Perinatal Care Program Research Articles

Challenges in Providing OB Services in a Rural State: An Iowa Statewide Perinatal Care Program Study [36H

INTRODUCTION: Over half the hospitals providing maternity services to the state of Iowa are rural Level I centers. OB services at these hospitals are closing annually at an increasing rate (21 in the last 15 years with 8 in 2018). We determined the current obstetrical provider workforce and identified reasons for the closures of these rural OB services. METHODS: Current OB provider workforce data were obtained by contacting all Level I hospitals via email, SurveyMonkey®'’ or telephone. Reasons for rural hospital OB service closures were identified through a six question survey mailed to the chief executive officers of all 93 Level I Iowa hospitals. RESULTS: 46 rural level 1 hospitals provide OB services in Iowa. Only 35% have an obstetrician (OB) on staff, while 65% are staffed solely by Family Medicine (FM) physicians. Cesarean sections performed in these rural hospitals are done by FM only (5), general surgeons only (8) or a combination of FM and GS (13). Thus 56.5% of these rural hospitals have no OB on staff to perform surgical deliveries or respond to obstetrical hemorrhagic emergencies. Only 1/46 rural hospitals has an anesthesiologist on staff; 45/46 utilizes only certified registered nurse anesthetists. Primary reason for rural OB service closures was the inability to recruit or retain physicians willing or capable of providing obstetric care. Additional reasons included concerns regarding quality of obstetric care, medical-legal liability and financial concerns. CONCLUSION: Several issues must be addressed to avoid a decline in access to high quality maternal healthcare in rural Iowa.

849: The association between engagement in a perinatal collaborative care program and breastfeeding

Perinatal collaborative care is a health systems approach to deliver mental health care within the obstetric setting. While perinatal collaborative care has been associated with improvements in mental health outcomes in randomized trials, not all referred women engage in the care provided. Untreated antenatal mental health disorders are associated with lack of initiation and early discontinuation of breastfeeding. Our objective was to examine whether engagement of women with a mental illness referred antenatally to a perinatal collaborative care program was associated with differences in breastfeeding intention and continuation, and whether any observed association was mediated by changes in depressive symptoms. This retrospective cohort study included all women who were referred antenatally by their obstetrician to a perinatal collaborative care program and who delivered viable infants between January 2017 and June 2018. Women were dichotomized by whether they engaged in collaborative care services, defined as participation in either therapy and/or medication management services. Breastfeeding intention (endorsed at delivery) and continuation at the postpartum visit were compared between women who did and did not engage in collaborative care by using bivariable and multivariable analyses. Mediation analyses were performed to determine if any observed associations were mediated by improvements or remission in depressive symptoms. Of the 340 eligible women referred to the perinatal collaborative care program, 264 (75.4%) engaged in the program. Compared to women who did not engage, women who engaged were more likely to intend breastfeeding [168 (95%) vs 47 (87%), p=0.046] and to continue breastfeeding at the postpartum visit [92 (74%) vs 20 (53%), p=0.012]. These associations persisted after controlling for potential confounders (Table) and were not mediated by improvements or remission in depressive symptoms. While antenatal mental health disorders are a risk factor for lack of intention or early cessation of breastfeeding, engagement in a collaborative care program is associated with improvement in both breastfeeding intention and continuation, independent of the mental health benefits.

839: Factors associated with engagement in a perinatal collaborative care program

839: Factors associated with engagement in a perinatal collaborative care program

Text messaging to support a perinatal collaborative care model for depression: A multi-methods inquiry.

Mental health care integrated into obstetric settings improves access to perinatal depression treatments. Digital interactions such as text messaging between patient and provider can further improve access. We describe the use of text messaging within a perinatal Collaborative Care (CC) program, and explore the association of text messaging content with perinatal depression outcomes. We analyzed data from an open treatment trial of perinatal CC in a rural obstetric clinic. Twenty five women with Patient Health Questionnaire-9 score of ≥10 enrolled in CC, and used text messaging to communicate with their Care Manager(CM). We used surveys and focus groups to assessacceptability of text messaging with surveys and focus groups. We calculated the number of text messages exchanged, and analyzed content to understand usage patterns. We explored association between text messaging content and depression outcomes. CMs initiated 85.4% messages, and patients responded to 86.9% messages. CMs used text messaging for appointment reminders, and patients used it to obtain obstetric and parenting information. CMs had concerns about the likelihood of boundary violations. Patients appreciated the asynchronous nature of text messaging. Text messaging is feasible and acceptable within a perinatal CC program. We need further research into the effectiveness of text messaging content, and response protocols.

