A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project

Evaluating Standard of Care and Obstetrical Outcomes in a Reduced Contact Prenatal Care Model in the COVID-19 Pandemic

INTRODUCTION

We aimed to investigate the impact of reduced contact prenatal care necessitated by the COVID-19 pandemic on meeting standards of care and perinatal outcomes.

METHODS

This was a retrospective case-control study of patients in low-risk obstetrics clinic at a tertiary care county facility serving solely publicly insured patients comparing reduced in-person prenatal care (R) over 12 weeks with a control group (C) receiving traditional prenatal care who delivered prior.

RESULTS

Total 90 patients in reduced contact (R) cohort were matched with controls (C). There were similar rates of standard prenatal care metrics between groups. Gestational age (GA) of anatomy ultrasound was later in R (p = 0.017). Triage visits and missed appointments were similar, though total number of visits (in-person and telehealth) was higher in R (p = 0.043). R group had higher GA at delivery (p = 0.001). Composite neonatal morbidity and length of stay were lower in R (p = 0.017, p = 0.048). Maternal and neonatal outcomes did not otherwise differ between groups. Using Kotelchuck Adequacy of Prenatal Care Utilization index, R had higher rates of adequate prenatal care (45.6% R vs. 24.4% C, p = 0.005).

DISCUSSION

Our study demonstrates the non-inferiority of a hybrid, reduced schedule prenatal schedule to traditional prenatal scheduling. In a reduced contact prenatal care model, more patients met criteria for adequate prenatal care, likely due to higher attendance of telehealth visits. These findings raise the question of revising the prenatal care model to mitigate disparities in disadvantaged populations.

Screening for Hypertensive Disorders of Pregnancy: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

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.

Screening for Hypertensive Disorders of Pregnancy: US Preventive Services Task Force Final Recommendation Statement

Importance

Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy.

Population

Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension.

Evidence Assessment

The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit.

Recommendation

The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).

Reduced Compared With Traditional Schedules for Routine Antenatal Visits: A Systematic Review

OBJECTIVE

To assess differences in maternal and child outcomes in studies comparing reduced routine antenatal visit schedules with traditional schedules.

DATA SOURCES

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, searching for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS

Five randomized controlled trials and five nonrandomized comparative studies compared reduced routine antenatal visit schedules with traditional schedules. Studies did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight. There was insufficient evidence for numerous prioritized outcomes of interest, including completion of the American College of Obstetricians and Gynecologists-recommended services and patient experience measures.

CONCLUSION

The evidence base is limited and heterogeneous and allowed few specific conclusions. Reported outcomes included, for the most part, standard birth outcomes that do not have strong plausible biological connection to structural aspects of antenatal care. The evidence did not find negative effects of reduced routine antenatal visit schedules, which may support implementation of fewer routine antenatal visits. However, to enhance confidence in this conclusion, future research is needed, particularly research that includes outcomes of most importance and relevance to changing antenatal care visits.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

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

OBJECTIVE

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

DATA SOURCES

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

METHODS OF STUDY SELECTION

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

It was tough, but necessary. Organizational changes in a community based maternity care system during the first wave of the COVID-19 pandemic: A qualitative analysis in the Netherlands

Introduction

The Coronavirus SARS-CoV-2pandemic necessitated several changes in maternity care. We investigated maternity care providers’ opinions on the positive and negative effects of these changes and on potential areas of improvement for future maternity care both in times of crisis and in regular maternity care.

Methods

We conducted nineteen semi-structured in-depth interviews with obstetricians, obstetric residents, community-based and hospital-based midwives and obstetric nurses. The interviews were thematically analysed using inductive Thematic analysis.

Results

Five themes were generated: ‘(Dis)proportionate measures’, ‘A significant impact of COVID-19’, ‘Differing views on inter-provider cooperation’, ‘Reluctance to seek help’ and ‘Lessons learnt’. The Central Organizing Concept was: ‘It was tough but necessary’. The majority of participants were positive about most of the measures that were taken and about their proportionality. These measures had a significant impact on maternity care providers, both mentally and on an organizational level. Most hospital-based care providers were positive about professional cooperation and communication, but some community-based midwives indicated that the cooperation between different midwifery care practices was suboptimal. Negative effects mentioned were a higher threshold for women to seek care, less partner involvement and perceived more fear among women and their partners, especially around birth. The most significant positive effect mentioned was increased use of eHealth tools. Recommendations for future care were to consider the necessity of prenatal and postnatal care more critically, to replace some face-to-face visits with eHealth and to provide more individualised care.

Conclusion

Maternity care providers experienced measures and organizational changes during the first wave of the COVID19-pandemic as tough, but necessary. They believed that a more critical consideration of medically necessary care, increased use of e-health and more individualised care might contribute to making maternity care more sustainable during and after the pandemic.

Evaluating the level of patient satisfaction with telehealth antenatal care during the COVID-19 pandemic at King Abdul-Aziz Medical City, Primary Health Care Center, Specialized Polyclinic

Aim:

To evaluate the client satisfaction with a phone-based antenatal care consultation and identify the associated factors during the COVID-19 pandemic at King Abdul-Aziz Medical City, Primary Health Care Center Specialized Polyclinic during 2020.

Method:

The study was a cross-sectional, retrospective study conducted with pregnant women attending the maternity clinic at the Specialized Polyclinic, Primary Health Care Center at King Abdul-Aziz Medical City, Jeddah. A self-administered questionnaire was sent via a text message (short message service) to collect the data after signed written consent.

Result:

Of 279 pregnant women, 262 (93.9%) attended phone clinic appointments one to five times. The total satisfaction level score was 73.4 ± 6.5, indicating a high level of satisfaction with the phone clinics, and 252 (90.3%) reported a high level of satisfaction. There was a significant difference in the total score regarding education, occupation, husband’s occupation, smoking, gravidity, parity, menstruation, gestational age, pregnancy complication, number of phone clinics during pregnancy, number of attending clinics during pregnancy, visiting another health facility, and reason of visiting phone clinic ( p < 0.0001, p < 0.0001, p < 0.0001, p = 0.015, p = 0.033, p < 0.0001, p < 0.0001, p = 0.027, p = 0.001, p < 0.0001, and p = 0.002).

Conclusion:

The study indicated a high level of satisfaction with the antenatal telephone clinics during the pandemic, which supports the trend of transition in the direction of the digitalization of antenatal care.

Virtual Visits in Prenatal Care: An Integrative Review

INTRODUCTION

Addressing gaps in access to prenatal care is an important step to reversing rising rates of maternal and neonatal morbidity and mortality and invites the exploration of innovative care models. This integrative review of published literature explores the patient, health care provider, and organizational experience of integrating virtual visits in prenatal care.

