Expect With Me: development and evaluation design for an innovative model of group prenatal care to improve perinatal outcomes

Discrimination and perinatal depressive symptoms: The protective role of social support and resilience

BACKGROUND

Discrimination is an important social determinant of perinatal depression; however, evidence is limited regarding modifiable social and psychological factors that may moderate this association. We examined whether social support and resilience could protect against the adverse effects of discrimination on perinatal depressive symptoms.

METHODS

Pregnant people (N = 589) receiving Expect With Me group prenatal care in Nashville, TN and Detroit, MI completed surveys during third trimester of pregnancy and six months postpartum. Linear regression models tested the association between discrimination and depressive symptoms, and the moderating effects of social support and resilience, during pregnancy and postpartum.

RESULTS

The sample was predominantly Black (60.6 %), Hispanic (15.8 %) and publicly insured (71 %). In multivariable analyses, discrimination was positively associated with depressive symptoms during pregnancy (B = 4.44, SE = 0.37, p ≤0.001) and postpartum (B = 3.78, SE = 0.36, p < 0.001). Higher social support and resilience were associated with less depressive symptoms during pregnancy (B = -0.49, SE = 0.08, p < 0.001 and B = -0.67, SE = 0.10, p < 0.001, respectively) and postpartum (B = -0.32, SE = 0.07, p < 0.001 and B = -0.56, SE = 0.08, p < 0.001, respectively). Social support was protective against discrimination (pregnancy interaction B = -0.23, SE = 0.09, p = 0.011; postpartum interaction B = -0.35, SE = 0.07, p < 0.001). There was no interaction between discrimination and resilience at either time.

LIMITATIONS

The study relied on self-reported measures and only included pregnant people who received group prenatal care in two urban regions, limiting generalizability.

CONCLUSIONS

Social support and resilience may protect against perinatal depressive symptoms. Social support may also buffer the adverse effects of discrimination on perinatal depressive symptoms, particularly during the postpartum period.

Association between mindful and practical eating skills and eating behaviors among racially diverse pregnant women in four selected clinical sites in the United States

Background: Mindful eating is a promising strategy to address problematic eating behaviors; however, little is known about its applicability during pregnancy. No studies have examined the combined effects of mindful and practical eating skills on eating behaviors. Aim: We examined associations between mindful and practical eating skills and eating behaviors (nutritional intake and emotional eating) among pregnant women who received psychoeducation on healthy eating and pregnancies. Methods: Participants were racially-diverse pregnant women (14-42 years) from four clinical sites in Detroit, Michigan, and Nashville, Tennessee (N = 741). We conducted multiple linear regression to examine associations between mindful (hunger cues, satiety cues, mindful check-ins) and practical (food diary/journal, MyPlate method) eating skills and nutritional intake. We calculated residualized change scores to represent changes in the quality of nutritional intake from second to third trimester. We performed multiple logistic regression to examine associations between mindful and practical eating skills and emotional eating. Results: Women improved over time in eating behaviors (better nutrition, less emotional eating). Regular use of MyPlate was associated with better nutritional intake (unstandardized coefficient [B] = -0.61), but food diaries were not. We found a significant interaction in predicting emotional eating: For those regularly paying attention to hunger cues, some use of MyPlate (Adjusted Odds Ratio [AOR] = 0.39) and especially regular use of MyPlate (AOR = 0.13) reduced the likelihood of emotional eating during pregnancy. Conclusion: Enhancing both mindful and practical eating skills, such as paying attention to hunger cues, and using the MyPlate method, may facilitate pregnant women's ability to improve their eating behaviors.

Perceived Stress and Depressive Symptoms Are Associated With Emotional Eating but Not Nutritional Intake During Pregnancy: A Prospective Cohort Study

INTRODUCTION

Pregnancy is a major life event during which women may experience increased psychological distress and changes in eating behaviors. However, few studies have investigated the influence of psychological distress on pregnant women's eating behaviors. The primary objective of this prospective study was to examine the associations of changes in perceived stress and depressive symptoms with emotional eating and nutritional intake during pregnancy. In addition, we examined the direct and moderating effects of perceived social support.

