Postpartum Visit Research Articles

Timing of outpatient postpartum care utilization among women with chronic hypertension and hypertensive disorders of pregnancy

The postpartum period represents an opportunity to assess the cardiovascular health of women who experience chronic hypertension or hypertensive disorders of pregnancy. This study aimed to determine whether women with chronic hypertension or hypertensive disorders of pregnancy access outpatient postpartum care more quickly compared to women with no hypertension. We used data from the Merative MarketScan Commercial Claims and Encounters Database. We included 275,937 commercially insured women aged 12 to 55 years who had a live birth or stillbirth delivery hospitalization between 2017 and 2018 and continuous insurance enrollment from 3 months before the estimated start of pregnancy to 6 months after delivery discharge. Using the International Classification of Diseases Tenth Revision Clinical Modification codes, we identified hypertensive disorders of pregnancy from inpatient or outpatient claims from 20 weeks gestation through delivery hospitalization and identified chronic hypertension from inpatient or outpatient claims from the beginning of the continuous enrollment period through delivery hospitalization. Distributions of time-to-event survival curves (time-to-first outpatient postpartum visit with a women's health provider, primary care provider, or cardiology provider) were compared between the hypertension types using Kaplan-Meier estimators and log rank tests. We used Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals. Time points of interest (3, 6, and 12 weeks) were evaluated per clinical postpartum care guidelines. Among commercially insured women, the prevalences of hypertensive disorders of pregnancy, chronic hypertension, and no documented hypertension were 11.7%, 3.4%, and 84.8%, respectively. The proportions of women with a visit within 3 weeks of delivery discharge were 28.5%, 26.4%, and 16.0% for hypertensive disorders of pregnancy, chronic, and no documented hypertension, respectively; by 12 weeks, the proportions increased to 62.4%, 64.5%, and 54.2%, respectively. Kaplan-Meier analyses indicated significant differences in utilization by hypertension type and interaction between hypertension type, and time before and after 6 weeks. In adjusted Cox proportional hazards models, the utilization rate before 6 weeks among women with hypertensive disorders of pregnancy was 1.42 times the rate for women with no documented hypertension (adjusted hazard ratio, 1.42; 95% confidence interval, 1.39-1.45). Women with chronic hypertension also had higher utilization rates compared to women with no documented hypertension before 6 weeks (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24-1.33). Only chronic hypertension was significantly associated with utilization compared to the no documented hypertension group after 6 weeks (adjusted hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). In the 6 weeks following delivery discharge, women with hypertensive disorders of pregnancy and chronic hypertension attended outpatient postpartum care visits sooner than women with no documented hypertension. However, after 6 weeks this difference extended only to women with chronic hypertension. Overall, postpartum care utilization remained around 50% to 60% by 12 weeks in all groups. Addressing barriers to postpartum care attendance can ensure timely care for women at high risk for cardiovascular disease.

Efektivitas Kunjungan Nifas, Motivasi Ibu dan Peran Keluarga terhadap Pengurangan Nyeri Perineum di Wilayah Kerja Puskesmas Desa Kairatu

Introduction: The postpartum period (Puerperium) is the period when the placenta comes out and usually this postpartum period only lasts approximately 6 weeks or 40 days. Puerperium is from the word Puer which means baby and Parous gives birth, so Puerperium means the period after giving birth to a baby and the period when the uterine organs return to their pre-pregnancy pre-pregnancy state. Objectives: This study aims to determine the Effectiveness of Postpartum Visits, Mother's Motivation and Family roles in Reducing Perineal Pain in the Kairatu Health Center area, West Seram Regency in 2021. Method: The type of research used is quantitative with descriptive techniques that provide an overview of the effectiveness of care during postpartum visits and the physical discomfort that exists during the postpartum period. The research instrument used in the research was a questionnaire to determine the effectiveness of postpartum visits, the role of the family and the reduction of physical discomfort to perineal pain. In this research, the number of samples taken was a total of 35 postpartum women with the accidental sampling technique used. Data collection by filling out a questionnaire and analyzing using univariate and bivariate analysis with Chi-Square testing. Result: Based on the results of data processing in this study, it shows that postpartum visits have a p-value or significance of 0.000 which is an area where the hypothesis is accepted, namely p-value ≤ 0.05. Conclusion: It can be concluded that postpartum visits are effective in reducing perineal pain.