METHODS

A literature search to identify original studies and quality improvement projects published between 2010 and 2020 was conducted in PubMed, Scopus, CINAHL, and Google Scholar using keywords associated with both telemedicine and prenatal care. Inclusion criteria specified articles pertaining to synchronous virtual visits between pregnant patients and health care providers, and articles were excluded if visits were not pregnancy-centric or pertaining to telemonitoring or mobile applications. Reference lists of identified reviews were screened, and a hand search of 4 applicable journals was also conducted. Findings were organized according to the factors of the social ecological model: individual, interpersonal, organizational, community, and public policy.

RESULTS

The search identified 2666 articles after duplicates were removed, of which 13 met all criteria. Findings across these 13 articles indicated strong patient and health care provider satisfaction with virtual care related to cost savings and convenience, with clinic wait times and cancellation rates also improving. Health care provider input and thoughtful organizational planning were key to a smooth telemedicine implementation process. There were notably no significant differences in clinical outcomes for those who used virtual care.

DISCUSSION

Although data are limited, offering an integrated model that uses both virtual visits and in-person visits has been well-received by patients and health care providers and could improve access to care well into the future. Virtual visits in prenatal care have been well-received by patients and health care providers, showing promise as an emerging model for improving access to care.

Patient and Professional Experiences With Virtual Antenatal Clinics During the COVID-19 Pandemic in a UK Tertiary Obstetric Hospital: Questionnaire Study

Background

The COVID-19 pandemic required rapid implementation of virtual antenatal care to keep pregnant women safe. This transition from face-to-face usual care had to be embraced by patients and professionals alike.

Objective

We evaluated patients’ and professionals’ experiences with virtual antenatal clinic appointments during the COVID-19 pandemic to determine satisfaction and inquire into the safety and quality of care received.

Methods

A total of 148 women who attended a virtual antenatal clinic appointment at our UK tertiary obstetric care center over a 2-week period provided feedback (n=92, 62% response rate). A further 37 health care professionals (HCPs) delivering care in the virtual antenatal clinics participated in another questionnaire study (37/45, 82% response rate).

Results

We showed that women were highly satisfied with the virtual clinics, with 86% (127/148) rating their experience as good or very good, and this was not associated with any statistically significant differences in age (P=.23), ethnicity (P=.95), number of previous births (P=.65), or pregnancy losses (P=.94). Even though 56% (83/148) preferred face-to-face appointments, 44% (65/148) either expressed no preference or preferred virtual, and these preferences were not associated with significant differences in patient demographics. For HCPs, 67% (18/27) rated their experience of virtual clinics as good or very good, 78% (21/27) described their experience as the same or better than face-to-face clinics, 15% (4/27) preferred virtual clinics, and 44% (12/27) had no preference. Importantly, 67% (18/27) found it easy or very easy to adapt to virtual clinics. Over 90% of HCPs agreed virtual clinics should be implemented long-term.

Conclusions

Our study demonstrates high satisfaction with telephone antenatal clinics during the pandemic, which supports the transition toward widespread digitalization of antenatal care suited to 21st-century patients and professionals.

A scoping review of evidence comparing models of maternity care in Australia

OBJECTIVES

To synthesize available evidence comparing outcomes and experiences of care received in different maternity models in Australia and identify the information gaps hindering women's decisions between alternative models.

DESIGN

A literature search was conducted to identify published research over the last twenty years that directly compared clinical and/or experiential outcomes of women in different maternity models of care in Australia. Outcome measures of included articles were identified and assessed to evaluate current comparative information available to women and health professionals. The quality of included studies was assessed using Joanna Briggs Institute (JBI) critical appraisal tools for randomised controlled studies (RCTs) and cohort studies. Quantitative data were extracted and synthesised for further analysis.

SETTING/PARTICIPANTS

Published studies comparing at least two maternity care models providing antenatal, intrapartum and postpartum care in Australia.

RESULTS

Eight studies (five RCTs and three observational studies) met inclusion criteria. Seven studies compared the outcomes of public midwifery continuity care and standard public care and one compared the outcomes of public midwifery continuity care, standard care and private obstetric care. There was no evidence directly comparing all broadly categorised available models in Australia. Data for clinical outcomes were collected from hospital records and experiential data were self-reported. Seven out of eight studies used data collected from single public hospital settings and one study included data from two tertiary hospitals. Women in public midwifery continuity models were more likely to have unassisted vaginal births, continuity of care and satisfaction and lower use of interventions (i.e., episiotomy, induction of labour, use of analgesia) and neonatal admission in intensive care units (ICU), compared with those in standard public models (and private obstetric care in one study).

CONCLUSION

This scoping review reveals lack of reliable direct comparison of clinical and experiential outcomes across the multiple available public and private maternity models of care in Australia. Quality alignment between women's needs and their maternity model of care can prevent under or over specialised care and avoidable health system costs. Comprehensive information comparing all available maternity care models can guide gatekeeper health professionals and women to choose the best model according to women's needs and preferences. There is a need for research providing more comprehensive and ecological comparisons between available models of maternity care to inform such decision making support. Moreover, women's experiential data across maternity model of care comparisons could be used more consistently to better represent the relative outcomes of alternative models from a consumer-centred perspective.

Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring

BACKGROUND

Standard prenatal care, consisting of 12-14 visits per pregnancy, is expensive and resource intensive, with limited evidence supporting the structure, rhythm, or components of care. Some studies suggest a reduced-frequency prenatal care model is as safe as the standard model of care for low-risk pregnant women, but evidence is limited. We developed and evaluated an innovative, technology-enhanced, reduced prenatal visit model (OB Nest).

OBJECTIVE

To evaluate the acceptability and effectiveness of OB Nest, a reduced-frequency prenatal care model enhanced with remote home monitoring devices and nursing support.

STUDY DESIGN

A single-center randomized controlled trial, composed of pregnant women, aged 18-36 years, recruited from an outpatient obstetric tertiary academic center in the Midwest United States. OB Nest care consisted of 8 onsite appointments with an obstetric provider; 6 virtual visits consisting of phone or online communication with an assigned nurse, supplemented with fetal Doppler and sphygmomanometer home monitoring devices; and access to an online community of pregnant women. Usual care consisted of 12 prescheduled prenatal clinic appointments with obstetric providers. Acceptability of OB Nest was measured by validated surveys of patient satisfaction with care at 36 weeks; perception of stress at 14, 24, and 36 weeks; and perceived quality of care at 36 weeks of gestation. Effectiveness was analyzed by comparing adherence to the American College of Obstetricians and Gynecologists recommended routine prenatal and ancillary services, maternal and fetal safety outcomes, and healthcare utilization.

