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Whyler NCA, Krishnaswamy S, Price S, Giles ML. Strategies to improve postpartum engagement in healthcare after high-risk conditions diagnosed in pregnancy: a narrative review. Arch Gynecol Obstet 2024; 310:69-82. [PMID: 38787416 PMCID: PMC11169054 DOI: 10.1007/s00404-024-07562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
Transition from antepartum to postpartum care is important, but often fragmented, and attendance at postpartum visits can be poor. Access to care is especially important for individuals diagnosed antepartum with conditions associated with longer-term implications, including gestational diabetes (GDM) and hypertensive disorders in pregnancy (HDP). Strategies to link and strengthen this transition are essential to support people to attend recommended appointments and testing. This narrative review evaluates what is known about postpartum transition of care after higher-risk antepartum conditions, discusses barriers and facilitators to uptake of recommended testing, and outlines strategies trialled to increase both postpartum attendance and testing. Barriers to attendance frequently overlap with general barriers to accessing healthcare. Specific postpartum challenges include difficulties with transport, coordinating breastfeeding and childcare access. Systemic challenges include inadequate communication to women around implications of health conditions diagnosed in pregnancy, and the importance of postpartum follow up. Uptake of recommended testing after a diagnosis of GDM and HDP is variable but generally suboptimal. Strategies which demonstrate promise include the use of patient navigators, focused education and specialised clinics. Reminder systems have had variable impact. Telehealth and technology are under-utilised in this field but offer promising options particularly with the expansion of virtual healthcare into routine maternity care. Strategies to improve both attendance rates and uptake of testing must be designed to address disparities in healthcare access and tailored to the needs of the community. This review provides a starting point to develop such strategies from the community level to the population level.
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Affiliation(s)
- Naomi C A Whyler
- Department of Obstetrics and Gynaecology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia.
| | - Sushena Krishnaswamy
- Department of Obstetrics and Gynaecology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
| | - Sarah Price
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Royal Parade, Parkville, VIC, 3000, Australia
- Department of Obstetric Medicine, Royal Women's Hospital, 20 Flemington Road, Parkville, VIC, 3000, Australia
| | - Michelle L Giles
- Department of Obstetrics and Gynaecology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
- Department of Obstetric Medicine, Royal Women's Hospital, 20 Flemington Road, Parkville, VIC, 3000, Australia
- Department of Infectious Diseases, University of Melbourne, Grattan Street, Parkville, VIC, 3000, Australia
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Stanhope KK, Stallworth T, Forest AD, Vuncannon D, Juarez G, Boulet SL, Geary F, Dunlop AL, Blake SC, Green VL, Jamieson DJ. Planning for the forgotten fourth trimester of pregnancy: A parallel group randomized control trial to test a postpartum planning intervention vs. standard prenatal care. Contemp Clin Trials 2024; 143:107586. [PMID: 38838985 DOI: 10.1016/j.cct.2024.107586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 04/24/2024] [Accepted: 05/28/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Black and brown birthing people experience persistent disparities in adverse maternal health outcomes, partially due to inadequate perinatal care. The goal of this study is to design and evaluate a patient-centered intervention for obstetric patients with one or more cardiometabolic risk factors for severe maternal morbidity [gestational diabetes, diabetes mellitus, hypertensive disorders of pregnancy (chronic hypertension, preeclampsia, eclampsia, or gestational hypertension), or preconception obesity (BMI > 30)] to promote postpartum visit attendance. METHODS To address identified unmet needs for postpartum support and barriers to postpartum care, we developed 20 thematic postpartum planning modules, each with corresponding patient educational materials, community resources, care coordination protocols, and clinician support tools (decision aids, electronic medical record prompts and fields). During prenatal care encounters, a research coordinator delivers the educational content (in English or Spanish), facilitates the participant's planning and shared decision-making, provides the participant with resources, and documents decisions in the electronic medical record. We will randomize 320 eligible patients with a 1:1 ratio to the intervention or standard prenatal care and evaluate the impact on postpartum visit attendance at 4-12 weeks and secondary outcomes (postpartum mental health, perceived future maternal and cardiometabolic risk, contraceptive use, primary care use, readmission, and patient satisfaction with care). DISCUSSION Through engagement with patients and community stakeholders, we developed a guideline-based, locally tailored intervention to address drivers of engagement with postpartum care for high-risk obstetric patients. If demonstrated to be effective, the educational materials and electronic medical record based-tool can be adapted to other settings. TRIAL REGISTRATION This trial was registered on ClinicalTrials.gov (NCT05430815) on June 23, 2022.
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Affiliation(s)
- Kaitlyn K Stanhope
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States; Emory University Rollins School of Public Health, Department of Epidemiology, 1518 Clifton Road NE Office 3023, Atlanta, Georgia, United States.
| | - Taé Stallworth
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Alexandra D Forest
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Danielle Vuncannon
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Gabriela Juarez
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Sheree L Boulet
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Franklyn Geary
- Morehouse School of Medicine, Department of Obstetrics and Gynecology, Atlanta, Georgia, United States
| | - Anne L Dunlop
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Sarah C Blake
- Emory University Rollins School of Public Health, Department of Health Policy and Management, Atlanta, Georgia, United States
| | - Victoria L Green
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States
| | - Denise J Jamieson
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, Georgia, United States; University of Iowa, School of Medicine, Johnson County, Iowa, United States
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Li S, Girgla S, Sherman A, Alpay-Savasan Z, Mehta N. Atrial fibrillation considerations in the fourth trimester (postpartum period). J Interv Card Electrophysiol 2024; 67:901-914. [PMID: 38363430 DOI: 10.1007/s10840-023-01611-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/18/2023] [Indexed: 02/17/2024]
Abstract
Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.
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Affiliation(s)
- Shuo Li
- Internal Medicine Residency, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Saavia Girgla
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Andrew Sherman
- Internal Medicine Residency, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Zeynep Alpay-Savasan
- Division of Maternal and Fetal Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Nishaki Mehta
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA.
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Green HM, Williams B, Diaz L, Carmona-Barrera V, Davis K, Feinglass J, Kominiarek MA, Dolan BM, Grobman WA, Yee LM. Evaluating feedback from an implementation advisory board to assess the rollout of a postpartum patient navigation program. Implement Sci Commun 2024; 5:50. [PMID: 38702751 PMCID: PMC11067255 DOI: 10.1186/s43058-024-00589-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Patient navigation is an individualized intervention to facilitate comprehensive care which has not yet been fully implemented in obstetric or postpartum care. METHODS We aimed to develop and evaluate a mechanism to incorporate feedback regarding implementation of postpartum patient navigation for low-income birthing individuals at an urban academic medical center. This study analyzed the role of an Implementation Advisory Board (IAB) in supporting an ongoing randomized trial of postpartum navigation. Over the first 24 months of the trial, the IAB included 11 rotating obstetricians, one clinic resource coordinator, one administrative leader, two obstetric nurses, one primary care physician, one social worker, and one medical assistant. Members completed serial surveys regarding program implementation, effects on patient care, and areas for improvement. Quarterly IAB meetings offered opportunities for additional feedback. Survey responses and meeting notes were analyzed using the constant comparative method and further interpreted within the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework. RESULTS Members of the IAB returned 37 surveys and participated in five meetings over 24 months. Survey analysis revealed four themes among the inner context: reduced clinician burden, connection of care teams, communication strategies, and clinic workflow. Bridging factors included improved patient access to care, improved follow-up, and adding social context to care. Innovation factors included availability of navigators, importance of consistent communication, and adaptation over time. Meeting notes highlighted the importance of bidirectional feedback regarding implementation, and members expressed positive opinions regarding navigators' effects on patient care, integration into clinic workflow, and responsiveness to feedback. IAB members initially suggested changes to improve implementation; later survey responses demonstrated successful program adaptations. CONCLUSIONS Members of an implementation advisory board provided key insights into the implementation of postpartum patient navigation that may be useful to promote dissemination of navigation and establish avenues for the engagement of implementing partners in other innovations. TRIAL REGISTRATION ClinicalTrials.gov, NCT03922334 . Registered April 19, 2019. The results here do not present the results of the primary trial, which is ongoing.
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Affiliation(s)
- Hannah M Green
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
| | - Brittney Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
| | - Laura Diaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
| | - Viridiana Carmona-Barrera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
| | - Ka'Derricka Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
| | - Joe Feinglass
- Division of General Internal Medicine, Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Michelle A Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
| | - Brigid M Dolan
- Division of General Internal Medicine, Departments of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, 43221, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, 60611, USA.
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Moore MD, Mazzoni SE, Wingate MS, Bronstein JM. Severe Maternal Morbidity among Low-Income Patients with Hypertensive Disorders of Pregnancy. Am J Perinatol 2024; 41:e563-e572. [PMID: 35977711 DOI: 10.1055/a-1925-9972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy (HDP) contribute significantly to the development of severe maternal morbidities (SMM), particularly among low-income women. The purpose of the study was to explore the relationship between maternal characteristics and SMM, and to investigate if differences in SMM exist among patients with HDP diagnosis. STUDY DESIGN This study utilized 2017 Alabama Medicaid administrative claims. SMM diagnoses were captured using the Centers for Disease Control and Prevention's classification by International Classification of Diseases codes. Maternal characteristics and frequencies were compared using Chi-square and Cramer's V statistics. Logistic regression analyses were conducted to examine multivariable relationships between maternal characteristics and SMM among patients with HDP diagnosis. Odds ratios and 95% confidence intervals (CIs) were used to estimate risk. RESULTS A higher proportion of patients experiencing SMM were >34 years old, Black, Medicaid for Low-Income Families eligible, lived in a county with greater Medicaid enrollment, and entered prenatal care (PNC) in the first trimester compared with those without SMM. Almost half of patients (46.2%) with SMM had a HDP diagnosis. After controlling for maternal characteristics, HDP, maternal age, county Medicaid enrollment, and trimester PNC entry were not associated with SMM risk. However, Black patients with HDP were at increased risk for SMM compared with White patients with HDP when other factors were taken into account (adjusted odds ratio [aOR] = 1.37, 95% CI: 1.11-1.69). Patients with HDP and SMM were more likely to have a prenatal hospitalization (aOR = 1.45, 95% CI: 1.20-1.76), emergency visit (aOR = 1.30, 95% CI: 1.07-1.57), and postpartum cardiovascular prescription (aOR = 2.43, 95% CI: 1.95-3.04). CONCLUSION Rates of SMM differed by age, race, Medicaid income eligibility, and county Medicaid enrollment but were highest among patients with clinical comorbidities, especially HDP. However, among patients with HDP, Black patients had an elevated risk of severe morbidity even after controlling for other characteristics. KEY POINTS · Patients with SMM were more likely to have a HDP diagnosis.. · Among those with HDP, Black patients had elevated risk of SMM.. · Differences in care delivery did not explain SMM disparities..
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Affiliation(s)
- Matthew D Moore
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Sara E Mazzoni
- Department of Obstetrics and Gynecology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Martha S Wingate
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Janet M Bronstein
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
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Nix KM, Lee-Ann Hawkins T, Vlasschaert M, Ma IW, Nerenberg KA. Understanding Patient Perspectives on Specialized, Longitudinal, Postpartum, Cardiovascular Risk-Reduction Clinics. CJC Open 2024; 6:165-173. [PMID: 38487052 PMCID: PMC10935677 DOI: 10.1016/j.cjco.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/27/2023] [Indexed: 03/17/2024] Open
Abstract
Background Females who experience hypertensive disorders of pregnancy (HDP) have an increased lifelong risk of cardiovascular disease. Thus, Canadian clinical practice guidelines recommend cardiovascular risk reduction follow-up after a patient has HDP. This study examined the experiences of patients with HDP who attended a specialized, longitudinal general internal medicine postpartum cardiovascular risk reduction clinic called PreVASC. PreVASC focuses on comprehensive cardiovascular risk reduction through cardiovascular risk factor screening and management tailored specifically for female patients after they have HDP. Methods This multimethod study examined the experiences of female patients with HDP via the following: (i) a quantitative survey (summarized with descriptive statistics); (ii) semistructured qualitative patient phone interviews (results grouped thematically); and (iii) triangulation of qualitative themes with quantitative survey results. Results Overall, 37% of eligible clinic patients (42 of 115) participated; 79% of participants (n = 33) reported being "very satisfied" with the PreVASC clinic's specialized longitudinal model of care, and 95% (n = 40) reported making at least one preventive health behaviour change after receiving individualized counselling on cardiovascular risk reduction. Qualitative results found improvements in patient-reported cardiovascular health knowledge, health behaviours, and health-related anxiety. A preference for in-person vs phone clinic visits was reported by participants. Conclusions An in-person, general internal medicine specialist-led, longitudinal model of cardiovascular disease preventive care focused specifically on cardiovascular risk reduction after HDP had positive impacts on patient experience, health knowledge, and preventive health behaviours. This novel knowledge on patient preferences for a longitudinal, specialized model of care advances cardiovascular risk reduction tailored specifically for high-risk people after HDP.
