Obstetric Care Settings Research Articles

Hepatitis B “Triple Panel” Testing Implementation in the Obstetric Care Setting: Unique Predictors of HBV Vaccine Immunity, Exposure, and HBV Positivity

Hepatitis B “Triple Panel” Testing Implementation in the Obstetric Care Setting: Unique Predictors of HBV Vaccine Immunity, Exposure, and HBV Positivity

Racism in obstetric care: a psychometric study of the Gendered Racial Microaggressions Scale among Global Majority birthing people in obstetric contexts

In the United States, maternal health inequities disproportionately affect Global Majority (e.g., Asian, Black, and Hispanic) populations. Despite a substantial body of research underscoring the influence of racism on these inequities, little research has examined how experiences of gendered racial microaggressions during pregnancy and birth impact racially and ethnically diverse Global Majority pregnant and birthing people in obstetric hospital settings. We evaluated the psychometric properties of an adapted version of Lewis & Neville’s Gendered Racial Microaggressions Scale, using data collected from 417 Global Majority birthing people. Findings from our study indicate that our adapted GRMS is a valid tool for assessing the experiences of gendered racial microaggressions in hospital-based obstetric care settings among Global Majority pregnant and birthing people whose preferred languages are English or Spanish. Item Response Theory (IRT) analysis demonstrated high construct validity of the adapted GRMS scale (Root Mean Square Error of Approximation = 0.1089 (95% CI 0.0921, 0.1263), Comparative Fit Index = 0.977, Standardized Root Mean Square Residual = 0.075, log-likelihood c2 = -85.6, df = 8). IRT analyses demonstrated that the unidimensional model was preferred to the bi-dimensional model as it was more interpretable, had lower AIC and BIC, and all items had large discrimination parameters onto a single factor (all discrimination parameters > 3.0). Given that we found similar response profiles among Black and Hispanic respondents, our Differential Item Functioning analyses support validity among Black, Hispanic, and Spanish-speaking birthing people. Inter-item correlations demonstrated adequate scale reliability, α = 0.97, and empirical reliability = 0.67. Pearsons correlations was used to assess the criterion validity of our adapted scale. Our scale’s total score was significantly and positively related to postpartum depression and anxiety. Researchers and practitioners should seek to address instances of gendered racial microaggressions in obstetric settings, as they are manifestations of systemic and interpersonal racism, and impact postpartum health.

“If They Don’t Ask, We Don’t Share” – A Qualitative Study on Barriers and Facilitators to Discussing Mental Health with Obstetric Care Providers in Urban Anganwadis among Pregnant Women in India

Abstract Background: Perinatal period is considered a high risk period for developing mental health problems. Screening for mental health problems is not routine in obstetric care settings in low and middle income countries. This qualitative study among low-income urban pregnant women in India aimed to understand the facilitators and barriers for discussing mental health problems with their obstetric health-care providers. Materials and Methods: Two focus group discussions with six pregnant women in each group were conducted using a semi structured interview guide. The transcribed data were translated to English and were analyzed and key themes were identified using a thematic analysis approach. Results: Participants had inadequate knowledge about the impact of maternal mental health problems on pregnancy, fetus and infant. The common barriers to discussing mental health problems were families normalizing mental stress, fear that family conflicts being revealed, stigma about being labeled mentally ill, lack of privacy in clinics and obstetric health-care providers being too busy. Women reported that being specifically asked about mental health problems as part of care and a sensitive attitude of the health-care providers encouraged them to discuss their concerns. Conclusion: This study identified more barriers than facilitators in discussing about mental health among pregnant women and the need for sensitive screening for mental health problems. To enhance screening and support for maternal mental health problems, it is necessary to increase awareness about the importance of mental health in the perinatal period among women and families. In addition, training obstetric health-care providers in sensitive screening for mental health problems, ensuring privacy in clinics and reducing stigma related to perinatal mental health problems.

Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings.

Perinatal mental health has garnered significant attention within obstetrics over the last couple of decades as the long- and short-term morbidities of untreated perinatal mental health disorders on both the mother and fetus/neonate have become increasingly apparent. There have been major strides in increasing screening for perinatal mental health disorders, clinician comfort with prescribing common psychiatric medications, and integrating mental health professionals into prenatal care via health services approaches such as the collaborative care model. Despite these advances, however, gaps still remain in the tools used for screening and diagnosis, obstetric clinician training in diagnosis and management of perinatal mood and anxiety disorders, as well as patient access to mental health care during pregnancy and especially postpartum. Herein we review the state of perinatal mental health from the perspective of the obstetric provider and identify areas of ongoing innovation.