METHODS

Participants were racially diverse pregnant women (14-42 years) from 4 clinical sites in Detroit, MI, and Nashville, TN (N = 678). We used multiple linear and logistic regression models to determine if changes in stress and depressive symptoms across pregnancy were associated with changes in emotional eating and nutritional intake. We examined residualized change in stress and depressive symptoms from second to third trimester of pregnancy; positive residualized change scores indicated increased stress and depressive symptoms.

RESULTS

Participants showed significant improvement in emotional eating and nutritional intake from second to third trimester of pregnancy (P < .001 for both). At second trimester, higher depressive symptoms were associated with a greater likelihood of emotional eating (P < .001) and worse nutritional intake (P = .044) at third trimester. Increased stress and depressive symptoms during pregnancy were both associated with increased risk, whereas increased perceived social support reduced risk of emotional eating at third trimester (stress: adjusted odds ratio [AOR], 1.17; 95% CI, 1.08-1.26; depressive symptoms: AOR, 1.05; 95% CI, 1.01-1.08; social support: AOR, 0.93; 95% CI, 0.88-0.99). None were associated with changes in nutritional intake. Perceived social support did not show any moderating effects.

DISCUSSION

Increased psychological distress during pregnancy may increase emotional eating. Efforts to promote healthy eating behaviors among pregnant women should consider and address mental health.

Psychosocial Factors Associated with Lower Urinary Tract Symptoms One Year Postpartum

Pregnancy carries substantial risk for developing lower urinary tract symptoms (LUTSs), with potential lifelong impacts on bladder health. Little is known about modifiable psychosocial factors that may influence the risk of postpartum LUTSs. We examined associations between depressive symptoms, perceived stress, and postpartum LUTSs, and the moderating effects of perceived social support, using data from a cohort study of Expect With Me group prenatal care (n = 462). One year postpartum, 40.3% participants reported one or more LUTS. The most frequent LUTS was daytime frequency (22.3%), followed by urinary incontinence (19.5%), urgency (18.0%), nocturia (15.6%), and bladder pain (6.9%). Higher odds of any LUTS were associated with greater depressive symptoms (adjusted odds ratio (AOR) 1.08, 95% confidence interval (CI) 1.04-1.11) and perceived stress (AOR 1.12, 95% CI 1.04-1.19). Higher perceived social support was associated with lower odds of any LUTS (AOR 0.94, 95% CI 0.88-0.99). Perceived social support mitigated the adverse effects of depressive symptoms (interaction AOR 0.99, 95% CI 0.98-0.99) and perceived stress (interaction AOR 0.97, 95% CI 0.95-0.99) on experiencing any LUTS. Greater depressive symptoms and perceived stress may increase the likelihood of experiencing LUTSs after childbirth. Efforts to promote bladder health among postpartum patients should consider psychological factors and social support.

Group Prenatal Care

Group prenatal care (GPC) is a novel model of health care delivery for pregnant patients. In GPC, a small group of patients of similar gestational age meet at scheduled intervals for both medical care and facilitated educational discussions. This care model encourages better communication and engages patients and providers in a supportive community. There is evidence that GPC leads to improved patient and provider satisfaction, health equity, and maternal and neonatal outcomes. Delivery of prenatal care in a group setting is a significant change from the traditional model and takes willingness, planning, and commitment for implementation and continued success.

Experience and severity of menopause symptoms and effects on health-seeking behaviours: a cross-sectional online survey of community dwelling adults in the United Kingdom

BACKGROUND

Almost all women will experience menopause, and the symptoms can have a severely detrimental impact on their quality of life. However, there is limited research exploring health-seeking behaviours and alternative service design or consultation formats. Group consultations have been successfully deployed in perinatal and diabetic care, improving accessibility and outcomes. This cross-sectional online survey was conducted to explore women's personal experiences of menopause, including perspectives on group consultations.