RESULTS

Three hundred pregnant women at <13 weeks of gestation were recruited and randomized to OB Nest or usual care (150 in each arm) using a minimization algorithm. Demographic characteristics were similar between groups. Compared to usual care, patients in OB Nest had higher satisfaction on a 100-point validated modified Littlefield and Adams Satisfaction scale (OB Nest = 93.9% vs usual care = 78.9%, P < .01). Pregnancy-related stress, measured, on a 0-2 point PreNatal Maternal Stress validated scale, with higher scores indicating higher levels of stress, was lower among OB Nest participants at 14 weeks (OB Nest = 0.32 vs usual care = 0.41, P < .01) and at 36 weeks of gestation (OB Nest = 0.34 vs usual care = 0.40, P < .03). There was no statistical difference in perceived quality of care. Adherence to the provision of American College of Obstetricians and Gynecologists prenatal services was similar in both arms. Maternal and fetal clinical outcomes were similar between groups. Total reported nursing time was higher in OB Nest (OB Nest = 171.2 minutes vs usual care = 108.2 minutes, 95% confidence interval, 48.7-77.4).

CONCLUSION

OB Nest is an innovative, acceptable, and effective reduced-frequency prenatal care model. Compared to routine prenatal care, OB Nest resulted in higher patient satisfaction and lower prenatal stress, while reducing the number of appointments with clinicians and maintaining care standards for pregnant women. This program is a step toward evidence-driven prenatal care that improves patient satisfaction.

Use of wearable sensors for pregnancy health and environmental monitoring: Descriptive findings from the perspective of patients and providers

Background

Wearable sensors and other smart technology may be especially beneficial in providing remote monitoring of sub-clinical changes in pregnancy health status. Yet, limited research has examined perceptions among pregnant patients and providers in incorporating smart technology into their daily routine and clinical practice.

Objective

The purpose of this study was to examine the perceptions of pregnant women and their providers at a rural health clinic on the use of wearable technology to monitor health and environmental exposures during pregnancy.

Methods

An anonymous 21-item e-survey was administered to family medicine or obstetrics and gynecology (n=28) providers at a rural health clinic; while a 21-item paper survey was administered to pregnant women (n=103) attending the clinic for prenatal care.

Results

Smartphone and digital technology use was high among patients and providers. Patients would consider wearing a mobile sensor during pregnancy, reported no privacy concerns, and felt comfortable sharing information from these devices with their physician. About seven out of 10 women expressed willingness to change their behavior during pregnancy in response to receiving personalized recommendations from a smartphone. While most providers did not currently use smart technologies in their medical practice, about half felt it will be used more often in the future to diagnose and remotely monitor patients. Patients ranked fetal heart rate and blood pressure as their top preference for health monitoring compared to physicians who ranked blood pressure and blood glucose. Patients and providers demonstrated similar preferences for environmental monitoring, but patients as a whole expressed more interests in tracking environmental measures compared to their providers.

Conclusions

Patients and providers responded positively to the use of wearable sensor technology in prenatal care. More research is needed to understand what factors might motivate provider use and implementation of wearable technology to improve the delivery of prenatal care.

OB Nest: Reimagining Low-Risk Prenatal Care

Using a human-centered design method, our team sought to envision a new model of care for women experiencing low-risk pregnancy. This model, called OB Nest, aimed to demedicalize the experience of pregnancy by providing a supportive and empowering experience that fits within patients' daily lives. To explore this topic, we invited women to use self-monitoring tools, a text-based smartphone application to communicate with their care team, and moderated online communities to connect with other pregnant women. Through observations of tool use and patient- and care team-provided feedback, we found that self-measurement and access to a fetal heart monitor provided women with confidence and joy in the progress of their pregnancies while shifting their position to being an active participant in their care. The smartphone application gave women direct access to their care team, provided continuity, and removed hurdles in establishing communication. The online community platform was a space where women in the same obstetric clinic could share nonmedical questions and advice with one another. This created a sense of community, leveraged the knowledge of women, and provided a venue beyond the clinic visit for information exchange. These findings were integrated into the design of the Mayo Clinic OB Nest model. This model redistributes care based on the individual needs of patients by providing self-measurement tools and continuous flexible access to their care team. By enabling women to meaningfully participate in their care, there is potential for cost savings and improved patient satisfaction.

Family Ruptures, Stress, and the Mental Health of the Next Generation

This paper studies how in utero exposure to maternal stress from family ruptures affects later mental health. We find that prenatal exposure to the death of a maternal relative increases take-up of ADHD medications during childhood and anti-anxiety and depression medications in adulthood. Further, family ruptures during pregnancy depress birth outcomes and raise the risk of perinatal complications necessitating hospitalization. Our results suggest large welfare gains from preventing fetal stress from family ruptures and possibly from economically induced stressors such as unemployment. They further suggest that greater stress exposure among the poor may partially explain the intergenerational persistence of poverty.

Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services

Women’s satisfaction is a part of the quality assurance process with potential to improve antenatal health services. The objective of this study was to assess the prevalence of women’s satisfaction with antenatal care in an urban Kazakhstani setting and investigate associated factors. A total of 1496 women who delivered in all maternity clinics from 6 February through 11 July 2013 in Semey, East Kazakhstan, filled out a standardized pretested questionnaire on satisfaction with antenatal care. Independent associations between dissatisfaction and its correlates were studied by logistic regression. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers, and shorter waiting times. The overall dissatisfaction was associated with long waiting times and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy, and breastfeeding. Although most of the women in the study setting were satisfied with the new antenatal care model, we identified the main sources of dissatisfaction that should be addressed. Given that Semey is a typical Kazakhstani city, the results can be generalized to other Kazakhstani urban settings.

Increasing the Connectivity and Autonomy of RNs with Low-Risk Obstetric Patients

: Objective: RNs are adopting an ever-larger role in health care models designed to reduce costs, increase patient satisfaction, and improve patient outcomes. Most research exploring such models has focused on those involving physicians or advanced practice nurses rather than RNs. This study explored the perspectives of patients, RNs, and other providers regarding a new prenatal connected care model for low-risk patients aimed at reducing in-office visits and creating virtual patient-RN connections.

METHODS

This qualitative evaluation was performed as part of a larger randomized controlled trial of the new care model. Individual interviews and asynchronous online focus groups were conducted with a total of 41 patients, up to 10 unit and connected care RNs, and up to 17 other providers (up to eight physicians and nine certified nurse midwives [CNMs]).

RESULTS

Thematic analysis indicated that patients in the new care model valued connectedness and relationships with the connected care RNs, including the ability to contact them as needed outside the office setting. Patients also valued their relationships with physicians and CNMs. Physicians appreciated having more time to care for higher-risk patients, and the connected care RNs appreciated being able to work to a fuller scope of practice, although participants in all provider groups suggested the increased use of protocols and other systems to ensure patient safety and improve communication among providers.

CONCLUSIONS

A prenatal connected care model for low-risk women allowed patients to decrease the number of scheduled in-person clinic visits with physicians or CNMs while building stronger nurse-patient relationships through virtual connected care visits with an RN. The results included increased patient satisfaction and greater autonomy for RNs, allowing them to work to a fuller scope of practice. Although the new model gave physicians more time in which to see higher-risk patients, CNM-patient relationships may have been limited.