Midwives’ empathy and shared decision making from women’s perspective - sensitivity of an assessment to compare quality of care in prenatal and obstetric care

BackgroundFor quality-oriented evaluation of prenatal and obstetric care, it is important to systematically consider the perspective of the women receiving care in order to comprehensively assess and optimize quality in a woman-centered manner. Empathy and Shared Decision Making (SDM) are essential components of woman-centered midwifery care. The aim of the study was to analyze measurement invariance of the items of the Consultation and Relational Empathy (CARE) and Shared Decision Making-Questionnaire (SDM-Q-9) scales depending on the prenatal versus obstetric care setting.MethodsOne hundred fifty women retrospectively assessed aspects of woman-centered midwifery care in both prenatal and obstetric care setting. The birth of the child was a maximum of 12 months ago. A structural equation modelling approach was adopted to separate true effects from response shift (RS) effects depending on care setting. The latter were analyzed in terms of recalibration (changing women’s internal measurement standards), Reprioritization (changing associations of items and construct) as well as Reconceptualization (redefining the target construct).ResultsA response shift model was identified for both assessments (pregnancy/birth: CFI = .96/.96; SRMR = .046/.051). At birth, both scales indicated lower quality of care compared with prenatal care (SDM-Q-9-M/CARE-8-M:|d| = 0.190/0.392). Although no reconceptualization is required for the items of both scales, RS effects are evident for individual items. Due to recalibration and reprioritization effects, the true differences in the items are partly underestimated (SDM-Q-9-M/CARE-8-M: 3/2 items) or overestimated (4/2 items).ConclusionThe structure of the constructs SDM and Empathy, indicating woman-centered midwifery care, are moderated by the care settings. To validly assess midwives’ empathy and shared decision making from women’s perspective, setting-dependent response shift effects have to be considered. The proven item-specific response effects contribute to a better understanding of construct characteristics in woman-centered care by midwives during pregnancy and childbirth.

Media use in gynecological and obstetric care and women’s perceived level of education received of lifestyle-related risks: A cross-sectional study

Objective:The application of media on lifestyle-related risk factors (LRRFs) by healthcare providers to educate women may improve women’s adherence, health literacy, and awareness of LRRFs, as well as offspring’s health outcomes. This study investigated whether exposure to media-based education in gynecological and obstetric care is associated with LRRFs perceived levels of education received during pregnancy and lactation.Methods:We conducted a cross-sectional, observational study across 14 randomly generated sample points in the 12 most populated cities in Baden-Württemberg, southwest Germany. Women were recruited from gynecological and obstetric institutions. Participants were 219 women who met our inclusion criteria and completed the quantitative questionnaire. We applied ordinal logistic regression analyses to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of women’s perceived level of education received related to healthcare providers’ exposure to media-based education.Results:Media-based education on LRRFs during pregnancy through gynecologists and/or midwives were significantly associated with women’s perceived level of education received (gynecologists: OR = 4.26 (95% CI: 2.04, 8.90; p < .001); midwives: OR = 3.86 (95% CI: 1.66, 8.98; p = .002)). Similar results were found for media-based education through gynecologists and/or midwives on LRRFs during lactation and its association with women’s self-assessed level of perceived level of education received (gynecologists: OR = 4.76 (95% CI: 2.15, 10.56; p < .001); midwives: OR = 7.61 (95% CI: 3.13, 18.53; p < .001)).Conclusions:This study suggests that the exposure to media-based education in gynecological and obstetric care increases women’s perceived level of education received of LRRFs during pregnancy and lactation. Therefore, it is recommendable to apply media in gynecological and obstetric care settings.

