Right-Sizing Prenatal Care to Meet Patients' Needs and Improve Maternity Care Value

Women's experiences with Centering-Based Group Care in Zhejiang China: A pilot study

BACKGROUND

The group prenatal care model, which caters to women with low medical needs but high support needs, has become a highly prevalent and innovative approach implemented globally. For Centering-Based Group Care (CBGC) to remain effective, women's evaluations of the quality of care and perspectives about the model are crucial.

AIM

This study aimed to describe women's appraisal of CBGC quality and explore the experiences of women in the mixed-methods pilot study conducted in Zhejiang, China.

METHODS

From August 2021 to December 2022, 20 women provided complete quantitative data using the Quality of Prenatal Care Questionnaire before hospital discharge. Semi-structured interviews were conducted at 6 months postpartum. Qualitative data were analysed using Colaizzi's method.

FINDINGS

The mean (standard deviation) total score (of the 5) of the questionnaire was 4.43 (0.1) with a good quality of CBGC. Qualitative research identified five themes: motivations and concerns for participation, the appeal of interactive learning, the development of community ties and social support, healing from psychological trauma with CBGC, and suggestions for CBGC enhancement.

DISCUSSION

Women rated CBGC quality as good and benefited significantly from it in the study. As a new alternative option, the women's accounts suggested that CBGC performed excellently in enhancing knowledge, strengthening social bonds, and providing psychological support.

CONCLUSION

CBGC quality cannot be determined based on limited the sample size. This pilot study provides evidence regarding the beneficial effects of knowledge, socialization, and psychological healing on CBGC. Further research is suggested to measure CBGC effectiveness and quality.

Improving Maternal Health Care Quality and Outcomes: Evaluation of a Pregnancy Medical Home

Current maternal care recommendations in the United States focus on monitoring fetal development, management of pregnancy complications, and screening for behavioral health concerns. Often missing from these recommendations is support for patients experiencing socioeconomic or behavioral health challenges during pregnancy. A Pregnancy Medical Home (PMH) is a multidisciplinary maternal health care team with nurse navigators serving as patient advocates to improve the quality of care a patient receives and health outcomes for both mother and infant. Using bivariate comparisons between PMH patients and reference groups, as well as interviews with project team members and PMH graduates, this evaluation assessed the impact of a PMH at an academic medical university on patient care and birth outcomes. This PMH increased depression screenings during pregnancy and increased referrals to behavioral health care. This evaluation did not find improvements in maternal or infant birth outcomes. Interviews found notable successes and areas for program enhancement.

Retrospective Use of Patients' Characteristics to Assess Variation in Prenatal Care Utilization

OBJECTIVE

 We used patients' medical and psychosocial risk factors to explore prenatal care utilization and health outcomes to inform prenatal care tailoring.

STUDY DESIGN

 This retrospective cohort study assessed patients who gave birth at an academic institution from January 1 to December 31, 2018, using electronic health record (EHR) data. Patients were categorized into four phenotypes based on medical/psychosocial risk factors available in the EHR: Completely low risk; High psychosocial risk only; High medical risk only; and Completely high risk. We examined patient characteristics, visit utilization, nonvisit utilization (e.g., phone calls), and outcomes (e.g., preterm birth, preeclampsia) across groups.

RESULTS

 Of 4,681 patients, the majority were age 18 to 35 (3,697, 79.0%), White (3,326, 70.9%), multiparous (3,263, 69.7%), and Completely high risk (2,752, 58.8%). More Black and Hispanic patients had psychosocial risk factors than White patients. Patients with psychosocial risk factors had fewer prenatal visits (10, interquartile range [IQR]: 8-12) than those without (11, IQR: 9-12). Patients with psychosocial risk factors experienced less time in prenatal care, more phone calls, and fewer EHR messages across the same medical risk group. Rates of preterm birth and gestational hypertension were incrementally higher with additional medical/psychosocial risk factors.

CONCLUSION

 Data readily available in the EHR can assess the compounding influence of medical/psychosocial risk factor on patients' care utilization and outcomes.

KEY POINTS

· Medical and psychosocial needs in pregnancy can inform patient phenotypes and are associated with prenatal care use and outcomes.. · Patient phenotypes are associated with prenatal care use and outcomes.. · Patients with high psychosocial risk spent less time in prenatal care and had more phone calls in pregnancy.. · Tailored prenatal care models may proactively address differences in patient's needs..

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service.

METHODS

We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors.

RESULTS

When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression.

DISCUSSION

No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

Antepartum Emergency Department Use and Associations with Maternal and Neonatal Outcomes in a Large Hospital System

Objectives

Prenatal care in the United States has remained unchanged for decades, with pregnant patients often experiencing high rates of hospital emergency department (ED) visits. It is unknown how many of these ED visits are potentially preventable with better access to timely and effective outpatient or home prenatal care. This multihospital health system quality improvement study was undertaken to analyze patient risk factors for acute antepartum hospital use as well as associations with adverse maternal and neonatal birth outcomes.

Methods

The retrospective cohort study analyzed electronic health record and administrative data on ED visits in the 270 days before a delivery admission for alive, singleton births at nine system hospitals over 52 months. We use logistic regression to estimate the likelihood of hospital use by patient demographic and clinical characteristics and present the association of acute antepartum hospital use with maternal and neonatal birth outcomes.

Results

Overall, 17.5% of 68,200 patients had antepartum ED visits, including 248 inpatient admissions, with significant variation between hospitals. As compared to non-Hispanic white patients, Hispanic and especially non-Hispanic Black and Medicaid patients had significantly higher odds of acute antepartum hospital use as did patients with preexisting conditions. Birth outcomes were significantly (p < 0.01) worse among individuals with antepartum hospital utilization.

Conclusion

Acute antepartum hospital use was concentrated among lower income, minority patients, and those with chronic conditions with significant variation across system hospitals. There is a need for research into innovations in prenatal care that are best at reaching our most vulnerable patients, reducing preventable hospital utilization, and improving birth outcomes.

Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012-2021

To evaluate associations between depression and/or anxiety disorders during pregnancy (DAP), delivery-related outcomes, and healthcare utilization among individuals with Michigan Medicaid-funded deliveries. We conducted a retrospective delivery-level analysis comparing delivery-related outcomes and healthcare utilization among individuals with and without DAP between January 2012 and September 2021. We used generalized estimating equation models assessing cesarean and preterm delivery; 30-day readmission after delivery; severe maternal morbidity within 42 days of delivery; and ambulatory, inpatient, emergency department or observation (ED), psychotherapy, or substance use disorders (SUD) visits during pregnancy. We adjusted models for age, race/ethnicity, urbanicity, federal poverty level, and obstetric comorbidities. Among 170,002 Michigan Medicaid enrollees with 218,890 deliveries, 29,665 (13.6%) had diagnoses of DAP. Compared to those without DAP, individuals with DAP were more often White, rural dwelling, had lower income, and had more comorbidities. In adjusted models, deliveries with DAP had higher odds of cesarean and preterm delivery OR = 1.02, 95% CI: [1.00, 1.05] and OR = 1.15, 95% CI: [1.11, 1.19] respectively), readmission within 30 days postpartum (OR = 1.14, 95% CI: [1.07, 1.22]), SMM within 42 days (OR = 1.27, 95% CI: [1.18, 1.38]), and utilization compared to those without DAP diagnoses (ambulatory: OR = 7.75, 95% CI: [6.75, 8.88], inpatient: OR = 1.13, 95% CI: [1.11, 1.15], ED: OR = 1.86, 95% CI: [1.80, 1.92], psychotherapy: OR = 172.8, 95% CI: [160.10, 186.58], and SUD: OR = 5.6, 95% CI: [5.37, 5.85]). Among delivering individuals in Michigan Medicaid, DAP had significant associations with adverse delivery-related outcomes and greater healthcare use. Early detection and intervention to address mental illness during pregnancy may help mitigate burdens of these complex yet treatable disorders.

Variation in Outpatient Postpartum Care Use in the United States: A Latent Class Analysis

INTRODUCTION

Despite efforts to improve postpartum health care in the United States, little is known about patterns of postpartum care beyond routine postpartum visit attendance. This study aimed to describe variation in outpatient postpartum care patterns.

METHODS

In this longitudinal cohort study of national commercial claims data, we used latent class analysis to identify subgroups of patients (classes) with similar outpatient postpartum care patterns (defined by the number of preventive, problem, and emergency department outpatient visits in the 60 days after birth). We also compared classes in terms of maternal sociodemographics and clinical characteristics measured at childbirth, as well as total health spending and rates of adverse events (all-cause hospitalizations and severe maternal morbidity) measured from childbirth to the late postpartum period (61-365 days after birth).

RESULTS

The study cohort included 250,048 patients hospitalized for childbirth in 2016. We identified six classes with distinct outpatient postpartum care patterns in the 60 days after birth, which we classified into three broad groups: no care (class 1 [32.4% of the total sample]); preventive care only (class 2 [18.3%]); and problem care (classes 3-6 [49.3%]). The prevalence of clinical risk factors at childbirth increased progressively from class 1 to class 6; for example, 6.7% of class 1 patients had any chronic disease compared with 15.5% of class 5 patients. Severe maternal morbidity was highest among the high problem care classes (classes 5 and 6): 1.5% of class 6 patients experienced severe maternal morbidity in the postpartum period and 0.5% in the late postpartum period, compared with less than 0.1% of patients in classes 1 and 2.

CONCLUSIONS

Efforts to redesign and measure postpartum care should reflect the current heterogeneity in care patterns and clinical risks in the postpartum population.

Routine Prenatal Care

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Personas of pregnant and parenting women with substance use and their barriers and pathways to system engagement

BACKGROUND

Women with prenatal substance use have been identified as at-risk for the lack of engagement in perinatal services, such as medical care and home visitation programs. This issue is of particular concern in Florida (United States) where rates of fetal substance exposure have been steadily increasing.

METHODS

To identify pathways of and barriers to perinatal system and service engagement, journey mapping was used to compile various personas of perinatal women with substance use. A structured guide was developed to elicit maternal personas, system and service touchpoints, and system strengths and weaknesses from focus group participants with statewide stakeholders, including perinatal service administrators and community coalition members within three Florida communities. Workshop transcripts, debriefing, and member-checking sessions were transcribed verbatim and analyzed manually.

RESULTS

Six journey-mapping workshops and two member-checking meetings with mothers in-recovery were conducted with a total of 109 participants. Four personas were identified: women who (1) have substance use on a recreational basis, (2) have prescription drug use/misuse, (3) have chronic substance dependence, and (4) are in-recovery from substance dependence. Pathways that promote and barriers that prevent perinatal women with substance use from being identified, referred, or willing to accept and engage in medical care and social services were identified.

CONCLUSIONS

While these personas shed light on differential pathways experienced by women with OUD, they were not intended as fixed-member groups but rather fluid descriptions of circumstances in which individuals could shift over time. These personas are beneficial to understand differences in circumstances, as well as variations in pathways and barriers to service engagement. Additionally, personas may be used to identify approaches to optimize service engagement by perinatal women with substance use and to support system improvements and integrations.

Changes to Prenatal Care Visit Frequency and Telehealth: A Systematic Review of Qualitative Evidence

OBJECTIVE

To systematically review patient, partner or family, and clinician perspectives, preferences, and experiences related to prenatal care visit schedules and televisits for routine prenatal care.

DATA SOURCES

PubMed, the Cochrane databases, EMBASE, CINAHL, ClinicalTrials.gov , PsycINFO, and SocINDEX from inception through February 12, 2022.

METHODS OF STUDY SELECTION

This review of qualitative research is a subset of a larger review on both the qualitative experiences and quantitative benefits and harms of reduced prenatal care visit schedules and televisits for routine prenatal care that was produced by the Brown Evidence-based Practice Center for the Agency for Healthcare Research and Quality. For the qualitative review, we included qualitative research studies that examined perspectives, preferences, and experiences about the number of scheduled visits and about televisits for routine prenatal care.

TABULATION, INTEGRATION, AND RESULTS

We synthesized barriers and facilitators to the implementation of reduced care visits or of televisits into 1 of 14 domains defined by the Theoretical Domains Framework (TDF) and a Best Fit Framework approach. We summarized themes within TDF domains. We assessed our confidence in the summary statements using the GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative research) tool. Four studies addressed the number of scheduled routine prenatal visits, and five studies addressed televisits. Across studies, health care professionals believed fewer routine visits may be more convenient for patients and may increase clinic capacity to provide additional care for patients with high-risk pregnancies. However, both patients and clinicians had concerns about potential lesser care with fewer visits, including concerns about quality of care and challenges with implementing new delivery-of-care models.

