Providing Maternity Care to the Underserved: A Comparative Case Study of Three Maternity Care Models Serving Women in Washington, D.C.

Compares the content and structure of maternity care provided at a city birth center, a safety net clinic, and a not-for-profit teaching and research hospital; populations served; providers; costs; and the women's and providers' perceptions of each model

Impact of prenatal care provider on the use of ancillary health services during pregnancy

BACKGROUND: Recent declines in the provision of prenatal care by family physicians and the integration of midwives into the Canadian health care system have led to a shift in the pattern of prenatal care provision; however it is unknown if this also impacts use of other health services during pregnancy. This study aimed to assess the impact of the type of prenatal care provider on the self-reported use of ancillary services during pregnancy. METHODS: Data for this study was obtained from the All Our Babies study, a community-based prospective cohort study of women’s experiences during pregnancy and the post-partum period. Chi-square tests and logistic regression were used to assess the association between type of prenatal care provider and use of ancillary health services in pregnancy. RESULTS: During pregnancy, 85.8% of women reported accessing ancillary health services. Compared to women who received prenatal care from a family physician, women who saw a midwife were less likely to call a nurse telephone advice line (OR = 0.30, 95% CI: 0.18-0.50) and visit the emergency department (OR = 0.47, 95% CI: 0.24-0.89), but were more likely receive chiropractic care (OR = 4.07, 95% CI: 2.49-6.67). Women who received their prenatal care from an obstetrician were more likely to visit a walk-in clinic (OR = 1.51, 95% CI: 1.11-2.05) than those who were cared for by a family physician. CONCLUSIONS: Prenatal care is a complex entity and referral pathways between care providers and services are not always clear. This can lead to the provision of fragmented care and create opportunities for errors and loss of information. All types of care providers have a role in addressing the full range of health needs that pregnant women experience

Identifying behavioral, demographic, and clinical risk factors for delayed access to emergency obstetrical care in preeclamptic women in Port au Prince, Haiti

OBJECTIVES: We conducted a mixed methods study of delayed access to emergency obstetrical care among preeclamptic and non-preeclamptic women in Port au Prince, Haiti, grounded in the Three Delays model of Thaddeus and Maine. The primary objectives were to identify factors affecting delays in accessing care and clinical consequences of delays. METHODS: 524 surveys were administered to women admitted to the Médecins Sans Frontières (MSF) obstetric emergency hospital. Survey questions addressed demographic, clinical, and behavioral risk factors; first (at home), second (transport) and third (health facility) delays; and clinical outcomes for women and infants. Bivariate statistics were used to assess relationships between preeclampsia status and delay, and between risk factors and delay. Twenty-six survey participants with lengthy delays (> 6 hours) were chosen for interviews, which elicited details about delays women experienced. Data were analyzed using a grounded theory approach. RESULTS: We found long delays to accessing care for preeclamptic women (median 5.0 hours, IQR 10.5, vs. 4.0 hours, IQR 5.0, for non-preeclamptic women, p<0.01), primarily due to delays at home before leaving for the hospital (median 2.6 hours, IQR 10.6). No demographic, clinical, or behavioral factors were related to access to care. Women's health prior to pregnancy was not associated with delays, with the exception of preeclamptic women who had previously seen a doctor, who had significantly longer delays than women who had not previously seen a doctor (22.8 hours versus 11.2 hours, p=0.02). Long delays for both preeclamptic and non-preeclamptic women were not associated with poorer clinical outcomes. Although the MSF hospital is free of charge, financial barriers at other hospitals limited access to emergency obstetric care for many women, who commonly experienced non-evidence-based care, including inappropriate education from antenatal care providers when diagnosed with hypertension or preeclampsia. CONCLUSIONS: Pregnant women with preeclampsia in Port au Prince reported significant delays in accessing emergency obstetric care. Many delays stemmed from poor quality antenatal care services, which fail to screen, treat, or educate women appropriately. Improvements should be made in education and supervision for antenatal care providers, and in accessibility of emergency services at public hospitals in Port au Prince

Perinatal Mental Health: Improving the Quality and Consistency of Health Care Delivery in Kootenai County