Detecting cardiomyopathies in pregnancy and the postpartum period using ECG

Abstract Background Cardiovascular disease (CVD) has been identified as a major threat to maternal health in the US and UK with cardiomyopathy being one of the most common acquired CVD in the pregnant and postpartum period. Diagnosing cardiomyopathy in pregnancy is challenging due to an overlap of cardiovascular symptoms with normal pregnancy symptoms. Purpose The purpose of this study was to evaluate the effectiveness of an ECG based deep learning model in identifying cardiomyopathy among pregnant and postpartum women. Methods We utilized an ECG based deep learning model to detect cardiomyopathy in a cohort of pregnant or postpartum women seen at multiple hospital sites. Model performance was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. Results 1,807 women were included. 7%, 10% and 13% had LVEF ≤35%, &amp;lt;45% and &amp;lt;50% respectively. The ECG based deep learning model identified cardiomyopathy with an AUC of 0.92 for left ventricular ejection fraction (LVEF) ≤35%, 0.89 for LVEF &amp;lt;45% and 0.87 for LVEF &amp;lt;50%. For LVEF ≤35%, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to white (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 and 0.72 respectively. Conclusions A deep learning model effectively identifies cardiomyopathy in pregnant or postpartum women, outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): This study was made possible using resources supported by the Mayo Clinic Women's Health Research Center and the Mayo Clinic Building Interdisciplinary Research Careers in Women's Health (BIRCWH) Program funded by the National Institutes of Health (NIH), grant number K12 HD065987. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Detecting cardiomyopathies in pregnancy and the postpartum period using ECG

Abstract Background Cardiovascular disease (CVD) has been identified as a major threat to maternal health in the US and UK with cardiomyopathy being one of the most common acquired CVD in the pregnant and postpartum period. Diagnosing cardiomyopathy in pregnancy is challenging due to an overlap of cardiovascular symptoms with normal pregnancy symptoms. Purpose The purpose of this study was to evaluate the effectiveness of an ECG based deep learning model in identifying cardiomyopathy among pregnant and postpartum women. Methods We utilized an ECG based deep learning model to detect cardiomyopathy in a cohort of pregnant or postpartum women seen at multiple hospital sites. Model performance was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. Results 1,807 women were included. 7%, 10% and 13% had LVEF ≤35%, &amp;lt;45% and &amp;lt;50% respectively. The ECG based deep learning model identified cardiomyopathy with an AUC of 0.92 for left ventricular ejection fraction (LVEF) ≤35%, 0.89 for LVEF &amp;lt;45% and 0.87 for LVEF &amp;lt;50%. For LVEF ≤35%, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to white (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 and 0.72 respectively. Conclusions A deep learning model effectively identifies cardiomyopathy in pregnant or postpartum women, outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): This study was made possible using resources supported by the Mayo Clinic Women's Health Research Center and the Mayo Clinic Building Interdisciplinary Research Careers in Women's Health (BIRCWH) Program funded by the National Institutes of Health (NIH), grant number K12 HD065987. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Women’s Media Use and Preferences of Media-Based Interventions on Lifestyle-Related Risk Factors in Gynecological and Obstetric Care: A Cross-Sectional Multi-Center Study in Germany

This study aimed to investigate factors affecting (1) women’s media use regarding health-related behaviors during pregnancy and lactation, (2) women’s preferences for media format, and (3) the content of media-based interventions on lifestyle-related risk factors during pregnancy and lactation. A cross-sectional observational multi-center study of pregnant and lactating women and women of childbearing age was carried out in 14 randomly selected obstetric and gynecologic care settings in the 12 most populated cities in Baden-Wuerttemberg, South-West Germany. Data from 219 surveyed women showed that older women, pregnant women, and lactating women have a higher probability of using media during pregnancy and lactation, respectively. The majority of women preferred a combination of analog and digital media-based interventions in gynecological (46.9%) and obstetric (47.1%) care settings and at home (73.0%). Women would like to see information brochures and flyers on health-related behaviors during pregnancy and lactation for use in gynecological and obstetric care settings, and for media use at home, they would like to have books. The probability of preferring the favored media formats in gynecological and obstetric care settings and at home were associated with pregnancy status, relationship status, socioeconomic status (SES), ethnicity, and health insurance status. About 80% of the surveyed women preferred media content regarding recommendations for a healthy lifestyle and healthy behavior during pregnancy and lactation. All of the independent variables were associated with the probability of preferring a specific media content. The SES was found to play a major role in the probability of preferring a specific media content, followed by pregnancy status, ethnicity, and health insurance status. The results from our study provide a basis for tailored preventive interventions in gynecological and obstetric care settings and for use at home. The results imply that a woman can be reached before conception, during pregnancy, or during lactation with preventive measures tailored to their requirements; however, acceptance may vary across personal attributes, such as SES, ethnicity, and others.

