A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting.

PURPOSE: Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. METHODS: The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. RESULTS: At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. CONCLUSIONS: Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Child Care as a Barrier to Perinatal Health Care in Illinois.

PURPOSE: Within a multi-state Collaborative Improvement and Innovation Network addressing the social determinants of health during 2017-2020, the Illinois Department of Public Health led an exploratory project to understand how the availability of child care affects maternal health care utilization. The project assessed whether lack of child care was a barrier to perinatal health care utilization and gathered information on health facility practices, resources, and policies related to child care DESCRIPTION: TWe surveyed (1) birthing hospitals (n = 98), (2) federally qualified health centers (FQHCs) (n = 40), and (3) a convenience sample of postpartum persons (n = 60). ASSESSMENT: Each group reported that child care concerns negatively affect health care utilization (66% of birthing hospitals, 50% of FQHCs, and 32% of postpartum persons). Among postpartum persons, the most common reported reason for missing a visit due to child care issues was "not feeling comfortable leaving my child(ren) in the care of others" (22%). The most common child care resource reported by facilities was "staff watching children" (53% of birthing hospitals, 75% of FQHCs); however, most did not have formal child care policies or dedicated space for children. Fewer than half of FQHCs (43%) discussed child care at the first prenatal visit. CONCLUSION: The project prompted the Illinois Title V program to add a child care-related strategy to their 2021-2025 Action Plan, providing opportunity for further examination of practices and policies that could be implemented to reduce child care barriers to perinatal care. Systematically addressing child care in health care settings may improve health care utilization among birthing/postpartum persons.

Learning from Graduate and Undergraduate Public Health Virtual Internship Experiences with State Title V Agencies During COVID-19, Summer 2020.

BACKGROUND: Since summer 2014, the National MCH Workforce Development Center has placed students from MCH public health graduate (Centers of Excellence and Catalyst) and undergraduate (MCH Pipeline) programs, all funded by the Maternal and Child Health Bureau, in summer internships with state and territorial Title V agencies. In 2020, due to the COVID-19 pandemic the Title V MCH Internship Program was offered virtually. PARTICIPANTS AND METHODS: This manuscript includes quantitative and qualitative data from 2017 to 2020 generated by both Title V MCH Internship student interns (n = 76) and their preceptors (n = 40) with a focus on a comparison between the 2020 virtual year and the 2017-2019 years. RESULTS: Evaluation data from the 2017 to 2020 Title V MCH Internship Program from both students and preceptors revealed the implementation of a robust and successful internship program in which students increased their confidence in a variety of team, mentorship, and leadership skills while gaining direct exposure to the daily work of state Title V agencies. However, students and preceptors identified more challenges during 2020 compared to previous years. CONCLUSIONS: The COVID-19 Pandemic was both a disruption and a catalyst for change in education. While there were clearly some challenges with the pivot to a virtual Title V MCH Internship Program in summer 2020, students were able to participate in meaningful internship experiences. This success can be attributed to the ability of the internship sponsor to engage in best practices, including extensive planning and provision of ongoing support to the students. Going forward, it is recognized that virtual internships may facilitate access to agencies in distant locales, eliminating issues related to housing and transportation. When both virtual and in-person relationships are available, those responsible for internship programs, including the Title V MCH Internship, will need to weigh these type of benefits against the potential missed opportunities students may have when not able to participate in on-site experiences.

The Critical Value of Maternal and Child Health (MCH) to Graduate Training in Public Health: A Framework to Guide Education, Research and Practice.