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Affiliation(s)
- Kimberley M. Nix
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - T. Lee-Ann Hawkins
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meghan Vlasschaert
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Irene W.Y. Ma
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kara A. Nerenberg
- Division of General Internal Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Zaman A, Ovalle B, Reyes C, Segall-Gutierrez P. Enhanced Participation in Diabetes Screening and Care After Gestational Diabetes Through Community Health Workers: Results from the Es Mejor Saber Randomized Controlled Trial. J Immigr Minor Health 2024; 26:45-53. [PMID: 37878217 PMCID: PMC10842185 DOI: 10.1007/s10903-023-01547-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2023] [Indexed: 10/26/2023]
Abstract
Gestational diabetes mellitus (GDM) is a strong risk factor for type 2 diabetes mellitus, but many women with GDM do not return for postpartum diabetes screening. Interventions utilizing community health workers have demonstrated improvements in health knowledge and participation in other disease settings. The objective of this study was to therefore determine whether bilingual, bicultural community health workers (i.e., promotoras) increase participation in postpartum disease screening and referral for diabetes prevention or care in an urban, low-resource Hispanic community. Ninety-four women with GDM were recruited from the postpartum ward of a safety-net hospital and randomized equally to receive either standard-of-care alone or standard-of-care with a promotora-based intervention consisting of education, appointment reminders, and assistance navigating the healthcare system. Adherence to diabetes screening visits by 12 weeks postpartum and referral for preventive or diabetes care by 18 weeks postpartum was assessed through electronic medical record review. Compared to controls, women in the promotora group completed more diabetes screening visits (74% vs. 96%; relative risk [RR] 3.9; 95% Confidence Interval [CI] 1.1-14.1; p = 0.04). Among those who completed diabetes screening visits, women in the promotora group were also more likely to complete a subsequent referral visit for preventive or diabetes care (17% vs. 83%; RR 4.0; 95% CI 2.1-7.4; p < 0.01). A promotora-based intervention consisting of bilingual, bicultural community health workers improved diabetes screening, prevention, and treatment visits in a resource-limited community of Hispanic women with GDM. ClinicalTrials.gov Identifier: NCT00998595.
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Affiliation(s)
- Adnin Zaman
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado, Anschutz Medical Campus, Mailstop C263, 12348 E. Montview Blvd, Aurora, CO, 80045, USA.
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| | - Blanca Ovalle
- Department of Obstetrics and Gynecology,, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Carolina Reyes
- Department of Obstetrics and Gynecology,, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Penina Segall-Gutierrez
- Department of Obstetrics and Gynecology,, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Pennington EL, Barner JC, Brown CM, Lawson KA. Pregnancy-related risk factors and receipt of postpartum care among Texas Medicaid pregnant enrollees: Opportunities for pharmacist services. J Am Pharm Assoc (2003) 2024; 64:260-267.e2. [PMID: 37981070 DOI: 10.1016/j.japh.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The United States (US) experiences the highest rate of maternal mortality of similar countries. Postpartum care (PPC) focused on chronic disease management is potentially lifesaving, especially among pregnancies complicated by risk factors such as diabetes, hypertension, and mental health conditions (MHCs), which are conditions in which pharmacists can have an impact. OBJECTIVE To evaluate the prevalence of maternal mortality risk factors and their relationships with receipt of PPC among Texas Medicaid enrollees. METHODS A retrospective study included women with a delivery between 3/25/2014-11/1/2019 who were continuously enrolled in Texas Medicaid during the study period from 84 days pre-delivery to 60 days post-delivery. PPC was defined as ≥1 visit associated with postpartum follow-up services. Maternal mortality risk factors (diabetes, hypertension, and MHCs) during and after pregnancy were identified using diagnoses and medication utilization. Age, race/ethnicity, cesarean delivery, and preterm birth served as covariates. Multivariable logistic regression was used to address the study objective. RESULTS The sample (N = 617,010) was 26.5±5.7 years, primarily (52.8%) Hispanic, and 33.0% had cesarean deliveries and 9.3% had preterm births. Risk factor prevalence included: diabetes (14.0%), hypertension (14.3%), and MHCs during (6.3%) and after (9.1%) pregnancy. A majority (77.9%) had a PPC visit within 60 days of delivery. The odds of receiving PPC were 1.2 times higher for patients with diabetes (OR = 1.183; 95% CI = 1.161-1.206; P < 0.0001), 1.1 times higher for patients with hypertension (OR = 1.109; 95% CI= 1.089-1.130; P < 0.0001), and 1.1 times higher for patients with MHCs (OR=1.138; 95% CI = 1.108-1.170; P < 0.0001) than patients without, respectively. CONCLUSION Over three-quarters of Texas Medicaid pregnant enrollees received PPC within 60 days of delivery and risk factors were prevalent and predictive of receipt of PPC. Pharmacists can have a positive impact on maternal health by addressing hypertension, diabetes, and MHC risk factors.
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Bose-Brill S, Gillespie SL, Venkatesh KK. Can We Implement Multispecialty Mother-Infant Dyadic Care to Systematize Interpregnancy Services After a Preterm Birth? WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:651-655. [PMID: 38155872 PMCID: PMC10754421 DOI: 10.1089/whr.2023.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Seuli Bose-Brill
- Combined Internal Medicine and Pediatrics Section, Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Shannon L. Gillespie
- The Martha S. Pitzer Center for Women, Children, and Youth, College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Kartik K. Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Huang J, Forde R, Parsons J, Zhao X, Wang J, Liu Y, Forbes A. Interventions to increase the uptake of postpartum diabetes screening among women with previous gestational diabetes: a systematic review and Bayesian network meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101137. [PMID: 37619781 DOI: 10.1016/j.ajogmf.2023.101137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE This study aimed to summarize the current interventions aimed at improving postpartum diabetes screening attendance and to compare their effectiveness. DATA SOURCES Literature searches were conducted in the Web of Science, Embase, Cochrane Library, CINAHL, and PubMed from inception to March 20, 2023. STUDY ELIGIBILITY CRITERIA Quantitative studies involving an intervention to increase postpartum diabetes screening attendance among women with gestational diabetes mellitus were included. METHODS The Joanna Briggs Institute checklists were used for the quality appraisal of the included studies. A Bayesian network meta-analysis was performed to synthesize the comparative effectiveness of the relevant interventions aimed at improving postpartum diabetes screening rates. RESULTS A total of 40 studies were included in this review with pooled data from 17,123 women. Studies included randomized controlled trials (n=11, including 3 US-based studies and 8 non-US-based studies) and nonrandomised studies (n=29, including 13 US-based studies and 16 non-US-based studies). Of the 14 studies that reported screening outcomes, 11 detected early type 2 diabetes at a rate ranging from 2.0% to 23.0%. The types of interventions identified included reminders (eg, postal letters, emails, and phone messages), educational interventions, screening methods and delivery, policy changes, antenatal groups, and multimodal interventions. Based on the network meta-analysis from randomized controlled trials, antenatal group intervention, which refers to antenatal patient education delivered in groups (1 US-based study), had the highest probability to be the most effective intervention (odds ratio, 10; 95% confidence interval, 1.6-77.0), followed by one-to-one educational intervention with written educational materials or counselling (odds ratio, 6.9; 95% confidence interval, 3.6-16.0). The results from nonrandomized studies indicated that flexible screening methods and delivery (2 US-based studies) had the greatest impact on screening uptake (odds ratio, 3.9; 95% confidence interval, 1.8-10.0), followed by educational interventions (1 US-based study and 2 non-US-based studies) with antenatal patient education and written educational materials (odds ratio, 3.4; 95% confidence interval, 1.9-6.3) and antenatal groups (odds ratio, 3.3; 95% confidence interval, 1.7-6.7). CONCLUSION The presented evidence suggests that antenatal patient education delivered in groups and offering more flexible screening methods were associated with the greatest increase in attendance. The multimodal interventions and reminders could still be important if they were more theoretically grounded and were more integrated into the healthcare system.
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Affiliation(s)
- Jing Huang
- Division of Care for Long-term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom (Ms Huang, Drs Forde and Parsons, Ms Zhao, and Dr Forbes).
| | - Rita Forde
- Division of Care for Long-term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom (Ms Huang, Drs Forde and Parsons, Ms Zhao, and Dr Forbes)
| | - Judith Parsons
- Division of Care for Long-term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom (Ms Huang, Drs Forde and Parsons, Ms Zhao, and Dr Forbes)
| | - Xiaoyan Zhao
- Division of Care for Long-term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom (Ms Huang, Drs Forde and Parsons, Ms Zhao, and Dr Forbes)
| | - Jianying Wang
- Labour room, Northwest Women's and Children's Hospital, Xi'an, China (Mses Wang and Liu)
| | - Yingjie Liu
- Labour room, Northwest Women's and Children's Hospital, Xi'an, China (Mses Wang and Liu)
| | - Angus Forbes
- Division of Care for Long-term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom (Ms Huang, Drs Forde and Parsons, Ms Zhao, and Dr Forbes)
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Henderson JT, Webber EM, Thomas RG, Vesco KK. Screening for Hypertensive Disorders of Pregnancy: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 330:1083-1091. [PMID: 37721606 DOI: 10.1001/jama.2023.4934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Importance Hypertensive disorders of pregnancy are a leading cause of pregnancy-related morbidity and mortality in the US. Objective To conduct a targeted systematic review to update the evidence on the effectiveness of screening for hypertensive disorders of pregnancy to inform the US Preventive Services Task Force. Data Sources MEDLINE and the Cochrane Central Register of Controlled Trials for relevant studies published between January 1, 2014, and January 4, 2022; surveillance through February 21, 2023. Study Selection English-language comparative effectiveness studies comparing screening strategies in pregnant or postpartum individuals. Data Extraction and Synthesis Two reviewers independently appraised articles and extracted relevant data from fair-or good-quality studies; no quantitative synthesis was conducted. Main outcomes and measures Morbidity or mortality, measures of health-related quality of life. Results The review included 6 fair-quality studies (5 trials and 1 nonrandomized study; N = 10 165) comparing changes in prenatal screening practices with usual care, which was routine screening at in-person office visits. No studies addressed screening for new-onset hypertensive disorders of pregnancy in the postpartum period. One trial (n = 2521) evaluated home blood pressure measurement as a supplement to usual care; 3 trials (total n = 5203) evaluated reduced prenatal visit schedules. One study (n = 2441) evaluated proteinuria screening conducted only for specific clinical indications, compared with a historical control group that received routine proteinuria screening. One additional trial (n = 80) only addressed the comparative harms of home blood pressure measurement. The studies did not report statistically significant differences in maternal and infant complications with alternate strategies compared with usual care; however, estimates were imprecise for serious, rare health outcomes. Home blood pressure measurement added to prenatal care visits was not associated with earlier diagnosis of a hypertensive disorder of pregnancy (104.3 vs 106.2 days), and incidence was not different between groups in 3 trials of reduced prenatal visit schedules. No harms of the different screening strategies were identified. Conclusions and Relevance This review did not identify evidence that any alternative screening strategies for hypertensive disorders of pregnancy were more effective than routine blood pressure measurement at in-person prenatal visits. Morbidity and mortality from hypertensive disorders of pregnancy can be prevented, yet American Indian/Alaska Native persons and Black persons experience inequitable rates of adverse outcomes. Further research is needed to identify screening approaches that may lead to improved disease detection and health outcomes.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Elizabeth M Webber
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
- CareOregon, Portland
| | - Kimberly K Vesco
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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12
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Marschner S, Mukherjee S, Watts M, Min H, Beale AL, O'Brien J, Juneja A, Tremmel JA, Zaman S. Prevention of Cardiovascular Disease in Women With Pregnancy-Related Risk Factors: A Prospective Women's Heart Clinic Study. J Am Heart Assoc 2023; 12:e030015. [PMID: 37642017 PMCID: PMC10547318 DOI: 10.1161/jaha.123.030015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/20/2023] [Indexed: 08/31/2023]
Abstract
Background Hypertensive disorders of pregnancy, gestational diabetes, and having a small-for-gestational-age baby are known to substantially increase a woman's risk of cardiovascular disease. Despite this, evidence for models of care that mitigate cardiovascular disease risk in women with these pregnancy-related conditions is lacking. Methods and Results A 6-month prospective cohort study assessed the effectiveness of a multidisciplinary Women's Heart Clinic on blood pressure and lipid control in women aged 30 to 55 years with a past pregnancy diagnosis of hypertensive disorders of pregnancy, gestational diabetes, or a small-for-gestational age baby in Melbourne, Australia. The co-primary end points were (1) blood pressure <140/90 mm Hg or <130/80 mm Hg if diabetes and (2) total cholesterol to high-density lipoprotein cholesterol ratio <4.5. The study recruited 156 women with a mean age of 41.0±4.2 years, 3.9±2.9 years from last delivery, 68.6% White, 20.5% South/East Asian, and 80.5% university-educated. The proportion meeting blood pressure target increased (69.2% to 80.5%, P=0.004), with no significant change in lipid targets (80.6% to 83.7%, P=0.182). Systolic blood pressure (-6.9 mm Hg [95% CI, -9.1 to -4.7], P<0.001), body mass index (-0.6 kg/m2 [95% CI, -0.8 to -0.3], P<0.001), low-density lipoprotein cholesterol (-4.2 mg/dL [95% CI, -8.2 to -0.2], P=0.042), and total cholesterol (-4.6 mg/dL [95% CI, -9.1 to -0.2] P=0.042) reduced. Heart-healthy lifestyle significantly improved with increased fish/olive oil (36.5% to 51.0%, P=0.012), decreased fast food consumption (33.8% to 11.0%, P<0.001), and increased physical activity (84.0% to 92.9%, P=0.025). Conclusions Women at high risk for cardiovascular disease due to past pregnancy-related conditions experienced significant improvements in multiple cardiovascular risk factors after attending a Women's Heart Clinic, potentially improving long-term cardiovascular disease outcomes. Registration URL: https://www.anzctr.org.au; Unique identifier: ACTRN12622000646741.
