Obstetric Care Consensus No. 8: Interpregnancy Care

Perinatal Remote Blood Pressure Monitoring

Perinatal mortality and severe maternal morbidity among individuals with hypertensive disorders of pregnancy (HDP) are often driven by persistent, uncontrolled hypertension. Whereas traditional perinatal blood pressure (BP) ascertainment occurs through in-person clinic appointments, self-measured blood pressure (SMBP) programs allow individuals to measure their BP remotely and receive remote management by a medical team. Though data remain limited on clinically important outcomes such as maternal morbidity, these programs have shown promise in improving BP ascertainment rates in the immediate postpartum period and enhancing racial and ethnic equity in BP ascertainment after hospital discharge. In this narrative review, we provide an overview of perinatal SMBP programs that have been described in the literature and the data that support their efficacy. Furthermore, we offer suggestions for practitioners, institutions, and health systems that may be considering implementing SMBP programs, including important health equity concerns to be considered. Last, we discuss opportunities for ongoing and future research regarding SMBP programs' effects on maternal morbidity, long-term health outcomes, inequities that are known to exist in HDP and HDP-related outcomes, and the cost effectiveness of these programs.

Obstetric Anal Sphincter Injury: Interpregnancy Interval and Route of Subsequent Delivery

IMPORTANCE

Knowledge on the interpregnancy interval (IPI) among women with an obstetric anal sphincter injury (OASI) is both limited and not well understood.

OBJECTIVES

The objectives of this study were to describe the IPI among women with OASI and to compare women with OASI based on the route of subsequent obstetric delivery and OASI recurrence.

STUDY DESIGN

This was a retrospective single-cohort study of women who had an OASI between 2013 and 2015 at a tertiary academic medical center. Demographics, obstetric delivery data, postpartum sequelae, and subsequent pregnancy delivery data from 2013 to 2021 were collected. The IPI was defined as the time from date of first vaginal delivery to date of conception of the subsequent pregnancy. Women without a subsequent pregnancy were censored at the date of last contact. The IPI was evaluated using a survival analysis (Kaplan-Meier estimator).

RESULTS

A total of 287 women experienced an OASI, and subsequent pregnancy occurred for 178 (62.0%) women. The median IPI was 26.4 months (95% confidence interval: 23.7-29.9) for women with a prior OASI. Of the 97 women who did not have a subsequent pregnancy documented during the study, the median follow-up was 64.0 months (interquartile range: 5.7-80.0). Subsequent delivery route data were available for 171 women; of those, 127 (74.3%) experienced a subsequent vaginal delivery and 44 (25.7%) experienced a cesarean delivery. Of the 127 women who experienced a subsequent vaginal delivery, 3 (2.4%) experienced a recurrent OASI.

CONCLUSION

The IPI among women with OASI is similar to the IPI for all women in Ohio and in the United States.

Gaps between current practice in perinatal depression screening and guideline recommendations: a systematic review

OBJECTIVE

Screening for perinatal depression is recommended by many guidelines to reduce the disease burden, but current implementation practices require clarification.

METHOD

Fifteen databases were searched for observational studies using a pre-tested search strategy. In addition, the websites of academic organizations were searched for guidelines, recommendations, and reports. Literature published between January 1, 2010, and December 19, 2021, in either English or Chinese, was included. The standard form of the Joanna Briggs Institute (JBI) was used to assess risk of bias of the included studies.

RESULTS

The data analysis covered 103 studies, 21 guidelines, 11 recommendations, five position statements, three reports, two committee opinions, three consensuses, one consultation, and one policy statement. All but one guideline recommended that mothers be routinely screened for perinatal depression at least once during the perinatal period. In addition, 39 documents recommended that perinatal mothers at risk of perinatal depression be provided with or referred to counseling services. In original studies, however, only 8.7% of the original studies conducted routine screenings, and only one-third offered referral services after the screening process. The EPDS emerged as the most frequently used screening tool to measure perinatal depression. 32% (n = 33) of studies reported the technology used for screening. The most commonly used method was face-to-face interviews (n = 22). Screening personnel the agents conducting the screening comprised researchers (n = 26), nurses (n = 15), doctors (n = 11).

CONCLUSIONS

A significant disparity was observed between the recommendations and implementation of perinatal depression screening, highlighting the need to integrate routine screening and referral processes into maternal care services.

Effect of Serial Pregnancies on Physical Fitness

INTRODUCTION

Pregnancy has a profound impact on physical fitness, and delivery does not allow for rapid return to peak performance levels as physiologic changes can persist for greater than 1 year postpartum. Multiple studies across all military services have documented decrements in physical performance with pregnancy among women. The purpose of this study was to determine the impact of serial pregnancies on physical fitness and body composition in a cohort of Army women. We hypothesized that a second pregnancy would be associated with increasing decrements in physical fitness in active duty soldiers beyond that seen following a first delivery.

MATERIALS AND METHODS

This retrospective cohort study screened all active duty soldiers who had delivered a singleton pregnancy of ≥32 weeks gestation between January 1, 2011 and March 31, 2017 at a single military medical center. This roster of eligible women was used to extract Army Physical Fitness Test (APFT) and height/weight data from the U.S. Army Digital Training Management System. Soldiers who delivered their first 2 pregnancies over this period were included. Select antepartum, intrapartum, and postpartum data were collected from the electronic medical record. The primary outcome variables were raw scores for push-ups, sit-ups, and run events as well as weight measures across the 2 pregnancies. The secondary outcomes were the failure rates on both the APFT events and body mass index measurements. Data were analyzed using paired t-tests to compare the means of APFT scores across the 2 pregnancies. The subjects served as their own controls. This study was approved by Regional Health Command-Pacific.

RESULTS

A total of 2,103 active duty soldiers delivered singleton pregnancies at Tripler Army Medical Center between January 2011 and March 2017. Among these, 16 women delivered both their first- and second-term pregnancies and had APFT data available for analysis. Average age at time of first and second delivery was 26.1 and 28.1 years, respectively. Mean time separating the first postpartum APFT from the delivery was 8.8 months for the first pregnancy and 7.3 months following the second.A significant decrease in mean sit-up score was found comparing APFT-1 with APFT-2 (72.1 vs 65.7, P = .043) and comparing APFT-1 to APFT-3 (72.1 vs 60.9, P = .002). A significant increase in mean run time was found comparing APFT-1 to APFT-3 (16.9 minutes vs 17.9 minutes, P = .010) and APFT-2 to APFT-3 (17.5 minutes vs 17.9 minutes, P = .027). Comparing APFT-1 to APFT-3 showed a significant decrease in sit-up raw scores (P = .002), run times (P = .010), and total APFT scores (P = .01). Overall, the data show a trend of decreasing performance in all APFT events across the 3 APFTs and a trend toward higher failure rates. This cohort of soldiers did not experience weight gain following the pregnancies.

CONCLUSIONS

The present study is the first to analyze the association of serial pregnancies on physical fitness utilizing a validated physical fitness test, and the results suggest that a second pregnancy is associated with progressive worsening of performance. This study is limited by the small sample size, and future studies could further elucidate the degree to which serial pregnancies affect physical fitness.

Interpregnancy interval after vacuum delivery and subsequent perinatal outcomes

OBJECTIVE

To evaluate whether a short interpregnancy interval (IPI) after vacuum extraction (VE), poses similar perinatal risks in a subsequent pregnancy.

METHODS

This was a retrospective, single-center cohort study between 2011 and 2021. Nulliparous women with term, singleton VE deliveries and with known pregnancy outcomes in their subsequent pregnancy were eligible for inclusion in the study. Each woman was allocated into one of two groups based on the IPI, <18 months and between 18 and 60 months. The primary outcome was the risk of spontaneous preterm birth (PTB) <37 weeks in the consecutive birth.