Investigating Maternal Stress, Depression, and Breastfeeding: A Pregnancy Risk Assessment Monitoring System (2016-2019) Analysis.

Breastfeeding is invaluable for postpartum physical healing and mental wellbeing, but psychosocial stress and depression impede such recovery processes. To inform future interventions and policies, associations between breastfeeding, maternal stress, and depression were examined. Data from the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed (2016-2019). Logistic regression models were used to calculate adjusted odds ratios with 95% confidence intervals. Of the total sample (n = 95,820), approximately 88% of participants attempted breastfeeding. Our findings indicate that participants who experienced any form of stress had a slightly higher likelihood of breastfeeding compared to those without stress. Specifically, partner-related and financial-related stressors were significantly associated with increased odds of breastfeeding. However, no significant associations were observed trauma-related or emotional-related stressors and breastfeeding. Additionally, no significant association was found between depression at different stages (preconception, prenatal, and postpartum) and breastfeeding. A significant interaction effect was noted between having experienced any of the 13 stressors and Black race/ethnicity on breastfeeding odds. Similarly, significant interaction effects were observed between partner-related, trauma, financial, or emotional stressors and Black race/ethnicity. These findings emphasize the importance of considering various factors when promoting breastfeeding in diverse populations, and screening for psychosocial stress during postpartum visits. Our study recommends tailoring breastfeeding interventions to address the needs of Black mothers which could significantly improve maternal health and breastfeeding outcomes.

Wellbeing Forecasting in Postpartum Anemia Patients.

Postpartum anemia is a very common maternal health problem and remains a persistent public health issue globally. It negatively affects maternal mood and could lead to depression, increased fatigue, and decreased cognitive abilities. It can and should be treated by restoring iron stores. However, in most health systems, there is typically a six-week gap between birth and the follow-up postpartum visit. Risks of postpartum maternal complications are usually assessed shortly after birth by clinicians intuitively, taking into account psychosocial and physical factors, such as the presence of anemia and the type of iron supplementation. In this paper, we investigate the possibility of using machine-learning algorithms to more reliably forecast three parameters related to patient wellbeing, namely depression (measured by Edinburgh Postnatal Depression Scale-EPDS), overall tiredness, and physical tiredness (both measured by Multidimensional Fatigue Inventory-MFI). Data from 261 patients were used to train the forecasting models for each of the three parameters, and they outperformed the baseline models that always predicted the mean values of the training data. The mean average error of the elastic net regression model for predicting the EPDS score (with values ranging from 0 to 19) was 2.3 and outperformed the baseline, which already hints at the clinical usefulness of using such a model. We further investigated what features are the most important for this prediction, where the EDPS score and both tiredness indexes at birth turned out to be by far the most prominent prediction features. Our study indicates that the machine-learning model approach has the potential for use in clinical practice to predict the onset of depression and severe fatigue in anemic patients postpartum and potentially improve the detection and management of postpartum depression and fatigue.

Trauma-Informed Psychosocial Screening and Care Planning: A Patient-Centered Improvement Project in a Midwife Clinic.

Traumatic stress is associated with increases in preterm birth, low birth weight, and other perinatal complications. Yet the identification of patients with traumatic stress and intervention for traumatic stress prevention or treatment remain low. Locally in this university hospital-based midwife clinic, a health records review found that trauma exposure was documented in 5% of patient records, and no records had a diagnosis of posttraumatic stress disorder (PTSD). This is lower than research-based population estimates of 25% to 50% for trauma exposure and 8% for PTSD during pregnancy. The clinic staff did not screen for posttraumatic stress, and exposure screening was limited to intimate personal violence. Staff had not been trained in trauma-informed care (TIC) as defined by the Substance Abuse and Mental Health Services Administration. The aim for this improvement project was to provide trauma screening and trauma-related care planning, collectively referred to as trauma-informed psychosocial care, to midwifery patients 85% of the time. Interventions were implemented over 4 plan-do-study-act (PDSA) cycles. These included staff training in TIC; written screening at the new prenatal, third trimester, and postpartum visits; verbal broad inquiry at every visit; and bidirectional trauma-specific care planning emphasizing patient and provider input into treatment choice. The clinic flow was changed to create privacy for patient-staff interaction at every visit. Field notes and data were analyzed every 2 weeks and iterative changes applied. Trauma disclosure increased from 5% to 30% and identification of PTSD from 0% to 7%. Bidirectional care plan documentation increased from 8% to 67%. Staff rated the workload as reasonable. Redesigning psychosocial screening to align with TIC principles increased the discovery of trauma to levels consistent with research-based population estimates. Gains were made in bidirectional care planning. This project illustrates practical methods of implementing TIC principles.