Implementing perinatal and infant oral health care program in private practice-10 year experience in private hospital in Shanghai

Implementing perinatal and infant oral health care program in private practice-10 year experience in private hospital in Shanghai

Newborn drug testing practices in Iowa birthing hospitals.

Federal law mandates states to have policies and procedures to identify newborns exposed to maternal substance use during pregnancy. National guidelines for newborn drug testing are lacking; therefore, procedures are variable and determined by state law and local practices. In Iowa, maternal substance use during pregnancy is considered child abuse and must be reported.The objective of this study was to identify newborn drug testing policies and procedures among birthing hospitals in Iowa. This was a cross sectional survey of all birthing hospitals in Iowa identified via the Statewide Perinatal Care Program. An electronic survey was sent to the representative at each affiliated hospital. Sixty-nine of 76 hospitals completed the survey for a 90.8% response rate. Newborn drug testing is ordered in 97.1% of responding hospitals with most testing 25% or less of newborns annually. The majority utilized a risk assessment tool (89.6%), although many (62.7%) also allowed for provider discretion. No hospital performed universal testing of all newborns. 86.6% of hospitals reported all positive newborn drug test results including illicit and/or prescription drugs to child protective services. 35.0% of hospitals notified mothers of the report and 45.5% offered substance abuse services and/or treatment to the mothers. Most Iowa birthing hospitals perform newborn drug testing and report all positive test results to child protective services. The majority use risk assessment tools. Maternal notification practices and referral for substance use disorder treatment are suboptimal and represent an area for future improvement.

Mental health status and related influence factors in the spouses of primipara

Objective To investigate the mental health status and related influence factors in the spouses of primipara, and to provide theoretical evidence of improving the quality of nursing care. Methods The symptom checklist 90 (SCL-90) was used to investigate the mental health status of primipara spouses (n=200) on the 42nd day after delivery. Results The participants had significantly higher scores of somatization (SOM) , obsessive-compulsive (O-C) , interpersonal sensitivity (I-S) , depression (DEP) , and anxiety (ANX) compared with the norms (t=13.87, 3.34, 8.75, 7.57, 6.49; P<0.01) . Spouses without stable work had significantly higher scores of SOM, O-C, ANX, phobic anxiety (PHOB) and Psychoticism (PSY) compared with those with stable work (t=2.58, 2.85, 1.98, 2.28, 2.02; P<0.05) . Furthermore, the SCL-90 scores were significantly higher in those who had an unplanned pregnancy, an absence of prenatal training, short neonatal sleep time (<10 h) , non-native residence in Beijing, and lived within stem families (P<0.05) . Conclusions The mental health of the primipara spouses can be affected by the pregnancy and delivery, who should be included in the perinatal care program. Key words: Spouses; Primipara; Perinatal period; Mental health

Changing prevalence of severe congenital heart disease: a population-based study.

Although the epidemiology of congenital heart disease (CHD) has been described, the authors believe changes in prenatal factors such as termination of pregnancy for fetal anomaly and prenatal vitamin supplementation have altered the birth prevalence of severe CHD. This population-based study reviewed the Nationwide Inpatient Sample (NIS) database and identified all cases with a severe CHD diagnosis among all live birth entries from 1999 to 2008. A time trend analysis then was performed for specific severe CHD diagnoses stratified by race, socioeconomic status, and geographic location. Overall, severe CHD prevalence was 147.4 per 100,000 live births, with a temporal decrease in prevalence from 168.9 per 100,000 in 1999 to 129.3 per 100,000 in 2008 (p = 0.03). Among the 12 severe CHD diagnoses included in our cohort, the prevalence of truncus arteriosus (p = 0.02), tetralogy of Fallot (p = 0.001), hypoplastic left heart syndrome (p = 0.001), and pulmonary atresia (p = 0.01) decreased significantly during the study period. The observed prevalence trends varied significantly by race (Caucasians), socioeconomic class (upper income quartiles), and geographic location (Northeast and West regions). The study findings showed a temporal decrease in severe CHD prevalence, which varied by race, socioeconomic status, and geographic location. The authors speculated that the observed trend might be due to increased termination of fetuses with prenatally diagnosed CHD. The impact of sociodemographic variables on the observed prevalence trend might be due to differences in access to specialized perinatal care and fetal heart programs or because of variability in termination of pregnancy.