METHODS

An online survey investigated the experiences of individuals at all stages of menopause and their receptiveness towards group consultations for menopause. Respondents were categorised by menopause stage according to the STRAW + 10 staging system. Associations between menopause stage, acceptability of group consultations and participant demographics were assessed using logistic regression.

RESULTS

Respondents experienced an average of 10.7 menopausal symptoms, but only 47% of respondents felt they had the knowledge and tools to manage their symptoms. Advice on menopause was sought from a healthcare professional (HCP) by 61% of respondents, the largest trigger for this being severity of symptoms and the main barrier for this was the perception that menopause wasn't a valid enough reason to seek help. Of the respondents seeking advice from HCPs, 32% were prescribed transdermal HRT, 29% received oral HRT, 19% were offered antidepressants, 18% received local oestrogen and 6% were prescribed testosterone. Over three quarters (77%) of respondents indicated that they would join a group consultation for menopause and would be comfortable sharing their experiences with others (75%). Logistic regression indicated premenopausal respondents were 2.84 times more likely than postmenopausal women to be interested in a group consultation where they can meet or learn from others' experiences.

CONCLUSIONS

This study highlighted a strong willingness of women aged 35-70 to participate in group consultations for menopause, with motivation being strongest amongst premenopausal women. Low awareness of self-management and lifestyle interventions to manage the symptoms of menopause highlight the need for greater outreach, research and interventions to build knowledge and confidence in the general population at scale. Future studies should focus on investigating the effectiveness and economic impact of menopause group consultations and the lived experience of individuals participating in group consultations.

Group antenatal care compared with standard antenatal care for Somali-Swedish women: a historically controlled evaluation of the Hooyo Project

OBJECTIVES

Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures.

DESIGN

A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study.

SETTING

Midwifery-led antenatal care clinic in a mid-sized Swedish town.

PARTICIPANTS

Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC.

INTERVENTION

Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife.

OUTCOMES

Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes.

RESULTS

Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy.

CONCLUSIONS

This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03879200).

Group antenatal care (gANC) for Somali-speaking women in Sweden - a process evaluation

Background

Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo (“mother” in Somali) gANC intervention, including implementation, mechanisms of impact and contextual factors.

Methods

A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations (n = 9), complementary, in-depth and key-informant interviews (women n = 6, midwives n = 4, interpreters and research assistants n = 3) and questionnaire data (women n = 44; midwives n = 8).

Results

Language-supported gANC offered more comprehensive ANC that seemed to correspond to existing needs of the participants and could address knowledge gaps related to pregnancy, birth and the Swedish health care system. The majority of women thought listening to other pregnant women was valuable (91%), felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC.

Conclusions

The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the “othering” of women in risk groups should be avoided.

Trial registration

The study was registered in ClinicalTrials.gov (Identifier: NCT03879200).

The Experience of Pregnant Women in the Health Management Model of Internet-Based Centering Pregnancy: A Qualitative Study

Background

CenteringPregnancy Care is a promising group prenatal care innovation that combines assessment, education, and peer support. In China, it is not clear how best to integrate the CenteringPregnancy Care into existing maternal health care models. This qualitative study aimed to explore Chinese pregnant women’s experience in the Internet-based CenteringPregnancy management model.

Methods

The Internet-based CenteringPregnancy was applied in a tertiary hospital between 2018 and 2019 in Wuhan, Hubei Province. Through purposive sampling, a total of 9 pregnant women who had experienced Internet-based CenteringPregnancy were recruited. A semi-structured interview was used to collect qualitative data, and Colaizzi’s 7-step method of phenomenological data analysis was used to analyze the collected data.

Results

Three themes were extracted from the participants’ interviews, including: 1) empowerment; 2) psychological and social support; 3) challenges of the Internet-based CenteringPregnancy. The Internet-based CenteringPregnancy management model retained advantages of CenteringPregnancy, emphasizing the pregnant woman as the subject of health care and promoting them to participate in health care. Participants believed that they could exchange pregnancy knowledge, help each other, and improve mood both timely and efficiently from the new model. However, it was found that there were challenges in seminar time arrangement, topic selection, and discussion management.