INTRODUCTION: In light of persistent health inequities, this commentary describes the critical role of maternal and child health (MCH) graduate training in schools and programs of public health (SPPH) and illustrates linkages between key components of MCH pedagogy and practice to 2021 CEPH competencies. METHODS: In 2018, a small working group of faculty from the HRSA/MCHB-funded Centers of Excellence (COEs) was convened to define the unique contributions of MCH to SPPH and to develop a framework using an iterative and consensus-driven process. The working group met 5 times and feedback was integrated from the broader faculty across the 13 COEs. The framework was further revised based on input from the MCHB/HRSA-funded MCH Public Health Catalyst Programs and was presented to senior MCHB leaders in October 2019. RESULTS: We developed a framework that underscores the critical value of MCH to graduate training in public health and the alignment of core MCH training components with CEPH competencies, which are required of all SPPH for accreditation. This framework illustrates MCH contributions in education, research and evaluation, and practice, and underscores their collective foundation in the life course approach. CONCLUSIONS: This new framework aims to enhance training for the next generation of public health leaders. It is intended to guide new, emerging, and expanding SPPH that may currently offer little or no MCH content. The framework invites further iteration, adaptation and customization to the range of diverse and emerging public health programs across the nation.

Setting the Agenda for Reproductive and Maternal Health in the Era of COVID-19: Lessons from a Cruel and Radical Teacher.

BACKGROUND: COVID-19 exposes major gaps in the MCH safety net and illuminates the disproportionate consequences borne by people living in low resource communities where systemic racism, community disinvestment, and social marginalization creates a perfect storm of vulnerability. METHODS: We draw eight lessons from the first 8 months of the pandemic, describing how COVID-19 has intensified pre-existing gaps in the MCH support network and created new problems. For each lesson identified, we present supporting evidence and a call for specific actions that can be taken by MCH practitioners, researchers and advocates. RESULTS: LESSON #1: COVID-19 hits communities of color hardest, exposing and exacerbating health inequities caused by systemic racism. LESSON #2: Women experience the most devastating social, economic and mental health tolls during COVID-19. LESSON #3: Virulent pathogens find and exacerbate cracks in our public health and health care systems. LESSON #4: COVID-19 has become a pretext to limit access to sexual and reproductive health care. LESSON #5: COVID-19 has exposed and deepened fault lines in maternity care: over-medicalization, discrimination, lack of workforce diversity, underutilization of collaborative team approaches, and lack of post-delivery follow-up. LESSON #6: The pandemic adds impetus to much-needed Medicaid policy reforms that can have a lasting positive effect on maternal health. LESSON #7: Social and health policy changes, heretofore deemed infeasible, ARE possible under pandemic threat. LESSON #8: Finally, an overarching COVID-19 lesson: We are all inextricably connected. CONCLUSION: COVID-19 is a loud wake up call for renewed action by MCH epidemiologists, policy-makers, and advocates.

A mixed methods study: Midlife African American women's knowledge, beliefs, and barriers to well-woman visit, flu vaccine, and mammogram use.

African American women (AAW) are particularly at risk for deleterious health outcomes that might be mitigated through increased preventive care use. A mixed methods study that examined relationships between knowledge of, beliefs about, and barriers to well-woman visits, flu vaccines, and mammograms was conducted with midlife AAW who participated in an online survey (n = 124) and in-depth interviews (n = 19). Findings showed that greater knowledge of preventive service recommendations and positive patient-provider relationships were associated with greater preventive service use. Flu vaccines were significantly underused. Study implications inform strategies to increase preventive care utilization among AAW and increase capacities to improve health disparities.

A Call to Revisit the Prenatal Period as a Focus for Action Within the Reproductive and Perinatal Care Continuum.

Objectives The broad maternal and child health community has witnessed increased attention to the entire continuum of reproductive and perinatal health concerns over the past few years. However, both recent discouraging trends in prenatal care access and utilization and a renewed understanding of prenatal care as a critical anchor of the reproductive/perinatal health continuum for women who do get pregnant demand a new effort to focus on the prenatal period as a gateway for maternal and infant health. Methods This commentary: describes the Medicaid expansions and the momentum for universal access to prenatal care of the 1980-1990s; examines the pivot away from this goal and its aftermath; provides a rationale for why renewed attention to prenatal care and the prenatal period is essential; and, explores the potential focus of an updated prenatal care agenda. Conclusion We conclude that increasing women's access to high quality prenatal care will require substantial effort at the clinical, community, policy, and system levels. Only when attention is paid to all phases of the reproductive/perinatal health continuum with an emphasis on continuity between all periods, and on the social determinants that affect health and well-being, will our nation be able to ensure the health of all women across the life course (whether or not they ever become mothers), while simultaneously fulfilling our nation's promise that all children-no matter their income or race/ethnicity-will have the opportunity to be born well.