RESULTS

We included 1094 pregnancies: 212 (19.4%) with IPI <18 months and 882 (80.6%) with IPI between 18 and 60 months following the previous VE delivery. The VE characteristics were comparable between the groups. Young maternal age was a risk factor for a short IPI (28.0 ± 4.8 vs 30.3 ± 4 years, P < 0.01). Spontaneous PTB <37 weeks was significantly higher in the IPI <18 months group with 18-60 months (7.1% vs 2.6%, P = 0.002). Polynomial regression analysis also confirmed a significantly increased risk of preterm birth <37 weeks (P < 0.01). Short IPI <18 months was also associated with an increase in the risk of low birthweight <2500 g (6.1% vs 2.8%, P = 0.02) and admission to the neonatal intensive care unit (6.1% vs 2.6%, P = 0.013). The incidence of recurrent VE, albeit significant (2.3% vs 4.9%, P = 0.049), was low in both groups. No differences were noted in any of the other secondary outcomes.

CONCLUSION

Short IPI (<18 months) following term VE delivery is associated with higher neonatal risks, particularly PTB, in the subsequent pregnancy. These findings are particularly important when counseling women planning an optimal IPI.

Examining Cesarean Among Individuals of Advanced Maternal Age in Nurse-Midwifery Care

INTRODUCTION

Cesarean rates are rising, especially for individuals of advanced maternal age (AMA), defined as aged 35 or older. The Robson 10-Group Classification System (TGCS) facilitates assessment and comparison of cesarean rates among individuals in different settings. In midwifery-led care, in which pregnant people are typically healthier and seek a vaginal birth, it is unknown whether individuals of AMA have different antecedents leading to cesarean compared with younger counterparts. This study aimed to examine antecedents contributing to cesarean using Robson TGCS for individuals across age groups in midwifery care.

METHODS

This study was a secondary analysis of 2 cohort data sets from Oregon Health & Science University (OHSU) and University of Michigan Health Systems (UMHS) hospitals. The samples were individuals in midwifery-led care birthing at either OHSU from 2012 to 2019 or UMHS from 2007 to 2019.

RESULTS

A total of 11,951 individuals were studied. Overall cesarean rates were low; however, the rate for individuals of AMA was higher than the rate of their younger counterparts (18.30% vs 15.10%). The Robson groups were similar; however, the primary contributor among AMA individuals was group 5 (multiparous with previous cesarean), followed by group 2 [nulliparous with labor induced or prelabor cesarean], and group 1 [nulliparous with spontaneous labor]. In contrast, the primary contributors for younger individuals were groups 1, 2, and 5, respectively. In addition, prelabor cesarean and induced labor partly mediated the relationship between AMA and cesarean among nulliparous individuals, whereas prelabor cesarean was the key contributor to cesarean among multiparous people.

DISCUSSION

The cesarean rate in midwifery-led care was low. Using Robson TGCS provided additional insight into the antecedents to cesarean, rather than viewing cesarean as a single outcome. Future studies should continue to use Robson TGCS and investigate antecedents to cesarean, including factors influencing successful vaginal birth after cesarean in individuals of AMA.

Prenatal and Postpartum Home Visits and Postpartum Contraceptive Use: A Cross-Sectional Analysis

Background: The postpartum period is a time of unmet contraceptive need for many women. Home visits by a health care worker during pregnancy or after delivery could increase postpartum contraceptive use and decrease barriers to accessing postpartum care. This study investigated the association between prenatal or postpartum home visits and postpartum contraceptive use using a large sample of U.S. women from 41 states. Subjects and Methods: We conducted a cross-sectional analysis using weighted survey data from the 2012-2015 Phase 7 Pregnancy Risk Assessment and Monitoring Systems Core and Standard Questionnaires. Descriptive statistics and multivariate logistic regression models estimated the association between having a prenatal or postpartum home visit and self-reported postpartum contraceptive use. Results: Of 141,296 women, approximately 21% received prenatal or postpartum home visits and 79% used postpartum contraception. After controlling for sociodemographic, reproductive, and health-related factors, women who received prenatal or postpartum home visits had a higher odds of postpartum contraception use (adjusted odds ratio 1.08, 95% confidence interval 1.02-1.15, p = 0.009). Women who were older, were minority race, had less than a high school education, received inadequate prenatal care, experienced partner abuse during pregnancy, or experienced multiple stressors during pregnancy had a lower odds of postpartum contraception use in adjusted analyses controlling for home visitation. Conclusion: Given the benefits of recommended interpregnancy intervals to both the mother and the baby, adding formal contraceptive counseling and offering a variety of postpartum contraceptive methods in the home could further strengthen home visitation programs in the United States and may support women in achieving their reproductive goals.

Postpartum and interpregnancy care of women with a history of hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are common complications associated with maternal and neonatal morbidity and mortality worldwide. Insights gained from long-term cohort studies have revealed that women with a history of HDP are predisposed to recurrent HDP in subsequent pregnancies and face heightened risks for cardiovascular and metabolic diseases later in life. Pregnancy is a unique condition that overloads maternal cardiac and metabolic functions, and is recognized as a "maternal stress test" for future cardiovascular and metabolic diseases. Pregnancy and postpartum period provide a valuable opportunity for identifying women with underlying and unrecognized cardiovascular and metabolic risk factors. Establishing an effective postpartum healthcare program for women who have experienced HDP is crucial in reducing the future risk of health complications. Postpartum care consists of supportive care for both mothers and children, including not only the assessment of physical and psychological well-being but also long-term postpartum preventive health management. Interpregnancy care is a continuum from postpartum care and includes supportive care to prepare for future pregnancies. Various initiatives across nations have been initiated to establish follow-up programs for women with a history of HDP; however, sufficient evidence of the impact of such programs is not available. Substantial challenges persist in establishing an efficient postpartum follow-up program, including educational strategies, selection of effective lifestyle interventions, and collaboration among various healthcare providers. This review outlines the postpartum and interpregnancy care of women who have experienced HDP as well as the current status and challenges of related healthcare initiatives in Japan.

Association between gestational diabetes and cardiovascular disease within 24 months postpartum

BACKGROUND

Cardiovascular disease is the leading cause of death among women in the United States. It is well established that gestational diabetes mellitus is associated with an overall lifetime increased risk of cardiometabolic disease, even among those without intercurrent type 2 diabetes. However, the association between gestational diabetes mellitus and short-term risk of cardiovascular disease is unclear. Establishing short-term risks of cardiovascular disease for patients with gestational diabetes mellitus has significant potential to inform early screening and targeted intervention strategies to reduce premature cardiovascular morbidity among women.

OBJECTIVE

This study aimed to compare the risk of cardiovascular disease diagnosis in the first 24 months postpartum between patients with and without gestational diabetes mellitus.

STUDY DESIGN

Our longitudinal population-based study included pregnant individuals with deliveries from 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Database. We excluded records with gestational age <20 weeks, non-Maine residence, multifetal gestation, no insurance in the month of delivery or the 3 months before pregnancy, an implausibly short interval until next pregnancy (<60 days), pregestational diabetes mellitus, and any prepregnancy diagnosis of the cardiovascular conditions being examined postpartum. Gestational diabetes mellitus and cardiovascular disease (heart failure, ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, cerebrovascular disease/stroke, and new chronic hypertension) were identified by International Classification of Diseases 9/10 diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors. We assessed whether the association between gestational diabetes mellitus and chronic hypertension was mediated by intercurrent diabetes mellitus.

RESULTS

Among the 84,746 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months postpartum for those with vs without gestational diabetes mellitus was 0.13% vs 0.20% for heart failure, 0.16% vs 0.14% for ischemic heart disease, 0.60% vs 0.44% for cerebrovascular disease/stroke, 0.22% vs 0.16% for arrhythmia/cardiac arrest, 0.20% vs 0.20% for cardiomyopathy, and 4.19% vs 1.83% for new chronic hypertension. After adjusting for potential confounders, those with gestational diabetes had an increased risk of new chronic hypertension (adjusted hazard ratio, 1.56; 95% confidence interval, 1.32-1.86) within the first 24 months postpartum compared with those without gestational diabetes. There was no association between gestational diabetes and ischemic heart disease (adjusted hazard ratio, 0.75; 95% confidence interval, 0.34-1.65), cerebrovascular disease/stroke (adjusted hazard ratio, 1.13; 95% confidence interval, 0.78-1.66), arrhythmia/cardiac arrest (adjusted hazard ratio, 1.16; 95% confidence interval, 0.59-2.29), or cardiomyopathy (adjusted hazard ratio, 0.75; 95% confidence interval, 0.40-1.41) within the first 24 months postpartum. Those with gestational diabetes appeared to have a decreased risk of heart failure within 24 months postpartum (adjusted hazard ratio, 0.45; 95% confidence interval, 0.21-0.98). Our mediation analyses estimated that 28% of the effect of gestational diabetes on new chronic hypertension was mediated through intercurrent diabetes mellitus.