Predictors of prenatal care satisfaction among pregnant women in American Samoa

Background

Pregnant women in American Samoa have a high risk of complications due to overweight and obesity. Prenatal care can mitigate the risk, however many women do not seek adequate care during pregnancy. Low utilization of prenatal care may stem from low levels of satisfaction with services offered. Our objective was to identify predictors of prenatal care satisfaction in American Samoa.

Methods

A structured survey was distributed to 165 pregnant women receiving prenatal care at the Lyndon B Johnson Tropical Medical Center, Pago Pago. Women self-reported demographic characteristics, pregnancy history, and satisfaction with prenatal care. Domains of satisfaction were extracted using principal components analysis. Scores were summed across each domain. Linear regression was used to examine associations between maternal characteristics and the summed scores within individual domains and for overall satisfaction.

Result

Three domains of satisfaction were identified: satisfaction with clinic services, clinic accessibility, and physician interactions. Waiting ≥ 2 h to see the doctor negatively impacted satisfaction with clinic services, clinic accessibility, and overall satisfaction. Living > 20 min from the clinic was associated with lower clinic accessibility, physician interactions, and overall satisfaction. Women who were employed/on maternity leave had lower scores for physician interactions compared with unemployed women/students. Women who did not attend all their appointments had lower overall satisfaction scores.

Conclusions

Satisfaction with clinic services, clinic accessibility and physician interactions are important contributors to prenatal care satisfaction. To improve patient satisfaction prenatal care clinics should focus on making it easier for women to reach clinics, improving waiting times, and increasing time with providers.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1563-6) contains supplementary material, which is available to authorized users.

Patient Satisfaction with Virtual Obstetric Care

Introduction The importance of patient satisfaction in US healthcare is increasing, in tandem with the advent of new patient care modalities, including virtual care. The purpose of this study was to compare the satisfaction of obstetric patients who received one-third of their antenatal visits in videoconference ("Virtual-care") compared to those who received 12-14 face-to-face visits in-clinic with their physician/midwife ("Traditional-care"). Methods We developed a four-domain satisfaction questionnaire; Virtual-care patients were asked additional questions about technology. Using a modified Dillman method, satisfaction surveys were sent to Virtual-care (N = 378) and Traditional-care (N = 795) patients who received obstetric services at our institution between January 2013 and June 2015. Chi-squared tests of association, t-tests, logistic regression, and ANOVA models were used to evaluate differences in satisfaction and self-reported demographics between respondents. Results Overall satisfaction was significantly higher in the Virtual-care cohort (4.76 ± 0.44 vs. 4.47 ± 0.59; p < .001). Parity ≥ 1 was the sole significant demographic variable impacting Virtual-care selection (OR = 2.4, 95% CI: 1.5-3.8; p < .001). Satisfaction of Virtual-care respondents was not significantly impacted by the incorporation of videoconferencing, Doppler, and blood pressure monitoring technology into their care. The questionnaire demonstrated high internal consistency as measured by domain-based correlations and Cronbach's alpha. Discussion Respondents from both models were highly satisfied with care, but those who had selected the Virtual-care model reported significantly higher mean satisfaction scores. The Virtual-care model was selected by significantly more women who already have children than those experiencing pregnancy for the first time. This model of care may be a reasonable alternative to traditional care.

Agreeableness and pregnancy: Relations with coping and psychiatric symptoms, a longitudinal study on Spanish pregnant women

Agreeableness is associated with good mental health during pregnancy. Although different studies have indicated that agreeableness is related to adaptive coping, this relation has scarcely been studied in pregnant women. The aim of this study was to analyze the possible differences between high and low agreeableness in relation to coping strategies and psychiatric symptoms in pregnant women. We conducted a longitudinal prospective study between October 2009 and January 2013. Pregnant women (n = 285) were assessed in the first trimester of pregnancy, and 122 of them were assessed during the third. Data were collected using the Coping Strategies Questionnaire, the Symptom Check List 90-R, and the agreeableness subscale of the NEO-FFI. Using the SPSS 21 statistics package, binary logistic regression, two-way mixed analysis of variance, and multiple regression analyses and a Sobel test were conducted. Higher levels of agreeableness were associated with positive reappraisal and problem-solving, and lower levels of agreeableness were associated with overt emotional expression and negative self-focused coping. Women with low agreeableness had poorer mental health, especially in the first trimester. These findings should be taken into account to improve women's experiences during pregnancy. Nevertheless, given the scarcity of data, additional studies are needed.

Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models

BACKGROUND

Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models.

METHODS

A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions.

RESULTS

Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.

CONCLUSIONS

Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.

Overutilization of antenatal care in Norway

Background: It has long been a common belief in Norway that all pregnant women attend antenatal care, but no documentation has been provided. In 1984, official guidelines were issued recommending a reduction of the number of routine visits. However, no studies have been performed in order to monitor whether the recommendations are followed. Aims: Utilization review of antenatal care in Norway. Method: A national cross-sectional study, comprising all deliveries in all obstetrical units in the country during a two-week registration period in June 1996. Information on onset of antenatal care, the number of visits, parity and gestational age at the time of delivery was collected. The study comprised 1,557 deliveries; 45 of the 60 obstetrical units in the country participated. Results: The mean number of antenatal visits was 12.2. Only two of the 1,557 women (0.1%) delivered without any previous antenatal care. A total of 80% started antenatal care in the first trimester, 0.4% had their first antenatal visit in the third trimester. The mean number of antenatal visits was substantially higher than the recommended number. Conclusion: Antenatal care-providers do not comply with the official guidelines.

Implementation of a new prenatal care model to reduce office visits and increase connectivity and continuity of care: protocol for a mixed-methods study

Background

Most low-risk pregnant women receive the standard model of prenatal care with frequent office visits. Research suggests that a reduced schedule of visits among low-risk women could be implemented without increasing adverse maternal or fetal outcomes, but patient satisfaction with these models varies. We aim to determine the effectiveness and feasibility of a new prenatal care model (OB Nest) that enhances a reduced visit model by adding virtual connections that improve continuity of care and patient-directed access to care.

Methods and design

This mixed-methods study uses a hybrid effectiveness-implementation design in a single center randomized controlled trial (RCT). Embedding process evaluation in an experimental design like an RCT allows researchers to answer both “Did it work?” and “How or why did it work (or not work)?” when studying complex interventions, as well as providing knowledge for translation into practice after the study. The RE-AIM framework was used to ensure attention to evaluating program components in terms of sustainable adoption and implementation.

Low-risk patients recruited from the Obstetrics Division at Mayo Clinic (Rochester, MN) will be randomized to OB Nest or usual care. OB Nest patients will be assigned to a dedicated nursing team, scheduled for 8 pre-planned office visits with a physician or midwife and 6 telephone or online nurse visits (compared to 12 pre-planned physician or midwife office visits in the usual care group), and provided fetal heart rate and blood pressure home monitoring equipment and information on joining an online care community.