Health Insurance Coverage and Postpartum Outcomes in the US

Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

The Effectiveness of Using Maternal and Child Health (MCH) Handbook through the 40 Days CARE Method for Independently Prevention of Postpartum Complications

The puerperium is the period after delivery up to 40 days when the reproductive organs recover. Postpartum services according to standards are provided to mothers and newborns from 6 hours to 42 days after delivery at least three times through home visits for early detection, treatment, or referral of complications that may occur during the postpartum period, as well as provide an explanation about health in general. One of the efforts made by the government is to procure MCH Handbook equipped with important information for mothers and babies, including screening for early detection of complications. Cadres will assist mothers in maximizing the utilization of MCH handbooks in the obedience of postpartum mothers to carry out postpartum visits, independent screening media for complications of the postpartum period and sources of receiving informational educational counseling during the postpartum period. This study aimed to analyze the effectiveness of using MCH handbook through the 40 Days CARE method for independently preventing complications in postpartum mothers. The design used was the Pre-Experiment (One Shot Case Study) with a sample of 30 respondents using a purposive sampling technique. Data collection used a questionnaire. Data analysis used T Test (α = 0.05). The results showed p value of 0.000, which means that there was an effect of using MCH handbook through the 40 Days CARE method on independently preventing complications in postpartum mothers. Based on this result, it is known that postpartum assistance has an influence and is effective in increasing the mothers’ independence in detecting and preventing postpartum complications, so the consistency in postpartum assistance and outreach to health cadres regarding this activity are badly needed

Clinical characteristics and subsequent need for anti-hypertensive agents in the postpartum period for hypertensive disorders of pregnancy.

The objective of this study was to identify clinical characteristics of patients with hypertensive disorders of pregnancy associated with requiring multiple anti-hypertensive medications to optimize blood pressure in the postpartum setting. We performed a retrospective cohort study of all women who had a diagnosis of hypertensive disorders of pregnancy who delivered at a single institution between October 1, 2017 and May 1, 2021. Demographics and clinical characteristics including category of anti-hypertensive medication and number of medications were collected. Models were adjusted for race. A total of 1,708 women were identified for inclusion. Of this cohort, 64.9% did not require any anti-hypertensive medications, while 24.8% used one medication and 10.2% required two or more medications. When comparing women by the number of medications that were required, their demographics were similar except for race (p<0.001). Women taking two or more medications were most prescribed a beta blocker (94.9%) followed by a calcium channel blocker (88.6%). Women with a history of chronic hypertension had the highest risk of requiring two or more medications for blood pressure control (adjusted RR 11.19, 95% CI 2.63-47.60). Chronic kidney disease also significantly increased the risk of requiring two or more medications (adjusted RR 3.09, 95% CI 1.24-7.69). Women with chronic hypertension and chronic kidney disease are at increased risk for requiring multiple anti-hypertensive medications in the postpartum setting. We recommend frequent postpartum visits, either in person or implementing telemedicine platforms to optimize blood pressure control for this high-risk cohort.

Spatial determinants affected maternal mortality of East Java province during the COVID-19 pandemic era, in 2020-2021

Background. Every life aspect and group of the community have changed during the COVID-19 pandemic, including the group of pregnant, childbirth, and postpartum woman. COVID-19 Pandemic occurred in 2020-2021. Maternal mortality in East Java Province was the highest in Indonesia during the pandemic. Objective. This study analyzed the effect of spatial determinants that consist of antenatal, childbirth, and post-partum care on maternal mortality in East Java Province during the Pandemic. Methods. This study used a crossectional method with the unit of analysis in this study was all pregnant, childbirth and postpartum women in 38 districts of East Java Province from 2020 until 2021. Data were analyzed with spatial regression by using Geographically Weighted Regression Software. Results. Maternal mortality in East Java had a spreading pattern and negative value of the diff criterion, so we concluded that there was a spatial influence. The variables of antenatal care, accessibility of healthcare service, third postpartum visit, and complication service had significant effects on maternal mortality in all regions (P&lt;0,05). There were four groups of districts that showed a similarity of significant factors. This result showed that each region’s diversity of the accessibility of health services affects maternal mortality during the COVID-19 era. Antenatal services, access to health facilities and complication services affected maternal mortality in regions with high maternal mortality rate. Conclusion. Every region has its spatial determinants of maternal mortality. The top government should give authority to local government to have programs to reduce maternal mortality according to the condition in their region.