Administration of the Coronavirus Disease 2019 (COVID-19) Vaccine to Hospitalized Postpartum Patients.

INTRODUCTION Recently published data demonstrate that vaccination against coronavirus disease 2019 (COVID-19) in pregnancy is safe and effective, with antibody transfer through the umbilical cord blood and breast milk.1–4 However, pregnant individuals are less likely than nonpregnant individuals to accept COVID-19 vaccination.5 Research on vaccine acceptance among obstetric populations has shown two factors increase vaccination rates: 1) vaccine availability in the obstetric health care setting, and 2) vaccine counseling from an obstetric clinician.6 We assessed the feasibility of inpatient COVID-19 vaccination among obstetric patients admitted for delivery and compared the characteristics of those who were vaccinated while inpatient with those who were vaccinated before admission. METHODS We performed a retrospective cohort study of all patients admitted for delivery in the first 36 days after Pfizer/BioNTech (BNT162b2) COVID-19 vaccine availability at a single institution to describe rates of eligibility, vaccination counseling, and uptake in the obstetric unit. The COVID-19 vaccine was available to hospitalized obstetric patients if they had not received a COVID-19 vaccination and did not have active COVID-19. Eligible patients were offered vaccination and counseled by obstetricians. Pharmacy staff administered vaccinations in the postpartum unit on weekdays (vaccination was not available on weekends). Second-dose appointments were scheduled before discharge. Characteristics of patients vaccinated before admission, including Area Deprivation Index, were compared with those of patients vaccinated during their admission using χ2, Fisher exact, and Mann-Whitney U tests as appropriate. We included race as a demographic variable in our analysis because of underlying racial disparities in vaccination.7 Area Deprivation Index is a measure of socioeconomic disadvantage in Census block groups; this analysis used the 2019 Area Deprivation Index.8,9 This project was deemed exempt by the Washington University in St. Louis Human Research Protection Office. RESULTS From June 1 to July 6, 2021, there were 329 deliveries: 75 (22.8%) individuals had been vaccinated before admission, and five (1.5%) were not eligible for vaccination due to active COVID-19, resulting in 249 eligible patients (75.7% of deliveries, Fig. 1). From medical record abstraction, we confirmed that 221(88.8%) eligible patients were offered vaccination and underwent counseling. Of the 221, 169 (76.5%) declined and 52 (23.5%) accepted. The vaccine was successfully administered to 43 (82.7%) patients. Six of the nine patients who desired vaccination but did not receive it were discharged over the weekend, when vaccination was not available. There was no explanation in the medical record for the other three patients.Fig. 1.: Patients who were admitted and delivered between June 1 and July 6, 2021, after availability of inpatient, postpartum coronavirus disease 2019 (COVID-19) vaccinations.Perez. Obstetric Inpatient COVID-19 Vaccine. Obstet Gynecol 2021.Compared with those vaccinated before admission, patients who received inpatient vaccination were more likely to be Black, have public insurance, have a hypertensive disorder of pregnancy, and reside in areas with a higher Area Deprivation Index (median [interquartile range]) 87 [65–94] vs 57 [38–80], P<.001 (Fig. 2). They were less likely to be nulliparous and exclusively breastfeeding at discharge (Table 1).Fig. 2.: Area deprivation index of those vaccinated before admission and those vaccinated while inpatient (P<.001).Perez. Obstetric Inpatient COVID-19 Vaccine. Obstet Gynecol 2021.Table 1.: Characteristics of Patients Who Were Vaccinated Before Admission and Those Who Received Vaccination During Inpatient HospitalizationDISCUSSION More than three quarters of patients admitted to our obstetric service for delivery were eligible for vaccination, and most of them were offered vaccination and underwent counseling with an obstetrician. Although vaccine uptake during hospitalization was low, the proportion of patients vaccinated at discharge was 50% higher than at admission. Importantly, inpatient vaccination may improve the health equity of obstetric patients. Patients vaccinated during admission were more likely to be from groups with higher health disparities in both COVID-19 acquisition and vaccination access, in addition to having higher rates of comorbidities that increase risk of severe disease.10,11 Availability of COVID-19 vaccination during obstetric hospitalization presents a feasible opportunity for counseling by obstetric clinicians and convenient timing for first-dose administration. However, given persistently low vaccination rates, strategies to optimize COVID-19 vaccination acceptance among obstetric patients are needed.