CONCLUSION

Although health care professionals and patients had some concerns about reduced visit schedules and use of televisits, several potential benefits were also noted. Our synthesis of qualitative evidence provides helpful insights into the perspectives, preferences, and experiences of important stakeholders with respect to implementing changes to prenatal care delivery that may complement findings of traditional quantitative evidence syntheses.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

What Is New in Obstetric Anesthesia: The 2021 Gerard W. Ostheimer Lecture

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiologists. In this review, some of the most influential articles discussed in the 2021 virtual lecture are highlighted. Themes include maternal mortality; disparities and social determinants of health; cognitive function, mental health, and recovery; quality and safety; operations, value, and economics; clinical controversies and dogmas; epidemics and pandemics; fetal-neonatal and child health; general clinical care; basic and translational science; and the future of peripartum anesthetic care. Practice-changing evidence is presented and evaluated. A priority list for clinical updates, systems, and quality improvement initiatives is presented.

Using medical expenditure panel survey data to explore the relationship between patient-centered medical homes and racial disparities in severe maternal morbidity outcomes

BACKGROUND

There are persistent racial/ethnic disparities in the occurrence of severe maternal morbidity. Patient-centered medical home care has the potential to address disparities in maternal outcomes.

OBJECTIVES

To examine (1) the association between receiving patient-centered medical home care and severe maternal morbidity outcomes and (2) the interaction of race/ethnicity on patient-centered medical home status and severe maternal morbidity.

DESIGN/METHODS

Using 2007 to 2016 data from the Medical Expenditures Panel Survey, we conducted a cross-sectional study to estimate the association between receipt of care from a patient-centered medical home and the occurrence of severe maternal morbidity, and racial-specific (White, Black, Asian, Other) relative risks of severe maternal morbidity. Our study used race as a proxy measure for exposure racism. We identified mothers (⩾15 years) who gave birth during the study period. We identified patient-centered medical home qualities using 11 Medical Expenditures Panel Survey questions and severe maternal morbidities using medical claims, and calculated generalized estimating equation models to estimate odds ratios of severe maternal morbidity and 95% confidence intervals.

RESULTS

Among all mothers who gave birth (N = 2801; representing 5,362,782 US lives), only 25% received some exposure patient-centered medical home care. Two percent experienced severe maternal morbidity, and this did not differ statistically (p = 0.11) by patient-centered medical home status. However, our findings suggest a 85% decrease in the risk of severe maternal morbidity among mothers who were defined as always attending a patient-centered medical home (odds ratios: 0.15; 95% confidence interval:0.01-1.87; p = 0.14) and no difference in the risk of severe maternal morbidity among mothers who were defined as sometimes attending a patient-centered medical home (odds ratios: 1.00; 95% confidence interval:0.16-6.42; p = 1.00). There was no overall interaction effect in the model between race and patient-centered medical home groups (p = 0.82), or ethnicity and patient-centered medical home groups (p = 0.62) on the severe maternal morbidity outcome.

CONCLUSION

While the rate of severe maternal morbidity was similar to US rates, few mothers received care from a patient-centered medical home which may be due to underreporting. Future research should further investigate the potential for patient-centered medical home-based care to reduce odds of severe maternal morbidity across racial/ethnic groups.

Association Between Utilization of Digital Prenatal Services and Vaginal Birth After Cesarean

INTRODUCTION

Digital health services are a promising but understudied method for reducing common barriers to vaginal birth after cesarean (VBAC), including connection to facilities offering labor after cesarean and patient-centered counseling about mode of birth. This study assesses the relationship between use of digital prenatal services and VBAC.

METHODS

In this retrospective cohort study, we analyzed the use of digital prenatal services and mode of birth among users of an employer-sponsored digital women's and family digital health platform. All users had a prior cesarean birth. Users' self-reported data included demographics, medical history, and birth preferences. We used basic descriptive statistics and logistic regression models to assess the association between digital services utilization and VBAC, adjusting for key patient characteristics.

RESULTS

Of 271 included users, 44 (16.2%) had a VBAC and 227 (83.8%) had a cesarean birth. Users of both groups were similar in age, race, and ethnicity. Fewer users in the VBAC group (5/44, 11.4%) as compared with the cesarean birth group (62/227, 27.3%) had a prepregnancy body mass index greater than or equal to 30 (P = 0.02). Likewise, more users in the VBAC group preferred vaginal birth (34/44, 77.3% vs 55/227, 24.2%; P < 0.01). In adjusted models, the services associated with VBAC were care advocate appointments (adjusted odds ratio [aOR], 7.67; 95% CI, 1.99-54.4), health care provider appointments (aOR, 1.12; 95% CI, 1.02-1.25), and resource reads (aOR, 1.05, 95% CI, 1.00-1.09). VBAC rates were higher for users who reported the digital health platform influenced aspects of their pregnancy and birth.

DISCUSSION

Reducing cesarean birth rates is a national priority. Digital health services, particularly care coordination and education, are promising for accomplishing this goal through increasing rates of trial of labor after cesarean and subsequent VBAC rates.

Patterns of Prenatal Care Delivery and Obstetric Outcomes before and during the COVID-19 Pandemic

OBJECTIVE

 Health care providers and health systems confronted new challenges to deliver timely, high-quality prenatal care during the coronavirus disease 2019 (COVID-19) pandemic as the pandemic raised concerns that care would be delayed or substantively changed. This study describes trends in prenatal care delivery in 2020 compared with 2018 to 2019 in a large, commercially insured population and investigates changes in obstetric care processes and outcomes.

STUDY DESIGN

 This retrospective cohort study uses de-identified administrative claims for commercially insured patients. Patients whose entire pregnancy took place from March 1 to December 31 in years 2018, 2019, and 2020 were included. Trends in prenatal care, including in-person, virtual, and emergency department visits, were evaluated, as were prenatal ultrasounds. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included preterm birth and stillbirth. To determine whether COVID-19 pandemic-related changes in prenatal care had an impact on maternal outcomes, we compared the outcome rates during the pandemic period in 2020 to equivalent periods in 2018 and 2019.

RESULTS

 In total, 35,112 patients were included in the study. There was a significant increase in the prevalence of telehealth visits, from 1.1 to 1.2% prior to the pandemic to 17.2% in 2020, as well as a significant decrease in patients who had at least one emergency department visit during 2020. Overall prenatal care and ultrasound utilization were unchanged. The rate of SMM across this period was stable (2.3-2.8%) with a statistically significant decrease in the preterm birth rate in 2020 (7.4%) compared with previous years (8.2-8.6%; p < 0.05) and an unchanged stillbirth rate was observed.