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Affiliation(s)
- Simone Marschner
- Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Swati Mukherjee
- Department of CardiologyCabrini HealthMelbourneAustralia
- Department of CardiologyAlfred HospitalMelbourneAustralia
- Faculty of Medicine, Nursing & Health SciencesMonash UniversityMelbourneAustralia
| | - Monique Watts
- Department of CardiologyAlfred HospitalMelbourneAustralia
- Faculty of Medical EducationUniversity of MelbourneMelbourneAustralia
| | - Haeri Min
- Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Anna L. Beale
- Department of CardiologyAlfred HospitalMelbourneAustralia
| | | | - Aashima Juneja
- Department of MedicineThe Northern HospitalMelbourneAustralia
| | - Jennifer A. Tremmel
- Department of Medicine (Cardiovascular)Stanford University School of MedicineStanfordCA
| | - Sarah Zaman
- Westmead Applied Research Centre, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneAustralia
- Department of CardiologyWestmead HospitalSydneyAustralia
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13
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Aqua JK, Ford ND, Pollack LM, Lee JS, Kuklina EV, Hayes DK, Vaughan AS, Coronado F. Timing of outpatient postpartum care utilization among women with chronic hypertension and hypertensive disorders of pregnancy. Am J Obstet Gynecol MFM 2023; 5:101051. [PMID: 37315845 PMCID: PMC10527898 DOI: 10.1016/j.ajogmf.2023.101051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The postpartum period represents an opportunity to assess the cardiovascular health of women who experience chronic hypertension or hypertensive disorders of pregnancy. OBJECTIVE This study aimed to determine whether women with chronic hypertension or hypertensive disorders of pregnancy access outpatient postpartum care more quickly compared to women with no hypertension. STUDY DESIGN We used data from the Merative MarketScan Commercial Claims and Encounters Database. We included 275,937 commercially insured women aged 12 to 55 years who had a live birth or stillbirth delivery hospitalization between 2017 and 2018 and continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Using the International Classification of Diseases Tenth Revision Clinical Modification codes, we identified hypertensive disorders of pregnancy from inpatient or outpatient claims from 20 weeks gestation through delivery hospitalization and identified chronic hypertension from inpatient or outpatient claims from the beginning of the continuous enrollment period through delivery hospitalization. Distributions of time-to-event survival curves (time-to-first outpatient postpartum visit with a women's health provider, primary care provider, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and log rank tests. We used Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals. Time points of interest (3, 6, and 12 weeks) were evaluated per clinical postpartum care guidelines. RESULTS Among commercially insured women, the prevalences of hypertensive disorders of pregnancy, chronic hypertension, and no documented hypertension were 11.7%, 3.4%, and 84.8%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.5%, 26.4%, and 16.0% for hypertensive disorders of pregnancy, chronic, and no documented hypertension, respectively; by 12 weeks, the proportions increased to 62.4%, 64.5%, and 54.2%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type, and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with hypertensive disorders of pregnancy was 1.42 times the rate for women with no documented hypertension (adjusted hazard ratio, 1.42; 95% confidence interval, 1.39-1.45). Women with chronic hypertension also had higher utilization rates compared to women with no documented hypertension before 6 weeks (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24-1.33). Only chronic hypertension was significantly associated with utilization compared to the no documented hypertension group after 6 weeks (adjusted hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). CONCLUSION In the 6 weeks following delivery discharge, women with hypertensive disorders of pregnancy and chronic hypertension attended outpatient postpartum care visits sooner than women with no documented hypertension. However, after 6 weeks this difference extended only to women with chronic hypertension. Overall, postpartum care utilization remained around 50% to 60% by 12 weeks in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.
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Affiliation(s)
- Jasmine Ko Aqua
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (Ms Aqua)
| | - Nicole D Ford
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado); Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA (Dr Ford)
| | - Lisa M Pollack
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Jun Soo Lee
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Elena V Kuklina
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Donald K Hayes
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
| | - Adam S Vaughan
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado).
| | - Fátima Coronado
- Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA (Ms Aqua, Drs Pollack, Lee, Kuklina, Hayes, Vaughan, and Coronado)
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14
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Interrante JD, Carroll C, Kozhimannil KB. Understanding categories of postpartum care use among privately insured patients in the United States: a cluster-analytic approach. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad020. [PMID: 38769945 PMCID: PMC11103737 DOI: 10.1093/haschl/qxad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 05/22/2024]
Abstract
The postpartum period is critical for the health and well-being of birthing people, yet little is known about the range of health care services and supports needed during this time. Maternity care patients are often targeted for clinical interventions based on "low risk" or "high risk" designations, but dichotomized measures can be imprecise and may not reflect meaningful groups for understanding needed postpartum care. Using claims data from privately insured patients with childbirths between 2016 and 2018, this study identifies categories and predictors of postpartum care utilization, including the use of maternal care and other, nonmaternal, care (eg, respiratory, digestive). We then compare identified utilization-based categories with typical high- and low-risk designations. Among 269 992 patients, 5 categories were identified: (1) low use (55% of births); (2) moderate maternal care use, low other care use (25%); (3) moderate maternal, high other (8%); (4) high maternal, moderate other (7%); and (5) high maternal, high other (5%). Utilization-based categories were better at differentiating postpartum care use and were more consistent across patient profiles, compared with high- and low-risk dichotomies. Identifying categories of postpartum care need beyond a simple risk dichotomy is warranted and can assist in maternal health services research, policymaking, and clinical practice.
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Affiliation(s)
- Julia D Interrante
- Division of Health Policy and Management, University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis, MN 55455, United States
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN 55455, United States
| | - Caitlin Carroll
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN 55455, United States
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis, MN 55455, United States
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN 55455, United States
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15
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Triebwasser JE, Lewey J, Walheim L, Sehdev HM, Srinivas SK. Electronic Reminder to Transition Care After Hypertensive Disorders of Pregnancy: A Randomized Controlled Trial. Obstet Gynecol 2023; 142:91-98. [PMID: 37294089 PMCID: PMC11180538 DOI: 10.1097/aog.0000000000005237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Scalable interventions are needed to improve preventive care for those with increased cardiovascular disease (CVD) risk identified during pregnancy. We hypothesized that an automated reminder message for clinicians (nudge) would increase counseling at the postpartum visit on patient transitions of care. METHODS We conducted a single-center, randomized controlled trial including birthing people with a hypertensive disorder of pregnancy evaluating a nudge compared with usual care. The nudge, including counseling phrases and patient-specific information on hypertensive diagnosis, was sent to the obstetric clinician through the electronic medical record up to 7 days before the postpartum visit. The primary outcome was documentation of counseling on transitions of care to primary care or cardiology. Secondary outcomes were documentation of CVD risk, use of counseling phrases, and preventive care visit within 6 months. A sample size of 94 per group (n=188) was planned to compare the nudge intervention with usual care; given the anticipated loss to follow-up, the sample size was increased to 222. Intention-to-treat analyses were performed, with P <.05 considered significant. RESULTS From February to June 2021, 392 patients were screened, and 222 were randomized and analyzed. Of these, 205 (92.3%) attended a postpartum visit. Groups were similar, but more women in the usual care group had diabetes (16.1% vs 6.7%, P =.03). After adjustment for diabetes, patients in the nudge group were more likely to have documented counseling on transitions of care (38.8% vs 26.2%, adjusted relative risk [aRR] 1.53, 95% CI 1.02-2.31), CVD risk (21.4% vs 8.4%, aRR 2.57, 95% CI 1.20-5.49), and use of aspirin in a future pregnancy (14.3% vs 1.9%, aRR 7.49, 95% CI 1.66-33.93). Counseling phrases were used more often in the nudge group (11.2% vs 0.9%, aRR 12.27, 95% CI 1.50-100.28). Preventive care visit attendance did not differ by group (22.1% vs 24.6%, aRR 0.91, 95% CI 0.57-1.47). CONCLUSION A timely electronic reminder to obstetric clinicians improved counseling about transitions of care after hypertensive disorders of pregnancy but did not result in increased preventive care visit attendance. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT04660032.
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Affiliation(s)
- Jourdan E Triebwasser
- Divisions of Maternal-Fetal Medicine and Cardiology, University of Pennsylvania Perelman School of Medicine, and the Department of Obstetrics & Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania; and the Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
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16
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Padua K, Robinson R, Ness A, Judy A, Lee GM, Gould J. Moms in the NICU: developing a pilot to engage and empower women who have delivered a prematurely born infant. BMC Pregnancy Childbirth 2023; 23:432. [PMID: 37301839 DOI: 10.1186/s12884-023-05738-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Mothers spend long hours at their preterm infant's bedside in the Neonatal Intensive Care Unit (NICU), giving clinicians the opportunity to engage mothers in caring for their own health. OBJECTIVE To develop a NICU based intervention to reduce the risk of a future premature birth by engaging and empowering mothers to improve their own health and identify barriers to implementing their improvement. DESIGN Development based on a framework of narrative discourse refined by the Quality Improvement Plan Do Study Act Approach. SETTING Level II Stepdown Neonatal Intensive Care Unit. PARTICIPANTS 14 mothers of preterm infants, ages 24-39 years. METHODS A team of Maternal Fetal Medicine Physicians, obstetricians, neonatologists, neonatal nurses, and parents developed guidelines to elicit the mother's birth story, review the story with a clinical expert to fill in knowledge gaps, identify strategies to improve health to reduce the risk of future preterm birth, and facilitate mother developing an action plan with specific six week goals. A phone interview was designed to assess success and identify barriers to implementing their health plan. The protocol was modified as needed after each intervention to improve the interventions. RESULTS "Moms in the NICU" toolkit is effective to guide any clinical facilitator to engage, identify health improvement strategies, and co-develop an individualized health plan and its take home summary reached stability after the 5th mother. Mothers reported experiencing reassurance, understanding, and in some cases, relief. Participants were enthusiastic to inform future quality improvement activities by sharing the six week barriers faced implementing their health plan. CONCLUSION Engaging in the NICU provides an opportunity to improve mothers' understanding of potential factors that may be linked to preterm birth, and promote personally selected actions to improve their health and reduce the risk of a future preterm birth.