Conclusion

The Internet-based CenteringPregnancy management model positively affected pregnant women’s empowerment, psychological, and social support. It is recommended to improve the seminar’s design in future studies.

A Qualitative Study Documenting Black Birthing Individuals' Perspectives on the Disproportionate Rate of Preterm Birth in the Black Community

Background:

Compared with all other racial and ethnic groups, the rate of preterm birth (PTB) is 50% higher among non-Hispanic Blacks (NHB). There are limited published data focused on the etiology of the racial disparity in PTB from the perspective of Black birthing individuals who have had a lived experience with PTB.

Methods:

To gain insights into the etiology of the race disparity in PTB from the NHB patient's perspective, we conducted a qualitative descriptive study with NHBs who have a history of PTB. We conducted both focus group discussions (FGDs), in-depth interviews (IDIs), and used applied thematic analysis to analyze the data.

Results:

Seven individuals participated in 3 FGDs and 15 individuals participated in an IDI. The majority of participants named stress as a contributor to PTB among NHBs. Participants described that stress becomes an ongoing cycle with a cumulative effect on health. Three primary sources of stress were identified: (1) individual including stress from lack of personal wellness, (2) relational stress from intimate partner and familial relationships, and (3) community-level stress from occupations and societal expectations.

Conclusion:

Uncovering NHB patient's perspectives on the etiology of PTB is a critical step to develop interventions that mitigate the disparity impacting the Black community. Our findings suggest that multilevel interventions targeting individual-, relational-, and community-level stress may be necessary to reduce rates of PTB among NHB individuals.

Group prenatal care and improved birth outcomes: Results from a type 1 hybrid effectiveness-implementation study

To compare birth outcomes for patients receiving Expect With Me (EWM) group prenatal care or individual care only, we conducted a type 1 hybrid effectiveness-implementation trial (Detroit and Nashville, 2014-2016). Participants entered care <24 weeks gestation, had singleton pregnancy, and no prior preterm birth (N = 2402). Mean participant age was 27.1 (SD = 5.77); 49.5% were Black; 15.3% were Latina; 59.7% publicly insured. Average treatment effect of EWM compared to individual care only was estimated using augmented inverse probability weighting (AIPW). This doubly-robust analytic method produces estimates of causal association between treatment and outcome in the absence of randomization. AIPW was effective at creating equivalent groups for potential confounders. Compared to those receiving individual care only, EWM patients did significantly better on three of four primary outcomes: lower risk of infants born preterm (<37 weeks gestation; 6.4% vs. 15.1%, risk ratio (RR) 0.42, 95% Confidence Interval (CI) 0.29, 0.54), low birthweight (<2500 g; 4.3% vs. 11.6%, RR 0.37, 95% CI 0.24, 0.49), and admission to NICU (9.4% vs. 14.6%, RR 0.64, 95% CI 0.49, 0.78). There was no difference in small for gestational age (<10% percentile of weight for gestational age). EWM patients attended a mean of 5.9 group visits (SD = 2.7); 70% attended ≥5 group visits. Post-hoc analyses indicated EWM patients utilizing the integrated information technology platform had lower risk for low birthweight infants (RR 0.47, 95% CI 0.24, 0.86) than non-users. Future research is needed to understand mechanisms by which group prenatal care improves outcomes, best practices for implementation, and health systems savings. Trial registration: ClinicalTrials.govNCT02169024.

A mobile education and social support group intervention for improving postpartum health in northern India: Development and usability study (Preprint)

Background

Structural and cultural barriers limit Indian women’s access to adequate postnatal care and support despite their importance for maternal and neonatal health. Targeted postnatal education and support through a mobile health intervention may improve postnatal recovery, neonatal care practices, nutritional status, knowledge and care seeking, and mental health.