Quantitative methods will include patient surveys and medical record abstraction. The primary quantitative outcome is patient-reported satisfaction. Other outcomes include fidelity to items on the American Congress of Obstetricians and Gynecologists standards of care list, health care utilization (e.g. numbers of antenatal office visits), and maternal and fetal outcomes (e.g. gestational age at delivery), as well as validated patient-reported measures of pregnancy-related stress and perceived quality of care. Quantitative analysis will be performed according to the intention to treat principle. Qualitative methods will include interviews and focus groups with providers, staff, and patients, and will explore satisfaction, intervention adoption, and implementation feasibility. We will use methods of qualitative thematic analysis at three stages. Mixed methods analysis will involve the use of qualitative data to lend insight to quantitative findings.

Discussion

This study will make important contributions to the literature on reduced visit models by evaluating a novel prenatal care model with components to increase patient connectedness (even with fewer pre-scheduled office visits), as demonstrated on a range of patient-important outcomes. The use of a hybrid effectiveness-implementation approach, as well as attention to patient and provider perspectives on program components and implementation, may uncover important information that can inform long-term feasibility and potentially speed future translation.

Trial registration

Trial registration identifier: NCT02082275

Submitted: March 6, 2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0762-2) contains supplementary material, which is available to authorized users.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

Health education during antenatal care: the need for more

The aim of health education during antenatal is to provide advice, education, reassurance and support, to address and treat the minor problems of pregnancy, and to provide effective screening during the pregnancy. Exploring current practices in this regard revealed the need for more organized educational activities to ensure high quality and clients satisfaction.

Antenatal telephone support intervention and uterine artery Doppler screening: A qualitative exploration of women׳s views

OBJECTIVES

to gain insight into low risk nulliparous women׳s experiences of a telephone support intervention (TSI) and TSI with uterine artery Doppler screening (UADS) intervention and their views of the structure of current antenatal care provision.

DESIGN

postnatal semi-structured interviews were analysed using a thematic framework approach. The interviews formed a subset of data from a mixed methods study.

SETTING AND PARTICIPANTS

participants were 45 low risk nulliparous women who had consented to take part in a randomised controlled trial of two antenatal support interventions; the trial was conducted at a large maternity unit in the North East of England, UK from 2004 to 2007.

FINDINGS

most of the women in the study expressed positive views about the telephone support intervention (TSI) and the antenatal care they had received. Uterine artery Doppler screening was acceptable to women but did not feature highly when women recalled their antenatal experiences. Those who viewed their pregnancy as complicated by medical, social or emotional difficulties would have preferred more frequent antenatal visits. Views of antenatal care provision were influenced by women׳s perception of their pregnancy progression and the relationship developed with their midwife.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

although the TSI was viewed positively by women, it was valued most by those who required additional support. The intervention was not a substitute for face to face midwifery visits. Future research is needed to investigate the potential of utilising telephone contact to provide antenatal care for women who have pregnancies complicated by physical, psychological or emotional issues. The findings were consistent with previous evidence to show that the relationship between women and midwives is fundamental to women׳s experience of antenatal care.

Early-life origins of life-cycle well-being: research and policy implications

Mounting evidence across different disciplines suggests that early-life conditions can have consequences on individual outcomes throughout the life cycle. Relative to other developed countries, the United States fares poorly on standard indicators of early-life health, and this disadvantage may have profound consequences not only for population well-being, but also for economic growth and competitiveness in a global economy. In this paper, we first discuss the research on the strength of the link between early-life health and adult outcomes, and then provide an evidence-based review of the effectiveness of existing U.S. policies targeting the early-life environment. We conclude that there is a robust and economically meaningful relationship between early-life conditions and well-being throughout the life cycle, as measured by adult health, educational attainment, labor market attachment, and other indicators of socioeconomic status. However, there is some variation in the degree to which current policies in the United States are effective in improving early-life conditions. Among existing programs, some of the most effective are the Special Supplemental Program for Women, Infants, and Children (WIC), home visiting with nurse practitioners, and high-quality, center-based early-childhood care and education. In contrast, the evidence on other policies such as prenatal care and family leave is more mixed and limited.

Prevention of pregnancy complications in iran following implementing a national educational program

OBJECTIVE

To determine the impact of a national intervention program on some pregnancy complications in Iran.

MATERIALS AND METHODS

This multicenter study was conducted in governmental sector in 14 provinces in Iran between 2003 and 2005. Intervention included education of all maternal health care providers including gynecologists, general physicians, and midwifes in the governmental sector. Time interval between the pre- (of 3,978 and 3,958 pregnancies) and post- (3,958 pregnancies) measurements were 18 months. Self reported data on pregnancy complications were registered. Interviews were conducted by trained personnel. Participants were interviewed when admitted for delivery or at the time attending for vaccination of their 2 month infants.

RESULTS

The following pregnancy complications were reduced significantly as compared to before intervention: 1) bleeding or spotting, 2) urinary tract complications, 3) blurred vision and severe headache, 4) premature labor pain, 5) anemia, 6) severe vomiting, 7) inappropriate weight gain, 8) endometritis, 9) urinary incontinence, 10) breast abscess or mastitis, 11) wound infection, and 12) bleeding was significantly reduced after intervention, compared to before intervention. Premature rupture of membrane showed a significant increase. These complications did not show a significant change: 1) hypertension, 2) fever and chills, 3) convulsion, shock, and loss of consciousness, and 4) obstetric fistula.

CONCLUSION

National programs may be proved to be largely effective by decreasing some of the pregnancy complications in developing countries.

Paging "Dr. Google": does technology fill the gap created by the prenatal care visit structure? Qualitative focus group study with pregnant women

Background

The prenatal care visit structure has changed little over the past century despite the rapid evolution of technology including Internet and mobile phones. Little is known about how pregnant women engage with technologies and the interface between these tools and medical care, especially for women of lower socioeconomic status.

Objective

We sought to understand how women use technology during pregnancy through a qualitative study with women enrolled in the Women, Infants, and Children (WIC) program.

Methods

We recruited pregnant women ages 18 and older who owned a smartphone, at a WIC clinic in central Pennsylvania. The focus group guide included questions about women’s current pregnancy, their sources of information, and whether they used technology for pregnancy-related information. Sessions were audiotaped and transcribed. Three members of the research team independently analyzed each transcript, using a thematic analysis approach. Themes related to the topics discussed were identified, for which there was full agreement.

Results

Four focus groups were conducted with a total of 17 women. Three major themes emerged as follows. First, the prenatal visit structure is not patient-centered, with the first visit perceived as occurring too late and with too few visits early in pregnancy when women have the most questions for their prenatal care providers. Unfortunately, the educational materials women received during prenatal care were viewed as unhelpful. Second, women turn to technology (eg, Google, smartphone applications) to fill their knowledge gaps. Turning to technology was viewed to be a generational approach. Finally, women reported that technology, although frequently used, has limitations.