Implementation and recommendation of postpartum visit methods during COVID-19 pandemic: a qualitative study from Indonesia

Background. The Maternal Mortality Rate (MMR) in Indonesia is still a health problem that must be solved. In 2018 and 2019, the postpartum period still dominates maternal mortality in Surabaya. The postpartum visit method is one of the essential things that can affect postpartum services, so it is necessary to evaluate the implementation of the postpartum visit method and recommend visiting methods to improve maternal health. Objective. The study explores the implementation and recommendation of postpartum visit methods during the COVID-19 Pandemic. Materials and Methods. It used a qualitative research type by assessing the interview and observation dept. The instruments used are questionnaires and observation sheets. Researchers conducted interviews with 14 mothers who had completed the postpartum period, five midwives, a stakeholder in the health office and two experts in the field of maternal health. The data is processed using organizing, reduction, coding, description, linking between themes, and data interpretation. Results. Offline visits to health facilities still dominate the implementation of the postpartum visit method. The recommended postpartum visit method combines visits to health facilities, home visits, and telehealth. Besides that, it is necessary to consider maternal postpartum services up to 3 months after delivery, especially for postpartum mothers who have problems. Conclusion. The postpartum visit method during the COVID-19 pandemic, has not run optimally because there are restrictions on offline visits. However, it has not been supported by online monitoring or home visits.

(119) Provider Habits Regarding Screening for Sexual Dysfunction in Pregnancy at a Tertiary Medical Center in Chicago, IL

Abstract Introduction A national survey of Ob/Gyns illustrates the majority do not routinely inquire about sexual dysfunction, pleasure, or satisfaction despite female sexual dysfunction (FSD) being an issue affecting an estimated 43% of women throughout their lifetime. Moreover, many studies have shown an increase in sexual dysfunction in pregnancy, including a Brazilian study showing 73.3% of women experience sexual dysfunction in their third trimester. No specific guidance exists for providers regarding the timing of screening nor the proper methods of education for sexual dysfunction in pregnancy. The International Society for the Study of Women’s Sexual Health (ISSWSH) detailed that certain sexual dysfunction disorders have numerous publications, yet lack of concise screening resources to aid the clinician in detection and management. Objective This study evaluated screening and education practices for sexual dysfunction in pregnancy at a tertiary medical center in a low-risk population. Methods From 2018 to 2021, an average of 1284 women received prenatal care at our institution annually. This study randomly reviewed 113 charts from patients receiving prenatal care with our low-risk providers. We conducted a retrospective chart review, collecting data including: pre-existing conditions, Edinburgh Postpartum Depression Screen (EPDS) scores, and characteristics of both the provider and the type of sexual dysfunction present. Results Of 113 pregnant women in our sample, 19% (N=21) were screened for sexual dysfunction throughout the course of their pregnancy and postpartum visits. There were no notable differences in screening habits based on patient age, Gravida, Para, BMI, marital status, or pregnancy complications. At any time, the median EPDS score for those screened for FSD was consistently greater compared to those who were not screened. Patients were more commonly screened by attendings (71%, N=15) rather than residents (29%, N=6) or APNs (10%, N=2). Patients were most commonly screened postpartum (N=13). No women were screened in the third trimester. Of the 21 who were screened, 76% (N=16) screened positive for sexual dysfunction. The majority of those with FSD had myofascial pain (N=9). A quarter had dyspareunia (N=4). Of those with FSD, 19% (N=3) were educated on sexual dysfunction postpartum. Conclusions Our chart review revealed that less than 20% of patients were screened for sexual dysfunction over the course of their pregnancy, including the postpartum period. We found no evidence of education provided on sexual dysfunction in pregnancy. Of those screened, the prevalence of sexual dysfunction was 76%. There were no notable changes in screening habits based on the specific patient characteristics studied or demographics, however screening tended to be more prevalent in patients with increased EPDS scores. At our institution, attending physicians more frequently screen for FSD over resident physicians or APNs in our practice. Postpartum was the most popular time to screen. Prenatal sexual dysfunction occurs most prominently in the third trimester, but we found no evidence of screening being performed during this time. Disclosure No