CONCLUSION

 At a time when many fields of health care were reshaped during the pandemic, these observations reveal considerable resiliency in both the processes and outcomes of obstetric care.

KEY POINTS

· Overall prenatal care and ultrasound were unchanged from 2018 to 2019 to 2020.. · There was a large increase in the prevalence of telehealth visits in 2020.. · There was no change in the rate of severe maternal morbidity or stillbirth in 2020 compared with 2018 to 2019..

Adequate Prenatal Care: An Integrative Review

INTRODUCTION

Prenatal care (PNC) is a core element of preventive care and is vital in identifying and managing conditions that can put the pregnant person and the fetus at risk. National and international guidelines differ in what is considered adequate or quality PNC. Indices of care adequacy rely only on number of attended PNC visits without regard to factors that affect a patient's ability to obtain care or the quality of the care received. This integrative review explored stakeholders' perceptions of adequate and quality PNC.

METHODS

Three electronic databases, CINAHL, PubMed, and Web of Science, were searched to identify original research articles published between 2012 and April 2022. Studies conducted in the United States, published in a peer-reviewed journal, and having a primary focus on the components of adequate or quality PNC were included. The quality of included studies was assessed via the Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

Thirteen articles met inclusion criteria. The concepts of adequate or quality PNC were not well defined in the literature. Studies revealed a variety of approaches to assessing individual components of PNC with at times conflicting results of what adequate or quality PNC is. Viewpoints regarding adequacy or quality of PNC were limited by the perceptions and interpretations of individual stakeholders, who included researchers, public health officials, insurers, health care providers, and patients.

DISCUSSION

Ideas of how to redesign PNC were affected by study setting and stakeholders, as well as the emergence and integration of telehealth into PNC delivery. This review is a first step in identifying the gap in the research literature regarding how these concepts are defined and measured. Future research is needed to identify the relevant components of PNC that are necessary to reach consensus definitions of both adequacy and quality of PNC.

Experiences With Prenatal Care Delivery Reported by Black Patients With Low Income and by Health Care Workers in the US: A Qualitative Study

IMPORTANCE

Black pregnant people with low income face inequities in health care access and outcomes in the US, yet their voices have been largely absent from redesigning prenatal care.

OBJECTIVE

To examine patients' and health care workers' experiences with prenatal care delivery in a largely low-income Black population to inform care innovations to improve care coordination, access, quality, and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

For this qualitative study, human-centered design-informed interviews were conducted at prenatal care clinics with 19 low-income Black patients who were currently pregnant or up to 1 year post partum and 19 health care workers (eg, physicians, nurses, and community health workers) in Detroit, Michigan, between October 14, 2019, and February 7, 2020. Questions focused on 2 human-centered design phases: observation (understanding problems from the end user's perspective) and ideation (generating novel potential solutions). Questions targeted participants' experiences with the 3 goals of prenatal care: medical care, anticipatory guidance, and social support. An eclectic analytic strategy, including inductive thematic analysis and matrix coding, was used to identify promising strategies for prenatal care redesign.

MAIN OUTCOMES AND MEASURES

Preferences for prenatal care redesign.

RESULTS

Nineteen Black patients (mean [SD] age, 28.4 [5.9] years; 19 [100%] female; and 17 [89.5%] with public insurance) and 17 of 19 health care workers (mean [SD] age, 47.9 [15.7] years; 15 female [88.2%]; and 13 [76.5%] Black) completed the surveys. A range of health care workers were included (eg, physicians, doulas, and social workers). Although all affirmed the 3 prenatal care goals, participants reported failures and potential solutions for each area of prenatal care delivery. Themes also emerged in 2 cross-cutting areas: practitioners and care infrastructure. Participants reported that, ideally, care structure would enable strong ongoing relationships between patients and practitioners. Practitioners would coordinate all prenatal services, not just medical care. Finally, care would be tailored to individual patients by using care navigators, flexible models, and colocation of services to reduce barriers.

CONCLUSIONS AND RELEVANCE

In this qualitative study of low-income, Black pregnant people in Detroit, Michigan, and the health care workers who care for them, prenatal care delivery failed to meet many patients' needs. Participants reported that an ideal care delivery model would include comprehensive, integrated services across the health care system, expanding beyond medical care to also include patients' social needs and preferences.

Modeling the Likelihood of Low Birth Weight: Findings from a Chicago-Area Health System

OBJECTIVE

This study presents a statistical model of the incidence of low birth weight (LBW) births in a large, Chicago-area hospital system. The study was undertaken to provide a strategic framework for future health system interventions.

METHODS

Administrative and electronic health records were matched to census Zip Code Tabulation Area (ZCTA) household poverty data for 42,681 births in 2016-2019 at seven system hospitals, serving a diverse patient population. A logistic regression model of LBW incidence was estimated to test the independent significance of maternal sociodemographic characteristics after controlling for clinical risk factors.

RESULTS

The incidence of LBW was 6.3% overall but 11.3% among non-Hispanic Black patients as compared to 5.1% among non-Hispanic White patients. LBW incidence ranged from 9.2% for patients from the poorest ZCTA (20% + poor households) compared to 5.6% of patients from the most affluent (< 5% poor) ZCTA. Nulliparous patients, patients with pre-existing chronic conditions, and patients with hypertensive disorders of pregnancy were significantly more likely to have LBW births. After controlling for clinical risk factors and poverty level, non-Hispanic Black patients were still over 80% more likely and to have a LBW birth.

DISCUSSION

Study findings reveal the joint effects of social and clinical risk factors. Findings profile our highest-risk populations for targeted interventions. Promising prenatal care redesign programs include pregnancy patient navigators, home and group visits, eHealth telemonitoring, improved mental health screening, and diversification of the maternity care workforce. Decreasing LBW births should be a national public health policy priority and will require major investments in the most impacted communities.

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women

OBJECTIVE

To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care.

DATA SOURCES AND STUDY SETTING

We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021.

STUDY DESIGN

Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery.

DATA COLLECTION / EXTRACTION METHODS

Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.

PRINCIPLE FINDINGS

We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.

CONCLUSIONS

Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.

Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations: A Practical Guide for Maternity Care Clinicians

Prenatal care is an important preventive service designed to improve the health of pregnant patients and their infants. Prenatal care delivery recommendations have remained unchanged since 1930, when the 12-14 in-person visit schedule was first established to detect preeclampsia. In 2020, the American College of Obstetricians and Gynecologists, in collaboration with the University of Michigan, convened a panel of maternity care experts to determine new prenatal care delivery recommendations. The panel recognized the need to include emerging evidence and experience, including significant changes in prenatal care delivery during the COVID-19 pandemic, pre-existing knowledge of the importance of individualized care plans, the promise of telemedicine, and the significant influence of social and structural determinants of health (SSDoH) on pregnancy outcomes. Recommendations were derived using the RAND-UCLA appropriateness method, a rigorous e-Delphi method, and are designed to extend beyond the acute public health crisis. The resulting Michigan Plan for Appropriate Tailored Healthcare in pregnancy (MiPATH) includes recommendations for key aspects of prenatal care delivery: (1) the recommended number of prenatal visits, (2) the frequency of prenatal visits, (3) the role of monitoring routine pregnancy parameters (blood pressure, fetal heart tones, weight, and fundal height), (4) integration of telemedicine into routine care, and (5) inclusion of (SSDoH). Resulting recommendations demonstrate a new approach to prenatal care delivery that incorporates medical, SSDoH, and patient preferences, to develop individualized prenatal care delivery plans. The purpose of this document is to outline the new MiPATH recommendations and to provide practical guidance on implementing them in routine practice.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020

PURPOSE

The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes.

METHODS

Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor.

RESULTS

While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication.

CONCLUSION

This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

Obstetrical Telehealth and Virtual Care Practices During the COVID-19 Pandemic

The coincidence of a global pandemic with 21st-century telecommunication technology has led to rapid deployment of virtual obstetric care beginning in March of 2020. Pregnancy involves uniquely time-sensitive health care that may be amenable to restructuring into a hybrid of telemedicine and traditional visits to optimize accessibility and outcomes. The coronavirus disease 2019 pandemic has provided an unprecedented natural laboratory to explore how virtual obstetric care programs can be developed, implemented, and maintained, both as a contingency model for the pandemic and potentially for the future. Here, we discuss the role of telehealth and virtual care for pregnancy management in the coronavirus disease 2019 pandemic, as well as anticipated barriers, challenges, and strategies for success for obstetric telemedicine.

Variation in guideline-based prenatal care in a commercially insured population

BACKGROUND

Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied.

OBJECTIVE

This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics.

STUDY DESIGN

This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment.

RESULTS

The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income.

CONCLUSION

In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.

The Impact of a Population-Based System of Care Intervention on Enhanced Prenatal Care and Service Utilization Among Medicaid-Insured Pregnant Women

INTRODUCTION

Enhanced prenatal/postnatal care home visiting programs for Medicaid-insured women have significant positive impacts on care and health outcomes. However, enhanced prenatal care participation rates are typically low, enrolling <30% of eligible women. This study investigates the impacts of a population-based systems approach on timely enhanced prenatal care participation and other healthcare utilization.

METHODS

This quasi-experimental, population-based, difference-in-differences study used linked birth certificates, Medicaid claims, and enhanced prenatal care data from complete statewide Medicaid birth cohorts (2009 to 2015), and was analyzed in 2019-2020. The population-based system intervention included cross-agency leadership and work groups, delivery system redesign with clinical-community linkages, increased enhanced prenatal care-Community Health Worker care, and patient empowerment. Outcomes included enhanced prenatal care participation and early participation, prenatal care adequacy, emergency department contact, and postpartum care.

RESULTS

Enhanced prenatal care (7.4 percentage points, 95% CI=6.3, 8.5) and first trimester enhanced prenatal care (12.4 percentage points, 95% CI=10.2, 14.5) increased among women served by practices with established clincial-community linkages, relative to that among the comparator group. First trimester enhanced prenatal care improved in the county (17.9, 95% CI=15.7, 20.0), emergency department contact decreased in the practices (-11.1, 95% CI= -12.3, -9.9), and postpartum care improved in the county (7.1, 95% CI=6.0, 8.2). Enhanced prenatal care participation for Black women served by the practices improved (4.4, 95% CI=2.2, 6.6) as well as early enhanced prenatal care (12.3, 95% CI=9.0, 15.6) and use of postpartum care (10.4, 95% CI=8.3, 12.4).

CONCLUSIONS

A population systems approach improved selected enhanced prenatal care participation and service utilization for Medicaid-insured women in a county population, those in practices with established clinical-community linkages, and Black women.

Association of Prenatal Care Services, Maternal Morbidity, and Perinatal Mortality With the Advanced Maternal Age Cutoff of 35 Years

Importance

Maternal and perinatal mortality remain high in the US despite growing rates of prenatal services and spending, and little rigorous evidence exists regarding the impact of prenatal care intensity on pregnancy outcomes. Patients with an expected date of delivery just after their 35th birthday may receive more intensive care owing to the advanced maternal age (AMA) designation; whether this increase in prenatal care is associated with improvements in outcomes has not been explored.

Objective

To determine the association between the AMA designation and prenatal care services, severe maternal morbidity, and perinatal mortality.

Design Setting and Participants

This cross-sectional study used a regression discontinuity design to compare individuals just above vs just below the 35-year AMA cutoff, using unidentifiable administrative claims data from a large, nationwide commercial insurer. All individuals with a delivery between January 1, 2008, and December 31, 2019, who were aged 35 years within 120 days of their expected date of delivery were included in the study. Analyses were performed from July 1, 2020, to February 1, 2021.

Exposures

Individuals who were aged 35.0 through 35.3 years on the expected date of delivery were designated as AMA.

Main Outcomes and Measures

Outcomes were visits with specialists (obstetrician-gynecologists and maternal-fetal medicine), ultrasound scan use, antepartum fetal surveillance, aneuploidy screening, severe maternal morbidity, preterm birth or low birth weight, and perinatal mortality.