EPA-0637 – Perinatal care program for women diagnosed with severe mental disease

Childbirth always constitutes a profound change in the life of the mother and the rest of the family. Pregnancy, birth and postpartum are crucial periods where the mother will have to face unknown situations and make decisions that are going to determine the strength and type of bond between mother and baby. In the specific case of women with mental illness, this time can involve an important risk of descompensation or aggravation of her condition. For this reason, a specific attention to these patients in moments of special vulnerability, as pregnancy and perinatal period, is necessary. In our community there are few resources for this need, and because of this we have initiated a program involving perinatal care for women diagnosed with severe mental diseases. The objective of the program is to improve clinical stability of the mother and strengthen the bond with the baby, trying to make it secure and stable. Our methodology is based on a comprehensive approach including clinical, pharmacological and familiar interventions. Health promotion and coordination with primary care, obstetrics and pediatrics are necessary as well. To illustrate this, we present here two clinical cases that are being followed in our program. The first one is an adolescent mother with an affective disorder consequence of an unstructured family and several years of violence at home. The second case is a patient with undiagnosed psychotic disorder with serious psychotic symptoms during the pregnancy requiring hospitalization.

Epidemiology of Twin Births in Southeast China: 1993–2005

Recently, there has been a significant increase in the rate of multiple births in most developed countries. However, few population-based studies have been conducted in China regarding the epidemiology of twin births in recent years. We performed a descriptive analysis of twin births from 1993 to 2005 using data from a population-based perinatal care program in southeast China. The twin birth rate in southeast China was 0.65%, and the twin birth rates from 1993 to 2005 fluctuated between 0.60% and 0.70%. During the three periods of 1993-1996, 1997-2000, and 2001-2005, the twin birth rate increased from 0.57% to 0.71% in urban areas (p = .005) and from 0.59% to 0.68% in mothers who had an education level of high school or higher (p = .046). After 2000, the twin birth rate of primiparae 30 years of age and older significantly increased from 0.72% to greater than 1.20%. We concluded that the twin birth rates in southeast China from 1993 to 2005 stayed constant in the overall population but increased in certain subgroups of women, presumably due to increased use of fertility treatment and the development of assisted reproductive technology.

A Model Program for Perinatal Palliative Services

Despite the fact that parents of infants with lethal anomalies may not want "full-blown" medical care for their infants after birth, most such infants die in neonatal intensive care units. Although neonatal nurses are trained to administer life-saving treatments, they may suffer from moral distress when faced with caring for babies with incompatible-with-life conditions. This article describes a Perinatal Comfort Care program in which (a) care is provided at the time of diagnoses/antenatally and includes home visits by members of an interdisciplinary hospice team; (b) care is collaborative, community-based, and family-centered, and takes place in labor and delivery and on the mother baby unit; and (c) follow-up to the family continues for 1 year after the death. Neonatal nurses can become involved either by initiating efforts to form a perinatal comfort care program or by joining an existing team.

Stephen K. Hunter, MD, PhD

Stephen Hunter is a Professor and Division Director of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of Iowa. He’s an outstanding clinician, is the Associate Director of the Iowa Statewide Perinatal Care Program, and maintains a high-quality research program.