CONCLUSION

Patients with gestational diabetes mellitus have a significantly increased risk of new chronic hypertension as early as 24 months postpartum. Most of this effect was not due to the development of diabetes mellitus. Our findings suggest that all women with gestational diabetes need careful monitoring and screening for new chronic hypertension in the first 2 years postpartum.

Parental Perceptions of Counseling Regarding Interpregnancy Interval after Stillbirth or Neonatal Death

OBJECTIVE

Although guidelines exist regarding optimal interpregnancy interval (IPI) after live birth, both optimal IPI and counseling regarding recommended IPI (rIPI) after stillbirth or neonatal death is not well established. Our goal was to describe the counseling bereaved parents receive regarding IPI, parents' reactions to that counseling, and actual IPI after loss.

STUDY DESIGN

Bereaved parents who had a previous pregnancy result in stillbirth or neonatal death participated in a web-based survey. Questions included demographics, details of stillbirth or neonatal death, IPI counseling, and pregnancy after loss. Demographic information, rIPI, and ac'tual IPI were reported using descriptive statistics. The Wilcoxon's rank sum test was used to test the association between rIPI and mode of delivery. The Spearman's correlation was used to test the association between rIPI and maternal age.

RESULTS

A total of 275 surveys were analyzed. Mean gestational age of stillbirth delivery was 33.1 (standard deviation: 6.6) weeks. A total of 29% delivered via cesarean. Median rIPI was 6 (interquartile ratio [IQR]: 2-9) months, with the primary reason for IPI reported as the need to heal (74%). Delivery via cesarean was associated with longer rIPI, 9 versus 4.2 months (p < 0.0001). Maternal age was not associated with rIPI. Of 144 people who pursued pregnancy again, median time until attempting conception was 3.5 (IQR: 2-6) months. Median actual IPI was 6 (IQR: 4-10) months.

CONCLUSION

Bereaved parents receive a wide range of counseling regarding rIPI. The majority receive rIPI and pursue actual IPI shorter than current national and international recommendations for optimal IPI.

KEY POINTS

· There is variation in IPI recommendation after stillbirth/neonatal death.. · Cesarean birth is associated with longer IPI recommendation, but maternal age is not.. · Median IPI after stillbirth or neonatal death was short: 6 (IQR: 4-10) months..

Postpartum versus postnatal period: Do the name and duration matter?

INTRODUCTION

Guidelines and other strategic documents were collated to understand the extent of the global use of terms postpartum and postnatal along with the duration and schedule of maternal care after delivery.

METHODS

Postpartum care guidelines and strategies published in English, by international organisations including the World Health Organization, and countries in either the Organization for Economic Co-operation and Development or Group of 20 were included in this scoping review. All documents available online with unrestricted access and published before May 31, 2023, were included. The evolution of the World Health Organization's definition of the period after delivery for mothers and the changes in the schedule of routine maternal care following delivery over time were displayed pictorially. A summary table was then developed to present the level of similarities and differences in the latest available documents from the international organisations and countries belonging to either the Organisation for Economic Co-operation and Development or the Group of 20.

RESULTS

Ten documents from the World Health Organization, one from the European Board, and 15 country-level guidelines from six countries met the inclusion criteria. The interchangeable use of 'postpartum' and 'postnatal' is common. While the World Health Organization mentions the definitive length (six weeks) of the postpartum/ postnatal period, it is not stated in documents from other organisations and countries. Additionally, the length and schedule of routine maternal care after delivery vary substantially between organisations/countries, spanning from six weeks to one year with two to six healthcare contacts, respectively.

CONCLUSION

Through this review, we make a case for a universal harmonisation of the term postpartum when referring to mothers after delivery; add clarity to the documents on the rationale for and duration of the postpartum period; and extend the routine maternal care schedule after delivery to support women in this vulnerable period.

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

Association between interpregnancy interval and gestational diabetes mellitus: A cohort study of the National Vital Statistics System 2020

OBJECTIVE

To assess the association between interpregnancy interval (IPI) and gestational diabetes mellitus (GDM).

METHODS

Data of this retrospective cohort study were obtained from the National Vital Statistics System (NVSS) 2020. The participants were divided into different groups according to different IPI (<6, 6-11, 12-17, 18-23, 24-59 (reference), 60-119, ≥120 months). Multivariate logistic models were constructed to evaluate the association between IPI and GDM. Subgroup analysis was further performed.

RESULTS

A total of 1 515 263 women were included, with 123 951 (8.18%) having GDM. Compared with the 24-59 months group, the <6 months (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.46-0.90, P = 0.009), 12-17 months (OR 0.96, 95% CI 0.94-0.98, P < 0.001), and 18-23 months (OR 0.94, 95% CI 0.93-0.96, P < 0.001) groups had a significantly lower risk of GDM, while the 60-119 months (OR 1.13, 95% CI 1.11-1.15, P < 0.001) and ≥120 months (OR 1.18, 95% CI 1.15-1.21, P < 0.001) groups had a significantly higher risk of GDM. No significant difference was observed in the risk of GDM between the 6-11 and 24-59 months groups (P = 0.542). The PI-GDM association varied across different groups of age, pre-pregnancy body mass index, pre-pregnancy smoking status, history of cesarean section, history of preterm birth, prior terminations, and parity.

CONCLUSION

An IPI of 18-23 months may be a better interval than 24-59 months in managing the risk of GDM.

Interconception care during well-child visits by family physicians in the United States: A cross-sectional study

Background

Interconception care (ICC) by family physicians during well-child visits (WCVs) has been broadly advocated in principle but has not been widely implemented. We aimed to investigate ICC at WCVs by family physicians at our facility, focusing on four maternal risk factors, including maternal tobacco use, maternal depression, contraception, and folic acid supplementation.

Methods

Mothers who visited WCVs with children up to the age of 24 months at our university-affiliated clinic were screened for the four maternal risks. Brief interventions were provided to mothers with positive screening results. We investigated mothers at WCVs from December 1, 2020, to November 30, 2022. We performed descriptive and binary logistic regression analyses to determine the maternal demographic factors associated with positive screenings.

Results

Of 1143 WCVs, 205 mothers were evaluated. Screening was positive in the following rates: tobacco use 5.9%, depression 11.5%, contraception 73.6%, and folic acid supplementation 40.5%. Single marital status was associated with positive screening for smoking (odds ratio [OR] 8.689, p = 0.016) and maternal depression (OR 3.470, p = 0.035). Maternal education level lower than a high school diploma was associated with positive screening for folic acid intake (OR 4.975, p = 0.004).

Conclusions

ICC conducted during WCVs by family physicians offers valuable opportunities to identify maternal risk factors and address modifiable factors that can influence future birth outcomes. Single marital status and educational level less than a high school diploma were more potent risk factors for maternal behavior in ICC. More research is needed to assess the outcomes of the interventions.

The Impact of Group Prenatal Care on Interpregnancy Interval

OBJECTIVE

To evaluate whether participation in CenteringPregnancy group prenatal care is associated with decreased risk of an interpregnancy interval (IPI) ≤6 months.

STUDY DESIGN

We conducted a retrospective cohort study of women enrolled in Missouri Medicaid from 2007 to 2014 using maternal Medicaid data linked to infant birth certificate records. Inclusion criteria were women ≥11 years old, ≥1 viable singleton delivery during the study period, residency in St. Louis city or county, and ≥2 prenatal visits. The primary outcome was an IPI ≤6 months. Secondary outcomes included IPI ≤12 months, IPI ≤18 months, postpartum long-acting reversible contraception (LARC) uptake, and postpartum LARC or depot medroxyprogesterone acetate (DMPA) uptake. Data were analyzed using descriptive statistics and logistic regression. Backward stepwise logistic regression was used to adjust for potential confounders including maternal age, race, obesity, nulliparity, marital status, diabetes, hypertension, prior preterm birth, and maternal education.