Results

The analysis included 51 290 individuals (mean [SD] age; 34.5 [0.5] years); 26 108 individuals (50.9%) were aged 34.7 to 34.9 years and 25 182 individuals (49.1%) were aged 35.0 to 35.3 years on the expected date of delivery. A total of 2407 pregnant individuals (4.7%) had multiple gestation, 2438 (4.8%) had pregestational diabetes, 2265 (4.4%) had chronic hypertension, and 4963 (9.7%) had obesity. Advanced maternal age was associated with a 4.27 percentage point increase in maternal-fetal medicine visits (95% CI, 2.27-6.26 percentage points; P < .001), a 0.21 unit increase in total ultrasound scans (95% CI, 0.06-0.37; P = .006), a 15.67 percentage point increase in detailed ultrasound scans (95% CI, 13.68-17.66 percentage points; P < .001), and a 4.86 percentage point increase in antepartum surveillance (95% CI, 2.83-6.89 percentage points; P < .001). The AMA designation was associated with a 0.39 percentage point decline in perinatal mortality (95% CI, -0.77 to -0.01 percentage points; P = .04).

Conclusions and Relevance

In this cross-sectional study, the AMA designation at age 35 years was associated with an increase in receipt of prenatal monitoring and a small decrease in perinatal mortality, suggesting that the AMA designation may be associated with clinical decision-making, with individuals just older than 35 years receiving more prenatal monitoring. These results suggest that increases in prenatal care services stemming from the AMA designation may have important benefits for fetal and infant survival for patients in this age range.

Evaluation of rapid telehealth implementation for prenatal and postpartum care visits during the COVID-19 pandemic in an academic clinic in Springfield, Massachusetts, United States of America

BACKGROUND AND AIMS

COVID-19 forced healthcare systems to implement telehealth programs, facilitated in Massachusetts by a policy requiring insurers to reimburse for telehealth visits. Prior studies suggest that telehealth is effective for obstetric care, but little is known about its implementation in response to policy changes in underserved communities. We utilized the RE-AIM framework to evaluate telehealth implementation in a large academic urban obstetric practice that serves a medically underserved population.

METHODS

RE-AIM elements were assessed through retrospective review of electronic health record (EHR) data for all obstetric encounters between March 19 and August 31, 2020 and review of clinic implementation processes. Data extracted included demographics, number and type (in-person or telehealth) of prenatal visits, prenatal diagnoses, delivery outcomes, and number and type of postpartum visits. Data were analyzed using descriptive statistics.

RESULTS

A total of 558 patients (60.6% Hispanic; 13.2% primary language Spanish) had 1788 prenatal visits, of which 698 (39.0%) were telehealth visits. A total of 209 patients had 230 postpartum visits, of which 101 (48.3%) were telehealth visits. The Reach of the intervention increased from 0% of patients at baseline to 69% in August. Effectiveness measures were limited but suggested potential for earlier diagnosis of some prenatal conditions. Adoption was high, with all 30 providers using telehealth, and the telehealth was found to likely be feasible and acceptable based on uptake. Increases in the percentage of telehealth visits over time and continuation post-lockdown suggested maintenance was potentially achievable.

CONCLUSIONS

The COVID-19 pandemic has changed traditional approaches to healthcare delivery. We demonstrate that the use of the RE-AIM framework can be effective in facilitating implementation of telephone visits in a large academic urban obstetric practice after state-level policy change. This may be of particular importance in settings serving patients at higher risk for maternal morbidity and poor birth outcomes.

Antepartum hospital use and delivery outcomes in California

BACKGROUND

There are few population-based studies of antepartum emergency department visits and inpatient hospitalizations and their implications for delivery outcomes.

OBJECTIVE

The study aimed to analyze the likelihood of pregnant patients's antepartum hospital use using population-based hospital discharge data for births in California. The study analyzed associations between antepartum hospital use and the likelihood of maternal delivery complications and postpartum hospital use.

STUDY DESIGN

This was a population-based retrospective cohort study of individuals with live births in state-licensed hospitals in California in 2017. Delivery admissions data were linked to antepartum hospital visits within 280 days of a delivery admission and 90 days after a delivery discharge. The most common principal or primary International Classification of Diseases, Tenth Revision-coded diagnoses for antepartum emergency department visits and inpatient hospitalizations were identified and Poisson regression estimates were used to determine the likelihood of antepartum hospital use by maternal demographic and clinical characteristics. Complicated deliveries were defined by International Classification of Diseases, Tenth Revision-coded severe maternal morbidity, vaginal or cesarean delivery complications, or long length of stay after delivery (>4 days for a vaginal delivery and >5 days for a cesarean delivery). Associations between specific types of antepartum visits, complicated deliveries, and postpartum hospital use were analyzed by chi-square tests. Logistic regression estimates were used to determine the significance of associations between antepartum hospital use and likelihood of a complicated delivery.

RESULTS

Of 348,848 deliveries at 246 hospitals in California, in 2017, with linkable data, almost one-third of the patients (30.4% with emergency department visits and 1.2% with inpatient hospital stays) experienced antepartum hospital use. Those who were younger, identified as a racial or ethnic minority, and with a low income, were the most likely to have antepartum hospital use. The most common primary diagnoses for antepartum emergency department visits were threatened abortions (19.6%), urinary tract infections (11.2%), and hemorrhage (9.3%). The most common principal diagnoses for antepartum hospitalizations were preterm labor (14.3%), pyelonephritis (10.2%), and hyperemesis gravidarum (6.3%). Patients with any antepartum hospital use were significantly more likely to experience a delivery complication, even after controlling for conditions coded during the delivery admission. Although having an antepartum emergency department visit was associated with only modestly increased adjusted odds (odds ratio, 1.04; 95% confidence interval, 1.01-1.08) of a complicated delivery, patients with any antepartum hospitalizations, especially those with preterm prelabor rupture of membranes, hypertension, diabetes, or hemorrhage, were at higher risk (odds ratio, 1.38; 95% confidence interval, 1.28-1.47).

CONCLUSION

Antepartum hospital use is frequent and is associated with patient clinical and demographic factors. Addressing the high prevalence of antepartum hospital use should be a part of future quality improvement and health equity efforts focused on improving care for patients with the greatest medical and social needs.

The Michigan Plan for Appropriate Tailored Health Care in Pregnancy Prenatal Care Recommendations

OBJECTIVE

To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare) in pregnancy panel process and key recommendations for prenatal care delivery.

METHODS

We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine).

RESULTS

The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices.

CONCLUSION

The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

A Review of Prenatal Care Delivery to Inform the Michigan Plan for Appropriate Tailored Health Care in Pregnancy Panel

OBJECTIVE

To perform a literature review of key aspects of prenatal care delivery to inform new guidelines.

DATA SOURCES

A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction.

TABULATION, INTEGRATION, AND RESULTS

Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth.