Maternal early pregnancy body mass index and risk of preterm birth

To determine the association between maternal body mass index (BMI) in early pregnancy and the risk of preterm birth (PTB) in Chinese women. Data were obtained from a population-based perinatal care program in China during 1993-2005. Women whose height and weight information was recorded at the first prenatal visit in the first trimester of pregnancy and delivered a singleton live infant were selected. Women with multiple gestations, stillbirths, delivery before 28 weeks or after 44 weeks of gestation, and infants affected by major external birth defects were excluded. BMI was categorized as underweight (less than 18.5 kg/m(2)), normal weight (18.5-23.9 kg/m(2)), overweight (24-27.9 kg/m(2)), and obese (≥28 kg/m(2)) based on BMI classification criteria for Chinese. Logistic regression analysis was conducted to adjust for potential confounders, such as maternal age, education, occupation, city or county, gender of infant, and year of delivery. A total of 353,477 women were selected. The incidence of preterm birth in women who were underweight, normal weight, overweight, obese was 3.69% (3.61-3.76%), 3.59% (3.55-3.62%), 3.83% (3.71-3.96%), 4.90% (4.37-5.43%), respectively. The incidence of elective preterm birth, overweight, and obesity increased remarkably during 2000-2005 compared with that during 1993-1996. After having adjusted for potential confounders including maternal age, maternal occupation, education, city or county, gender of the infant and year of birth, the risk of PTB increased significantly with BMI (P < 0.05). Among nulliparae, the risk of elective preterm birth increased with increasing BMI. Nulliparae who were underweight were less likely to deliver elective preterm births (OR = 0.89, 95% CI 0.80-0.98). Nulliparae who were overweight and obese in early pregnancy were at a greater risk of elective PTB than normal weight nulliparae (for the overweight OR = 1.36, 95% CI 1.18-1.56, for the obese OR = 2.94, 95% CI 2.04-4.25). In this study, indigenous Chinese cohort women who are overweight, obese, and nulliparous are at an increased risk of elective preterm birth.

Community Remoteness, Perinatal Outcomes and Infant Mortality among First Nations in Quebec~!2009-12-02~!2010-04-12~!2010-07-06~!

OBJECTIVE: Little is known about community remoteness in relation to birth outcomes among Indigenous populations. We assessed whether community remoteness matters for perinatal outcomes and infant mortality in Quebec First Nations communities. STUDY DESIGN: A retrospective cohort study of all births (n=11,033) to residents of First Nations communities in Quebec 1991-2000, using linked vital statistics data. First Nations communities were grouped by community remoteness into four zones from the least to most remote. RESULTS: Preterm birth rates declined progressively from the least remote (8.0%) to the most remote (5.7%) zones (p=0.002). In contrast, total fetal and infant mortality rose progressively from the least remote (10.4 per 1000) to the most remote (22.7 per 1000) zones (p<0.001). The excess infant mortality in the more remote zones was mainly due to higher rates of postneonatal mortality. Similar patterns were observed after adjusting for maternal age, education, parity and marital status. Substantially elevated risks in most remote communities remained for perinatal death (adjusted OR=2.1), postneonatal death (adjusted OR=2.7), and total fetal and infant death (adjusted OR=2.3). CONCLUSION: Living in more remote First Nations communities was associated with a substantially higher risk of fetal and infant death, especially postneonatal death, despite a lower risk of preterm delivery. There is a need for more effective perinatal and infant care programs in more remote First Nations communities to reduce perinatal and infant mortality.

Best Practices: An Emerging Best Practice Model for Perinatal Depression Care

Best Practices: An Emerging Best Practice Model for Perinatal Depression Care

Reorganization of perinatal care in Greenland

Introduction. September 2000 the planning of a major reform of health services was launched aimed at improving perinatal care and decreasing perinatal mortality and morbidity. The activities became effective from January 2002. Methods. A new organization plan was developed, a special medical record was designed for perinatal care and training programs for health workers in perinatal care were instituted, including basic ultrasound scan for gestational age. Professional guidelines for perinatal care were distributed countrywide, stipulating that at risk pregnancies should be referred for delivery to Queen Ingrid’s Hospital, as well as offering treatment suggestions for various complications. Results. There was a marked improvement in the referral rate for at risk pregnancies and consequently a sharp rise in the share of at risk patients in Queen Ingrid’s Hospital, calling for extra resources to be allocated. However, the rate for instrumental deliveries remained low at the special unit at the same time as the rural health care centres were relieved of the burden of high-risk deliveries. Discussion. Transferring women for delivery, in many cases leaving their families for a substantial amount of time, undoubtedly has psychosocial implications. Will the impact of the programme on perinatal mortality and morbidity make up for these costs? Will we be able to reduce the rate of instrumental deliveries in the rural health care centres as well as the number of acute - and very costly - evacuations of patients by chartered aircraft? The questions are many - we hope to provide some answers.