Guidelines and Interventions Related to the Postpartum Visit for Low-Risk Postpartum Women in High and Upper Middle Income Countries.

Objectives A two-part review was undertaken to: (1) summarize current guidelines on the timing and frequency of postpartum follow-up care for generally healthy, non-high risk postpartum women and to delineate the evidence on which these guidelines are based; and, (2) summarize the results of intervention studies focused on increasing utilization of the postpartum visit for generally healthy, non-high risk postpartum women. Methods A review of guidelines from high and upper middle income countries published between 2000 and 2016 in English related to non-high risk postpartum follow-up visits was conducted in 2014-2016 using four databases and additional sources. In addition, articles published between 1990 and 2016 which evaluated interventions from high to upper middle income countries related to increasing attendance at the postpartum visit were gathered using three databases. Results This review located eight guidelines, all of which relied on expert opinion/group consensus as the evidence for their recommendations regarding the timing of the postpartum visit. The review located 19 intervention studies focused on increasing use of the postpartum visit; in 12 there was statistically significant evidence that these approaches improved utilization. However, no intervention strategy was evaluated more than a few times and many of the evaluations were relatively dated. Conclusions Guidelines for the timing of the postpartum visit are variable and are typically based on weak evidence; however, there is support for increased flexibility to meet women's needs. Additionally, while there is a diverse set of promising interventions to increase utilization of the postpartum visit, there is limited evaluative information. Future initiatives should focus on more rigorous evaluation.

USDA Snack Policy Implementation: Best Practices From the Front Lines, United States, 2013-2014.

INTRODUCTION: The Smart Snacks in Schools interim final rule was promulgated by the US Department of Agriculture (USDA) as authorized by the Healthy, Hunger-Free Kids Act of 2010 (PL 111-296) and implementation commenced beginning July 1, 2014; however, in the years leading up to this deadline, national studies suggested that most schools were far from meeting the USDA standards. Evidence to guide successful implementation of the standards is needed. This study examined snack policy implementation in exemplary high schools to learn best practices for implementation. METHODS: Guided by a multiple case study approach, school professionals (n = 37) from 9 high schools across 8 states were recruited to be interviewed about perceptions of school snack implementation; schools were selected using criterion sampling on the basis of the HealthierUS Schools Challenge: Smarter Lunchrooms (HUSSC: SL) database. Interview transcripts and internal documents were organized and coded in ATLAS.Ti v7; 2 researchers coded and analyzed data using a constant comparative analysis method to identify best practice themes. RESULTS: Best practices for snack policy implementation included incorporating the HUSSC: SL award's comprehensive wellness approach; leveraging state laws or district policies to reinforce snack reform initiatives; creating strong internal and external partnerships; and crafting positive and strategic communications. CONCLUSION: Implementation of snack policies requires evidence of successful experiences from those on the front lines. As federal, state, and local technical assistance entities work to ensure implementation of the Smart Snacks standards, these best practices provide strategies to facilitate the process.

The MCH navigator: tools for MCH workforce development and lifelong learning.