CONCLUSION

Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

Using human centered design to identify opportunities for reducing inequities in perinatal care

Background

Extreme disparities in access, experience, and outcomes highlight the need to transform how pregnancy care is designed and delivered in the United States, especially for low-income individuals and people of color.

Methods

We used human-centered design (HCD) to understand the challenges facing Medicaid-insured pregnant people and design interventions to address these challenges. The HCD method has three phases: Inspiration, Ideation, and Implementation. This study focused on the first and second. In the Inspiration phase we conducted semi-structured interviews with a purposeful sample of stakeholders who had either received or participated in the care of Medicaid-insured pregnant people within our community, with a specific emphasis on representation from marginalized communities. Using a general inductive approach to thematic analysis, we identified themes, which were then framed into design opportunities. In the Ideation phase, we conducted structured brainstorming sessions to generate potential prototypes of solutions, which were tested and iterated upon through a series of community events and engagement with a diverse community advisory group.

Results

We engaged a total of 171 stakeholders across both phases of the HCD methodology. In the Inspiration phase, interviews with 23 community members and an eight-person focus group revealed seven insights centered around two main themes: (1) racism and discrimination create major barriers to access, experience, and the ability to deliver high-value pregnancy care; (2) pregnancy care is overmedicalized and does not treat the pregnant person as an equal and informed partner. In the Ideation phase, 162 ideas were produced and translated into eight solution prototypes. Community scoring and feedback events with 140 stakeholders led to the progressive refinement and selection of three final prototypes: (1) implementing telemedicine (video visits) within the safety-net system, (2) integrating community-based peer support workers into healthcare teams, and (3) delivering co-located pregnancy-related care and services into high-need neighborhoods as a one-stop shop.

Conclusions

Using HCD methodology and a collaborative community-health system approach, we identified gaps, opportunities, and solutions to address perinatal care inequities within our urban community. Given the urgent need for implementable and effective solutions, the design process was particularly well-suited because it focuses on understanding and centering the needs and values of stakeholders, is multi-disciplinary through all phases, and results in prototyping and iteration of real-world solutions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06609-8.

Geographic barriers to prenatal care access and their consequences

BACKGROUND

Although prenatal care has long been viewed as an important strategy toward improving maternal morbidity and mortality, limited data exist that support the premise that access to prenatal care impacts perinatal outcomes. Furthermore, little is known about geographic barriers that impact access to care in an underserved population and how this may influence perinatal outcomes.

OBJECTIVE

This study aimed to (1) evaluate perinatal outcomes among women with and without prenatal care and (2) examine barriers to receiving prenatal care according to block-level data of residence. We hypothesized that women without prenatal care would have worse outcomes and more barriers to receiving prenatal care services.

STUDY DESIGN

This was a retrospective cohort study of pregnant women delivering at ≥24 weeks' gestation in a large inner-city public hospital system. Maternal and neonatal data were abstracted from the electronic health record and a community-wide data initiative data set, which included socioeconomic and local geographic data from diverse sources. Maternal characteristics and perinatal outcomes were examined among women with and without prenatal care. Prenatal care was defined as at least 1 visit before delivery. Outcomes of interest were (1) preterm delivery at <37 weeks' gestation, (2) preeclampsia or eclampsia, and (3) days in the neonatal intensive care unit after delivery. Barriers to care were analyzed, including public transportation access and location of the nearest county-sponsored prenatal clinic according to block-level location of residence. Statistical analysis included chi-square test and analysis of variance with logistic regression performed for adjustment of demographic features.

RESULTS

Between January 1, 2019, and October 31, 2019, 9488 women received prenatal care and 326 women did not. Women without prenatal care differed by race and were noted to have higher rates of substance use (P=.004), preterm birth (P<.001), and longer lengths of newborn admission (P<.001). After adjustment for demographic features, higher rates of preterm birth in women without prenatal care persisted (adjusted odds ratio, 2.65; 95% confidence interval, 1.95-3.55). Women without prenatal care resided in areas that relied more on public transportation and required longer transit times (42 minutes vs 30 minutes; P=.005) with more bus stops (29 vs 17; P<.001) to the nearest county-sponsored prenatal clinic.

CONCLUSION

Women without prenatal care were at a significantly increased risk of adverse pregnancy outcomes. In a large inner city, women without prenatal care resided in areas with significantly higher demands for public transportation. Alternative resources, including telemedicine and ridesharing, should be explored to reduce barriers to prenatal care access.

Preterm Birth Prevention in Appalachia: Restructuring Prenatal Care to Address Rural Health Disparities and Establish Perinatal Health Equity

Purpose: This perspective piece reflects off previously published qualitative work to explore (1) themes surrounding equitable prenatal care in Appalachia and (2) strategies to restructure care delivery in a population with disparate rates of preterm birth (PTB). Methods: This study reflects in-depth interviews with 22 Appalachian women who experienced PTB and 14 obstetric providers. Results: Our findings underscore the need for greater cultural humility in prenatal care, heightened awareness of social determinants of health, and strategic planning to establish equity in birth outcomes. Conclusion: Prenatal care must undergo a paradigm shift to include a comprehensive discussion of cultural humility, social disparities, and health equity.

The evolution of prenatal care delivery guidelines in the United States

The coronavirus disease 2019 pandemic led to some of the most drastic changes in clinical care delivery ever seen in the United States. Almost overnight, providers of prenatal care adopted virtual visits and reduced visit schedules. These changes stood in stark contrast to the 12 to 14 in-person prenatal visit schedule that had been previously recommended for almost a century. As maternity care providers consider what prenatal care delivery changes we should maintain following the acute pandemic, we may gain insight from understanding the evolution of prenatal care delivery guidelines. In this paper, we start by sketching out the relatively unstructured beginnings of prenatal care in the 19th century. Most medical care fell within the domain of laypeople, and childbirth was a central feature of female domestic culture. We explore how early discoveries about "toxemia" created the groundwork for future prenatal care interventions, including screening of urine and blood pressure-which in turn created a need for routine prenatal care visits. We then discuss the organization of the medical profession, including the field of obstetrics and gynecology. In the early 20th century, new data increasingly revealed high rates of both infant and maternal mortalities, leading to a greater emphasis on prenatal care. These discoveries culminated in the first codification of a prenatal visit schedule in 1930 by the Children's Bureau. Surprisingly, this schedule remained essentially unchanged for almost a century. Through the founding of the American College of Obstetricians and Gynecologists, significant technological advancements in laboratory testing and ultrasonography, and calls of the National Institutes of Health Task Force for changes in prenatal care delivery in 1989, prenatal care recommendations continued to be the same as they had been in 1930-monthly visits until 28 weeks' gestation, bimonthly visits until 36 weeks' gestation, and weekly visits until delivery. However, coronavirus disease 2019 forced us to change, to reconsider both the need for in-person visits and frequency of visits. Currently, as we transition from the acute pandemic, we should consider how to use what we have learned in this unprecedented time to shape future prenatal care. Lessons from a century of prenatal care provide valuable insights to inform the next generation of prenatal care delivery.