L’effet des politiques publiques sur les résultats périnatals en France

The effect of public policies on perinatal results is examined through three French examples that show the complexity of the problem and the limitations of policies. The first example relates to the perinatal program which was in force from 1971 to 1981 and carried out during a period of economic growth. Generously provided for, it was relatively well implemented. Its role in the reduction in perinatal mortality and premature births will be studied. The second example relates to the period that followed, i. e. from 1980 to 1992. Faced with innovations in intra-uterine diagnosis and medically-assisted fertilization, public policies were put on hold. Inequalities between maternity units gave rise to concern about the establishment of a two-tier health care system. The decline in health indicators, which was not entirely attributable to the policies being on hold, prompted the government to promote a new perinatal care program. This marked the beginning of the third period (1994) and constituted the third example. The political and economic context was much less favourable than in 1971 and so were the results. Thus, if the policies were put back in their context, could they have been improved? Four conditions are essential: greater continuity, better preparations for decisions, a longer term vision and a thorough implementation of measures whose effects must be assessed continuously. If a reform of the system is necessary, it should be gradual, thus avoiding the pitfalls of excessive liberalism and statism.

Adverse outcomes of underuse of beta-blockers in elderly patients

To the Editor. —I read with interest the Editorial by Drs Felch and Scanlon.1 They speak of the dream for medicine for the new millennium, "that the care of patients will be evidence based," and that this can only be "fully realized when the major players in the health care field find improved ways to work together." They close by saying, "We envision the likelihood that new mechanisms will be found to alert clinicians about the existence of innovation. We hold firm to the right of frontline physicians to make the choice of using it (to follow a recommendation) or to cite their reasons for not using it." In Iowa, we are proud to point to the existence of a program that for the past 24 years has done this very thing—the Iowa Statewide Perinatal Care Program. This program consists of a perinatal review team that includes a maternal-fetal medicine specialist, a neonatologist,

Adverse Outcomes of Underuse of β-Blockers in Elderly Patients

To the Editor. —I read with interest the Editorial by Drs Felch and Scanlon.1 They speak of the dream for medicine for the new millennium, the care of patients will be evidence based, and that this can only be fully realized when the major players in the health care field find improved ways to work together. They close by saying, envision the likelihood that new mechanisms will be found to alert clinicians about the existence of innovation. We hold firm to the right of frontline physicians to make the choice of using it (to follow a recommendation) or to cite their reasons for not using it. In Iowa, we are proud to point to the existence of a program that for the past 24 years has done this very thing—the Iowa Statewide Perinatal Care Program. This program consists of a perinatal review team that includes a maternal-fetal medicine specialist, a neonatologist,

Staff evaluation of a high-risk pregnancy program.

A southeastern state implemented a multidisciplinary health care program for Medicaid eligible, medically high-risk pregnant women and their infants as part of a statewide effort to reduce perinatal morbidity and mortality. The purpose of this study was to obtain the staff's evaluation of this high-risk-pregnancy program. Clinical, supervisory, and clerical staff (N = 182) completed a questionnaire about the operation of the program and its perceived benefits. Staff identified program strengths: nurse case management, interdisciplinary structure, quality care, and positive health outcomes. Staff also identified program limitations including limited staff and time, inflexible protocols, administrative tasks, and narrow enrollment criteria. The majority of staff reported that the following barriers interfered with the effective operation of the program: paperwork, limited support, time, difficulty locating patients, and mandated time frames for patient contact. The majority of staff also reported that transportation most interfered with patient access to the program. The findings of this study support the need for ongoing staff evaluation of all perinatal health care programs.