Objective

We sought to understand the feasibility and acceptability of our first pilot phase, a flexible 6-week postnatal mobile health intervention delivered to 3 groups of women in Punjab, India, and adapt our intervention for our next pilot phase, which will formally assess intervention feasibility, acceptability, and preliminary efficacy.

Methods

Our intervention prototype was designed to deliver culturally tailored educational programming via a provider-moderated, voice- and text-based group approach to connect new mothers with a social support group of other new mothers, increase their health-related communication with providers, and refer them to care needed. We targeted deployment using feature phones to include participants from diverse socioeconomic groups. We held moderated group calls weekly, disseminated educational audios, and created SMS text messaging groups. We varied content delivery, group discussion participation, and chat moderation. Three groups of postpartum women from Punjab were recruited for the pilot through community health workers. Sociodemographic data were collected at baseline. Intervention feasibility and acceptability were assessed through weekly participant check-ins (N=29), weekly moderator reports, structured end-line in-depth interviews among a subgroup of participants (15/29, 52%), and back-end technology data.

Results

The participants were aged 24 to 28 years and 1 to 3 months postpartum. Of the 29 participants, 17 (59%) had their own phones. Half of the participants (14/29, 48%) attended ≥3 of the 6 calls; the main barriers were childcare and household responsibilities and network or phone issues. Most participants were very satisfied with the intervention (16/19, 84%) and found the educational content (20/20, 100%) and group discussions (17/20, 85%) very useful. The participants used the SMS text messaging chat, particularly when facilitator-moderated. Sustaining participation and fostering group interactions was limited by technological and sociocultural challenges.

Conclusions

The intervention was considered generally feasible and acceptable, and protocol adjustments were identified to improve intervention delivery and engagement. To address technological issues, we engaged a cloud-based service provider for group calls and an interactive voice response service provider for educational recordings and developed a smartphone app for the participants. We seek to overcome sociocultural challenges through new strategies for increasing group engagement, including targeting midlevel female community health care providers as moderators. Our second pilot will assess intervention feasibility, acceptability, and preliminary effectiveness at 6 months. Ultimately, we seek to support the health and well-being of postpartum women and their infants in South Asia and beyond through the development of efficient, acceptable, and effective intervention strategies.

A systematic review of providers' experiences of facilitating group antenatal care

Background

Group antenatal care is a rapidly expanding alternative antenatal care delivery model. Research has shown it to be a safe and effective care model for women, but less is known about the perspectives of the providers leading this care. This systematic review examined published literature that considered health care professionals’ experiences of facilitating group antenatal care.

Methods

Systematic searches were conducted in seven databases (Cinahl, Medline, Psychinfo, Embase, Ovid Emcare, Global Health and MIDRS) in April 2020. Qualitative or mixed methods studies with a significant qualitative component were eligible for inclusion if they included a focus on the experiences of health care providers who had facilitated group antenatal care. Prisma screening guidelines were followed and study quality was critically appraised by three independent reviewers. The findings were synthesised thematically.

Results

Nineteen papers from nine countries were included. Three main themes emerged within provider experiences of group antenatal care. The first theme, ‘Giving women the care providers feel they want and need’, addresses richer use of time, more personal care, more support, and continuity of care. The second theme, ‘Building skills and relationships’, highlights autonomy, role development and hierarchy dissolution. The final theme, ‘Value proposition of group antenatal care’, discusses provider investment and workload.

Conclusions

Health care providers’ experience of delivering group antenatal care was positive overall. Opportunities to deliver high-quality care that benefits women and allows providers to develop their professional role were appreciated. Questions about the providers’ perspectives on workload, task shifting, and the structural changes needed to support the sustainability of group antenatal care warrant further exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01200-0.