Maternal and child health (MCH) leadership requires an understanding of MCH populations and systems as well as continuous pursuit of new knowledge and skills. This paper describes the development, structure, and implementation of the MCH Navigator, a web-based portal for ongoing education and training for a diverse MCH workforce. Early development of the portal focused on organizing high quality, free, web-based learning opportunities that support established learning competencies without duplicating existing resources. An academic-practice workgroup developed a conceptual model based on the MCH Leadership Competencies, the Core Competencies for Public Health Professionals, and a structured review of MCH job responsibilities. The workgroup used a multi-step process to cull the hundreds of relevant, but widely scattered, trainings and select those most valuable for the primary target audiences of state and local MCH professionals and programs. The MCH Navigator now features 248 learning opportunities, with additional tools to support their use. Formative assessment findings indicate that the portal is widely used and valued by its primary audiences, and promotes both an individual's professional development and an organizational culture of continuous learning. Professionals in practice and academic settings are using the MCH Navigator for orientation of new staff and advisors, "just in time" training for specific job functions, creating individualized professional development plans, and supplementing course content. To achieve its intended impact and ensure the timeliness and quality of the Navigator's content and functions, the MCH Navigator will need to be sustained through ongoing partnership with state and local MCH professionals and the MCH academic community.

The Role of a Local Health Department in Advancing Health Equity: Universal Postpartum Home Visiting in a Large Urban Setting.

Introduction: Racial and ethnic inequities persist among birthing families in urban U.S. communities, despite public health efforts to improve outcomes. To address these inequities, in 2020, the Chicago Department of Public Health (CDPH) launched Family Connects Chicago (FCC), an evidence-based, universal, postpartum home visiting program. We examine CDPH's transition from "high risk" to universal home visiting to determine whether and how this change represent an explicit commitment to advancing maternal and child health equity. Methods: We conducted a secondary analysis of key informant interview data (n=45 interviews) collected from stakeholders involved in FCC's early implementation. Our analysis involved identifying processes used by CDPH in their planning and early implementation of FCC and examining the alignment of these processes with approaches for promoting health equity proposed by Calancie et al. Results: The processes used by CDPH to plan and implement the FCC pilot are reflected in two major themes: (1) CDPH emphasized improving outcomes for all birthing families, and (2) CDPH prioritized engaging multiple stakeholders throughout planning and implementation. Alignment of these themes and their subthemes with the approaches proposed by Calancie et al. demonstrated that CDPH's implementation of FCC represents a commitment to advancing health equity. Discussion: In their planning and implementation of FCC, CDPH appears to have exhibited a concerted effort to address Chicago's persistent health inequities. Institutional commitment, continued stakeholder engagement, ongoing data sharing, and sustainable funding will be crucial to implementing and expanding FCC. Health Equity Implications: The implementation of FCC, a new service delivery approach for maternal and infant health, marks a new beginning in tackling inequities for Chicago's birthing families.

Addressing Maternal Health Disparities: Building a Novel Two-Generation Approach to Comprehensive Postpartum Care.

The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.

Addressing Women's Health Care Needs During Pediatric Care.

Objective: To determine if the use of a simple self-administered Postpartum Questionnaire for Mothers (PQM) at the well-baby visit (WBV) increased the proportion of women who received health care and contraception by 6 months postpartum (PP). Methods: This was a single-site, system-level, intervention. Women were recruited from the pediatric clinic when presenting with their infants for a 2-month WBV. During phase 1 of the study, a control group was enrolled, followed by an 8-week washout period; then enrollment of the intervention group (phase 2). During phase 2, the PQM was administered and reviewed by the pediatrician during the infant's visit; the tool prompted the pediatrician to make a referral for the mother's primary or contraceptive care as needed. Data were collected at baseline and at 6 months PP, and additional data were extracted from the electronic medical record. Results: We found that PP women exposed to the PQM during their infant's WBV were more likely to have had a health care visit for themselves between 2 and 6 months PP, compared with the control group (relative risk [RR] 1.66, [confidence interval (CI) 0.91-3.03]). In addition, at 6 months PP, women in the intervention group were more likely to identify a primary care provider (RR 1.84, [CI 0.98-3.46]), and more likely to report use of long-acting reversible contraception (LARC) (RR 1.24, [CI 0.99-1.58]), compared with women in the control group. Conclusion: A simple self-administered PQM resulted in an increase in women's receipt of health care and use of LARC by 6 months PP. Clinical Trial Registration: Use of a reproductive life planning tool at the pediatric well-baby visit with postpartum women, NCT03448289.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action.

