pregnancy at baseline) and 17% were unintended (occurring in women not considering a future pregnancy at baseline). Pregnancies occurred in 28% of women who at baseline were considering future pregnancy and 5% of women not considering pregnancy. In adjusted analysis, baseline pregnancy intention was predictive of with pregnancy occurrence in women ages 25-34 (adjusted odds ratio [OR], 4.19; 95% confidence interval [CI], 2.20-7.97) and ages 35-45 (adjusted OR, 26.89; 95% CI, 9.05-79.93), but not in women ages 18-24.

CONCLUSIONS

In this prospective study, pregnancy intention was strongly associated with pregnancy incidence over a 2-year follow-up period among women ages 25 and older, suggesting that pregnancy intentions could be used to identify women at greater risk of pregnancy. Future investigation is needed to confirm these findings and to explore the reasons why pregnancy intentions were not predictive for women ages 18-24.

Rural mothers experiencing the stress of intimate partner violence or not: their newborn health concerns

Pregnancy and the postpartum period is a time of great physical, psychological, and emotional upheaval. Women who experience intimate partner violence experience more depression and anxiety and a higher risk of adverse pregnancy outcomes (such as those related to the abuse). While the literature supports the presence of increased health care utilization for abused women, there is little information on the way that these mothers seek medical care for their infants. This secondary analysis is part of a larger study on smoking cessation in low-income, rural pregnant women called Baby Behavioral Education Enhancement of Pregnancy (Baby BEEP). Women (N = 616) were classified as abused or not abused based on their answers to the Abuse Assessment Screen. At 6 weeks postdelivery, each woman was asked, "Has your baby had any problems that you talked to the doctor or nurse about?" The abused women (n = 211) sought health care advice significantly more often than the nonabused women (n = 405; Pearson chi(2) = 4.89; P = .027). Stress scores were elevated for all women in the study, but women categorized as abused experienced significantly more stress (P < .001).