Receiving antenatal care in a group setting has been found to be safe and satisfying for women and is supported by international public health guidelines. However, questions remain about the experience of health care professionals tasked with providing this model, such as whether they like working in this model and whether they support its expansion. To answer these questions, the team searched for studies about the experiences of health care providers with group antenatal care, and only included those studies where providers themselves spoke about their own experiences of providing this kind of care. Our review demonstrated that midwives, doctors, nurses and community health workers mostly enjoyed facilitating group antenatal care. They particularly appreciated the ability to give women the kind of care they felt women want and need. Health care providers also experienced some changes in their professional roles, in relation to both the women they serve and their colleagues and organizations. In order to determine if group antenatal care models are a satisfying and sustainable option for health care professionals in the long term, more research is needed.

Risks of Adverse Neonatal Outcomes in Early Adolescent Pregnancy Using Group Prenatal Care as a Strategy for Public Health Policies: A Retrospective Cohort Study in Brazil

Background: Adolescent pregnancy is a public health concern and many studies have evaluated neonatal outcomes, but few have compared younger adolescents with older using adequate prenatal care. Objective: To compare the risks of adverse neonatal outcomes in younger pregnant adolescents who are properly followed through group prenatal care (GPC) delivered by specialized public services. Methods: This retrospective cohort study followed pregnant adolescents (aged 10-17 years) who received GPC from specialized public services in Brazil from 2009 to 2014. Data were obtained from medical records and through interviews with a multidisciplinary team that treated the patients. The neonatal outcomes (low birth weight, prematurity, Apgar scores with 1 and 5 min, and neonatal death) of newborns of adolescents aged 10-13 years were compared to those of adolescents aged 14-15 years and 16-17 years. Incidence was calculated with 95% confidence intervals (CIs) and compared over time using a chi-squared test to observe trends. Poisson Multivariate logistic regression was used to adjust for confounding variables. The results are presented as adjusted relative risks or adjusted mean differences. Results: Of the 1,112 adolescents who were monitored, 758 were included in this study. The overall incidence of adverse neonatal outcomes (low birth weight and prematurity) was measured as 10.2% (95% CI: 9.7-11.5). Apgar scores collected at 1 and 5 min were found to be normal, and no instance of fetal death occurred. The incidence of low birth weight was 16.1% for the 10-13 age group, 8.7% for the 14-15 age group and 12.1% for the 16-17 age group. The incidence of preterm was measured at 12, 8.5, and 12.6% for adolescents who were 10-13, 14-15, and 16-17 years of age, respectively. Neither low birth weight nor prematurity levels significantly differed among the groups (p > 0.05). The infants born to mothers aged 10-13 years presented significantly (p < 0.05) lower Apgar scores than other age groups, but the scores were within the normal range. Conclusions: Our findings showed lower incidence of neonatal adverse outcomes and no risk difference of neonatal outcomes in younger pregnancy adolescents. It potentially suggests that GPC model to care pregnant adolescents is more important than the age of pregnant adolescent, however further research is needed.

Associations between Adverse Childhood Experiences and Sexual Risk among Postpartum Women

Epidemiological evidence suggests that exposure to adverse childhood experiences (ACEs) is associated with sexual risk, especially during adolescence, and with maternal and child health outcomes for women of reproductive age. However, no work has examined how ACE exposure relates to sexual risk for women during the postpartum period. In a convenience sample of 460 postpartum women, we used linear and logistic regression to investigate associations between ACE exposure (measured using the Adverse Childhood Experiences Scale) and five sexual risk outcomes of importance to maternal health: contraceptive use, efficacy of contraceptive method elected, condom use, rapid repeat pregnancy, and incidence of sexually transmitted infections (STIs). On average, women in the sample were 25.55 years of age (standard deviation = 5.56); most identified as Black (60.4%), White (18%), or Latina (14.8%). Approximately 40% were exposed to adversity prior to age 18, with the modal number of experiences among those exposed as 1. Women exposed to ACEs were significantly less likely to use contraception; more likely to elect less-efficacious contraceptive methods; and used condoms less frequently (p = 0.041 to 0.008). ACE exposure was not associated with rapid repeat pregnancy or STI acquisition, p > 0.10. Screening for ACEs during pregnancy may be informative to target interventions to reduce risky sexual behavior during the postpartum period.