Conclusions

The results of this qualitative research suggest that the current prenatal care visit structure is not patient-centered in that it does not allow women to seek advice when they want it most. A generational shift seems to have occurred, resulting in pregnant women in our study turning to the Internet and smartphones to fill this gap, which requires significant skills to navigate for useful information. Future steps may include developing interventions to help health care providers assist patients early in pregnancy to seek the information they want and to become better consumers of Internet-based pregnancy resources.

Antenatal telephone support intervention with and without uterine artery Doppler screening for low risk nulliparous women: a randomised controlled trial

BACKGROUND

The number of routine antenatal visits provided to low risk nulliparous women has been reduced in the UK, acknowledging this change in care may result in women being less satisfied with their care and having poorer psychosocial outcomes. The primary aim of the study was to investigate whether the provision of proactive telephone support intervention (TSI) with and without uterine artery Doppler screening (UADS) would reduce the total number of antenatal visits required. A secondary aim was to investigate whether the interventions affected psychological outcomes.

METHODS

A three-arm randomised controlled trial involving 840 low risk nulliparous women was conducted at a large maternity unit in North East England. All women received antenatal care in line with current UK guidance. Women in the TSI group (T) received calls from a midwife at 28, 33 and 36 weeks and women in the telephone and Doppler group (T + D) received the TSI and additional UADS at 20 weeks' gestation. The main outcome measure was the total number of scheduled and unscheduled antenatal visits received after 20 weeks' gestation.

RESULTS

The median number of unscheduled (n = 2.0), scheduled visits (n = 7.0) and mean number of total visits (n = 8.8) were similar in the three groups. The majority (67%) of additional antenatal visits were made to a Maternity Assessment Unit because of commonly occurring pregnancy complications. Additional TSI+/-UADS was not associated with differences in clinical outcomes, levels of anxiety, social support or satisfaction with care. There were challenges to the successful delivery of the telephone support intervention; 59% of women were contacted at 29 and 33 weeks gestation reducing to 52% of women at 37 weeks.

CONCLUSIONS

Provision of additional telephone support (with or without UADS) in low risk nulliparous women did not reduce the number of unscheduled antenatal visits or reduce anxiety. This study provides a useful insight into the reasons why this client group attend for unscheduled visits.

TRIAL REGISTRATION

ISRCTN62354584.

Ambulatory obstetric care

Prenatal care is focused on improving the health of women and babies. Traditional models of prenatal care focus on individual provider-patient interactions. Newer models, including group prenatal care and specialty clinics, may be useful models in certain situations.

A survey of worries of pregnant women: reliability and validity of the Greek version of the Cambridge Worry Scale

OBJECTIVE

to examine the psychometric properties of the Greek version of the Cambridge Worry Scale (CWS) and to assess worries during pregnancy.

SETTING

public hospital in Athens, Greece.

DESIGN

a cross sectional study.

PARTICIPANTS

one hundred and thirty two pregnant women with a gestational age between 11 and 14 weeks who were booked for antenatal screening.

METHODS

CWS was 'forward-backward' translated from English into Greek. The translated instrument was pilot-tested and administered to a sample of 132 pregnant women. Principal component analysis with promax rotation was used to test the factor structure of CWS. Measures of state-trait anxiety (STAI) and depression (CES-D) were used to assess the convergent validity of CWS. Cronbach's α was used to measure internal consistency of the FPI scales.

FINDINGS

results from exploratory factor analysis suggested the existence of four factors. Therefore, the Greek version replicated the original factor structure. Construct validity was confirmed by computing correlations between the CWS factors and conceptually similar constructions of anxiety, and depression. Internal consistency reliability was satisfactory. The major worries that pregnant women referred to were the possibility that something might be wrong with the baby, the process of giving birth, financial issues and the possibility of miscarriage.

CONCLUSION

the CWS was found to have a relatively stable factor structure and satisfactory reliability and convergent and discriminant validity. CWS may enable researchers and clinicians to apply a reliable measure that focuses on worries during pregnancy.

Pregnancy worries: a longitudinal study of Spanish women

OBJECTIVE

To identify pregnancy worries in women by assessing the intensity of these worries and how they change over the course of pregnancy, as well as their relations with sociodemographic and clinical variables.

DESIGN

Longitudinal study using a postal questionnaire.

SETTING

University hospital in Madrid.

POPULATION

285 pregnant women.

METHOD

Women were asked about their pregnancy-specific worries in their first trimester (mean gestational age 14.4 weeks) and third trimester (mean gestational age 34.3 weeks).

MAIN OUTCOME MEASURES

The women completed a questionnaire that included sociodemographic information and the Cambridge Worry Scale.

RESULTS

Pregnancy worries were significantly reduced during the third trimester. The main concern throughout gestation was worry about fetal health. Multiparity and pregnancy planning protected women from pregnancy worries, whereas having had a miscarriage had a negative effect. A younger age and being employed contributed to greater socioeconomic worries.

CONCLUSIONS

Worries related to the health of the fetus are universal across different nationalities. A first pregnancy, unplanned pregnancy, and previous miscarriage are risk factors that influence the intensity of a woman's worries. To improve the health and quality of life of pregnant women, a holistic approach to their care should include evaluation of their worries and appropriate intervention in particular groups considered at risk.

Stressful life events, social health issues and low birthweight in an Australian population-based birth cohort: challenges and opportunities in antenatal care

BACKGROUND

Investment in strategies to promote 'a healthy start to life' has been identified as having the greatest potential to reduce health inequalities across the life course. The aim of this study was to examine social determinants of low birthweight in an Australian population-based birth cohort and consider implications for health policy and health care systems.

METHODS

Population-based survey distributed by hospitals and home birth practitioners to >8000 women six months after childbirth in two states of Australia. Participants were women who gave birth to a liveborn infant in Victoria and South Australia in September/October 2007. Main outcome measures included stressful life events and social health issues, perceived discrimination in health care settings, infant birthweight.

RESULTS

4,366/8468 (52%) of eligible women returned completed surveys. Two-thirds (2912/4352) reported one or more stressful life events or social health issues during pregnancy. Women reporting three or more social health issues (18%, 768/4352) were significantly more likely to have a low birthweight infant (< 2500 grams) after controlling for smoking and other socio-demographic covariates (Adj OR = 1.77, 95% CI 1.1-2.8). Mothers born overseas in non-English speaking countries also had a higher risk of having a low birthweight infant (Adj OR = 1.85, 95% CI 1.2-2.9). Women reporting three or more stressful life events/social health issues were more likely to attend antenatal care later in pregnancy (OR = 2.06, 95% CI 1.3-3.1), to have fewer antenatal visits (OR = 2.17, 95% CI 1.4-3.4) and to experience discrimination in health care settings (OR = 2.69, 95% CI 2.2-3.3).

CONCLUSIONS

There is a window of opportunity in antenatal care to implement targeted preventive interventions addressing potentially modifiable risk factors for poor maternal and infant outcomes. Developing the evidence base and infrastructure necessary in order for antenatal services to respond effectively to the social circumstances of women's lives is long overdue.