Elisha, Leanne. Perinatal Mental Health: Improving the Quality and Consistency of Health Care Delivery in Kootenai County. Unpublished Doctor of Nursing Practice scholarly project, University of Northern Colorado, 2019. Perinatal mental health issues including depression, anxiety, posttraumatic stress disorder, mania, and psychosis occur frequently during pregnancy and after delivery; these issues have potentially devastating impacts on mothers, infants, other family members, and communities. Despite increasing awareness of perinatal mental health issues and formal recommendations to implement universal screening and ensure access to appropriate follow-up, there is wide variation in clinical practice across regions and providers. Inconsistent screening, paired with limited local resources for follow up, might prevent women from receiving appropriate treatment. The objective of this project was to develop a guide for clinician use to improve screening, referral, and follow up of perinatal mental health issues. The guide identifies an appropriate screening instrument, screening intervals, methods, recording practices, and follow-up recommendations. Additionally, an integrated mental health model was proposed for ongoing treatment and coordination of care. The project was developed using the Delphi method and ongoing engagement with seven local stakeholders to create a streamlined, consistent process that would match clinician needs with available resources

Social and Biological Determinants of Pregnancy-Related Mortality and Morbidity in a Rural, Underserved Population

Cases of severe maternal morbidity (SMM) and pregnancy-related mortality (PRM) are increasing in the US. Research concerning SMM and PRM has neglected women in Central Appalachia; a largely rural, health-disparate population. The aims of this study are two-fold: (1) Examine patient-level and place-based predictors of SMM/PRM via hierarchical logistic regression modeling, and (2) Elucidate Appalachian healthcare patients’ and providers’ experiences with SMM/PRM, perceptions of contributing factors, and insights on points of intervention. This study uses a mixed methods approach guided by the WHO’s conceptual framework for action on social determinants of health to identify determinants of SMM and PRM among Appalachian women. Aim 1 involved hierarchical logistic regression modeling to assess patient-level and regional predictors of SMM and PRM using the MarketScan Research Database. Aim 2 involved 30 qualitative interviews with Appalachian participants: 10 patients with histories of SMM, 10 providers, and 10 emergency medical technicians (EMTs). Quantitative results demonstrate patient-level chronic diseases and regional measures of economic security as predictive of SMM. Qualitative results echoed the effect of regional economic hardship on maternal health. Participants expressed a link between changes in the socioeconomic landscapes of their communities and more proximal determinants of maternal health, including patient nutritional status, chronic disease burden, and underutilization of healthcare. Patients with histories of SMM pointed to geographic constraints in healthcare resources and biases within healthcare surrounding patients’ reflections of class. Participants identified many points of intervention, including collaborations between EMS and obstetric care providers, partnerships with local school systems to introduce comprehensive health education curricula, and expansion of community paramedics programs. Findings warrant further investigation into how regional economic policy may influence maternal health outcomes among women living in economically insecure regions. Findings highlight the need for medical stewardship. Additionally, results reflect how current care-delivery models for medically and socially complex patients may be inadequate for women in rural communities

Knowing Their Story: The Experiences of Perinatal Nurses Who Care for Women Using Marijuana During Pregnancy

While remaining federally illegal, the use of both medical and recreational marijuana in the United States continues to rise as individual state laws become more permissive and its use more socially acceptable. Paralleling this trend, the use of marijuana during pregnancy is also increasing. However legally defined, marijuana use during pregnancy is discouraged and has been associated with serious health concerns for the mother and her infant. Its use during pregnancy is challenging for healthcare providers as it is not well researched and its effects are not clearly understood. While the experiences of perinatal nurses working with women affected by general substance use are well-documented, what is not well understood is how marijuana use by itself is viewed by these nurses. As no previous studies were identified exploring this phenomenon, the three-fold purpose of this study was to understand the experiences, perceptions, and beliefs of perinatal nurses who provided care for women who used marijuana during their pregnancies; to gain a deeper understanding of their beliefs, feelings, and how they perceived use of marijuana during pregnancy; and to understand the educational needs these nurses perceived regarding prenatal marijuana use. Thirteen nurses (N = 13) who practiced in the perinatal field from across the United States agreed to participate in this study and be audio and video recorded. Twelve interviews were conducted via Zoom and one was conducted in person. The interviews were recorded, transcribed, and interpreted for their meaning. Six themes were identified and validated with participants through member checking. The following themes that emerged provided a glimpse into the experiences, perspectives, and beliefs of perinatal nurses who cares for women using marijuana during pregnancy: (a) mixed emotions, (b) more and more patients are positive, (c) forming a relationship, (d) effects on the baby, (e) the healthcare team needs to be on the same page, and (f) we need to know more. This study revealed a strong need for more knowledge and education regarding marijuana use during pregnancy and the development of strategies to improve communication skills for nurses who work with this population of women. Further, findings provided a foundation for the development of educational strategies and interventions targeted to enhance knowledge and communication skills for perinatal nurses and nursing students who might work with women who used marijuana during pregnancy