Delivering Perinatal Health Information via a Voice Interactive App (SMILE): Mixed Methods Feasibility Study

BACKGROUND

Perinatal health care is critically important for maternal health outcomes in infants. The United States fares considerably worse than comparable countries for maternal and infant mortality rates. As such, alternative models of care or engagement are warranted. Ubiquitous digital devices and increased use of digital health tools have the potential to extend the reach to women and infants in their everyday lives and make a positive impact on their health outcomes. As voice technology becomes more mainstream, research is prudent to establish evidence-based practice on how to best leverage voice technology to promote maternal-infant health.

OBJECTIVE

The aim of this study is to assess the feasibility of using voice technology to support perinatal health and infant care practices.

METHODS

Perinatal women were recruited from a large Midwest Children's Hospital via hospital email announcements and word of mouth. Owing to the technical aspects of the intervention, participants were required to speak English and use an iPhone. Demographics, patterns of technology use, and technology use specific to perinatal health or self-care practices were assessed at baseline. Next, participants were onboarded and asked to use the intervention, Self-Management Intervention-Life Essentials (SMILE), over the course of 2 weeks. SMILE provided users with perinatal health content delivered through mini podcasts (ranging from 3 to 8 minutes in duration). After each podcast, SMILE prompted users to provide immediate verbal feedback to the content. An exit interview was conducted with participants to gather feedback on the intervention and further explore participants' perceptions of voice technology as a means to support perinatal health in the future.

RESULTS

In total, 19 pregnant women (17 to 36 weeks pregnant) were consented. Themes identified as important for perinatal health information include establishing routines, expected norms, and realistic expectations and providing key takeaways. Themes identified as important for voice interaction include customization and user preferences, privacy, family and friends, and context and convenience. Qualitative analysis suggested that perinatal health promotion content delivered by voice should be accurate and succinctly delivered and highlight key takeaways. Perinatal health interventions that use voice should provide users with the ability to customize the intervention but also provide opportunities to engage family members, particularly spouses. As a number of women multitasked while the intervention was being deployed, future interventions should leverage the convenience of voice technology while also balancing the influence of user context (eg, timing or ability to listen or talk versus nonvoice interaction with the system).

CONCLUSIONS

Our findings demonstrate the short-term feasibility of disseminating evidence-based perinatal support via podcasts and curate voice-captured data from perinatal women. However, key areas of improvement have been identified specifically for perinatal interventions leveraging voice technology. Findings contribute to future content, design, and delivery considerations of perinatal digital health interventions.

Group Prenatal Care as a Strategy to Address Diabesity

Group prenatal care is a health care delivery model that utilizes shared medical appointments to place greater focus on patient education, mutual support, and increased time with the clinician to promote a healthy pregnancy. Several studies suggest that medically low-risk women participating in group prenatal care have improved pregnancy outcomes, but the same tenants can likely be used to help women with diabetes and obesity achieve healthy outcomes during pregnancy and throughout their life course. This chapter will review the background, care model, and evidence regarding group medical visits for pregnant women with diabetes and obesity.

Towards deep phenotyping pregnancy: a systematic review on artificial intelligence and machine learning methods to improve pregnancy outcomes

Objective

Development of novel informatics methods focused on improving pregnancy outcomes remains an active area of research. The purpose of this study is to systematically review the ways that artificial intelligence (AI) and machine learning (ML), including deep learning (DL), methodologies can inform patient care during pregnancy and improve outcomes.

Materials and methods

We searched English articles on EMBASE, PubMed and SCOPUS. Search terms included ML, AI, pregnancy and informatics. We included research articles and book chapters, excluding conference papers, editorials and notes.

Results

We identified 127 distinct studies from our queries that were relevant to our topic and included in the review. We found that supervised learning methods were more popular (n = 69) than unsupervised methods (n = 9). Popular methods included support vector machines (n = 30), artificial neural networks (n = 22), regression analysis (n = 17) and random forests (n = 16). Methods such as DL are beginning to gain traction (n = 13). Common areas within the pregnancy domain where AI and ML methods were used the most include prenatal care (e.g. fetal anomalies, placental functioning) (n = 73); perinatal care, birth and delivery (n = 20); and preterm birth (n = 13). Efforts to translate AI into clinical care include clinical decision support systems (n = 24) and mobile health applications (n = 9).