Detecting cardiomyopathies in pregnancy and the postpartum period with an electrocardiogram-based deep learning model.

AimsCardiovascular disease is a major threat to maternal health, with cardiomyopathy being among the most common acquired cardiovascular diseases during pregnancy and the postpartum period. The aim of our study was to evaluate the effectiveness of an electrocardiogram (ECG)-based deep learning model in identifying cardiomyopathy during pregnancy and the postpartum period.Methods and resultsWe used an ECG-based deep learning model to detect cardiomyopathy in a cohort of women who were pregnant or in the postpartum period seen at Mayo Clinic. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. The study cohort included 1807 women; 7%, 10%, and 13% had left ventricular ejection fraction (LVEF) of 35% or less, <45%, and <50%, respectively. The ECG-based deep learning model identified cardiomyopathy with AUCs of 0.92 (LVEF ≤ 35%), 0.89 (LVEF < 45%), and 0.87 (LVEF < 50%). For LVEF of 35% or less, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to White (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 to 0.86 and 0.72, respectively.ConclusionsAn ECG-based deep learning model effectively identifies cardiomyopathy during pregnancy and the postpartum period and outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting.

Health Knowledge of Lifestyle-Related Risks during Pregnancy: A Cross-Sectional Study of Pregnant Women in Germany.

This study aimed to investigate (1) pregnant women’s level of knowledge of lifestyle-related risk factors during pregnancy and their potential health impact on their offspring, and (2) the factors affecting women’s knowledge of lifestyle-related risk factors during pregnancy. A cross-sectional observational study of pregnant women was carried out in obstetric and gynecologic care settings at three hospitals in Southern Germany. Data from 209 pregnant women revealed large knowledge gaps on lifestyle-related risk factors during pregnancy and their potential health impact. Factors affecting women’s knowledge of lifestyle-related risk factors during pregnancy were specifically associated with socioeconomic status, e.g., lower household net income, middle educational level, and statutory health insurance status. Women who had received information from their gynecologist had a higher level of knowledge of lifestyle-related risk factors during pregnancy. This study showed that health promotion regarding lifestyle-related risks during pregnancy specifically needs to address women from the low-to-middle socioeconomic status group. Gynecologists seem particularly effective in providing this information.

ISUOG Safety Committee Position Statement on safe performance of obstetric and gynecological scans and equipment cleaning in context of COVID-19.

ISUOG Safety Committee Position Statement on safe performance of obstetric and gynecological scans and equipment cleaning in context of COVID-19.

2735. Improving Uptake of Maternal Immunizations in the Obstetric Care Setting Through an Adaptation of the CDC’s Immunization Quality Improvement Program (AFIX)

BackgroundInfluenza and Tdap vaccines are recommended for pregnant women in every pregnancy. However, vaccine uptake remains suboptimal. Obstetrics practices need quality improvement models to improve their vaccination delivery programs. CDC’s AFIX program has been shown to be effective at increasing vaccination uptake in primary care settings. Our objective was to adapt and evaluate CDC’s AFIX program in the obstetrical setting (AFIIX-OB).MethodsAn average of 40 charts per practice were randomly reviewed pre- and post-intervention. Baseline immunization rates and vaccine administration practices were collected in the Assessment phase. Feedback was provided at meetings conducted by study staff where baseline immunization rates were shared and practices selected quality improvement measures to implement. Practices were required to implement either standing orders for influenza and Tdap vaccines or improve their vaccine documentation. As an Incentive, providers could receive continuing medical education and maintenance of certification part IV credit. After implementing the practice specific measures for 6 months, practice-wide vaccine rates were assessed and a post-intervention meeting was held with providers and staff at each practice to eXchange the results.ResultsAFIX-OB was implemented in 11 obstetric practices: 5 in Georgia and 6 in Colorado. Practices were primarily urban, their patients largely Caucasian and African American and most patients carried private insurance. Baseline practice-level immunization rates ranged from 10% to 82.9% for influenza vaccine and 12.5% to 97.6% for Tdap. 4 practices implemened standing orders, 6 improved their vaccine documentation and 1 did both. After the 6 month follow-up period, all 11 practices saw improvements in their overall Tdap vaccine acceptance (3 with statistically significant increases, P < 0.05) with final rates ranging from 25% to 100%. 9 practices either maintained or improved their influenza vaccination rates (4 with statistically significant increases, P < 0.05) with final rates ranging from 32.5% to 85.0%.ConclusionThe AFIX-OB model provides a promising intervention to improve maternal immunization uptake that can be administered widely but still be tailored to the needs of individual clinics.Disclosures All authors: No reported disclosures.