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Affiliation(s)
- Kimber Padua
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA.
| | - Rebecca Robinson
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | - Amen Ness
- Division of Maternal Fetal Medicine, St. Elizabeth Medical Center, Boston, MA, USA
| | - Amy Judy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Grace M Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | - Jeffrey Gould
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
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17
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Marschner S, Pant A, Henry A, Maple‐Brown LJ, Moran L, Cheung NW, Chow CK, Zaman S. Cardiovascular risk management following gestational diabetes and hypertensive disorders of pregnancy: a narrative review. Med J Aust 2023; 218:484-491. [PMID: 37149790 PMCID: PMC10953444 DOI: 10.5694/mja2.51932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 05/08/2023]
Affiliation(s)
| | - Anushriya Pant
- Westmead Applied Research CentreUniversity of SydneySydneyNSW
| | - Amanda Henry
- University of New South WalesSydneyNSW
- St George HospitalSydneyNSW
| | - Louise J Maple‐Brown
- Diabetes across the Lifecourse: Northern Australia Partnership, Menzies School of Health ResearchDarwinNT
- Royal Darwin HospitalDarwinNT
| | - Lisa Moran
- Monash Centre for Health Research and ImplementationMonash UniversityMelbourneVIC
- Monash HealthMelbourneVIC
| | - N Wah Cheung
- Westmead Applied Research CentreUniversity of SydneySydneyNSW
- Westmead HospitalSydneyNSW
| | - Clara K Chow
- Westmead Applied Research CentreUniversity of SydneySydneyNSW
- Westmead HospitalSydneyNSW
| | - Sarah Zaman
- Westmead Applied Research CentreUniversity of SydneySydneyNSW
- Westmead HospitalSydneyNSW
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18
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Oben A, Moore M, Wallace E, Muntner P, Oparil S, Tita A, Sinkey R. Validation of a Remote Monitoring Blood Pressure Device in Pregnancy. Am J Hypertens 2023; 36:341-347. [PMID: 36810671 PMCID: PMC10439484 DOI: 10.1093/ajh/hpad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/11/2022] [Accepted: 01/08/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND The Ideal Life Blood Pressure Manager measures blood pressure (BP) and automatically transmits results to the patient's medical record independent of internet access, but has not been validated. Our objective was to conduct a validation study of the Ideal Life BP Manager in pregnant women using a validation protocol. METHODS Pregnant participants were enrolled into three subgroups per the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization protocol: normotensive (systolic blood pressure (SBP) < 140 and diastolic blood pressure (DBP) < 90), hypertensive without proteinuria (SBP ≥ 140 or DBP ≥ 90), and preeclampsia (SBP ≥ 140 or DBP ≥ 90 with proteinuria). Two trained research staff used a mercury sphygmomanometer to validate the device, alternating sphygmomanometer, and device readings for a total of 9 measurements. RESULTS Among 51 participants, the mean SBP and DBP differences and standard deviations between the device and the mean staff measurements for all participants were 1.7 ± 7.1 and 1.5 ± 7.0 mm Hg, respectively. The standard deviations of the individual participant's paired device and mean staff SBP and DBP measurements were 6.0 and 6.4 mm Hg, respectively. The device was more likely to overestimate rather than underestimate BP (SBP: mean difference = 1.67, 95% CI [-12.15 to 15.49]; DBP: mean difference = 1.51, 95% CI [-12.26 to 15.28]). Most paired readings had a difference of less than 10 mm Hg across averaged paired readings. CONCLUSION The Ideal Life BP Manager met internationally recognized validity criteria in this sample of pregnant women.
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Affiliation(s)
- Ayamo Oben
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthew Moore
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eric Wallace
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul Muntner
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Epidemiology, University of Alabama at Birmingham, University of Alabama at Birmingham, USA
| | - Suzanne Oparil
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Vascular Biology and Hypertension Program, Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Alan Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel Sinkey
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Alexander BT, South AM, August P, Bertagnolli M, Ferranti EP, Grobe JL, Jones EJ, Loria AS, Safdar B, Sequeira-Lopez MLS. Appraising the Preclinical Evidence of the Role of the Renin-Angiotensin-Aldosterone System in Antenatal Programming of Maternal and Offspring Cardiovascular Health Across the Life Course: Moving the Field Forward: A Scientific Statement From the American Heart Association. Hypertension 2023; 80:e75-e89. [PMID: 36951054 PMCID: PMC10242542 DOI: 10.1161/hyp.0000000000000227] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
There is increasing interest in the long-term cardiovascular health of women with complicated pregnancies and their affected offspring. Emerging antenatal risk factors such as preeclampsia appear to increase the risk of hypertension and cardiovascular disease across the life course in both the offspring and women after pregnancy. However, the antenatal programming mechanisms responsible are complex and incompletely understood, with roots in alterations in the development, structure, and function of the kidney, heart, vasculature, and brain. The renin-angiotensin-aldosterone system is a major regulator of maternal-fetal health through the placental interface, as well as kidney and cardiovascular tissue development and function. Renin-angiotensin-aldosterone system dysregulation plays a critical role in the development of pregnancy complications such as preeclampsia and programming of long-term adverse cardiovascular health in both the mother and the offspring. An improved understanding of antenatal renin-angiotensin-aldosterone system programming is crucial to identify at-risk individuals and to facilitate development of novel therapies to prevent and treat disease across the life course. Given the inherent complexities of the renin-angiotensin-aldosterone system, it is imperative that preclinical and translational research studies adhere to best practices to accurately and rigorously measure components of the renin-angiotensin-aldosterone system. This comprehensive synthesis of preclinical and translational scientific evidence of the mechanistic role of the renin-angiotensin-aldosterone system in antenatal programming of hypertension and cardiovascular disease will help (1) to ensure that future research uses best research practices, (2) to identify pressing needs, and (3) to guide future investigations to maximize potential outcomes. This will facilitate more rapid and efficient translation to clinical care and improve health outcomes.
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Mousavi S, Safari A, Nateghian H, Ghojazadeh M, Nikniaz L. Comparing the detection rate of postpartum diabetes in early and 4-12 week postpartum screening tests in women with gestational diabetes mellitus: A systematic review and meta-analysis. Taiwan J Obstet Gynecol 2023; 62:396-401. [PMID: 37188442 DOI: 10.1016/j.tjog.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 05/17/2023] Open
Abstract
Gestational Diabetes Mellitus (GDM) is one of the critical risk factors for diabetes mellitus (DM). An early postpartum test done in the first few postpartum days can increase the screening rate in women with GDM. Therefore, this systematic review and meta-analysis aimed to combine and analyze data from different studies reporting the detection rate of postpartum diabetes in early and 4-12 week postpartum screening tests in women with GDM. ProQuest, Web of Science, EMBASE, PubMed, Cochrane, and Scopus were searched for English articles from January 1985 to January 2021. Two independent reviewers selected the eligible studies, and the outcomes of interest were extracted. The quality of studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for diagnostic test accuracy studies. Sensitivity and specificity, negative likelihood ratio (NLR), and positive likelihood ratio (PLR) were calculated for the early postpartum oral glucose tolerance test (OGTT). Of 1944 initially identified articles, four studies were included. The sensitivity and specificity of the early test were 74% and 56%, respectively, and the PLR and NLR were calculated as 1.7 and 0.4, respectively. The sensitivity of the early test was higher than the specificity. Based on this sensitivity and specificity, normal cases could be distinguished from abnormal cases, including diabetes and glucose intolerance. Early postpartum OGTT can be advised before hospital discharge. Early testing is a practical option in patients with GDM. Further studies are required to evaluate the early test detection rate for DM and glucose intolerance separately.
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Affiliation(s)
- Sanaz Mousavi
- Women's Reproductive Health Research, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aylar Safari
- Residency of Obstetrics and Gynecology, Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hooman Nateghian
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Nikniaz
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran.
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21
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Hinkle SN, Schisterman EF, Liu D, Pollack AZ, Yeung EH, Mumford SL, Grantz KL, Qiao Y, Perkins NJ, Mills JL, Mendola P, Zhang C. Pregnancy Complications and Long-Term Mortality in a Diverse Cohort. Circulation 2023; 147:1014-1025. [PMID: 36883452 PMCID: PMC10576862 DOI: 10.1161/circulationaha.122.062177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 02/01/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Pregnancy complications are associated with increased risk of development of cardiometabolic diseases and earlier mortality. However, much of the previous research has been limited to White pregnant participants. We aimed to investigate pregnancy complications in association with total and cause-specific mortality in a racially diverse cohort and evaluate whether associations differ between Black and White pregnant participants. METHODS The Collaborative Perinatal Project was a prospective cohort study of 48 197 pregnant participants at 12 US clinical centers (1959-1966). The Collaborative Perinatal Project Mortality Linkage Study ascertained participants' vital status through 2016 with linkage to the National Death Index and Social Security Death Master File. Adjusted hazard ratios (aHRs) for underlying all-cause and cause-specific mortality were estimated for preterm delivery (PTD), hypertensive disorders of pregnancy, and gestational diabetes/impaired glucose tolerance (GDM/IGT) using Cox models adjusted for age, prepregnancy body mass index, smoking, race and ethnicity, previous pregnancies, marital status, income, education, previous medical conditions, site, and year. RESULTS Among 46 551 participants, 45% (21 107 of 46 551) were Black, and 46% (21 502 of 46 551) were White. The median time between the index pregnancy and death/censoring was 52 years (interquartile range, 45-54). Mortality was higher among Black (8714 of 21 107 [41%]) compared with White (8019 of 21 502 [37%]) participants. Overall, 15% (6753 of 43 969) of participants had PTD, 5% (2155 of 45 897) had hypertensive disorders of pregnancy, and 1% (540 of 45 890) had GDM/IGT. PTD incidence was higher in Black (4145 of 20 288 [20%]) compared with White (1941 of 19 963 [10%]) participants. The following were associated with all-cause mortality: preterm spontaneous labor (aHR, 1.07 [95% CI, 1.03-1.1]); preterm premature rupture of membranes (aHR, 1.23 [1.05-1.44]); preterm induced labor (aHR, 1.31 [1.03-1.66]); preterm prelabor cesarean delivery (aHR, 2.09 [1.75-2.48]) compared with full-term delivery; gestational hypertension (aHR, 1.09 [0.97-1.22]); preeclampsia or eclampsia (aHR, 1.14 [0.99-1.32]) and superimposed preeclampsia or eclampsia (aHR, 1.32 [1.20-1.46]) compared with normotensive; and GDM/IGT (aHR, 1.14 [1.00-1.30]) compared with normoglycemic. P values for effect modification between Black and White participants for PTD, hypertensive disorders of pregnancy, and GDM/IGT were 0.009, 0.05, and 0.92, respectively. Preterm induced labor was associated with greater mortality risk among Black (aHR, 1.64 [1.10-2.46]) compared with White (aHR, 1.29 [0.97-1.73]) participants, while preterm prelabor cesarean delivery was higher in White (aHR, 2.34 [1.90-2.90]) compared with Black (aHR, 1.40 [1.00-1.96]) participants. CONCLUSIONS In this large, diverse US cohort, pregnancy complications were associated with higher mortality nearly 50 years later. Higher incidence of some complications in Black individuals and differential associations with mortality risk suggest that disparities in pregnancy health may have life-long implications for earlier mortality.
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Affiliation(s)
- Stefanie N Hinkle
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (S.N.H., E.F.S., S.L.M)
| | - Enrique F Schisterman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (S.N.H., E.F.S., S.L.M)
| | - Danping Liu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute (D.L.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Anna Z Pollack
- Global and Community Health Department, College of Health and Human Services, George Mason University, Fairfax, VA (A.Z.P.)
| | - Edwina H Yeung
- Division of Population Health Research, Division of Intramural Research (E.H.Y., K.L.G., N.J.P., J.L.M.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Sunni L Mumford
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia (S.N.H., E.F.S., S.L.M)
| | - Katherine L Grantz
- Division of Population Health Research, Division of Intramural Research (E.H.Y., K.L.G., N.J.P., J.L.M.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Yan Qiao
- The Prospective Group, Rockville, MD (Y.Q.)
| | - Neil J Perkins
- Division of Population Health Research, Division of Intramural Research (E.H.Y., K.L.G., N.J.P., J.L.M.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - James L Mills
- Division of Population Health Research, Division of Intramural Research (E.H.Y., K.L.G., N.J.P., J.L.M.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Pauline Mendola
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, NY (P.M.)
| | - Cuilin Zhang
- Global Centre for Asian Women's Health, Human Potential Translational Research Program; Department of Obstetrics and Gynecology; and National University of Singapore Bia-Echo Asia Centre for Reproductive Longevity and Equality, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (C.Z.)
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22
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D'Amico R, Dalmacy D, Akinduro JA, Hyer M, Thung S, Mao S, Fareed N, Bose-Brill S. Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes. JAMA Netw Open 2023; 6:e2254765. [PMID: 36745454 DOI: 10.1001/jamanetworkopen.2022.54765] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
IMPORTANCE Gestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening. OBJECTIVE To describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022. MAIN OUTCOMES AND MEASURES Primary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively. RESULTS A total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum. CONCLUSIONS AND RELEVANCE In this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.