Women's perception as a barrier to focused antenatal care in Nigeria: the issue of fewer antenatal visits

The attitude of pregnant women to a new antenatal care model with four antenatal visits (focused antenatal care) is examined using a cross-sectional survey in Enugu, Nigeria. Only 20.3% of the parturients desired a change to the new model. Parturients who defaulted from antenatal care three or more times, those dissatisfied with their current antenatal care, senior civil servants and parturients who received secondary school education or less most commonly desired a change to the new model (P < 0.05). Default from antenatal care and dissatisfaction with current antenatal care were most predictive of the desire for change in multiple logistic regression analysis. The most common reasons for desiring the change were convenience (65.1%) and cost considerations (24.1%). Reasons given for the rejection of the new model were: fear of inadequate learning during antenatal care (45.7%), the suspicion that four visits were inadequate for familiarization with care providers (12.9%), the need for early detection of disease (6.7%) and social satisfaction from antenatal visits (6.7%). These concerns are amenable to change by health education and social mobilization.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, with standard care.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02). There were no clear differences between the groups for the other reported clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

A survey on worries of pregnant women--testing the German version of the Cambridge worry scale

Background

Pregnancy is a transition period in a woman's life characterized by increased worries and anxiety. The Cambridge Worry Scale (CWS) was developed to assess the content and extent of maternal worries in pregnancy. It has been increasingly used in studies over recent years. However, a German version has not yet been developed and validated.

The aim of this study was (1) to assess the extent and content of worries in pregnancy on a sample of women in Germany using a translated and adapted version of the Cambridge Worry Scale, and (2) to evaluate the psychometric properties of the German version.

Methods

We conducted a cross-sectional study and enrolled 344 pregnant women in the federal state of Baden-Württemberg, Germany. Women filled out structured questionnaires that contained the CWS, the Spielberger-State-Trait-Anxiety Inventory (STAI), as well as questions on their obstetric history. Antenatal records were also analyzed.

Results

The CWS was well understood and easy to fill in. The major worries referred to the process of giving birth (CWS mean value 2.26) and the possibility that something might be wrong with the baby (1.99), followed by coping with the new baby (1.57), going to hospital (1.29) and the possibility of going into labour too early (1.28). The internal consistency of the scale (0.80) was satisfactory, and we found a four-factor structure, similar to previous studies. Tests of convergent validity showed that the German CWS represents a different construct compared with state and trait anxiety but has the desired overlap.

Conclusions

The German CWS has satisfactory psychometric properties. It represents a valuable tool for use in scientific studies and is likely to be useful also to clinicians.

Doppler velocimetry of the uterine, umbilical and fetal middle cerebral arteries in pregnant women undergoing tocolysis with oral nifedipine

OBJECTIVES

To evaluate Doppler velocimetry (resistance index (RI) and peak systolic velocity (PSV)) in the maternal-fetal circulation before and 5 and 24 h after tocolysis with oral nifedipine.

METHODS

This was a prospective, observational, analytic cohort study performed in 47 pregnant women undergoing nifedipine tocolysis, each subject acting as her own control. Doppler assessment of uterine, umbilical and fetal middle cerebral (MCA) arteries was performed before and 5 and 24 h after an initial 20-mg sublingual dose, which was repeated twice at 20-min intervals if contractions failed to diminish. The maintenance dose consisted of 20 mg orally every 6 h for 24 h up to a total of 100-120 mg nifedipine. We analyzed whether there was a time effect and compared values at the different time-points.

RESULTS

The MCA-RI had decreased significantly after 24 h of tocolysis (0 h = 0.85; 5 h = 0.85; 24 h = 0.81; P = 0.001), with no differences in uterine or umbilical arteries or in the MCA to umbilical artery ratio. The MCA-PSV had reduced significantly after 5 h (0 h = 41.5 cm/s; 5 h = 34.7 cm/s; P = 0.001), returning close to baseline levels between 5 and 24 h. The PSV increased significantly between 5 and 24 h in the right uterine artery (5 h = 55.1 cm/s; 24 h = 65.0 cm/s; P = 0.037) and in the umbilical artery (5 h = 28.4 cm/s; 24 h = 33.1 cm/s; P = 0.038).

CONCLUSIONS

Nifedipine tocolysis is associated with a reduction in RI in the MCA but not in the uterine or umbilical arteries, a reduction in PSV in the MCA after 5 h but returning to baseline within 24 h, and an increase in PSV between 5 and 24 h in the umbilical and right uterine arteries.

Reducing stillbirths: behavioural and nutritional interventions before and during pregnancy

BACKGROUND

The vast majority of global stillbirths occur in low- and middle-income countries, and in many settings, the majority of stillbirths occur antenatally, prior to the onset of labour. Poor nutritional status, lack of antenatal care and a number of behaviours increase women's risk of stillbirth in many resource-poor settings. Interventions to reduce these risks could reduce the resulting burden of stillbirths, but the evidence for the impact of such interventions has not yet been comprehensively evaluated.

METHODS

This second paper of a systematic review of interventions that could plausibly impact stillbirth rates covers 12 different interventions relating to behavioural and socially mediated risk factors, including exposures to harmful practices and substances, antenatal care utilisation and quality, and maternal nutrition before and during pregnancy. The search strategy reviewed indexed medical journals on PubMed and the Cochrane Library. If any eligible randomised controlled trials were identified that were published after the most recent Cochrane review, they were added to generate new meta-analyses. Interventions covered in this paper have a focus on low- and middle-income countries, both because of the large burden of stillbirths and because of the high prevalence of risk factors including maternal malnutrition and harmful environmental exposures. The reviews and studies belonging to these interventions were graded and conclusions derived about the evidence of benefit of these interventions.

RESULTS

From a programmatic perspective, none of the interventions achieved clear evidence of benefit. Evidence for some socially mediated risk factors were identified, such as exposure to indoor air pollution and birth spacing, but still require the development of appropriate interventions. There is a need for additional studies on culturally appropriate behavioural interventions and clinical trials to increase smoking cessation and reduce exposure to smokeless tobacco. Balanced protein-energy supplementation was associated with reduced stillbirth rates, but larger well-designed trials are required to confirm findings. Peri-conceptional folic acid supplementation significantly reduces neural tube defects, yet no significant associated reductions in stillbirth rates have been documented. Evidence for other nutritional interventions including multiple micronutrient and Vitamin A supplementation is weak, suggesting the need for further research to assess potential of nutritional interventions to reduce stillbirths.

CONCLUSION

Antenatal care is widely used in low- and middle-income countries, and provides a natural facility-based contact through which to provide or educate about many of the interventions we reviewed. The impact of broader socially mediated behaviors, such as fertility decision-making, access to antenatal care, and maternal diet and exposures like tobacco and indoor air pollution during pregnancy, are poorly understood, and further research and appropriate interventions are needed to test the association of these behaviours with stillbirth outcomes. For most nutritional interventions, larger randomised controlled trials are needed which report stillbirths disaggregated from composite perinatal mortality. Many antepartum stillbirths are potentially preventable in low- and middle-income countries, particularly through dietary and environmental improvement, and through improving the quality of antenatal care - particularly including diagnosis and management of high-risk pregnancies - that pregnant women receive.