Conclusions

Overall, we found that ML and AI methods are being employed to optimize pregnancy outcomes, including modern DL methods (n = 13). Future research should focus on less-studied pregnancy domain areas, including postnatal and postpartum care (n = 2). Also, more work on clinical adoption of AI methods and the ethical implications of such adoption is needed.

PROCESS AND SYSTEMS: A systems approach to embedding group consultations in the NHS

Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.

Effects of customer self-audit on the quality of maternity care in Tabriz: A cluster-randomized controlled trial

Objective

To study the effects of customer self-audit on the service quality (SQ) and customer quality (CQ) of maternity care.

Design

A community-based cluster-randomized controlled trial.

Setting

Twenty-one health centres and health posts in Tabriz, Iran.

Participants

Of 21 health centres/health posts, 10 were randomly assigned to the intervention group and 11 randomly assigned to the control group. Participants were 185 pregnant women selected from health centre/post registration lists (intervention group: n = 92; control group: n = 93).

Interventions

The intervention was a customer self-audit based on the CenteringPregnancy^® model of prenatal group care. The intervention group attended group support sessions focused on participants’ opinions, questions, and self-management concerns. They also received sessions on experiential learning, coping, problem-solving, and goal-setting by a family health expert, a midwife, and a doctor. Control group participants continued to receive individual care.

Primary outcome measures

SQ and CQ were assessed using questionnaires. Patients rated the importance and performance of non-health quality dimensions. SQ was calculated as: SQ = 10 − (Importance × Performance).

Results

Total mean SQ scores were 7.63 (0.91) and 8.91 (0.76) for the control and intervention groups, respectively, a statistically significant difference (p<0.001). Compared with the control group, the intervention group scored higher on the SQ aspects confidentiality, communication, autonomy, availability of support group, dignity, safety, prevention, and accessibility. Total mean CQ scores for the control and intervention groups were 82.63(7.21) and 87.47 (6.75), respectively, a statistically significant difference (p<0.001). After intervention, 82.6% of intervention group participants and 50.5% of control group participants reached the highest stage of self-management, showing an ability to take care of themselves under stress and financial constraints.

Conclusions

The group prenatal care customer self-audit improved the SQ and CQ of maternity care by increased involvement of participants and giving them active roles in the care process.

Use of a Facilitated Group Process to Design and Implement a Group Antenatal and Postnatal Care Program in Rwanda

INTRODUCTION

The government of Rwanda is exploring strategies that may reduce the incidence of prematurity and low birth weight. Large-scale implementation of group antenatal care (ANC) and postnatal care (PNC) within the context of the Rwanda national health care system is under consideration. To launch a cluster randomized controlled trial of group ANC and PNC in 5 districts in Rwanda, the implementation team needed a customized group care model for this context and trained health care workers to deliver the program.

PROCESS

Adapting the group ANC and group PNC model for the Rwandan context was accomplished through a group process identical to that which is fundamental to group care. A technical working group composed of 10 Rwandan maternal-child health stakeholders met 3 times over the course of 3 months, for 4 to 8 hours each time. Their objectives were to consider the evidence on group ANC, agree on the priorities and constraints of their ANC delivery system, and ultimately define the content and structure of a combined group ANC and PNC model for implementation in Rwanda. The same group process was employed to train health care workers to act as group ANC facilitators.

OUTCOMES

A customized group ANC and PNC model and guidelines for its introduction were developed in the context of a cluster randomized controlled trial in 36 health centers. Descriptions of this model and the implementation plan are included in this article.

DISCUSSION

Our experience suggests that the group process fundamental to successful group ANC and PNC is an effective method to customize and implement this innovative health services delivery model in a new context and is instrumental in achieving local ownership.