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Affiliation(s)
- Rachel D'Amico
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Djhenne Dalmacy
- Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Jenifer A Akinduro
- Department of Obstetrics and Gynecology, Indiana University, Bloomington
| | - Madison Hyer
- Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Stephen Thung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Shengyi Mao
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Naleef Fareed
- Department of Biomedical Informatics, The Ohio State University, Columbus
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
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23
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Neuwahl SJ, Sharma AJ, Zhang P, Hoerger TJ. Postdelivery Intervention to Prevent Type 2 Diabetes and the Cost-Effectiveness of Screening Criteria for Gestational Diabetes. Prev Chronic Dis 2022; 19:E89. [PMID: 36580414 PMCID: PMC9809391 DOI: 10.5888/pcd19.220055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE AND OBJECTIVES The objective of our study was to model the costs and benefits of 2 screening criteria for people with gestational diabetes. Because people with a history of gestational diabetes are at increased risk for type 2 diabetes, we modeled the effects of a postdelivery intervention based on the Diabetes Prevention Program, which is offered to all people with a history of gestational diabetes defined by either set of criteria. INTERVENTION APPROACH We used a probabilistic decision tree model to compare the cost-effectiveness of the International Association of Diabetes in Pregnancy Study Group's (IADPSG's) screening criteria and the Carpenter-Coustan screening criteria for gestational diabetes through delivery and a follow-up period during which people might develop type 2 diabetes after pregnancy. EVALUATION METHODS The model included perinatal outcomes for the infant and mother and a 10-year postdelivery period to model maternal progression to type 2 diabetes. The model assumed the health care system perspective. People with gestational diabetes received treatment for gestational diabetes during pregnancy, and we assumed that 10% would participate in a Diabetes Prevention Program-based postdelivery intervention to reduce the risk of type 2 diabetes. We estimated the cost-effectiveness of each screening strategy in quality-adjusted life-years (QALYs) in 2022 dollars. RESULTS At 10% participation in a Diabetes Prevention Program-based postdelivery intervention, the Carpenter-Coustan criteria were cost-effective, compared with no screening ($66,085 per QALY). The IADPSG screening criteria were slightly less cost-effective, compared with no screening ($97,878 per QALY) or Carpenter-Coustan screening criteria ($122,279 per QALY). With participation rates of 23% or higher, the IADPSG screening criteria were highly cost-effective ($48,588 per QALY), compared with Carpenter-Coustan screening criteria. IMPLICATIONS FOR PUBLIC HEALTH Diagnosing a larger proportion of pregnant people using the IADPSG screening criteria, compared with using Carpenter-Coustan screening criteria, is not cost-effective at low levels of participation. However, with moderate levels of participation (23%) in a Diabetes Prevention Program-based postdelivery intervention, the expanded IADPSG screening criteria are cost-effective and reach up to 4 times as many people as Carpenter-Coustan screening.
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Affiliation(s)
| | - Andrea J. Sharma
- Centers for Disease Control and Prevention, Atlanta, Georgia,US Public Health Service Commissioned Corps, Atlanta, Georgia
| | - Ping Zhang
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Gemkow JW, Liss DT, Yang TY, Padilla R, King PL, Pereyra S, Cox-Batson S, Tenfelde S, Masinter L. Predicting Postpartum Transition to Primary Care in Community Health Centers. Am J Prev Med 2022; 63:689-699. [PMID: 35840450 DOI: 10.1016/j.amepre.2022.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Although the transition to primary care after routine postpartum care has been recommended to mitigate adverse maternal outcomes, little is known about real-world transition patterns. The objective of this study was to describe the patterns and predictors of transition in a postpartum cohort receiving care at federally qualified health centers and a subcohort of clinically high-risk patients. METHODS Electronic health record data collected between 2017 and 2019 were analyzed in 2021 for unadjusted analyses and multivariable regression models for both the full and high-risk cohorts. The primary outcome was completion of a primary care visit within 6 months of delivery. Primary predictors in both cohorts were insurance loss, postpartum visit, first-trimester visit, and medical visit within the year prepregnancy; for the full cohort, high-risk status was also studied. RESULTS The full cohort (N=7,926) analysis showed that 17.3% completed a primary care visit. In unadjusted and adjusted analysis, all 5 predictors were significantly associated with primary care visit completion; 25.0% of high-risk patients completed a primary care visit, and patients who lost insurance had 66% lower odds of primary care visit completion (95% CI=0.24, 0.48). In unadjusted and adjusted analysis for the high-risk cohort (n=1,956, 24.7% of full cohort), all predictors except postpartum visit were significantly associated with primary care visit completion. CONCLUSIONS Postpartum patients at federally qualified health centers transitioned to primary care at low rates; insurance loss was one significant barrier to care. Strategies to increase continuity, including improving insurance access, should be studied. Future research is needed to study structural inequity, the impact of primary care on maternal outcomes, and patient experience.
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Affiliation(s)
| | - David T Liss
- Health Research and Education Team, AllianceChicago, Chicago, Illinois; Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ta-Yun Yang
- Health Research and Education Team, AllianceChicago, Chicago, Illinois
| | - Roxane Padilla
- Health Research and Education Team, AllianceChicago, Chicago, Illinois
| | | | | | | | - Sandi Tenfelde
- Near North Health Service Corporation, Chicago, Illinois; Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois
| | - Lisa Masinter
- Health Research and Education Team, AllianceChicago, Chicago, Illinois
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25
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Interrante JD, Admon LK, Carroll C, Henning-Smith C, Chastain P, Kozhimannil KB. Association of Health Insurance, Geography, and Race and Ethnicity With Disparities in Receipt of Recommended Postpartum Care in the US. JAMA HEALTH FORUM 2022; 3:e223292. [PMID: 36239954 PMCID: PMC9568809 DOI: 10.1001/jamahealthforum.2022.3292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Importance Little is known about the quality of postpartum care or disparities in the content of postpartum care associated with health insurance, rural or urban residency, and race and ethnicity. Objectives To examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity. Design, Settings, and Participants This cross-sectional survey of patients with births from 2016 to 2019 used data from the Pregnancy Risk Assessment Monitoring System (43 states and 2 jurisdictions). A population-based sample of patients conducted by state and local health departments in partnership with the Centers for Disease Control and Prevention were surveyed about maternal experiences 2 to 6 months after childbirth (mean weighted response rate, 59.9%). Patients who attended a postpartum visit were assessed for content at that visit. Analyses were performed November 2021 to July 2022. Exposures Medicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups). Main Outcomes and Measures Receipt of 2 postpartum care components recommended by national quality standards (depression screening and contraceptive counseling), and/or other recommended components (smoking screening, abuse screening, birth spacing counseling, eating and exercise discussions) with estimated risk-adjusted predicted probabilities and percentage-point (pp) differences. Results Among the 138 073 patient-respondents, most (59.5%) were in the age group from 25 to 34 years old; 59 726 (weighted percentage, 40%) were insured by Medicaid; 27 721 (15%) were rural residents; 9718 (6%) were Asian, 24 735 (15%) were Black, 22 210 (15%) were Hispanic, 66 323 (60%) were White, and fewer than 1% were Indigenous (Native American/Alaska Native) individuals. Receipt of both depression screening and contraceptive counseling both significantly lower for Medicaid-insured patients (1.2 pp lower than private; 95% CI, -2.1 to -0.3), rural residents (1.3 pp lower than urban; 95% CI, -2.2 to -0.4), and people of racially minoritized groups (0.8 pp lower than White individuals; 95% CI, -1.6 to -0.1). The highest receipt of these components was among privately insured White urban residents (80%; 95% CI, 79% to 81%); the lowest was among privately insured racially minoritized rural residents (75%; 95% CI, 72% to 78%). Receipt of all other components was significantly higher for Medicaid-insured patients (6.1 pp; 95% CI, 5.2 to 7.0), rural residents (1.1 pp; 95% CI, 0.1 to 2.0), and people of racially minoritized groups (8.5 pp; 95% CI, 7.7 to 9.4). The highest receipt of these components was among Medicaid-insured racially minoritized urban residents (34%; 95% CI, 33% to 35%), the lowest was among privately insured White urban residents (19%; 95% CI, 18% to 19%). Conclusions and Relevance The findings of this cross-sectional survey of postpartum individuals in the US suggest that inequities in postpartum care content were extensive and compounded for patients with multiple disadvantaged identities. Examining only 1 dimension of identity may understate the extent of disparities. Future studies should consider the content of postpartum care visits.
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Affiliation(s)
- Julia D. Interrante
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis,Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Lindsay K. Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Caitlin Carroll
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Carrie Henning-Smith
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis,Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Phoebe Chastain
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis,Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Katy B. Kozhimannil
- University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis,Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
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Choi E, Kazzi B, Varma B, Ortengren AR, Minhas AS, Vaught AJ, Bennett WL, Lewey J, Michos ED. The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care. CURRENT CARDIOVASCULAR RISK REPORTS 2022; 16:219-229. [PMID: 36159207 PMCID: PMC9490714 DOI: 10.1007/s12170-022-00706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 01/26/2023]
Abstract
Purpose of Review The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester. Recent Findings A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness. Summary Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.
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Affiliation(s)
- Eunjung Choi
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Brigitte Kazzi
- Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA
| | - Bhavya Varma
- Department of Medicine, Johns Hopkins University School of Medicine, MD 21287 Baltimore, USA
| | | | - Anum S. Minhas
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Arthur Jason Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Wendy L. Bennett
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287 USA
| | - Jennifer Lewey
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
- Division of Cardiology, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 524-B, Baltimore, MD 21287 USA
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Linnenkamp U, Greiner GG, Haastert B, Adamczewski H, Kaltheuner M, Weber D, Icks A. Postpartum screening of women with GDM in specialised practices: Data from 12,991 women in the GestDiab register. Diabet Med 2022; 39:e14861. [PMID: 35472098 DOI: 10.1111/dme.14861] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 03/29/2022] [Accepted: 04/20/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gestational diabetes (GDM) in the short term is associated with various complications during pregnancy; however, in the long run, women have an increased risk of type 2 diabetes mellitus (T2DM). Therefore, short- and long-term follow-up postpartum is recommended. METHODS We assessed the proportion of postpartum diabetes screening among 12,991 women with their first GDM-diagnosed pregnancy in the study period in the nationwide German GestDiab register between 2015 and 2017. In addition to assessing prevalence, we assessed if the probability of postpartum screening was associated with maternal characteristics or pregnancy outcomes. RESULTS In total, 38.2% (95% CI 32.8%-43.7%) of our sample underwent postpartum diabetes screening, irrespective of its timing. Around 50% of women (19.3% of the total sample) undertook the screening in the recommended time frame of 6-12 weeks postpartum. We found that age, native language, pre-pregnancy BMI, smoking status, number of previous pregnancies, fasting plasma glucose and HbA1c levels as well as previous pregnancies with GDM and treatment with insulin were associated with participation in the postpartum diabetes screening in our sample. CONCLUSION In our study, more than 60% of the women with GDM did not participate in postpartum diabetes screening. This is a missed opportunity in a high-risk population to detect glucose intolerance. Consequently, appropriate interventions to prevent the progression to T2DM cannot be initiated. Further research should investigate barriers and enabling factors and allow developing a multilevel approach for GDM postpartum care.