The impact of recommending iron supplements to women with depleted iron stores in early pregnancy on use of supplements, and factors associated with changes in iron status from early pregnancy to postpartum in a multi-ethnic population-based cohort

BackgroundWe aimed to evaluate the impact of recommending supplementation to pregnant women with serum ferritin (SF) < 20 µg/L in early pregnancy on use of supplements, and to explore which factors were associated with changes in iron status by different iron indicators to 14 weeks postpartum.MethodsA multi-ethnic population-based cohort study of 573 pregnant women examined at mean gestational week (GW) 15 (enrolment), at mean GW 28 and at the postpartum visit (mean 14 weeks after delivery). Women with SF < 20 µg/L at enrolment were recommended 30-50 mg iron supplementation and supplement use was assessed at all visits. Change of SF, soluble transferrin receptor and total body iron from enrolment to postpartum were calculated by subtracting the concentrations at the postpartum visit from that at enrolment. Linear and logistic regression analyses were performed to assess associations between use of supplements in GW 28 and changes in iron status and postpartum iron deficiency/anaemia. Change of iron status was categorized into ‘steady low’, ‘improvement’, ‘deterioration’, and ‘steady high’ based on SF status at enrolment and postpartum. Multinomial logistic regression analyses were performed to identify factors associated with change of iron status.ResultsAt enrolment, 44% had SF < 20 µg/L. Among these women (78% non-Western European origin), use of supplements increased from 25% (enrolment) to 65% (GW 28). Use of supplements in GW 28 was associated with improved iron levels by all three indicators (p < 0.05) and with haemoglobin concentration (p < 0.001) from enrolment to postpartum, and with lower odds of postpartum iron deficiency by SF and TBI (p < 0.05). Factors positively associated with ‘steady low’ were: use of supplements, postpartum haemorrhage, an unhealthy dietary pattern and South Asian ethnicity (p ≤ 0.01 for all); with ‘deterioration’: postpartum haemorrhage, an unhealthy dietary pattern, primiparity and no use of supplements (p < 0.01 for all), and with ‘improvement’: use of supplements, multiparity and South Asian ethnicity (p < 0.03 for all).ConclusionsBoth supplement use and iron status improved from enrolment to the postpartum visit among women recommended supplementation. Dietary pattern, use of supplements, ethnicity, parity and postpartum haemorrhage were identified as factors associated with change in iron status.

Changes and Determinants of Maternal Health Services Utilization in Ethnic Minority Rural Areas in Central China, 1991-2015: An Ecological Systems Theory Perspective.

Universal maternal health coverage is a proven, effective strategy for maternal survival. This study aimed to describe the changes and determinants of maternal health service use between 1991 and 2015 in central China. The study was conducted in Enshi Prefecture. Women were eligible for inclusion if they were rural women who lived in villages, had live births during 1991-2015, could recall their maternal care histories, and had no communication problems. This retrospective study included 470 rural women in 9 villages and collected 770 records. The conceptual framework was designed based on the Society Ecosystem Theory. The determinants included micro-factors (individual characteristics), meso-factors (family factors, community factors, healthcare factors), and macro-factors (government-run maternal and child health programs, abbreviated as MCH programs). Multivariate logistic regressions were applied to analyze the determinants of maternal health service utilization. The utilization of maternal healthcare has improved in Enshi. The hospital birth rate was 98.1% in 2009 and mostly 100% in subsequent years. The prenatal examination rate, the postpartum visit rate, and the continuum of maternal health service (CMHS) rate increased to 73.3%, 67.7%, and 53.4%, respectively, in 2009-2015. The utilization of maternal health services was affected by macro-factors, meso-factors, and micro-factors, with macro-factors being the most notable contributors. Despite the remarkable improvements in antenatal care (ANC) use and hospital birth, gaps in postpartum visits remain. Promoting the integrated continuum of maternal and child healthcare in ethnic minority rural areas requires the joint efforts of the government, health and other sectors, communities, families, and individuals.