Ensuring Equitable Implementation of Telemedicine in Perinatal Care

Telemedicine in perinatal care has the potential to reduce disparities in maternal and perinatal health outcomes if implemented in an equitable manner.

The use of telemedicine in U.S. perinatal care has drastically increased during the coronavirus disease 2019 (COVID-19) pandemic, and will likely continue given the national focus on high-value, patient-centered care. If implemented in an equitable manner, telemedicine has the potential to reduce disparities in care access and related outcomes that stem from systemic racism, implicit biases and other forms of discrimination within our health care system. In this commentary, we address implementation factors that should be considered to ensure that disparities are not widened as telemedicine becomes more integrated into care delivery.

The contribution of group prenatal care to maternal psychological health outcomes: A systematic review

PROBLEM

Poor mental health remains a significant cause of morbidity for childbearing women globally.

BACKGROUND

Group care has been shown to be effective in reducing select clinical outcomes, e.g., the rate of preterm birth, but less is known about the effect of Group Prenatal Care (GPC) on mental health outcomes of stress, depression and anxiety in pregnant women.

AIM

To conduct a systematic review of the current evidence of the effect of group pregnancy care on mental health and wellbeing outcomes (i.e., stress, depression and/or anxiety) in childbearing women.

METHODS

A comprehensive search of published studies in Medline, PsychInfo, CINAHL, ProQuest databases, ClinicalTrials.gov and Google Scholar. Databases were systematically searched without publication period restriction until Feb 2020. Inclusion criteria were randomized controlled trials (including quasi-experimental) and observational studies comparing group care with standard pregnancy care. Included were studies published in English, whose primary outcome measures were stress, depression and/or anxiety.

RESULTS

Nine studies met the inclusion criteria, five randomized controlled trials and four observational studies, involving 1585 women (39%) in GPC and 2456 women (61%) in standard (individual) pregnancy care. Although evidence is limited, where targeted education was integrated into the group pregnancy care model, significant reductions in depressive symptoms were observed. In addition, secondary analysis across several studies identified a subset of GPC women, i.e., higher risk for psychological symptoms, who reported a decrease in their depression, stress and anxiety symptoms, postpartum. Due to the diversity of group care structure and content and the lack of outcomes measures universally reported, a comprehensive meta-analysis could not be performed.

CONCLUSION

The evidence suggests improvements in some markers of psychological health outcomes with group pregnancy care. Future research should involve larger well-designed studies encompassing cross-population data using a validated scale that is comparable across diverse childbearing populations and clinical settings to better understand the impact of group pregnancy care.

Prenatal care redesign: creating flexible maternity care models through virtual care

Each year, nearly 4 million pregnant patients in the United States receive prenatal care—a crucial preventive service that improves pregnancy outcomes for mothers and their children. National guidelines currently recommend 12–14 in-person prenatal visits, a schedule that has remained unchanged since 1930. When scrutinizing the standard prenatal visit schedule, it becomes clear that prenatal care is overdue for a redesign. We have strong evidence of the benefits of prenatal services, such as screening for gestational diabetes and maternal vaccination. However, how to deliver these services is not clear. Studies of prenatal services consistently demonstrate that such care can be delivered in fewer than 14 visits and that patients do not need to visit clinics in person to receive all maternity services. Telemedicine has emerged as a promising care delivery option for patients seeking greater flexibility, and early trials leveraging virtual care and remote monitoring have shown positive maternal and fetal outcomes with high patient satisfaction.

Our institution has worked for the past year on a new prenatal care pathway. Our initial work assessed the literature, elicited patient perspectives, and captured the insights of experts in patient-centered care delivery. There are 2 key principles that guide prenatal care redesign: (1) design care delivery around essential services, using in-person care for services that cannot be delivered remotely and offering video visits for other essential services, and (2) creation of flexible services for anticipatory guidance and psychosocial support that allow patients to tailor support to meet their needs through opt-in programs. The rise of coronavirus disease 2019 prompted us to extend this early work and rapidly implement a redesigned prenatal care pathway. In this study, we outline our experience in transitioning to a new prenatal care model with 4 in-person visits, 1 ultrasound visit, and 4 virtual visits (the 4-1-4 prenatal plan). We then explore how insights from this implementation can inform patient-centered prenatal care redesign during and beyond the coronavirus disease 2019 pandemic.

Implementation of Obstetric Telehealth During COVID-19 and Beyond

PURPOSE

The purpose of this article is to illustrate and discuss the impact the 2019 novel Coronavirus (COVID-19) pandemic on the delivery of obstetric care, including a discussion on the preexisting barriers, prenatal framework and need for transition to telehealth.

DESCRIPTION

The COVID-19 was first detected in China in December of 2019 and by March 2020 spread to the United States. As this virus has been associated with severe illness, it poses a threat to vulnerable populations-including pregnant women. The obstetric population already faces multiple barriers to receiving quality healthcare due to personal, environmental and economic barriers, now challenged with the additional risks of COVID-19 exposure and limited care in times much defined by social distancing.

ASSESSMENT

The current prenatal care framework requires patients to attend multiple in-office prenatal visits that can exponentially multiply depending on maternal and fetal comorbidities. To decrease the rate of transmission of the COVID-19 and limit exposure to patients, providers in Hillsborough County, Florida (and nationwide) are rapidly transitioning to telehealth. The use of a virtual care model allows providers to reduce in-person visits and incorporate virtual visits into the schedule of prenatal care.

CONCLUSION

Due to the COVID-19 pandemic, implementation of telehealth and telehealth have become crucial to ensure the safe and effective delivery of obstetric care. This implementation is one that will continue to require attention to planning, procedures and processes, and thoughtful evaluation to ensure the sustainability of telehealth and telehealth post COVID-19 pandemic.