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Affiliation(s)
- Ute Linnenkamp
- Institute for Health Services Research and Health Economics, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
| | - Gregory Gordon Greiner
- German Center for Diabetes Research (DZD), Partner Düsseldorf, München-Neuherberg, Germany
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Burkhard Haastert
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- mediStatistica, Wuppertal, Germany
| | - Heinke Adamczewski
- winDiab gGmbH, wissenschaftliches Institut der niedergelassenen Diabetologen, Neuss, Germany
| | - Matthias Kaltheuner
- winDiab gGmbH, wissenschaftliches Institut der niedergelassenen Diabetologen, Neuss, Germany
| | - Dietmar Weber
- winDiab gGmbH, wissenschaftliches Institut der niedergelassenen Diabetologen, Neuss, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Fetal and Neonatal Middle Cerebral Artery Hemodynamic Changes and Significance under Ultrasound Detection in Hypertensive Disorder Complicating Pregnancy Patients with Different Severities. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6110228. [PMID: 35799667 PMCID: PMC9256346 DOI: 10.1155/2022/6110228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 11/18/2022]
Abstract
Colour Doppler ultrasound was applied for monitoring the hemodynamic parameters of fetal uterine artery (UtA), umbilical artery (UA), and middle cerebral artery (MCA) during pregnancy. In hypertension disease complicating pregnancy, these hemodynamic measures and their therapeutic applicability value were reviewed (HDCP). 120 singleton pregnant women were chosen, with 40 cases of mild preeclampsia (mild group), 40 cases of severe preeclampsia (severe group), and 40 normal control pregnant women (control group). The hemodynamic parameters of UtA, MCA, and UA were monitored in the three groups, including pulsatility index (PI), resistance index (RI), and the systolic/diastolic velocity (S/D). The parameters PI, RI, S/D, and venous catheter shunt rate (Qdv/Quv) of UtA and UA in the severe group were higher than those in the normal group and the mild group, showing the differences statistically significant (
). The PI, RI, and S/D of MCA in the severe group were lower than those in the normal group and the mild group (
). The changing trends of PI, RI, and S/D in the severe group were all first increased and then decreased in the early, middle, and later pregnancy (
). The area under the curve (AUC) was 0.98 in the receiver operating characteristic (ROC) curve created using a combination of hemodynamic measures and pregnancy outcomes, and the sensitivity and specificity for predicting bad outcomes were 94.7 percent and 96.4 percent, respectively. Colour Doppler ultrasound may accurately detect changes in the PI, RI, and S/D of UtA, MCA, and UA in pregnant women and serve as a reference for determining the intrauterine state of the fetuses and predicting bad pregnancy outcomes. In particular, the parameters in later pregnancy were higher worthy of diagnostic value for adverse pregnancy outcomes. The combination of various parameters could make an improvement of the diagnostic accuracy and provide a basis for guiding treatment as well as determining the optimal timing of delivery.
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Hutchins F, El Khoudary SR, Catov J, Krafty R, Colvin A, Barinas-Mitchell E, Brooks MM. Excessive Gestational Weight Gain and Long-Term Maternal Cardiovascular Risk Profile: The Study of Women's Health Across the Nation. J Womens Health (Larchmt) 2022; 31:808-818. [PMID: 35442810 PMCID: PMC9245790 DOI: 10.1089/jwh.2021.0449] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Excessive gestational weight gain (GWG) is consistently linked with maternal risk of obesity. However, the literature on its long-term cardiovascular risk is minimal and conflicting. We evaluated whether excessive GWG is associated with a high-risk cardiovascular profile among parous women in midlife. Materials and Methods: Participants were women in the multiethnic cohort Study of Women's Health Across the Nation with a history of live birth(s). Excessive GWG was defined according to Institute of Medicine guidelines and collected by self-recall. Outcomes were the atherosclerotic cardiovascular disease (ASCVD) risk score and C-reactive protein (CRP), measured at the study baseline when mean age was 47 years, and at 10 follow-up visits (1996-2017). We estimated the association of excessive GWG with outcomes through linear mixed model regression. Results: The analytic sample included 1318 women with 3049 singleton births. Over 40% (536) reported one or more pregnancies with excessive GWG. Longitudinal models estimated that at a mean age of 67, women with a history of excessive GWG had a 9.8% (9.2, 10.5) 10-year ASCVD risk, compared to 9.5% (8.9, 10.1) for those without, and mean CRP of 2.20 mg/L (1.89, 2.57) versus 1.85 mg/L (1.61, 2.14), respectively, adjusted for participant characteristics. Conclusions: In this multiethnic cohort of parous women, a history of excessive GWG was associated with a small, but statistically significant difference in ASCVD risk, and a moderate, statistically significant difference in CRP across midlife. More research is necessary to understand the mechanistic pathway between excessive GWG and long-term maternal cardiovascular health.
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Affiliation(s)
- Franya Hutchins
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Samar R. El Khoudary
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Janet Catov
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert Krafty
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alicia Colvin
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Emma Barinas-Mitchell
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Maria M. Brooks
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
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Thakkar A, Hailu T, Blumenthal RS, Martin SS, Harrington CM, Yeh DD, French KA, Sharma G. Cardio-Obstetrics: the Next Frontier in Cardiovascular Disease Prevention. Curr Atheroscler Rep 2022; 24:493-507. [PMID: 35524915 PMCID: PMC9076812 DOI: 10.1007/s11883-022-01026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 12/05/2022]
Abstract
Purpose of Review Internationally, cardiovascular disease (CVD) is the leading cause of death in women. With risk factors for CVD continuing to rise, early identification and management of chronic diseases such as hypertension, diabetes, and obstructive sleep apnea is necessary for prevention. Pregnancy is a natural stress test for women with risk factors who may be predisposed to CVD and offers a unique opportunity to not only recognize disease but also implement effective and long-lasting strategies for prevention. Recent Findings Prevention begins before pregnancy, as preconception screening, counseling, and optimization of chronic diseases can improve maternal and fetal outcomes. Throughout pregnancy, women should maintain close follow-up, continued reevaluation of risk factors, with counseling when necessary. Continued healthcare engagement during the “fourth trimester,” 3 months following delivery, allows clinicians to continue monitoring the evolution of chronic diseases, encourage ongoing lifestyle counseling, and connect women with primary care and appropriate specialists if needed. Unfortunately, this postpartum period represents a major care gap, as a significant proportion of most women do not attend their scheduled visits. Social determinants of health including decreased access to care and economic instability lead to increased risk factors throughout pregnancy but particularly play a role in poor compliance with postpartum follow-up. The use of telemedicine clinics and remote monitoring may prove to be effective interventions, bridging the gap between physicians and patients and improving follow-up for at-risk women. Summary While many clinicians are beginning to understand the impact of CVD on women, screening and prevention strategies are not often implemented until much later in life. Pregnancy creates an opportunity to begin engaging women in cardiovascular protective strategies before the development of the disease.
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Affiliation(s)
- Aarti Thakkar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Blalock 559, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Tigist Hailu
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Blalock 559, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Blalock 559, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Blalock 559, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Colleen M Harrington
- Division of Cardiovascular Medicine, University of Massachusetts Memorial Healthcare, Worcester, MA, USA
| | - Doreen DeFaria Yeh
- Division of Cardiology, Adult Congenital Heart Disease Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Katharine A French
- Lifespan Cardiovascular Institute, Division of Cardiology, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Blalock 559, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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Kuster A, Lee KA, Sligar K. Quality Improvement Project to Increase Postpartum Clinic Visits for Publicly Insured Women. J Obstet Gynecol Neonatal Nurs 2022; 51:313-323. [PMID: 35240046 DOI: 10.1016/j.jogn.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To increase the percentage of women who attend postpartum visits and decrease the number of days to the first postpartum visit by implementing a scheduling change. DESIGN Quality improvement project. SETTING/LOCAL PROBLEM A small nurse practitioner maternity care clinic in an academic health center at which only 74% of the women who attended two or more prenatal visits attended postpartum clinic visits. PARTICIPANTS A diverse sample of 25 publicly insured women who gave birth during the 5-month implementation period. INTERVENTION/MEASUREMENTS We added a 2- to 3-week postpartum appointment to our standard 6-week postpartum appointment. The measurable outcomes were the percentage of women who attended postpartum clinic visits and the number of days to the first postpartum visit. RESULTS During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation. CONCLUSION Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings.
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Sylvester SV, Marr M, Jones RR. Maternal health expert feedback on the attributes of a predictive analytics tool to improve pregnancy-related cardiovascular and mental health outcomes in the United States. Inform Health Soc Care 2022; 47:424-433. [PMID: 35139740 DOI: 10.1080/17538157.2022.2032717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Identify pregnancy-related challenges and opportunities to improve maternal health care in the United States and understand the potential role of predictive analytics tool(s) in bridging the existing gaps, specifically, in CVD (cardiovascular disease) and depression. Experts in maternal health care, research, patient advocacy, CVD, psychiatry, and technology were interviewed during February and March of 2020. Additionally, published literature was reviewed to assess existing data, insights, and best practices that might help develop effective predictive analytics tool(s). The majority (78%) of the 18 experts interviewed were women. The feedback revealed several insights, including multiple barriers to diagnosis and treatment of pregnancy-related CVD and depression. In experts' collective opinion, predictive analytics could play an important role in maternal health care and in limiting pregnancy-related CVD and depression, but it must be grounded in quality data and integrate with existing health management systems. A holistic approach to maternal health that factors in racial-ethnic, regional, and socioeconomic disparities is needed that starts with preconception counseling and continues through 1 year postpartum. Predictive analytics tool(s) that are based on diverse and high-quality data could bridge some of the existing gaps in maternal health care and potentially help limit pregnancy-related CVD and depression.
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Affiliation(s)
- Shirley V Sylvester
- Johnson & Johnson, Health of Women, Office of the Chief Medical Officer, New Brunswick, New Jersey, USA
| | - Meghan Marr
- Global Health, Rabin Martin, New York, New York, USA
| | - Robyn R Jones
- Johnson & Johnson, Health of Women, Office of the Chief Medical Officer, New Brunswick, New Jersey, USA
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Moore MD, Mazzoni SE, Wingate MS, Bronstein JM. Characterizing Hypertensive Disorders of Pregnancy Among Medicaid Recipients in a Nonexpansion State. J Womens Health (Larchmt) 2022; 31:261-269. [PMID: 34115529 PMCID: PMC8864437 DOI: 10.1089/jwh.2020.8741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: The incidence of hypertensive disorders of pregnancy (HDP) are on the rise in the United States, especially in the South, which has a heavy chronic disease burden and large number of Medicaid nonexpansion states. Sizeable disparities in HDP outcomes exist by race/ethnicity, geography, and health insurance coverage. Our objective is to explore HDP in the Alabama Medicaid maternity population, and the association of maternal sociodemographic, clinical, and care utilization characteristics with HDP diagnosis. Materials and Methods: Data were from Alabama Medicaid delivery claims in 2017. Bivariate analyses were used to examine maternal characteristics by HDP diagnosis. Hierarchical generalized linear models, with observations nested at the county level, were used to assess multivariable relationships between maternal characteristics and HDP diagnosis. Results: Among women with HDP diagnosis, a higher proportion were older, Black, had other comorbidities, and had more perinatal hospitalizations or emergency visits compared with those without HDP diagnosis. There were increased odds of an HDP diagnosis for older women and those with comorbidities. Black women (adjusted odds ratio [aOR] = 1.24, 95% confidence interval [CI]: 1.16-1.33), women insured only during pregnancy by Sixth Omnibus Reconciliation Act Medicaid (aOR = 1.08, 95% CI: 1.02-1.15), and women entering prenatal care (PNC) in the second trimester (aOR = 1.10, 95% CI: 1.03-1.18) had elevated odds of HDP diagnosis compared with their counterparts. Conclusions: Beyond traditional demographic and clinical risk factors, not having preconception insurance coverage or first trimester PNC entry were associated with higher odds of HDP diagnosis. Improving the provision and timing of maternity coverage among Medicaid recipients, particularly in nonexpansion states, may help identify and treat women at risk of HDP and associated adverse perinatal outcomes.
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Affiliation(s)
- Matthew D. Moore
- Department of Health Care Organization and Policy, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA.,Address correspondence to: Matthew D. Moore, DrPH, MPH, Department of Health Care Organization and Policy, School of Public Health, The University of Alabama at Birmingham, 1665 University Boulevard, Birmingham, AL 35294, USA
| | - Sara E. Mazzoni
- Department of Obstetrics and Gynecology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Martha S. Wingate
- Department of Health Care Organization and Policy, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Janet M. Bronstein
- Department of Health Care Organization and Policy, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Campbell A, Stanhope KK, Platner M, Joseph NT, Jamieson DJ, Boulet SL. Demographic and Clinical Predictors of Postpartum Blood Pressure Screening Attendance. J Womens Health (Larchmt) 2021; 31:347-355. [PMID: 34610249 DOI: 10.1089/jwh.2021.0161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly dangerous, as it can go undiagnosed and cause complications. The American College of Obstetricians and Gynecologists recommends women with HDP undergo blood pressure (BP) screening 7-10 days after delivery to detect postpartum hypertension. This study aimed to describe predictors of postpartum BP screening attendance among a high-risk safety-net population in Atlanta, Georgia. Materials and Methods: We conducted a population-based cohort study of pregnant women who delivered at a large public hospital in Atlanta between July 1, 2016, and June 30, 2018. We manually abstracted demographic and clinical data from electronic medical records and used multivariable log binomial regression to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) for associations with BP screening attendance. Results: Of 1260 women diagnosed with HDP, 13.7% attended a BP screening visit within 10 days of delivery. Women with preeclampsia with severe features were more likely to attend a BP visit than women with gestational hypertension (aRR 2.10, 95% CI 1.35-3.27). Rates of BP screening attendance were lower for women with inadequate (aRR 0.42, 95% CI 0.26-0.67) and intermediate (aRR 0.40, 95% CI 0.21-0.74) prenatal care utilization relative to women with adequate utilization. Conclusions: Among a high-risk safety-net population with HDP, most women did not attend a BP screening visit within 10 days of delivery. Addressing this gap requires further research and creative solutions to address barriers at the individual, provider, and system levels.