RESULTS

Of the 54,968 pregnancies meeting inclusion criteria, 1,550 (3%) participated in CenteringPregnancy. CenteringPregnancy participants were less likely to have an IPI ≤6 months (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.47-0.79) and an IPI ≤12 months (aOR: 0.74; 95% CI: 0.62-0.87). However, there was no difference for an IPI ≤18 months (aOR: 0.89; 95% CI: 0.77-1.13). Women in CenteringPregnancy were more likely to use LARC for postpartum contraception (aOR: 1.37; 95% CI: 1.20-1.57).

CONCLUSION

Participation in CenteringPregnancy is associated with a significant decrease in an IPI ≤6 and ≤12 months and a significant increase in postpartum LARC uptake among women enrolled in Missouri Medicaid compared with women in traditional prenatal care.

KEY POINTS

· CenteringPregnancy is associated with a significant decrease in interpregnancy intervals ≤6 and ≤12 months.. · LARC uptake is significantly higher among patients participating in CenteringPregnancy.. · CenteringPregnancy participation enhances self-efficacy in making contraception decisions and promotes healthy pregnancy spacing..

High-risk pregnancy in India: Prevalence and contributing risk factors - a national survey-based analysis

Background

High-risk pregnancies (HRP) place women and their offspring at the highest risk for morbidity and mortality. Maternal and medical risks increase pregnancy risk and complications during pregnancy and childbirth. Here, we reported the current prevalence of high-risk pregnancies among Indian women, which is defined through various factors such as maternal, lifestyle, medical, current health risk and adverse birth outcomes.

Methods

This is a cross-sectional study based on secondary data from India's National Family Health Survey-5 (NFHS-5). A total of 23 853 currently pregnant women were considered for analysis after considering the inclusion and exclusion criteria. The prevalence and contributing factors of high-risk pregnancies were estimated using descriptive statistics and logistic regression, respectively.

Results

The prevalence of high-risk pregnancies among Indian women was 49.4%, with 33% of women having a single high-risk, and 16.4% having multiple high-risk pregnancies. Notably, pregnant women from Meghalaya and Manipur states had 67.8% and 66.7% with one or more high-risk factors, respectively. About 31.1% of women had short birth spacing, and 19.5% of women had adverse birth outcomes during the last birth. Logistic regression analysis showed that women with no education (adjusted odds ratio (AOR) = 2.02; 95% confidence interval (CI) = 1.84-2.22) and the poorest wealth quintile (AOR = 1.33; 95% CI = 1.04-1.29) had significantly higher odds of having HRP than those with higher education and the highest wealth quintile, respectively.

Conclusions

Nearly half of all pregnancies in India have one or more high-risk factors, which is a matter of concern, and the risks were higher among the vulnerable population such as no educated, poorest groups etc. The leading high-risk factors such as short-birth spacing, adverse birth outcomes, and caesarean deliveries should be addressed through the health policy and programmes.

Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment

A cesarean scar ectopic pregnancy (CSEP) occurs when the embryo implants on the scar of a previous cesarean delivery. The number of births delivered by cesarean section has climbed by 50% over the last decade, from a nadir of 20.7% in 1996 to 32.1% in 2021. As a result, the incidence of CSEP has also increased. Because CSEP may cause serious morbidity such as life-threatening hemorrhage, uterine rupture, placental accreta spectrum, hysterectomy, and even mortality, accurate diagnosis and appropriate management of this condition are essential. This review focuses on the etiology, incidence, clinical diagnosis, and management of CSEPs.

Prenatal Contraceptive Counseling

Pregnancy care should include open discussions with patients about their ideal family size and pregnancy spacing. With these patient-voiced goals in mind, clinicians should review contraceptive tools to meet these goals, including special considerations after birth. For patients that desire contraception, it is important to prioritize the provision of their chosen method as soon as safely possible and desired after birth.

Breastfeeding and Hormonal Contraception: A Scoping Review of Clinical Guidelines, Professional Association Recommendations, and the Literature

Background: Postpartum contraceptive use can help prevent short-interval pregnancies, which have been associated with adverse neonatal and maternal health outcomes. Many contraceptive methods are safe for postpartum use, but patients and providers may be confused as to what impact hormonal contraception has on lactation. We performed a scoping review of the most recent U.S.-based guidelines regarding hormonal contraception on lactation to provide synthesis and recommendations to aid providers in counseling their patients. Methods: We conducted a scoping review by identifying the most recent clinical recommendations and guidelines from the Centers for Disease Control and Prevention (CDC) and three maternal and child health professional associations (American College of Obstetricians and Gynecologists [ACOG], Society for Maternal-Fetal Medicine [SMFM], and Academy of Breastfeeding Medicine [ABM]). We also reviewed the citations in these guidelines used in their development. We then conducted an updated literature review to capture studies published since the most recent systematic reviews were conducted. Results: We reviewed 1 clinical guideline from the CDC and 2 systematic reviews cited in its references, 6 professional association recommendations, and 28 publications identified through the updated literature review. Progestin-only contraceptive methods continue to demonstrate safety in breastfeeding patients, while low-quality evidence supports concerns of decreased milk supply with combined hormonal contraception. Discussion: Organizations should consider updating counseling recommendations regarding progestin-only contraceptives and lactation. Further research is needed to examine new contraceptive methods as well as the effect of hormonal contraception on lactation in the setting of preterm birth.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

Impact of the interpregnancy interval after cesarean delivery on subsequent perinatal risks: a retrospective study

PURPOSE

To assess the impact of the interpregnancy interval (IPI) after cesarean delivery on the risks of adverse perinatal events during subsequent pregnancies.

METHODS

We retrospectively examined perinatal outcomes of subsequent pregnancies of women whose most recent birth experience involved cesarean delivery at our hospital between January 2014 and December 2019. IPI was defined as the time between live birth and subsequent conception. Three IPI groups: < 18 months, 18-60 months, and > 60 months, were assessed. The risks of preterm birth, preeclampsia, placenta previa, placental abruption, fetal growth restriction, and successful vaginal birth were compared among the three IPI groups using uni- and multivariate analyses.

RESULTS

We registered 592 births after cesarean delivery: 178, 288, and 126 in the IPI < 18 months, 18-60 months, and > 60 months groups, respectively. The groups did not differ significantly regarding perinatal outcomes. The multivariate analysis revealed no significant differences in the risks of adverse perinatal outcomes among all groups. The odds ratios (ORs) for preterm birth at < 37 weeks of gestation were 1.24 and 1.64 for those in the < 18 months and > 60 months groups, respectively (P = 0.362 and P = 0.055, respectively). The groups did not differ significantly regarding vaginal birth success rate (ORs 1.72 for the < 18 months group, 0.49 for the > 60 months group; P = 0.486 and P = 0.446, respectively).

CONCLUSION

After cesarean delivery, IPIs shorter than 18 months and longer than 60 months do not significantly impact the risks of adverse perinatal outcomes or successful vaginal birth compared with IPIs of 18-60 months.

Health Experiences of African American Mothers, Wellness in the Postpartum Period and Beyond (HEAL): A Qualitative Study Applying a Critical Race Feminist Theoretical Framework

The objective of this study is to explore the cultural, social, and historical factors that affect postpartum primary care utilization among Black women with cardiometabolic risk factors and to identify the needs, barriers, and facilitators that are associated with it. We conducted in-depth interviews of 18 Black women with one or more cardiometabolic complications (pre-pregnancy chronic hypertension, diabetes, obesity, preeclampsia, or gestational diabetes) within one year of delivery. We recruited women from three early home-visiting programs in Baltimore, Maryland, between May 2020 and June 2021. We used Critical Race Feminism theory and a behavioral model for healthcare utilization as an analytical lens to develop a codebook and code interview transcripts. We identified and summarized emergent patterns and themes using textual and thematic analysis. We categorized our findings into six main themes: (1) The enduring influence of structural racism, (2) personally mediated racism in healthcare and beyond, (3) sociocultural beliefs about preventative healthcare, (4) barriers to postpartum care transitions, such as education and multidisciplinary communication, (5) facilitators of postpartum care transitions, such as patient-provider relationships and continuity of care, and (6) postpartum health and healthcare needs, such as mental health and social support. Critical race feminism provides a valuable lens for exploring drivers of postpartum primary care utilization while considering the intersectional experiences of Black women.

Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.

Preventing Adverse Cardiovascular Outcomes in Pregnancy Complicated by Obesity

Purpose of review

Obesity is a chronic disease that is becoming increasingly prevalent, and more individuals of reproductive age have obesity prior to becoming pregnant. Obesity in pregnancy is associated with short- and long-term adverse consequences for both the birthing person and their offspring which have been associated with increased long-term cardiovascular morbidity and mortality. The goal of this review is to discuss what is currently understood about the relationship between maternal obesity and adverse pregnancy outcomes (APOs), the association between APOs and future cardiovascular disease (CVD) risk, and what evidence-based interventions can be implemented to prevent adverse outcomes in this population.

Recent findings

Maternal obesity has been associated with an increased risk of APOs such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth as well as an increased risk of future CVD, such as metabolic syndrome, chronic hypertension, coronary heart disease, and stroke. The impact of maternal obesity also extends beyond the pregnant individual to the offspring, increasing the risk of fetal, neonatal, and infant mortality, as well as of congenital malformations, prematurity, and long-term health problems such as insulin resistance and childhood obesity. Prevention guidelines are incorporating the increased risk of adverse outcomes from maternal obesity into formalized risk assessments to guide both prenatal and postpartum care. It is becoming evident that a multidisciplinary cardio-obstetrics team is an important part of providing comprehensive care for pregnant individuals with obesity and other cardiovascular risk factors, including preexisting CVD and a history of prior APOs. There remains a need for further studies to better understand the mechanisms underlying the relationship between maternal obesity and APOs, as well as the racial and ethnic disparities that have been noted in the prevalence of APOs and associated CVD risk and mortality.

Summary

There is increasing awareness that obesity in pregnancy is associated with various short- and long-term adverse maternal and offspring outcomes. There are multiple screening and prevention strategies that may be implemented before, during, and after pregnancy to prevent these adverse outcomes.

Interpregnancy Interval After Stillbirth and Adverse Perinatal Outcomes

We used a retrospective cohort of 5,581 individuals to examine the association between interpregnancy interval (IPI) after stillbirth and pregnancy outcomes of preterm birth, preeclampsia, small for gestational age, recurrent stillbirth, infant death, and neonatal intensive care unit admission in the subsequent pregnancy. The IPI was divided in six categories, with 18-23 months as referent. Association between IPI category and adverse outcomes was determined with logistic regression models adjusted for maternal race and ethnicity, age, education, insurance, and gestational age at preceding stillbirth. Adverse perinatal outcome was common in pregnancies after stillbirth, with 26.7% of individuals delivering preterm. None of the IPI categories were associated with increased risk of adverse perinatal outcomes, including the shortest category (IPI less than 3 months). This finding is meaningful for bereaved parents who desire to conceive shortly after stillbirth.

Definition and diagnosis of cesarean scar ectopic pregnancies

Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy, where the pregnancy implants into a myometrial defect caused by a cesarean scar. Its incidence is predicted to increase, given the global increase in cesarean deliveries. As most cesarean scar ectopic pregnancies present as failing pregnancies or patients choose termination of pregnancy, there are limited data on their natural history. However, early first trimester diagnosis is essential, given the associated significant maternal morbidity. Transvaginal sonography is generally considered to be the optimal method for diagnosing cesarean scar ectopic pregnancy. There is no evidence that MRI adds to the diagnostic accuracy, and it is therefore not recommended for routine evaluation of cesarean scar ectopic pregnancy. There is no agreed reference standard for the diagnosis of cesarean scar ectopic pregnancy; therefore, the validity of several proposed sonographic diagnostic criteria reported by different authors remains unknown. There are also various suggested classification systems for cesarean scar ectopic pregnancy, which divide them in differet types. However, the proposals are very heterogeneous, and superiority of one classification system over another is yet to be established.

Usage of postpartum intrauterine contraceptive device (postpartum-IUD) after an increase in the institutional delivery rate in India: time to re-visit the effect of timing of counselling on its acceptance

PURPOSE

While increase in institutional deliveries brings an opportunity to counsel women for postpartum family planning (PPFP), its uptake remains low. Reasons for poor acceptance of postpartum intrauterine contraceptive device (postpartum-IUD), and its relation with the timing of counselling need to be investigated.

METHODS

Women attending the antenatal clinic, reporting in labour, and within 48 h of delivery respectively were invited to participate. Eligible women were asked about awareness and choice for PPFP. After counselling, acceptance for PPFP was compared with the baseline. Acceptance and continuation of postpartum-IUD were compared between women counselled in the antenatal, intrapartum, and postpartum periods.

RESULTS

Only 23% of 360 women were aware of postpartum-IUD. After counselling, acceptance for PPFP increased from 14% to 97% and for postpartum-IUD, from 0.5% to 33.9%. Acceptance of postpartum-IUD among women counselled in the antenatal, intrapartum and postpartum period was 45%, 35% and 21.7% respectively. Acceptance was higher among the antenatal-counselling group than the postpartum-counselling group (OR 0.45; CI 0.22-0.94; p = 0.03).

CONCLUSION

Counselling, irrespective of its timing, improves acceptance for PPFP. Acceptance and continuation of postpartum-IUD are higher following counselling in antenatal period. All eligible women should be counselled irrespective of 'when' they approach the facility.

Evaluation and Management of Premature Rupture of Membranes: A Review Article

Premature rupture of membranes (PROM), now also referred to as "pre-labour rupture of membranes," is the rupture of gestational membranes after 37 weeks but before the process of labour begins. When membrane rupture occurs before 37 weeks of gestation, it is referred to as preterm PROM (PPROM). Prematurity is held accountable for the majority of newborn morbidity and mortality. PROM causes around one-third of all preterm deliveries and complicates 3% of pregnancies. Significant morbidity and mortality rates have been associated with PROM. Preterm (PROM) pregnancies are more difficult to manage. Pre-labour rupture of membranes is characterised by its short latency, higher intrauterine infection risk, and greater umbilical cord compression probability. Women with preterm PROM are more likely to develop chorioamnionitis and placental abruption. Various diagnostic modalities include sterile speculum examination, the nitrazine test, the ferning test, and the latest advances, which are the Amnisure test and the Actim test. Despite all these tests, there is still a need for newer, non-invasive, rapid, and accurate tests. Admission to a hospital, amniocentesis to rule out infection, and, if necessary, prenatal corticosteroids and broad-spectrum antibiotics are all alternatives for treatment. As a result, the clinician managing a pregnant woman whose pregnancy has been affected by PROM plays a crucial role in the management and must be well aware of probable complications and control measures to reduce risks and increase the likelihood of the required outcome. PROM's proclivity for recurrence in later pregnancies provides a chance for prevention. Furthermore, prenatal and neonatal care developments will continue to enhance the outcomes of women and their children. The purpose of this article is to summarise the concepts related to the evaluation and management of PROM.

Measuring Variation in Interpregnancy Interval: Identifying Hotspots for Improvement Initiatives

OBJECTIVE

The study aimed to determine if single year birth certificate data can be used to identify regional and hospital variation in rates of short interpregnancy interval (IPI < 6 months).

STUDY DESIGN

IPI was estimated for multiparous women ages 15 to 44 years with singleton live births between 2015 and 2016. Perinatal outcomes, place of birth, maternal race, and data for IPI calculations were obtained by using birth certificates. IPI frequencies are presented as observed rates.

RESULTS

The cohort included 562,039 multiparous women. Short IPI rates were similar to those obtained with analyses by using linked longitudinal data and confirmed the association with preterm birth. Short IPI rates varied by race and Hispanic nativity. There was substantial hospital (0.8-9%) and regional (2.9-6.2%) variation in short IPI rates.

CONCLUSION

IPI rates can be reliably obtained from current year birth certificate data. This can be a useful tool for quality improvement projects targeting interventions and rapidly assessing their progress to promote optimal birth spacing.

KEY POINTS

· Near-real time regional and hospital IPI rates can be reliably obtained from current year birth certificate data.. · Substantial variations in rates of short IPI exist between hospital and perinatal regions.. · IPI rates from individual birth certificates can be a tool to target and assess interventions..

Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes

BACKGROUND

Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear.

OBJECTIVE

This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes.

STUDY DESIGN

This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery.

RESULTS

Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated.

CONCLUSION

Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

"She told me no, that you cannot change": Understanding provider refusal to remove contraceptive implants

Enthusiasm for long-acting reversible contraception (LARC) is growing among donors and NGOs throughout the global reproductive health field. There is an emerging concern, however, that the push to insert these methods has not been accompanied by a commensurate push for access to method removal. We use data from 17 focus group discussions with women of reproductive age in an anonymized African setting to understand how users approach providers to request method removal, and how they understand whether or not such a request will be granted. Focus group participants described how providers took on a gatekeeping role to removal services, adjudicating which requests for LARC removal they deemed legitimate enough to be granted. Participants reported that providers often did not consider a simple desire to discontinue the method to be a good enough reason to remove LARC, nor the experience of painful side-effects. Respondents discussed the deployment of what we call legitimating practices, in which they marshalled social support, medical evidence, and other resources to convince providers that their request for removal was indeed serious enough to be honored. This analysis examines the starkly gendered nature of contraceptive coercion, in which women are expected to bear the brunt of contraceptive side-effects, while men are expected to tolerate no inconvenience at all, even vicarious. This evidence of contraceptive coercion and medical misogyny demonstrates the need to center contraceptive autonomy not only at the time of method provision, but at the time of desired discontinuation as well.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Mi Plan: Using a Pediatric-Based Community Health Worker Model to Facilitate Obtainment of Contraceptives Among Latino Immigrant Parents with Contraceptive Needs

BACKGROUND

Bilingual community health workers (CHWs) play an important role in helping Latino immigrants with limited English proficiency (LEP) access health care services and information. Contraceptive health care services and Spanish-language contraceptive information are particularly challenging to access for uninsured LEP immigrants. Contraceptive and reproductive care are longitudinal health needs, and pediatric settings pose a unique opportunity to address these needs among parents whose children access pediatric care. The purpose of this study was to pilot the feasibility of a CHW to support parental contraceptives needs within a pediatric setting serving a high number of Latino immigrant families. This article describes Mi Plan/My Plan, a CHW contraceptive counseling and resource navigation pilot program.

METHODS

The research team conducted a retrospective analysis of demographic and contraceptive use data from a 15-month CHW pilot within an urban, primary care pediatrics clinic. The CHW provided contraceptive counseling, referral, and appointment coordination. The outcome was desired contraceptive method obtainment within three months of counseling.

RESULTS

All 311 individuals counseled were Latina mothers with median child age of 3 months. At baseline, 64.3% were using contraception and 76.5% desired to start or change their current method. Among those who desired a change, 47.9% (114/238) obtained their desired method within three months of initial counselor contact.

CONCLUSION

Bilingual CHW contraceptive counseling and care coordination is feasible and acceptable in a pediatric setting serving a high number of Latino immigrant families. CHWs in pediatric settings support health care access equity and are relevant to optimal maternal and child health.

Optimal annual body mass index change for preventing spontaneous preterm birth in a subsequent pregnancy

Preterm birth (PTB) is a leading cause of neonatal morbidity and mortality. Although PTB is known to recur, interpregnancy preventive strategies for PTB have not been established to date. Annual BMI change can serve as a specific target value for preventing obstetric complications during interpregnancy care/counseling. This value can also account for age-related weight gain (0.2 kg/m²/year). In a multicenter retrospective study, we investigated the optimal annual BMI change for preventing PTB recurrence using the data of individuals who had two singleton births from 2009 to 2019. The association between annual BMI change and spontaneous PTB (sPTB) was analyzed by separating cases of medically indicated PTB (mPTB) from those of sPTB. Previous history of sPTB was strongly associated with sPTB in the subsequent pregnancy (adjusted odds ratio [aOR], 12.7; 95% confidence interval [CI], 6.5-24.8). Increase in annual BMI was negatively associated with sPTB (aOR, 0.6; 95% CI 0.5-0.9). The sPTB recurrence rate was significantly lower in patients with an annual BMI change of ≥ 0.25 kg/m²/year than in those with an annual BMI change of < 0.25 kg/m²/year (7.7% vs. 35.0%, p = 0.011). Our findings suggest that age-related annual BMI gain between pregnancies may help prevent sPTB recurrence.

The effect of interpregnancy interval on preterm birth and low birth weight in singleton pregnancies conceived without assistance or by infertility treatments

OBJECTIVE

To determine the association of interpregnancy interval on perinatal outcomes and whether this was influenced by mode of conception.

DESIGN

Retrospective cohort.

SETTING

Centers for Disease Control and Prevention's natality national database.

PATIENT(S)

Patients who had an index singleton live birth with a preceding live birth. Index pregnancies from 2016 to 2019 were conceived with in vitro fertilization (IVF) (n = 32,829) or ovulation induction/intrauterine insemination (OI/IUI) (n = 23,016) or without assistance (n = 7,564,042).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcomes evaluated were preterm birth (<37 weeks) and low birth weight (<2,500 g). Multivariable logistic regression was performed to evaluate the association of interpregnancy intervals with perinatal outcomes stratified by mode of conception. Adjusted odds ratios and 95% confidence intervals (CIs) were presented.

RESULT(S)

Compared with the interpregnancy interval reference group of 12 to <18 months, a <12 month interpregnancy interval was associated with an increase in preterm birth (<37 weeks) for pregnancies conceived with OI/IUI or without assistance (aOR, 1.42; 95% CI, 1.16-1.74, and aOR, 1.14; 95% CI, 1.13-1.15, respectively), whereas IVF was not associated with an increase (aOR, 0.90; 95% CI, 0.77-1.04). A <12 month interpregnancy interval was associated with an increase in low birth weight for pregnancies conceived with IVF or OI/IUI or without assistance (aOR, 1.34; 95% CI, 1.09-1.64; aOR, 1.33; 95% CI, 1.01-1.76; and aOR, 1.26; 95% CI, 1.24-1.27, respectively).

CONCLUSION(S)

An interpregnancy interval of at least 12 months reduces adverse perinatal outcomes for pregnancies conceived with and without infertility treatment.

Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy

Cesarean scar ectopic pregnancy is a complication in which an early pregnancy implants in the scar from a previous cesarean delivery. This condition presents a substantial risk for severe maternal morbidity and mortality because of challenges in securing a prompt diagnosis. Ultrasound is the primary imaging modality for cesarean scar ectopic pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar ectopic pregnancy management, but the optimal treatment is unknown. Patients who decline treatment of a cesarean scar ectopic pregnancy should be counseled regarding the risk for severe morbidity. The following are the Society for Maternal-Fetal Medicine recommendations: we recommend against expectant management of cesarean scar ectopic pregnancy (GRADE 1B); we suggest that operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided uterine aspiration be considered for the surgical management of cesarean scar ectopic pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for the medical treatment of cesarean scar ectopic pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar ectopic pregnancy (GRADE 1C); in patients who choose expectant management and continuation of a cesarean scar ectopic pregnancy, we recommend repeated cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that patients with a cesarean scar ectopic pregnancy be advised on the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).

Barriers and Facilitators to Implementing Immediate Postpartum Contraceptive Implant Programs: A Formative Implementation Research

Objective

This study sought to identify the factors that act as barriers and facilitators to developing and implementing Immediate postpartum (IPP) insertion of contraceptive implants service according to the Consolidated Framework for Implementation Research (CFIR).

Methods

We conducted in-depth interviews and focus group discussions to explore IPP contraceptive implantation programs implemented in community, regional, and university hospitals in Thailand. The CFIR was used to guide the data collection and analyses.

Results

All CFIR domains were found to have an impact on planning and implementation. Out of 38 constructs, nine were identified as either barriers or facilitators, and four were determined to be both. Barriers included an insufficient training budget, lack of policy to support non-teenagers, disconnect among organizations, and lack of knowledge on the part of the clients. Facilitators included the relative advantage of implants over other contraceptive methods, reimbursement policy, laws that promote teenage autonomy, setting IPP implants as a key performance indicator (KPI), identifying project champions, and educating clients through antenatal counseling or multimedia intervention.