Intrauterine foetal and child growth in the context of Ethiopian Health system: Implications for Prenatal care : Intrauterine foetal growth and child linear growth in Ethiopia

Fostervekst og vekst hos små barn på den etiopiske landsbygd. Etiopia er fortsatt et av verdens fattigste land, og bruken av helsetjenester er lav. Mødre dødeligheten er også høy. Og, mange barn har både akutt og kronisk underernæring. Det er derfor behov for studier til å bedre forståelsen av fostervekst og barns vekst. Bedre innsikt av intrauterin fostervekst er en viktig for tidlig identifisering av normal og unormal fostervekst, noe som kan påvirke fødselsvekt ved fødselen og vekst i tidlig barndom. Målsetningen med denne avhandlingen var å måle intrauterin fostervekst, og se hvorledes barns lengdevekst var i de første to leveår. Avhandlingen vurderer også hvorledes slike mål kan brukes i den eksisterende mødre- og barnehelsetjenesten på den etiopiske landsbygd. Studien ble utført i den sentrale delen av Riftdalen i Etiopia. Omtrent 700 gravide kvinner ble undersøkt, og deres barn ble fulgt opp til de var omtrent to år. Studieområdet er et typisk landbruksområde, har gjentatte ganger vært rammet av tørke og hungersnød. Selv om det har vært matmangel i området, viser studien at intrauterin vekst er sammenlignbart med Verdens helseorganisasjon (WHO) og INTERGROWTH-21st referansene. Imidlertid er det mange barn som får en lav lengdevekst de først to år. Dette kan forklares både med faktorer under graviditeten og årsaker som oppstår i de tidlige barneårene. I den siste artikkelen i avhandlingen beskrives og analyseres hvorledes svangerskapsomsorgen fungerer sammenlignet med de nasjonale og WHOs retningslinjer. Det er betydelige mangler med dagens graviditetskontroller. Det er derfor viktig å styrke mor-barn helsearbeidet.Introduction Ethiopia is a country with a low coverage of antenatal care services. In 2019, only 43% of pregnant women had the recommended four antenatal care (ANC) visits during their pregnancy while 24% of women in Ethiopia had no ANC visits at all. Different national initiatives are underway to expand and improve maternal health services utilization. These are aligned with international and national agendas and goals. In the first 1000 days of life, starting from the time of conception, growth is viewed as a continuum between the foetal period, infancy, and early childhood. Foetal growth is dynamic. Defining normal or abnormal foetal growth requires the taking of serial measurements. If the foetal growth is abnormal, it can result in low birth weight or prematurity. Low birth weight and prematurity are major contributors of neonatal and infant mortality and morbidity. ANC is an important care point that has a positive influence in identifying pregnancy-related complications. It can also contribute to improved pregnancy outcomes. Ethiopia implemented the World Health Organization’s (WHO) focused ANC (FANC) model at all health facilities until February 2022, which was a goal orientated approach to delivering evidence-based interventions carried out at four critical times during pregnancy. Population specific foetal growth charts that can be used to monitor foetal growth patterns are lacking, particularly in areas affected by food insecurity and drought such as are found in Ethiopia. Moreover, the influence of intrauterine uterine growth on birth weight and early childhood growth has not been examined in this country. In addition, even though ANC is taken as an opportunity for influencing the well-being of pregnant mothers and growing foetus, the evidence supporting a relationship between ANC and adverse pregnancy outcomes is unclear in Ethiopia.   Objective The overall objective of this thesis was to examine intrauterine and child growth in a drought-affected rural area of Ethiopia in the context of the country’s health system. The first objective was to assess intrauterine uterine growth patterns in comparison to the WHO and the INTERGROWTH 21st intrauterine uterine growth standards. The second objective was to examine the influence of intrauterine foetal growth on length-for-age Z-score and weight-for-length Z-score in early childhood 11–24 months of age. The third objective was to assess the compliance of ANC utilization with national and WHO guidelines and whether adverse pregnancy outcomes were associated with the use of antenatal care services. Methods We conducted a prospective cohort study in the rural community of Adami Tullu district in the