Efficacy and safety of three antiretroviral therapy regimens started in pregnancy up to 50 weeks post partum: a multicentre, open-label, randomised, controlled, phase 3 trial

Drugs taken during pregnancy can affect maternal and child health outcomes, but few studies have compared the safety and virological efficacy of different antiretroviral therapy (ART) regimens. We report the primary safety outcomes from enrolment up to 50 weeks post partum and a secondary virological efficacy outcome at 50 weeks post partum of three commonly used ART regimens for HIV-1. In this multicentre, open-label, randomised, controlled, phase 3 trial, we enrolled pregnant women aged 18 years or older with confirmed HIV-1 infection at 14-28 weeks of gestation. Women were enrolled at 22 clinical research sites in nine countries (Botswana, Brazil, India, South Africa, Tanzania, Thailand, Uganda, the USA, and Zimbabwe). Participants were randomly assigned (1:1:1) to one of three oral regimens: dolutegravir, emtricitabine, and tenofovir alafenamide; dolutegravir, emtricitabine, and tenofovir disoproxil fumarate; or efavirenz, emtricitabine, and tenofovir disoproxil fumarate. Up to 14 days of antepartum ART before enrolment was permitted. Women with known multiple gestation, fetal anomalies, acute significant illness, transaminases more than 2·5 times the upper limit of normal, or estimated creatinine clearance of less than 60 mL/min were excluded. Primary safety analyses were pairwise comparisons between ART regimens of the proportion of maternal and infant adverse events of grade 3 or higher up to 50 weeks post partum. Secondary efficacy analyses at 50 weeks post partum included a comparison of the proportion of women with plasma HIV-1 RNA of less than 200 copies per mL in the combined dolutegravir-containing groups versus the efavirenz-containing group. Analyses were done in the intention-to-treat population, which included all randomly assigned participants with available data. This trial was registered with ClinicalTrials.gov, NCT03048422. Between Jan 19, 2018, and Feb 8, 2019, we randomly assigned 643 pregnant women to the dolutegravir, emtricitabine, and tenofovir alafenamide group (n=217), the dolutegravir, emtricitabine, and tenofovir disoproxil fumarate group (n=215), and the efavirenz, emtricitabine, and tenofovir disoproxil fumarate group (n=211). At enrolment, median gestational age was 21·9 weeks (IQR 18·3-25·3), median CD4 count was 466 cells per μL (308-624), and median HIV-1 RNA was 903 copies per mL (152-5183). 607 (94%) women and 566 (92%) of 617 liveborn infants completed the study. Up to the week 50 post-partum visit, the estimated probability of experiencing an adverse event of grade 3 or higher was 25% in the dolutegravir, emtricitabine, and tenofovir alafenamide group; 31% in the dolutegravir, emtricitabine, and tenofovir disoproxil fumarate group; and 28% in the efavirenz, emtricitabine, and tenofovir disoproxil fumarate group (no significant difference between groups). Among infants, the estimated probability of experiencing at least one adverse event of grade 3 or higher by postnatal week 50 was 28% overall, with small and non-statistically significant differences between groups. By postnatal week 50, 14 infants whose mothers were in the efavirenz-containing group (7%) died, compared with six in the combined dolutegravir groups (1%). 573 (89%) women had HIV-1 RNA data available at 50 weeks post partum: 366 (96%) in the dolutegravir-containing groups and 186 (96%) in the efavirenz-containing group had HIV-1 RNA less than 200 copies per mL, with no significant difference between groups. Safety and efficacy data during pregnancy and up to 50 weeks post partum support the current recommendation of dolutegravir-based ART (particularly in combination with emtricitabine and tenofovir alafenamide) rather than efavirenz, emtricitabine, and tenofovir disoproxil fumarate, when started in pregnancy. National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute of Mental Health.

Associations between adverse childhood experiences and obstetrical outcomes in a predominantly Black-identifying and low-income pregnant population