Determinants of Insomnia among Mothers during Postpartum Period in Northwest Ethiopia.

Objective Postpartum period is a state of instability that may be accompanied by mood liability, anxiety, insomnia, and neuropsychiatric disturbance in women. This neuropsychiatric disturbance has a negative influence on the child's psychological and physical development. Our aim was to see the level of sleep difficulties among postpartum mothers in three obstetric care settings in Ethiopia. Method Institutional based cross-sectional study was conducted at one referral hospital and two health centers. A total of 988 postpartum mothers had been interviewed for sleep difficulties by using Athens Insomnia Scale (AIS). Adjusted Odd Ratio (AOR) and 95% Confidence Interval (CI) were used and P-value <0.05 was used for indicating significant variables. Result The prevalence of sleep difficulty between four to six weeks of postpartum period was 21.8% (215/988). Marital status of divorced/widowed/separated [AOR= 2.29, 95% CI (1.40, 6.08)], no educational opportunity [AOR= 2.35, 95% CI (1.57, 3.51)], having poor social support [AOR=2.82, 95% CI (1.63, 4.88)], alcohol use [AOR=1.58, 95% CI (1.13, 2.22)], history of depression [AOR=1.93, 95% CI (1.13, 3.31)], and who has poor support from husband [AOR=1.94, 95% CI (1.18, 3.18)] had association with sleep difficulty. Conclusion There is a high magnitude of sleep difficulties during four to six weeks of postpartum period in postpartum mothers and they are associated with many preventable risk factors.

Assessing congestion in emergency obstetric care in public hospitals in Tamil Nadu

PurposeThe purpose of this paper is to assess congestion as the simultaneous occurrence of desirable health output (e.g. maternal admissions) along with undesirable output (e.g. still births (SB)), in emergency obstetric care settings of public hospitals in Tamil Nadu.Design/methodology/approachThe study is based on a cross-sectional data set of 97 public hospitals collected by the statistical cell of Tamil Nadu Health Systems Project for the year 2013–2014. The study uses three inputs – beds, doctors and nurses; three desirable outputs – maternal admissions, neonatal admission and live births; and four undesirable outputs – SB, intra-uterine deaths, neonatal deaths and maternal deaths. Congestion analysis, a variant of the data envelopment analysis (DEA) method and slack analysis, has been applied to detect an excessive use of some inputs or a shortfall in some outputs across these hospitals. Furthermore, the association between congestion and some contextual factors has been examined.FindingsOn an average, the hospitals in our sample can increase the total amount of outputs by 62.8 percent by improving overall efficiency, and about 34.2 percent of this inefficiency can be attributed to congestion. Analysis of sub-samples showed that government hospitals at the taluk level have higher congestion than district headquarter hospitals. Congestion seems to decrease with greater hospital volume up to a limit; beyond that, it increases in obstetric care settings.Originality/valueHospital-based efficiency studies in the Indian context, so far, have estimated relative efficiency among hospitals using the classical DEA method, but ignoring adverse health outcomes. Congestion analysis, an advance in the DEA method, considers how much the desirable outputs can be increased as also how much undesirable outputs affect efficiency.

A Systematic Review of Integrated Care Interventions Addressing Perinatal Depression Care in Ambulatory Obstetric Care Settings.

This systematic review searched 4 databases (PubMed/MEDLINE, Scopus, CINAHL, and PsychINFO) and identified 21 articles eligible to evaluate the extent to which interventions that integrate depression care into outpatient obstetric practice are feasible, effective, acceptable, and sustainable. Despite limitations among the available studies including marked heterogeneity, there is evidence supporting feasibility, effectiveness, and acceptability. In general, this is an emerging field with promise that requires additional research. Critical to its real-world success will be consideration for practice workflow and logistics, and sustainability through novel reimbursement mechanisms.