Oromia Regional State in south central Ethiopia from July 2016 to November 2018. We included 704 pregnant women, with a gestational age of less than 24 weeks and followed them to delivery. We followed the children until they were 24 months postnatal. At enrolment, we collected data on maternal, sociodemographic and household characteristics. We also collected data on maternal weight, blood pressure, mid upper arm circumference (MUAC), haemoglobin, and malaria test results at 26, 30, and 36 weeks of gestation. We obtained foetal biometric measurements (head circumference, biparietal diameter, abdominal circumference, and femoral length) and estimated foetal weight using ultrasound at each visit. We subsequently followed the new-borns postnatally and measured their lengths and weights once at the age of 11-24 months. Foetal weight was estimated using the Hadlock algorithm, and the 5th, 10th, 25th, 50th, 75th, 90th, and 95th centiles were generated from this model. We compared the Z-scores and percentiles of biometric measurements and estimated foetal weight with the INTERGROWTH 21st and WHO multicentre foetal growth reference standards (Paper I). After birth, we measured the weights and lengths of 554 children at age of 11–24 months. The birth-weight-for-gestational-age Z-score was calculated using INTERGROWTH 21st international new-born birth standards. We determined Z-scores of length-for-age, weight-for-age and weight-for-length of the children using the 2006 WHO child growth standards. We used a multilevel mixed effect linear regression model to examine the influence of foetal biometric measurements, new-born (birth weight, gestational age at delivery, sex), maternal (age, height, education, occupation, parity) and household (household wealth, family size) characteristics on birth weight, child length-for-age and weight-for-age (Paper II). We used the WHO and national ANC guidelines to compare the service utilization patterns, and collected data on ANC utilization among 704 pregnant women at three prescheduled visits during pregnancy and at birth. Data on the extent of antenatal care content received, timing of antenatal care, location of antenatal care, and location and mode of delivery were obtained by interviewing the pregnant women. Adverse pregnancy outcomes was computed as the sum of preterm birth, intrauterine foetal deaths, and stillbirths (Paper III). Results The distribution of biometric measurements and estimated foetal weight in our study were similar to the WHO and INTERGROWTH-21st references. Most measurements were between -2 and +2 of the reference Z-scores. Based on the smoothed percentiles, the 5th, 50th, and 95th percentiles, our study had similar distribution patterns to the WHO chart, and the 50th percentile was similar to the INTERGROWTH-21st chart (Paper I). We found that foetal factors, duration of pregnancy, child age, maternal height and family size were the main predictors of linear growth. Both birth weights and linear growth were influenced by early intrauterine foetal growth. Birth weight was also influenced by foetal growth during late pregnancy. Environmental factors had more influence on the child’s linear growth compared to their effect on birth weight. We observed a large variation in length-for-age Z-score (30%) and weight-for-length Z-score (22%) among kebeles (local wards) than in the birth weight of new-borns (11%) indicating more heterogeneity in clusters for length-for-age Z-score and weight-for-length Z-score than for birth weight (Paper II). We found that pregnant mothers had a poor compliance of ANC utilization compared to the national and the WHO guidelines. In addition, we found that the current FANC utilization status were not associated with the adverse pregnancy outcomes that we measured (Paper III). Conclusions In conclusion, this thesis demonstrated that; (i) foetal growth patterns were similar to the INTERGROWTH-21st and the WHO multicentre foetal growth reference standards, (ii) early intrauterine foetal growth affected both birth weight and linear growth while foetal growth during late pregnancy influenced birth weight only. In addition, there was more influence of environmental factors on child linear growth compared to their effects on birth weight and, (iii) ANC service utilization is low in the context of national and WHO guidelines. In addition, there was no association between the current focused antenatal health care service and adverse pregnancy outcomes.  Doktorgradsavhandlin