Recent literature indicates that adverse childhood experiences have been associated with poor obstetrical outcomes, including pregnancy loss, preterm birth, and low birthweight. Several studies have been conducted in primarily self-identified White individuals who report middle to high income levels. Less is known about the impact of adverse childhood experiences on obstetrical outcomes in minority-identifying and low-income populations, who are known to experience a greater number of adverse childhood experiences and are at higher risk of maternal morbidity. This study aimed to examine associations between adverse childhood experiences and a broad range of obstetrical outcomes among predominantly Black-identifying pregnant persons who have low income and live in an urban area. This is a single-center retrospective cohort study of pregnant persons referred to a mental healthcare manager because of elevated psychosocial risks identified by screening tools or provider concerns during the study period from April 2018 to May 2021. Pregnant persons aged <18 years and those who did not speak English were excluded. Patients completed validated mental and behavioral health screening tools including the Adverse Childhood Experiences Questionnaire. Medical charts were reviewed for obstetrical outcomes, including preterm birth, low birthweight, hypertensive disorders of pregnancy, gestational diabetes mellitus, chorioamnionitis, sexually transmitted infection, maternal group B streptococcus carrier status, type of delivery, and attendance of a postpartum visit. Associations between high (≥4) and very high (≥6) of 10 adverse childhood experience score and obstetrical outcomes were analyzed using bivariate analysis and multivariate logistic regression, adjusting for confounding factors (significant at P<.05 in bivariate analysis). Our cohort included 192 pregnant persons, of whom 176 (91.7%) self-identified as Black or African American and 181 (94.8%) had public insurance (used as a proxy for low income). Adverse childhood experience score ≥4 was reported by 91 (47.4%) individuals and score ≥6 by 50 (26%). On univariate analysis, adverse childhood experience score ≥4 was associated with preterm birth (odds ratio, 2.17; 95% confidence interval, 1.02-4.61). Adverse childhood experience score ≥6 was associated with hypertensive disorders of pregnancy (odds ratio, 2.09; 95% confidence interval, 1.05-4.15) and preterm birth (odds ratio, 2.29; 95% confidence interval, 1.05-4.96). After accounting for chronic hypertension, associations between adverse childhood experience score and obstetrical outcomes were no longer significant. Approximately half of the pregnant persons referred to a mental healthcare manager had a high adverse childhood experience score, underscoring the high burden of childhood trauma on populations facing long-standing systemic racism and barriers to healthcare access. High and very high adverse childhood experience score may be associated with chronic health conditions that predate pregnancy and can alter obstetrical outcomes. Obstetrical care providers have a unique opportunity to mitigate risk of associated poor health outcomes during preconception and prenatal care by screening for adverse childhood experiences.

Wellness Opportunities for Migrant Beginnings, Kansas City, Missouri.

To create a collaboration among health care professionals and community organizers to advance health equity and increase access to high-quality perinatal health care for Afghan refugees. This project was developed to create relationships among the health care industry, community partners, and nonprofit organizations to improve the perinatal health status of the refugee population of Kansas City, Missouri. Meetings were held among leaders of three medical systems (Samuel U. Rodgers Clinic, Swope Health, and University Health) and the two major resettlement agencies (Della Lamb and Jewish Vocational Services) to discuss barriers to care. These included communication, coordination of care, time limitations, and misunderstandings of the system. The following focus areas were identified, and interventions then were implemented:1. Education a. Seminars for health care professionals regarding specific perinatal health care needs b. Tours and classes for refugees during which they were introduced to the facility, including labor and delivery, and prenatal, antenatal, and postpartum care2. Communication a. Medical passports for patients to better facilitate perinatal care among organizations, because all facilities provide care but deliveries occur only at University Health3. Research a. Performing surveillance activities and disseminating findings to aid other communities The project is now expanding to include all refugee populations in the Kansas City area. Regular meetings are held quarterly with community leaders for continued quality improvement. Primary outcomes focus on our refugee patients: increased patient autonomy, adherence to prenatal and postpartum visits, and developing trust in the system. Secondary outcomes include improved communication between clinics and resettlement agencies and improved cultural awareness among obstetric care professionals. Equity in perinatal care requires individualized services when serving a diverse population. Refugees in particular have a unique perspective and unique needs. Through collaboration, we were able to improve the health status of the most vulnerable members of our community.

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation

BackgroundImmigrant women’s challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women’s possibility to choose and initiate effective contraceptive methods post-partum.MethodsThis Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study’s intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women’s choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women’s experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project’s primary outcome involving women’s choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents.DiscussionThe intervention’s co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services.Trial registrationNCT05521646, August 30, 2022.