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Affiliation(s)
- Alexa Campbell
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Kaitlyn K Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marissa Platner
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Naima T Joseph
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Denise J Jamieson
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
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Lai F, Li Z, Yue S, Pei L, Xiao H, Li Z, Li Y, Xiao H, Cao X. Early postpartum abnormal glucose metabolism subtype differs according to mid-trimester lipid profile in women with gestational diabetes mellitus. Lipids Health Dis 2021; 20:91. [PMID: 34429117 PMCID: PMC8386098 DOI: 10.1186/s12944-021-01519-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022] Open
Abstract
Background It is unknown whether early postpartum abnormal glucose metabolism (AGM) in women with previous gestational diabetes mellitus (GDM) is related to their mid-trimester lipid profile. The aim of this study was to characterize the mid-trimester lipid profile of women who experienced GDM and developed into different pathophysiologic subtypes of early postpartum AGM. Methods A retrospective cohort study of 498 women with history of GDM was conducted. A 75-g oral glucose tolerance test (OGTT) and plasma lipid measurements were performed at 24–28 weeks of gestation and 6–12 weeks of postpartum. Insulin secretion and sensitivity were estimated using early postpartum OGTT-based indices. Results Women in the mid-trimester dyslipidemia group had higher postpartum 30-min and 2-h plasma glucose, higher postpartum 2-h plasma insulin, higher postpartum triglyceride (TG), higher postpartum low density lipoprotein cholesterol (LDL-c) concentrations, lower postpartum 30-min insulinogenic index (IGI30), lower postpartum insulin sensitivity index (ISI), and lower postpartum disposition index than those in the normal lipid group (all P < 0.05). Abnormal mid-trimester TG and LDL-c concentrations were associated with postpartum AGM (adjusted odds ratio [OR] = 1.786, 95 % confidence interval [CI] = 1.142–2.425; and adjusted OR = 1.621, 95 % CI = 1.323–2.051, respectively; both P < 0.05). AGM women with low IGI30 and low ISI had higher mid-trimester total cholesterol and LDL-c concentrations, and AGM women with low ISI had higher mid-trimester TG concentrations than women with NGT or other subtypes of AGM (all P < 0.05). Conclusions GDM women with abnormal mid-trimester TG and LDL-c were predisposed to early postpartum AGM. Postpartum AGM women who experienced GDM had heterogeneous mid-trimester lipid profile when classified according to their pathophysiologic subtype.
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Affiliation(s)
- Fenghua Lai
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Zeting Li
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Shufan Yue
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Ling Pei
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Huangmeng Xiao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Zhuyu Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, 510080, Guangzhou, China
| | - Yanbing Li
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Haipeng Xiao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China
| | - Xiaopei Cao
- Department of Endocrinology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Rd, 510080, Guangzhou, China.
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Shankar M, Chan CS, Frayne SM, Panelli DM, Phibbs CS, Shaw JG. Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans' Re-Engagement in VA Primary Care after Pregnancy. Womens Health Issues 2021; 31:603-609. [PMID: 34229932 DOI: 10.1016/j.whi.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition. METHODS We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n = 18,414), and subcohorts of veterans with GDM (n = 1,253), and hypertensive disorders of pregnancy (HDP; n = 2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor. RESULTS In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity. CONCLUSIONS One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations like VA maternity care coordinators to address such gaps merits attention.
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Affiliation(s)
- Megha Shankar
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California; Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Policy (CHP), Stanford, California
| | - Caitlin S Chan
- Health Economics Research Center and Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California; Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Policy (CHP), Stanford, California; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Danielle M Panelli
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Stanford University, Palo Alto, California
| | - Ciaran S Phibbs
- Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Policy (CHP), Stanford, California; Health Economics Research Center and Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California; Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California; Stanford University Center for Primary Care and Outcomes Research (PCOR) and Center for Health Policy (CHP), Stanford, California; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California.
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Chaisson CE, Ameli O, Paterson VJ, Weiseth A, Genen L, Thayer S. Using a Claims-Based Framework to Identify Severe Maternal Morbidities in a Commercially Insured US Population. J Perinat Neonatal Nurs 2021; 35:237-246. [PMID: 34171882 DOI: 10.1097/jpn.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many severe maternal morbidities (SMMs) are preventable, and understanding circumstances in which complications occur is crucial. The objective was to evaluate a framework for SMM benchmarking and quality improvement opportunities. Building upon metrics defined by the Centers for Disease Control and Prevention on the basis of an inpatient sample, analysis included indicators across 5 domains (Hemorrhage/Transfusion, Preeclampsia/Eclampsia, Cardiovascular, Sepsis, and Thromboembolism/Cerebrovascular). Morbidity rates per 10 000 deliveries were calculated using de-identified administrative claims in commercially insured women in the United States. Longitudinal data linked inpatient delivery episodes and 6-week postpartum period, and SMMs were assessed for present on admission and geographic variation. This retrospective analysis of 356 838 deliveries identified geographic variation in SMMs. For example, hemorrhage rates per 10 000 varied 3-fold across states from 279.7 in Alabama to 964.69 in Oregon. Administrative claims can be used to calculate SMM rates, identify geographic variations, and assess problems locally, nationally, and across payers. Identifying conditions present on admission and a postpartum window is valuable in differentiating events occurring during preadmission, inpatient stay, and postpartum periods. Targeting preventable SMMs through local and hospital-level interventions and limiting SMM progression through postdischarge monitoring may reduce the prevalence of SMM and postpartum complications.
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Affiliation(s)
- Christine E Chaisson
- OptumLabs, Eden Prairie, Minnesota (Ms Chaisson and Drs Ameli and Thayer); Ariadne Labs, Boston, Massachusetts (Ms Paterson and Dr Weiseth); and ProgenyHealth, Plymouth Meeting, Pennsylvania (Dr Genen)
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Triebwasser JE, Janssen MK, Sehdev HM. Postpartum counseling in women with hypertensive disorders of pregnancy. Am J Obstet Gynecol MFM 2021; 3:100285. [PMID: 33451593 DOI: 10.1016/j.ajogmf.2020.100285] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/10/2020] [Accepted: 11/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are associated with increased cardiovascular disease risk across the lifespan. The American College of Obstetricians and Gynecologists and the American Heart Association emphasize the postpartum period as an important opportunity to identify and intervene women at high risk of future cardiovascular disease. OBJECTIVE This study aimed to determine the proportion of women with documented counseling on risks and transitions of care after hypertensive disorders of pregnancy at the postpartum visit. STUDY DESIGN This was a retrospective longitudinal descriptive study of women with hypertensive disorders of pregnancy who were enrolled in a text-based blood pressure program from September 2018 to February 2019. We abstracted counseling in the discharge summary and postpartum note from the electronic medical record. The primary outcome was counseling at the postpartum visit defined as documentation of (1) follow-up with primary care or cardiology, (2) risk of cardiovascular disease, or (3) recommendation for aspirin in a future pregnancy. We assessed demographic and clinical factors that may influence counseling through multivariable logistic regression. We also compared the proportion of women counseled on hypertensive disorders of pregnancy vs contraception and glucose tolerance tests at the postpartum visit. RESULTS Of 320 eligible women, most women had gestational hypertension or preeclampsia without severe features (64%). Postpartum visits were scheduled in our hospital system for 284 women, of whom 253 attended (89%). Documented counseling occurred for 62 women (25%). Counseling on follow-up with primary care or cardiology, cardiovascular disease risk, and aspirin in future pregnancies was documented for 51 (20%), 15 (6%), and 1 (0.4%), respectively. Only 1 woman had documented counseling on all 3 components. In multivariable analysis, black race remained an independent factor that increased the likelihood of counseling on hypertensive disorders of pregnancy (adjusted odds ratio, 2.77; 95% confidence interval, 1.32-5.83). Women were significantly less likely to be counseled on hypertensive disorders of pregnancy than on contraceptives (99%, P<.001) or glucose tolerance testing after gestational diabetes mellitus (79%, P<.001). CONCLUSION Postpartum counseling on hypertensive disorders of pregnancy merits urgent improvement efforts among obstetrical care providers.
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Affiliation(s)
- Jourdan E Triebwasser
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew K Janssen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Harish M Sehdev
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Britt AJ, Carlson NS, Joseph NT, Amore AD. The Convergence of COVID-19 and Systemic Racism: An Evaluation of Current Evidence, Health System Changes, and Solutions Grounded in Reproductive Justice. J Midwifery Womens Health 2021; 66:298-303. [PMID: 34114324 DOI: 10.1111/jmwh.13250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/23/2021] [Accepted: 04/30/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Abby J Britt
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nicole S Carlson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Naima T Joseph
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Alexis Dunn Amore
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
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Farid H, Blake R, Hacker MR, Erlinger AL, Modest AM. Strategies to improve postpartum glucose screening rates are needed. J Obstet Gynaecol Res 2021; 47:2641-2645. [PMID: 34041808 DOI: 10.1111/jog.14868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
AIMS Women with gestational diabetes mellitus (GDM) require postpartum glucose screening, as they have a 70% lifetime risk of developing Type 2 diabetes mellitus. However, less than half complete postpartum screening. METHODS We conducted a retrospective chart review of patients who delivered at our institution from 2001 to 2019. Inclusion criteria were patients with gestational diabetes who were at least 18 years old and had delivered an infant at >24 weeks of gestation. Our primary outcome was completion of postpartum gestational diabetes screening. RESULTS The majority of patients (62%) did not complete screening. After adjusted risk ratio analyses, the only variables that remained significantly associated with an increased likelihood of completing screening were Asian race and having prenatal care at one particular community health center, which served a predominantly Asian population. CONCLUSIONS This community health center protocol for scheduling patients with GDM that complied with recommendations for postpartum care, indicating that evidence-based methods can improve maternal health.
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Affiliation(s)
- Huma Farid
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel Blake
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Adrienne L Erlinger
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
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Roberts SP, Brown SJ, Roberts SH. Women's engagement, views and experiences of postnatal follow-up after gestational diabetes mellitus in pregnancy. Midwifery 2021; 101:103043. [PMID: 34126338 DOI: 10.1016/j.midw.2021.103043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The evidence base relating to women's engagement and experiences of postnatal care following Gestational Diabetes Mellitus in the United Kingdom is limited. Additionally, the uptake of a postnatal fasting blood glucose testing following Gestational Diabetes Mellitus appears to be poor. OBJECTIVE This study aimed to explore women's engagement, views and experiences of postnatal care following Gestational Diabetes Mellitus in the United Kingdom. DESIGN AND PARTICIPANTS An online survey of participants that had Gestational Diabetes Mellitus was undertaken to gather mixed-methods data regarding women's engagement, views and experiences of postnatal care. Demographic data were also collected. FINDINGS A total of 31 participants completed the online survey; respondents were from two countries in the United Kingdom only (England and Wales). Some respondents indicated positive postnatal experiences following Gestational Diabetes Mellitus (such as good family support) with effective communication by some healthcare teams and screening coinciding with engagement with the routine six week follow-up appointment. Overall, findings indicated a general dissatisfaction with the care provided, mostly due to the inconsistency of information and advice in relation to the type of screening test and the timing, location and organisation of blood glucose screening and follow up care. CONCLUSION This study provides an insight into ways that may improve women's engagement, views and experiences of postnatal care following Gestational Diabetes Mellitus in England and Wales. IMPLICATIONS FOR PRACTICE Findings indicate a lack of consistent adherence to national guidance. A clear care pathway facilitating continuity of care for women in the postnatal period following Gestational Diabetes Mellitus, along with further education and support for health professionals, may improve the provision of postnatal care. The authors recognise the limitations of this small standalone study however, findings highlight the need for further exploration of postnatal follow up following Gestational Diabetes Mellitus in the UK.