A systematic review of the treatment and management of pre-eclampsia and eclampsia in Pakistan

Pakistan is one of the six countries that account for more than 50 percent of the world’s maternal deaths. According to Population Council estimates, each year nearly 8.6 million women become pregnant in the country. Of these, 1.2 million women are likely to face obstetric complications. Each year, there are nearly 14,000 pregnancy-related deaths. Information is lacking on context-specific health-system barriers that prevent optimal use of the lifesaving medicine magnesium sulfate (MgSO4) in Pakistan. Although efforts in Pakistan both at the national and subnational level are ongoing on the prevention and treatment of pre-eclampsia and eclampsia (PE/E), results are generally suboptimal and program interventions remain uncoordinated and fragmented. A fragmented system for registration, procurement, and distribution is at the source of the low use of magnesium sulfate, even though policies are all aligned with international standards. To fully appreciate the enormity of the problem at the country level, this systematic review of published papers on PE/E was conducted in Pakistan from 2005 to 2015 to understand key challenges, gaps, and interventions related to the prevention and treatment of pre-eclampsia and eclampsia

The Electronic Health Record's Impact on Labor and Delivery Nurses' Cognitive Work

The Electronic Health Record’s Impact on Labor and Delivery Nurses’ Cognitive WorkAbstractBackground and objective: Despite recognition that electronic health record (EHR) use has introduced cognitive challenges for clinicians, few studies have evaluated its impact on the cognitive dimension of nurses’ work. Labor and delivery nurses may encounter unique challenges when using the electronic health record since they also interact with an electronic fetal monitoring system. This study sought to explore labor and delivery nurses’ perceptions of the EHR’s impact on their cognitive work with the goal of identifying patient safety implications. Methods and setting: This was a grounded theory study using dimensional and situational analysis. Data were interviews and observations with 21 labor nurses at two community hospitals in the Western United States. Results: The ways that nurses configured care when using the EHR varied across participants and sites and depended on how easily they integrated it into their practice. Individual, group, and situational factors facilitated or constrained integration. This took place in a dynamic, high-acuity, specialty clinical environment while using EHRs that were not designed for pregnant women. Nurses used clinical decision support and other cognitive support features that rarely worked as intended due to the lack of EHR customization to account for pregnancy physiology and unique risk factors in the perinatal patient. Nurses viewed the quality of their relationships with patients and their families as an integral part of caring for laboring women and felt that interaction with the EHR sometimes threatened this dimension of their work. Conclusions: When nurses were unable to integrate the EHR into care it resulted in numerous consequences that have important safety implications. Available cognitive support features lacked the specialty-specific support needed to care for laboring women and instead required nurses to track information in other ways that added to their cognitive burden and work routines. As a result, nurses and patients were not benefitting from the intended decision support and patient safety protections offered by appropriate risk assessment screens or critical alerts. These findings have important implications for the configuration and design of EHRs in perinatal settings

Pregnancy in the COVID-19 pandemic, prenatal care, and digital technologies: women’s experiences

Objective: to know the experience of being pregnant and using technologies for gestational care during the COVID-19 pandemic. Methods: qualitative study, conducted in a virtual environment. A total of 20 women who used digital technologies in pregnancy care during the pandemic were interviewed by videoconference. The data were submitted to content analysis supported by the Atlas.ti9 program. Results: two categories emerged: "Women's feelings on being pregnant during the pandemic of COVID-19", encompassing feelings, expressed by fear, insecurity, and loneliness, related to facing a new disease and social isolation; "Women's experiences with the use of digital technologies in pregnancy care", showing autonomy in the search for online information about pregnancy and groups of pregnant women, in applications or social networks. Furthermore, they remotely experienced bonding and maintenance of prenatal care by health professionals. Conclusion: the use of digital technologies in the pandemic was an imposed reality that positively contributed to clarifying doubts, care, and emotional support during pregnancy. Contributions to practice: the use of digital technologies showed benefits in the pandemic and can be extended to the daily routine of prenatal care, especially in situations that make it difficult for pregnant women to access services