Trends in comorbidity, acuity, and maternal risk associated with preeclampsia across obstetric volume settings

Objective: The objective of this study was to characterize morbidity, acuity, and maternal risks associated with preeclampsia across hospitals with varying obstetric volumes.Methods: This retrospective cohort analysis used a large administrative data source, the Perspective database, to characterize the risk for preeclampsia from 2006 to 2015. Hospitals were classified as having either low (≤1000), moderate (1001–2000), or high (≥2000) delivery volume. The primary outcomes included preeclampsia, antihypertensive administration, comorbidity, and related severe maternal morbidity. Severe maternal morbidity was estimated using criteria from the Centers for Disease Control and Prevention. Comorbidity was estimated using an obstetric comorbidity index. Univariable comparisons were made with Chi-squared test. Adjusted log linear regression models were fit to assess factors associated with severe morbidity with risk ratios with 95% confidence intervals as the measures of effect. Population weights were applied to create national estimates.Results: Of 36,985,729 deliveries included, 1,414,484 (3.8%) had a diagnosis of preeclampsia. Of these, 779,511 (2.1%) had mild, 171,109 (0.5%) superimposed, and 463,864 (1.3%) severe preeclampsia. The prevalence of mild, superimposed, and severe preeclampsia each increased over the study period with severe and superimposed preeclampsia as opposed to mild preeclampsia increasing the most proportionately (53.2 and 102.5 versus 10.8%, respectively). The use of antihypertensives used to treat severe range hypertension increased with use of intravenous labetalol increasing 31.5%, 43.2%, and 36.1% at low-, medium-, and high-volume hospitals. Comorbid risk also increased across hospital volume settings as did risk for severe maternal morbidity.Conclusions: Preeclampsia is increasing across obstetric care settings with preeclamptic patients demonstrating increasing comorbid risk, increased risk for severe morbidity, and more frequent need for treatment of acute hypertension.

Rotational Thromboelastometry Use in Obstetric Hemorrhage: A Current Review [11C

INTRODUCTION: Obstetric hemorrhage is the leading cause of maternal mortality in all countries. Novel technology that accurately and rapidly predicts hematologic status has considerable value in patient care and safety. Rotational thromboelastometry, or ROTEM, is a point of care viscoelastic test which provides results within minutes, making this modality highly useful in acute obstetric care settings. METHODS: We performed a database review of PubMed and MEDLINE for all articles regarding the use of ROTEM in obstetric hemorrhage. The search words employed were “ROTEM”, “rotational thromboelastometry”, “obstetric”, “hemorrhage”, “pregnancy”, “PPH” and “coagulation”. A total of 9 articles were identified with the primary outcome. Case studies were excluded. A review of the remaining 5 articles is summarized in Table 1 as collective results with supported conclusions. RESULTS: Rotational thromboelastometry has been used in critical care and trauma for many years. The articles report a considerable clinical utility of ROTEM in obstetric hemorrhage, but limited use in the United States. ROTEM is well correlated with conventional laboratory tests and is able to accurately and quickly assess coagulation disruption. The test is able to guide and modify transfusion choices in an acute obstetric setting. Because obstetric data is limited, further need for ROTEM protocols and procedure is necessary to guide physician practice. CONCLUSION: ROTEM use is limited in pregnancy and education is needed among obstetric care providers. As point of care test for rapid assessment of coagulation profile there is significant potential for more robust application in obstetric hemorrhage.

Early Childhood Mental Health: Starting Early with the Pregnant Mother.

Perinatal mental health has important implications for maternal and child outcomes. Most women with psychiatric disorders during pregnancy go undiagnosed and untreated, despite widespread initiatives for early identification. Universal screening for psychiatric disorders, particularly depression and anxiety, has been implemented in obstetric and primary care settings. However, there is little evidence regarding the effectiveness on psychiatric symptom reduction or prevention of adverse outcomes in children. Recently, comprehensive screening and follow-up programs integrated within obstetric or primary care settings have shown promising results in improving maternal mental health outcomes. Further work is needed to determine best clinical and most cost-effective practices.