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Affiliation(s)
- Siân Pierce Roberts
- Midwifery Department, School of Healthcare Sciences, Bangor University, Fron Heulog, Ffriddoedd Road, Bangor, Gwynedd, Wales, LL57 2DG.
| | - Sheila Js Brown
- School of Healthcare Sciences Bangor University, Fron Heulog, Ffriddoedd Road, Bangor, Gwynedd, Wales, LL57 2DG
| | - Seren Haf Roberts
- School of Health Care Sciences, Bangor University, Archimedes Centre, Wrexham Technology Park, Croesnewydd Road, Wrexham, Wales, LL13 7YP
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Miller C, Lim E. The risk of diabetes after giving birth to a macrosomic infant: data from the NHANES cohort. Matern Health Neonatol Perinatol 2021; 7:12. [PMID: 33980302 PMCID: PMC8114492 DOI: 10.1186/s40748-021-00132-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/28/2021] [Indexed: 12/02/2022] Open
Abstract
Aims Gestational diabetes (GDM) increases the risk of developing type 2 diabetes and thus warrants earlier and more frequent screening. Women who give birth to a macrosomic infant, as defined as a birthweight greater than 9 lbs. (or approximately 4000 g), are encouraged to also get early type 2 diabetes screening, as macrosomia may be a surrogate marker for GDM. This study investigates whether a macrosomic infant, as defined as 9lbs, apart from GDM, increases the risk for diabetes later in life. Methods Data on parous women from the National Health and Nutrition Examination Survey (NHANES) 2007–2016 were utilized. Rates of diabetes were compared in those with and without macrosomic infants in Rao-Scott’s chi-square test. Multiple logistic regression was used to test the independent effect of macrosomia on type 2 diabetes controlling for the confounding covariates and adjusting for the complex sampling design. To investigate how onset time affects diabetes, we implemented Cox proportional hazard regressions on time to have diabetes. Results Among 10,089 parous women, macrosomia significantly increased the risk of maternal diabetes later in life in the chi-square test and logistic regression. Independent of GDM, women who deliver a macrosomic infant have a 20% higher chance of developing diabetes compared to women who did not. The expected hazards of having type 2 diabetes is 1.66 times higher in a woman with macrosomic infant compared to counterparts. Conclusions Women who gave birth to a macrosomic infant in the absence of GDM should be offered earlier and more frequent screening for type 2 diabetes.
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Affiliation(s)
- Corrie Miller
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA.
| | - Eunjung Lim
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
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43
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McCloskey L, Bernstein J, The Bridging The Chasm Collaborative, Amutah-Onukagha N, Anthony J, Barger M, Belanoff C, Bennett T, Bird CE, Bolds D, Brenna BW, Carter R, Celi A, Chachere B, Crear-Perry J, Crossno C, Cruz-Davis A, Damus K, Dangel A, Depina Z, Deroze P, Dieujuste C, Dude A, Edmonds J, Enquobahrie D, Eromosele E, Ferranti E, Fitzmaurice M, Gebel C, Blount LG, Greiner A, Gullo S, Haddad A, Hall N, Handler A, Headen I, Heelan-Fancher L, Hernandez T, Johnson K, Jones E, Jones N, Klaman S, Lund B, Mallampalli M, Marcelin L, Marshall C, Maynard B, McCage S, Mitchell S, Molina R, Montasir S, Nicklas J, Northrup A, Norton A, Oparaeke E, Ramos A, Rericha S, Rios E, Bloch JR, Ryan C, Sarfaty S, Seely E, Souter V, Spain M, Spires R, Theberge S, Thompson T, Wachman M, Yarrington T, Yee LM, Zera C, Clayton J, Lachance C. Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action. Womens Health Issues 2021; 31:204-218. [PMID: 33707142 PMCID: PMC8154664 DOI: 10.1016/j.whi.2021.01.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.
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Affiliation(s)
- Lois McCloskey
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts(b) The names and affiliations of all authors in the Bridging the Chasm Collaborative are listed in Table 1..
| | - Judith Bernstein
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts(b) The names and affiliations of all authors in the Bridging the Chasm Collaborative are listed in Table 1
| | | | | | | | - Mary Barger
- University of San Diego, Hahn School of Nursing
| | | | - Trude Bennett
- University of North Carolina Gillings School of Global Public Health
| | | | | | | | | | - Ann Celi
- Brigham and Women's Hospital, Harvard Medical School
| | | | | | - Chase Crossno
- University of North Texas Health Sciences Center/Texas Christian University School of Medicine
| | | | - Karla Damus
- Boston University Medical Campus, Office of Human Research Affairs
| | | | | | | | | | - Annie Dude
- University of Chicago School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | - Arden Handler
- University of Illinois at Chicago School of Public Health
| | - Irene Headen
- Drexel University Dornsife School of Public Health
| | | | | | | | - Emily Jones
- University of Oklahoma Health Sciences Center, Ziegler College of Nursing
| | | | - Stacey Klaman
- University of North Carolina Gillings School of Global Public Health
| | | | | | | | | | | | | | | | - Rose Molina
- Beth Israel Deaconess Medical Center / The Dimock Center
| | | | | | | | | | | | | | | | | | | | | | | | - Ellen Seely
- Brigham and Women's Hospital, Harvard Medical School
| | | | | | | | | | | | - Madi Wachman
- Boston University Center for Innovation in Social Work and Health
| | | | - Lynn M Yee
- Northwestern University, Feinberg School of Medicine
| | - Chloe Zera
- Beth Israel Deaconess Medical Center, Harvard Medical School
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Stanhope KK, Kramer MR. Variation in the Content of Postpartum Visits by Maternal Race/Ethnicity, Preconception, and Pregnancy-Related Cardiovascular Disease Risk, PRAMS, 2016-2017. Public Health Rep 2021; 137:516-524. [PMID: 33874796 PMCID: PMC9109536 DOI: 10.1177/00333549211005814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content. METHODS We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status. RESULTS Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0). CONCLUSIONS Health systems should consider novel strategies to improve and standardize the content of postpartum visits.
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Affiliation(s)
- Kaitlyn K. Stanhope
- Department of Epidemiology, Emory University, Atlanta, GA,
USA,Department of Gynecology and Obstetrics, Emory University School of
Medicine, Atlanta, GA, USA,Kaitlyn K. Stanhope, PhD, MPH, Emory
University School of Medicine, Department of Obstetrics and Gynecology, Division
of Reproductive Specialties, 100 Woodruff Cir, Atlanta, GA 30322, USA;
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McCloskey L, Bernstein J, Goler-Blount L, Greiner A, Norton A, Jones E, Bird CE. It's Time to Eliminate Racism and Fragmentation in Women's Health Care. Womens Health Issues 2021; 31:186-189. [PMID: 33691995 DOI: 10.1016/j.whi.2020.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/08/2020] [Accepted: 12/23/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Lois McCloskey
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts.
| | - Judith Bernstein
- Community Health Sciences Department, Boston University School of Public Health, Boston, Massachusetts
| | | | - Ann Greiner
- Primary Care Collaborative, Washington District of Columbia
| | | | - Emily Jones
- Zigler College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Chloe E Bird
- Affiliation Withheld in Concordance with Organizational Policy, Santa Monica, California
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46
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Demers S, Wagner JM. Nurses’ and Physicians’ Perspectives on Text-Based Postpartum Blood Pressure Monitoring. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Family-Oriented Social Service Touchpoints as Opportunities to Enhance Diabetes Screening following a History of Gestational Diabetes. J Am Board Fam Med 2020; 33:616-619. [PMID: 32675273 PMCID: PMC7836091 DOI: 10.3122/jabfm.2020.04.190382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Women with a history of gestational diabetes (GDM) are at increased risk for type 2 diabetes and thus require regular follow-up screening for diabetes; however, many women do not receive this screening, and in particular low-income women face disparities in receipt of recommended follow-up care. While these women may have limited access to healthcare following pregnancy, they may more regularly access social service programs that serve themselves or their young children. Leveraging these social service touchpoints could broaden opportunities to improve follow-up care receipt among women with a history of GDM. To describe these potential opportunities, we used national representative data to characterize diabetes screening needs among women with a history of GDM who access the Special supplemental nutrition program for Women, Infants and Children (WIC) or Head Start programming for their young children. METHODS We analyzed national representative data from the National Health Interview Survey from calendar years 2016 and 2017. Our analytic sample included women aged 18 to 45 years who were linked to at least one of their children in the dataset and who had a self-reported history of GDM but did not have prediabetes or diabetes. We examined the proportion of these women who accessed WIC or Head Start who did not report having testing for diabetes within the past 3 years. RESULTS Of 432 (representing 2,002,675 weighted) women meeting inclusion criteria, 21.7% accessed WIC and 8.7% Head Start. Nearly 1 in 10 women with a history of GDM in either group did not report recent diabetes screening. In sensitivity analyses that excluded likely pregnancy-related testing, 35.0% of women accessing WIC and 21.2% of those accessing Head Start had not had recent screening. DISCUSSION There is an unmet need for follow-up diabetes screening among women with a history of GDM who access WIC or Head Start services for their young children. Leveraging women's touchpoints with these programs could enhance opportunities to improve recommended diabetes screening among a high-risk population.
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Gunn C, Bernstein J, Bokhour B, McCloskey L. Narratives of Gestational Diabetes Provide a Lens to Tailor Postpartum Prevention and Monitoring Counseling. J Midwifery Womens Health 2020; 65:681-687. [PMID: 32568461 DOI: 10.1111/jmwh.13122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 03/02/2020] [Accepted: 03/10/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Women with gestational diabetes mellitus (GDM) have a marked increased risk of early onset type 2 diabetes, but less than half initiate postpartum glucose testing or connect with a primary care provider for continued follow-up after giving birth. This study analyzed women's narratives about their GDM-affected pregnancies to (1) identify different patterns (narrative archetypes) that capture the GDM experience; (2) explore how these patterns relate to awareness of ongoing risk after pregnancy and affect participation in self-care, monitoring, and preventive health care going forward; and (3) explore the use of identified patterns to tailor conversations with patients during prenatal and postpartum care to their actual perceptions and concerns about future risk. METHODS Open-ended interviews elicited women's experiences and perspectives about GDM and its management. A narrative analysis first identified segments of text related to risk and behaviors and then applied Frank's narrative archetypes (restitution, chaos, quest) as an interpretive lens. RESULTS Interviews were completed in English (n = 15), Spanish (n = 7), and Haitian Creole (n = 7). We found distinct patterns: stories of restitution (n = 13), quest (n = 4), chaos (n = 4), and mixed narratives (n = 7). Using these archetypes, we found differences in how women respond to challenges related to disease complexity, treatment, and future risks. These patterns led to marked differences in the steps women took to prevent early onset type 2 diabetes. DISCUSSION Frank's narrative types provided insight into women's responses to clinical protocols, health care advice, and subsequent prevention actions. A restitution pattern may result in premature closure and lack of awareness of risk. Similarly, a chaos pattern may contribute to a sense of helplessness to implement follow-up recommendations, despite risk awareness. Understanding these patterns can help clinicians tailor individualized support as women transition from GDM with its focus on a healthy fetus and newborn to preventive self-care to protect their health.
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Affiliation(s)
- Christine Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, Massachusetts.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Judith Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.,Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Barbara Bokhour
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts.,Center for Health Quality, Outcomes and Economic Research at the Bedford Veterans Affairs, Boston, Massachusetts
| | - Lois McCloskey
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
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Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.
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Farabi SS, Hernandez TL. Low-Carbohydrate Diets for Gestational Diabetes. Nutrients 2019; 11:nu11081737. [PMID: 31357598 PMCID: PMC6723585 DOI: 10.3390/nu11081737] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023] Open
Abstract
Nutrition therapy provides the foundation for treatment of gestational diabetes (GDM), and has historically been based on restricting carbohydrate (CHO) intake. In this paper, randomized controlled trials (RCTs) are reviewed to assess the effects of both low- and higher CHO nutrition approaches in GDM. The prevailing pattern across the evidence underscores that although CHO restriction improves glycemia at least in the short-term, similar outcomes could be achievable using less restrictive approaches that may not exacerbate IR. The quality of existing studies is limited, in part due to dietary non-adherence and confounding effects of treatment with insulin or oral medication. Recent evidence suggests that modified nutritional manipulation in GDM from usual intake, including but not limited to CHO restriction, improves maternal glucose and lowers infant birthweight. This creates a platform for future studies to further clarify the impact of multiple nutritional patterns in GDM on both maternal and infant outcomes.
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Affiliation(s)
- Sarah S Farabi
- Goldfarb School of Nursing, Office of Nursing Research, Barnes-Jewish College, St. Louis, MO 63110, USA
- Department of Medicine, Division of Nutritional Science, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Teri L Hernandez
- Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
- College of Nursing, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
- Department of Research, Innovation, and Professional Practice, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA.
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