Systematic review of effect of community-level interventions to reduce maternal mortality

BACKGROUND

The objective was to provide a systematic review of the effectiveness of community-level interventions to reduce maternal mortality.

METHODS

We searched published papers using Medline, Embase, Cochrane library, CINAHL, BNI, CAB ABSTRACTS, IBSS, Web of Science, LILACS and African Index Medicus from inception or at least 1982 to June 2006; searched unpublished works using National Research Register website, metaRegister and the WHO International Trial Registry portal. We hand searched major references.Selection criteria were maternity or childbearing age women, comparative study designs with concurrent controls, community-level interventions and maternal death as an outcome. We carried out study selection, data abstraction and quality assessment independently in duplicate.

RESULTS

We found five cluster randomised controlled trials (RCT) and eight cohort studies of community-level interventions. We summarised results as odds ratios (OR) and confidence intervals (CI), combined using the Peto method for meta-analysis. Two high quality cluster RCTs, aimed at improving perinatal care practices, showed a reduction in maternal mortality reaching statistical significance (OR 0.62, 95% CI 0.39 to 0.98). Three equivalence RCTs of minimal goal-oriented versus usual antenatal care showed no difference in maternal mortality (1.09, 95% CI 0.53 to 2.25). The cohort studies were of low quality and did not contribute further evidence.

CONCLUSION

Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality. This challenges the view that investment in such interventions is not worthwhile. Programmes to improve maternal mortality should be evaluated using randomised controlled techniques to generate further evidence.

Components and timing of prenatal care

The primary objective for prenatal care has not changed in the past 100 years: to have the pregnancy end with a healthy baby and mother. By identifying risk factors for pregnancy complications or other maternal health concerns that need to be addressed, the provider hopes to optimize pregnancy outcome. By using a series of screening and diagnostic tests, as well as serially trending certain components of the physical examination, the provider monitors the ongoing "health" of the pregnancy. As the ability to screen and intervene has improved over the last century, the issues to be assessed have expanded to include not only medical aspects of care but also barriers to access, psychologic considerations, and patient education about general health, pregnancy, and childbirth.

[Maternal perception of premature birth and the experience of pre-eclampsia pregnancy]

OBJECTIVE

To analyze maternal experiences of preeclampsia pregnancy with premature birth at a neonatal intensive care unit.

METHODS

A qualitative study using the focus group technique was conducted with 28 women in a facility specialized in high-risk pregnancies in the state of Rio Grande do Norte, Northeastern Brazil, in 2004. Mothers included had had preeclampsia during pregnancy and a preterm delivery with consequent hospitalization of their baby at a neonatal intensive care unit. The data were analyzed using thematic content analysis of three thematic nuclei subjects: information about preeclampsia during prenatal care; experiences with the preterm newborn, and their perception of neonatal intensive care unit professionals' attitudes.

RESULTS

Maternal reports showed subjects' lack of knowledge with regard to preeclampsia and its association with prematurity. Difficulties inherent to the maternal role of caring for the child in the neonatal intensive care unit were identified, accentuated by communication flaws between health professionals and users.

CONCLUSIONS

Some difficulties experienced by the mothers, in the context of preeclampsia and prematurity, were aggravated by lack or inadequacy of information provided to the users.

What is the place of the new WHO antenatal care model in a teaching hospital setting?

The basic component of the new World Health Organization (WHO) antenatal care model prescribes reduced number of clinic visits and limited investigations for low-risk pregnant women. The objectives of this study were to determine the proportion of pregnant women seeking antenatal care in a Nigerian teaching hospital who qualify for the basic component and to document difficulties that may arise with the classifying form.

In December 2004, 234 pregnant women who had initiated antenatal care were enrolled for the study. Using the classifying form, 157 (67%) were eligible for the basic component, 41 (18%) for special care, but 36 (15%) women could not be classified. Those that did not know the birth weight of their last babies accounted for most (89%) of the unclassified group.

The WHO antenatal care model was the most appropriate and relevant method for our hospital where a large percentage (67%) of prenatal women were eligible for the basic component. However, we consider that the classifying form should be adapted to accommodate all pregnant women.

Do the changes in energy balance that occur during pregnancy predispose parous women to obesity?

The aim of this review was to re-assess whether the changes in energy balance that accompany pregnancy predispose parous women to obesity. A number of cross-sectional studies have sought to answer this question by examining the relationship between parity and maternal body weight. However, these studies were unable to control for the large number of sociobehavioural confounders that might be responsible for the apparent effect of parity on body weight. Longitudinal studies that examine changes in maternal body weight before and after regnancy avoid these problems by using each mother as her own control. Nevertheless, these studies have to overcome three methodological constraints: They must obtain an accurate measure of prepregnant body weight, they must give each mother sufficient time to lose any weight retained following delivery, and they must take into account the effect of ageing on maternal weight gain during pregnancy and the follow-up period. More than 90% of the studies reviewed found body weight to be greater after pregnancy than it was before (by 0.2–10.6kg). and previous researchers who have examined the evidence for pregnancy-related weight gains suggest that body weight increases by an average of 04–4.8kg following pregnancy. However, only three of the 71 longitudinal studies examined in the present review complied with the three methodological criteria. These studies concluded that mothers gain, on average, 0.9–3.3kg more weight following pregnancy than nonpregnant controls, and that mean body weight remained 0.4–3.0kg higher, even after controlling for a number of sociobehavioural confounders. This apparently modest increase in mean maternal body weight for women having one or two children conceals the fact that some mothers experience a substantial increase in body weight and become obese following pregnancy. It remains unclear whether these increases are simply the result of changes in energy metabolism during pregnancy and lactation, or whether they are influenced by inherent changes in lifestyle that accompany pregnancy and motherhood. Understanding the relative importance of these alternatives might help to explain the aetiology of maternal obesity.

“Clover was a stout motherly mare approaching middle life, who had never quite got her figure back after her fourth foal”

George Well (1945) Animal Farm. London: Secker and Warburg.

A literature review on integrated perinatal care

CONTEXT

The perinatal period is one during which health care services are in high demand. Like other health care sub-sectors, perinatal health care delivery has undergone significant changes in recent years, such as the integrative wave that has swept through the health care industry since the early 1990s.

PURPOSE

The present study aims at reviewing scholarly work on integrated perinatal care to provide support for policy decision-making.

RESULTS

Researchers interested in integrated perinatal care have, by assessing the effectiveness of individual clinical practices and intervention programs, mainly addressed issues of continuity of care and clinical and professional integration.

CONCLUSIONS

Improvements in perinatal health care delivery appear related not to structurally integrated health care delivery systems, but to organizing modalities that aim to support woman-centred care and cooperative clinical practice.