Implementation of In-Hospital Postpartum Glucose Tolerance Testing for People With Gestational Diabetes [ID: 1375592

INTRODUCTION: The 2-hour glucose tolerance test (GTT) performed during delivery hospitalization is as predictive of postpartum dysglycemia as the 4- to 12-week test. Our objective was to assess test uptake as part of routine care rather than a research protocol. METHODS: This is a retrospective cohort study of patients with gestational diabetes mellitus (GDM) at a high volume center. The in-hospital (“early”) GTT began being offered in early 2021 as postpartum glucose screening option, and we collected 6 months of postimplementation data. Adherence to the GTT was compared between those who elected an early GTT versus those who deferred testing. Descriptive characteristics including demographics, care team characteristics, and postpartum testing/visit attendance were compared between those who received an early GTT and those who did not. Institutional review board approval was waived. RESULTS: Six hundred eighty-one patients with GDM delivered during the study period, and 340 (50%) received the early GTT. Of those who had an early GTT ordered (n=408), 83.3% completed the test. Among those who did not receive an early GTT, only 104 (30.5%) completed any postpartum glucose testing. There were significant differences in demographic characteristics among those who completed the early GTT compared to those who did not. When postpartum visit attendance was assessed, those who completed an early GTT had a lower rate of attendance compared to those who deferred (75.6% versus 91.5%, P&lt;.01). CONCLUSION: When an early GTT is offered in clinical practice, adherence rates are still significantly higher than when the test is deferred until the postpartum visit.

Diagnosis of Fetal Congenital Malformation as Risk Factor for Postpartum Depression [ID: 1377045

INTRODUCTION: Annually, more than 7.9 million children, or 6% of all neonates worldwide, are diagnosed with fetal congenital malformations (FCMs). This diagnosis is the second largest cause of infant mortality and is an important cause of maternal vulnerability during pregnancy. This study aims to determine whether the incidence of postpartum depression (PPD) is increased in mothers with FCM, in comparison to mothers without such diagnosis. METHODS: A retrospective chart review was conducted between January 1, 2015, and April 1, 2022. Inclusion criteria required a) at least one prenatal visit, b) a postpartum visit, c) completion of Edinburgh Postpartum Depression Scale (EPDS), and d) prenatal diagnosis of FCM. The control group required a–c with absence of significant perinatal complications. Two hundred FCM and 200 control participants were included. An EPDS score of greater than 12 was considered positive and at risk of PPD. Independent-samples t test and χ2 analysis were conducted. RESULTS: Independent-samples t test, comparing the study and control participants, noted a statistically significant difference in at-risk EPDS scores. Mothers with FCM diagnosis scored higher on questions 3, 7, and 8. Chi-square analysis noted a statistically significant difference in risk of PPD between mothers with FCM and those without such diagnosis. CONCLUSION: Mothers with a diagnosis of FCM are more likely to score higher on EPDS and be at-risk for PPD, thereby revealing the importance to closely monitor their psychiatric status. Future studies should analyze the incidence of maternal psychiatric diagnoses based on the severity of newborn intervention required postpartum.

Should Severe Preeclampsia Be Considered a Risk Factor for Postpartum Depression and Anxiety? [ID: 1376999

INTRODUCTION: Postpartum mood disorders are common and seen in approximately 20% of women. It is important to understand risk factors associated with this diagnosis so that earlier interventions can be initiated. To date, the effect of preeclampsia on postpartum mood disorders has not been thoroughly investigated. The purpose of this study was to investigate whether severe preeclampsia (SPE) acts as a risk factor for postpartum depression (PPD) or postpartum anxiety (PPA). METHODS: A retrospective chart review of participants who delivered between January 1, 2015, and April 1, 2022, was conducted after IRB approval. Inclusion criteria required: 1) at least one prenatal visit, 2) a postpartum visit, 3) an Edinburgh Postnatal Depression Scale (EPDS) score, 4) a SPE diagnosis, and 5) no other significant perinatal complications. Control records met #1–3 and #5 criteria. Data analysis was conducted using an independent-samples t test. RESULTS: Of 216 SPE participants and 253 control participants queried, 150 and 200 participants respectively met inclusion criteria. An independent-samples t test comparing EPDS scores of SPE and control participants found no significant difference, t(299)=0.40, P=.693. Comparing EPDS anxiety scores (EPDS-3A) likewise found no significant difference between the two groups, t(240)=.85, P=.397. CONCLUSION: Results indicate that SPE is not a risk factor for PPD or PPA diagnosis. Despite null findings, those with and without preeclampsia must be screened for PPD because of its prevalence and detrimental effect if left untreated. Future studies should examine PPD and PPA diagnoses within 12 months postpartum instead of the immediate postpartum period.