Conclusion

Barriers and facilitators to the successful implementation of an IPP contraceptive implant program were identified. In order to successfully implement this service, modifiable barriers should be overcome and facilitators should be strengthened. Strategies tailored to the local context should be developed to ensure the sustainability of the program. Educating clients is crucial and need both hospital- and community interventions.

Digital Scarlet Letters: Sexually Transmitted Infections in the Electronic Medical Record

ABSTRACT

The harms of implicit bias in clinical settings are acknowledged but poorly understood and difficult to overcome. We discuss how structural components of electronic medical record (EMR) user interfaces may contribute to sex and gender-based discrimination against patients via constant, duplicative presentation of stigmatizing sexually transmitted infection (STI) data irrespective of clinical significance. Via comparison with symbolism and representative quotes in Hawthorne's 1850 novel The Scarlet Letter, we propose a metaphor to examine how EMRs function as a platform for moral judgment, which may display an indelible "scarlet letter" for pregnant patients with STI history. We consider whether current depictions of STIs in EMRs are structurally unjust and may contribute to biased treatment by directing attention to violations of hegemonic sex/gender norms regarding sexual behavior and thus triggering moral judgments of maternal fitness. We conclude with recommendations for how to address these challenges to improve ethical stewardship of sensitive sexual/reproductive health data.

Etonogestrel Implant in the Postpartum Period and its Impact on Biochemical Markers in Secretory Activation: A Pilot Study

BACKGROUND

Secretory activation is characterized biochemically in human milk by a fall in sodium concentration, an increase in potassium concentration, and a decreased sodium to potassium ratio. These markers can be used to identify a delay in secretory activation which can result from hormonal birth control.

RESEARCH AIM

To evaluate if the insertion of the Etonogestrel implant early in the postpartum period would delay the time to secretory activation as measured by biochemical markers.

METHODS

We conducted a prospective, longitudinal, non-randomized, observational cohort study. Women with singleton pregnancies were identified as wanting either no birth control or the Etonogestrel implant in the postpartum period. Human milk samples were collected starting at 12 hours after delivery, and then in 12-hour increments. Samples were tested for sodium and potassium levels.

RESULTS

As in the unadjusted models, there was evidence of a difference in sodium levels at two days postpartum, with the sodium level higher by 32.29 mM (95% CI [7.39, 57.20], p = .013) in the implant group than in the no birth control method group. A difference at day 2 was observed in the ratio (sodium/potassium) levels, with a higher mean ratio in the implant group by 2.49 (95% CI [0.14, 4.85], p = .039). For potassium levels, the only difference was observed at day 4, with lower values in the implant group (p = .045).

CONCLUSION

The transition from colostrum to copious milk secretion is delayed by the early insertion of the Etonogestrel device. This is evidenced by the delay in biochemical markers normally seen in secretory activation.

Cesarean Audit Using Robson Classification at a Tertiary Care Center in Bihar: A Retrospective Study

Background

Since 1985, the international healthcare community has considered the ideal rate for cesarean section (CS) to be between 10% and 15%.However, CS has been increasing both in developed and developing countries. The aim of the present study was to audit CS using Robson’s Ten Group Classification System (TGCS).

Methodology

This retrospective, hospital record-based study was conducted over a period of three years from April 1, 2016, to March 31, 2019, in the Department of Obstetrics and Gynecology at Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India. Data of patients who delivered by CS during this period were recorded and categorized in the 10 groups of TGCS. The size of each group, CS rate, and contribution of each group toward overall CS were calculated. Indications of CS in each group were analyzed, and strategies were planned to optimize the use of CS. The Chi-square test was used to analyse the statistical significance of the differences in the number of CS between the different Robson's groups.

Results

The total number of deliveries was 2,128 during the study period, of which CS was performed in 812 deliveries, with a CS rate of 38.16% in our institute. Robson’s group 5 (34.97%) was the major contributor to the overall CS rate, followed by group 2 (26.35%), group 1 (15.51%), and group 10 (7.14%). The incidence of primary CS (61.82%) was more than repeat CS (38.17%). Previous CS, fetal distress, failed induction, arrest of labor, and malpresentation were the main indications for CS.

Conclusions

Robson’s TGCS serves as an important tool for auditing CS. Indications of CS among major contributors and primary group should be analyzed regularly and uniform and standard protocols should be used. Standardization of indications for CS, regular audits, and definite protocols will help in reducing the CS rate in our hospital.

Primary Care-Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.

Periconceptional diet quality is associated with gestational diabetes risk and glucose concentrations among nulliparous gravidas

BACKGROUND

Gestational diabetes mellitus (GDM) and elevated glucose concentrations below the threshold for GDM diagnosis have been associated with adverse pregnancy and offspring outcomes. Dietary interventions initiated during pregnancy have demonstrated inconsistent beneficial effects. Limited data exist regarding the effects of periconceptional diet on gestational glycemia.

OBJECTIVE

To evaluate independent associations between periconceptional diet quality with GDM frequency and glucose concentrations from GDM screening and diagnostic tests among nulliparous gravidas.

DESIGN

This is a secondary analysis of N=7997 participants from the NuMoM2b multicenter, prospective, observational cohort study of first pregnancies. The Alternative Healthy Eating Index (AHEI)-2010 was computed from food frequency questionnaires completed in early pregnancy (6-13 weeks), reporting usual dietary intake over the preceding 3 months. GDM screening was performed either by non-fasting 1-hour 50g glucose load (N=6845), followed by 3-hour 100g glucose tolerance test (GTT) for those with raised glucose concentrations (N=1116; at risk for GDM), or by a single 2-hour 75g GTT (N=569; all GDM risk levels). Logistic and linear regression were used to estimate the associations between the AHEI-2010 score with odds of GDM, having raised blood glucose on the 1-hour screening test, and continuous glucose concentrations on screening and diagnostic tests. All models were adjusted for a priori covariates: maternal age, race/ethnicity, early-pregnancy body mass index, smoking habits, rate of gestational weight gain, energy intake, nausea and vomiting in early pregnancy, study site.

RESULTS

Poorer periconceptional diet quality was observed among participants who were younger, with higher BMI, lower income levels, and of non-Hispanic Black or Hispanic ethnicity. The GDM rate was 4%. Each 1-point increase in AHEI-2010 score was associated with a 1% decrease in the odds of being diagnosed with GDM (beta=-0.015, p=0.022, OR=0.986, 95% CI 0.973 to 0.998). Diet quality was inversely associated with each post glucose load concentration on the non-fasting screening test and the 2-hour and 3-hour GTT.

CONCLUSION

Poor periconceptional diet quality is independently associated with an increased risk of GDM and with minor elevations in serum glucose concentrations on GDM screening and diagnostic tests, in a diverse cohort of nulliparas. Periconception intervention studies targeting diet quality are warranted.

Perinatal depression screening: a systematic review of recommendations from member countries of the Organisation for Economic Co-operation and Development (OECD)

Perinatal depression (PND) screening recommendations are made by national, state-based and professional organisations; however, there is disagreement regarding screening timing, provider responsible, screening setting, screening tool as well as the follow-up and referral pathways required post-screening. This systematic review aimed to identify, describe and compare PND screening recommendations from member countries of the Organisation for Economic Co-operation and Development (OECD). Publications were identified through systematically searching PubMed, Google and the Guidelines International Network (GIN). Recommendations regarding PND screening endorsement, timing, frequency, responsible provider, tools/assessments and follow-up and referral were extracted. Twenty-one publications, including guidelines, from five countries were included. Most made recommendations in support of PND screening using the Edinburgh Postnatal Depression Scale. Details differed regarding terminology used, as well as frequency of screening, follow-up mechanisms and referral pathways. A broad range of health providers were considered to be responsible for screening. This is the first review to identify and compare PND screening recommendations from OECD member countries; however, only online publications published in English, from five countries were included. Heterogeneity of publication types and inconsistency in definitions rendered quality assessment inappropriate. While most publications generally endorsed PND screening, there are exceptions and the associated details pertaining to the actual conduct of screening vary between and within countries. Developing clear, standardised recommendations based on current evidence is necessary to ensure clarity amongst healthcare providers and a comprehensive approach for the early detection of PND.

Annual body mass index gain and risk of hypertensive disorders of pregnancy in a subsequent pregnancy

Weight gain during interpregnancy period is related to hypertensive disorders of pregnancy (HDP). However, in interpregnancy care/counseling, the unpredictability of the timing of the next conception and the difficulties in preventing age-related body weight gain must be considered while setting weight management goals. Therefore, we suggest considering the annual change in the body mass index (BMI). This study aimed to clarify the association between annual BMI changes during the interpregnancy period and HDP risk in subsequent pregnancies. A multicenter retrospective study of data from 2009 to 2019 examined the adjusted odds ratio (aOR) of HDP in subsequent pregnancies. The aORs in several annual BMI change categories were also calculated in the subgroups classified by HDP occurrence in the index pregnancy. This study included 1,746 pregnant women. A history of HDP (aOR, 16.76; 95% confidence interval [CI], 9.62 − 29.22), and annual BMI gain (aOR, 2.30; 95% CI, 1.76 − 3.01) were independent risk factors for HDP in subsequent pregnancies. An annual BMI increase of ≥ 1.0 kg/m²/year was related to HDP development in subsequent pregnancies for women without a history of HDP. This study provides data as a basis for interpregnancy care/counseling, but further research is necessary to validate our findings and confirm this relationship.

Differences in postpartum contraceptive choices and patterns following low- and high-risk pregnancy

OBJECTIVE

To assess the impact of a high-risk pregnancy on postpartum contraceptive planning and use.

METHODS

We conducted a retrospective cohort study of women who gave birth in a teaching hospital in 2020. We classified women into 2 groups based on their risk status according to the Society for Maternal-Fetal Medicine. The World Health Organization (WHO) tiers of contraceptive efficacy were used to categorize contraceptive planning and administration. The primary outcome was the utilization rate of Tier 1contraceptive methods at their postpartum visit in women with prior high-risk pregnancy. Univariate and multivariate analyses were carried out to determine the relationships between risk status, characteristics, contraceptive preference, and actual utilization.

RESULTS

This study included 788 low-risk and 482 high-risk postpartum women. High risk women indicated greater interest in (43.5% low-risk vs 52.2% high-risk, p < 0.01) and usage rates of (45.7% low-risk vs 54.3% high-risk, p = 0.01) Tier 1 contraception. The most commonly chosen contraceptive methods among low- and high-risk women were progestin-only pills (30.6%) and tubal ligation (36.4%), respectively. Uptake rates of immediate postpartum contraceptive implants did not differ between low (9.3%) and high-risk (11%) women (p = 0.32). Few patients adopted intrauterine devices (1.1%).

CONCLUSION

High-risk status was associated with intention to use and uptake of effective contraceptive methods, which persisted through the postpartum period.

IMPLICATIONS

To assist women in achieving the recommended interpregnancy intervals, counseling tailored to their individual risks and needs should be provided. Reasons for low intrauterine devices uptake should be explored. Postnatal care should include immediate postpartum long-acting reversible contraception (LARC) services.

What you don't know can hurt you: Patient and provider perspectives on postpartum contraceptive care in Illinois Catholic Hospitals

OBJECTIVE

Catholic Religious and Ethical Directives restrict access to contraception; yet offering contraception during a delivery hospitalization facilitates birth spacing and is a convenient option for patients during the postpartum period. We assessed patient and provider experiences with hospital transparency around postpartum contraceptive care in Illinois Catholic Hospitals.

STUDY DESIGN

We interviewed 44 participants with experience in Illinois Catholic Hospitals: 21 patients, and 23 providers, including clinicians, nurses, doulas, and postpartum program staff. We used an open-ended interview approach, with a semistructured guide focused on postpartum contraceptive care. We conducted interviews by phone between November 2019 and June 2020. We audio-recorded interviews, transcribed them verbatim, and coded transcripts in Dedoose. We developed narrative memos for each code, identifying themes and subthemes. We organized these in a matrix for analysis and present here themes regarding hospital transparency that emerged across interviews.

RESULTS

Many patients knew they were delivering in a Catholic hospital; however, few were aware that Catholic policies limited their health care options. Patients expressed a desire for hospitals to be transparent, even "very vocal," about religious restrictions and described consequences of restrictions on patient care. Patients lacked information to make contraceptive decisions, experienced limits on or delays in care, and some lost continuity with trusted providers. Consequences for providers included moral distress in trying to provide care using workarounds such as documenting false medical diagnoses.

CONCLUSIONS

Religious restrictions on postpartum contraception restrict access, cause unnecessary delays in care, and lead to misdiagnosis and marginalization of contraceptive care. Restrictions also cause moral distress to providers who balance career repercussions and professional integrity with patient needs.

IMPLICATIONS

To protect patient autonomy, especially during the vulnerable postpartum period, Catholic hospitals should increase transparency regarding limitations on reproductive health care. Insurers and policy-makers should guarantee that patients have the option to receive care at hospitals without these limitations and facilitate public education about what to expect at Catholic facilities.

Interconception Care for Primary Care Providers: Consensus Recommendations on Preconception and Postpartum Management of Reproductive-Age Patients With Medical Comorbidities

Severe maternal morbidity and mortality continue to increase in the United States, largely owing to chronic and newly diagnosed medical comorbidities. Interconception care, or care and management of medical conditions between pregnancies, can improve chronic disease control before, during, and after pregnancy. It is a crucial and time-sensitive intervention that can decrease maternal morbidity and mortality and improve overall health. Despite these potential benefits, interconception care has not been well implemented by the primary care community. Furthermore, there is a lack of guidelines for optimizing preconception chronic disease, risk stratifying postpartum chronic diseases, and recommending general collaborative management principles for reproductive-age patients in the period between pregnancies. As a result, many primary care providers, especially those without obstetric training, are unclear about their specific role in interconception care and may be unsure of effective methods for collaborating with obstetric care providers. In particular, internal medicine physicians, the largest group of primary care physicians, may lack sufficient clinical exposure to medical conditions in the obstetric population during their residency training and may feel uncomfortable in caring for these patients in their subsequent practice.

The objective of this article is to review concepts around interconception care, focusing specifically on preconception care for patients with chronic medical conditions (eg, chronic hypertension, chronic diabetes mellitus, chronic kidney disease, venous thromboembolism, and obesity) and postpartum care for those with medically complicated pregnancies (eg, hypertensive disorders of pregnancy, gestational diabetes mellitus, excessive gestational weight gain, peripartum cardiomyopathy, and peripartum mood disorders). We also provide a pragmatic checklist for preconception and postpartum management.

Early Resumption of Sexual Intercourse after First Childbirth and Unintended Pregnancy within Six Months

OBJECTIVE

We aimed to evaluate factors associated with early resumption of sexual intercourse after first childbirth and assess whether early intercourse is associated with unprotected intercourse, subsequent pregnancy, and unintended pregnancy over 6 months.

METHODS

This secondary analysis used data from the First Baby Study, a prospective study of women aged 18-35 years with singleton pregnancies who delivered at 76 hospitals in Pennsylvania. At 1 and 6 months postpartum, women were asked about intercourse and the use of birth control since childbirth. We compared women who resumed intercourse in the first month after childbirth (early resumption) with those who resumed intercourse later, via multivariable logistic regression models.

RESULTS

In our cohort, 261 of 2,643 women (9.9%) reported first intercourse within the first postpartum month (7-31 days). Women who resumed intercourse early were less educated, younger, and less likely to breastfeed, have had a perineal laceration, or have had an episiotomy than those who resumed intercourse later. In addition, they were more likely to have unprotected intercourse in at least one of the first 6 months after first childbirth (adjusted odds ratio [aOR], 2.33; 95% confidence interval [CI], 1.76-3.09); to be pregnant by 6 months postpartum (aOR, 3.03; 95% CI, 1.48-6.20); and to report that pregnancy as unintended (aOR, 3.32; 95% CI, 1.50-7.36).

CONCLUSIONS

Nearly 10% of women resumed intercourse in the first month after childbirth. Because early resumption of intercourse was associated with a greater likelihood of unprotected intercourse and unintended pregnancy within 6 months of first childbirth, clinicians should focus efforts on comprehensive family planning and contraception counseling beginning in the prenatal period.