BACKGROUND: Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care. METHODS: We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility. FINDINGS: Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences. CONCLUSIONS: The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Draft Opioid-Prescribing Guidelines for Uncomplicated Normal Spontaneous Vaginal Birth.

Women who experience an uncomplicated vaginal delivery have acute intrapartum pain and variable pain in the immediate postpartum period. Although the Centers for Disease Control and Prevention (CDC) has urged clinicians to improve opioid-prescribing behavior, there are no published clinical practice guidelines for prescribing opioids during labor and delivery and at discharge for patients with uncomplicated normal spontaneous vaginal delivery. To address the knowledge gap regarding guidelines for pain management in this population, we used the national Premiere Health Care Database for deliveries of uncomplicated vaginal births from January 1, 2014, to December 31, 2016, to determine the prevalence of opioid administration. Among the 49,133 women who met inclusion criteria, 78.2% were administered opioids during hospitalization and 29.8% were administered opioids on the day of discharge. Descriptive statistics were generated to document the characteristics of the patients receiving opioids as well as the characteristics of hospitals administering opioids during inpatient labor and delivery and on discharge. Patient-level variables included age group, marital status, race, ethnicity, payer type, and length of stay. Hospital-level variables included bed size, geographic region, teaching status, and urbanicity status. These data were then presented in an electronic Delphi survey to 14 participants. The survey participants were obstetrician-gynecologists identified by the American College of Obstetricians and Gynecologists as being thought leaders in the obstetrics field and who had also demonstrated an active interest in the opioid epidemic and its effect on women's health. After the panelists viewed the opioid administration data, they were presented with an adapted version of the CDC's guidelines for opioid prescribing for chronic pain management. The eight adapted guidelines were constructed to be more relevant and appropriate for the inpatient normal spontaneous vaginal delivery population. After three rounds of the surveying process, seven of the eight adapted guidelines were endorsed by the survey participants. These seven draft consensus guidelines could now be used as a starting point to develop more broadly endorsed and studied guidelines for appropriately managing pain control for women with uncomplicated spontaneous vaginal birth.

Welfare reform and insurance coverage during the pregnancy period: implications for preconception and interconception care.

Welfare reform has had far-reaching consequences for unmarried women and their children, including effects on their health insurance status. Those who would be receiving cash assistance absent welfare reform may have lower rates of health insurance if they failed to enroll separately for Medicaid (whose rules did not tighten over this time period), or if the new employment they entered did not provide health insurance. Administrative difficulties involved in accessing Medicaid separately from cash welfare may also have been a factor in the short run. Our research uses data from a large and nationally representative household survey that tracks the same individuals over time, the Survey of Income and Program Participation, to examine the effect of welfare reform (AFDC waivers and TANF implementation) on the health insurance status of unmarried mothers with High School completion or less (the population whose health insurance we expect would be affected by the welfare reform, or the "treatment group") in the time period surrounding a particularly important life event, pregnancy. We look at the effects of these policies over the time period 1990--1999, as well as over the time period 1990--2003, to explore the short run vs. long run impact. Our "control group", those who should not be affected by welfare reform itself but are expected to be affected by other national or state events that are happening contemporaneously, consists of married mothers with High School completion or less; the insurance experience of these women is used to control for the other forces that might otherwise lead us to attribute too little or too large an effect to welfare reform. Given the importance of access to health care at all points in the period surrounding and during pregnancy, we look at how welfare reform has affected insurance status before conception, during pregnancy, and after the birth of the child. We find that the Aid to Families with Dependent Children (AFDC) waivers of the 1990s as well as Temporary Assistance for Needy Families implementation have decreased access to Medicaid health insurance, increased access to employer health insurance, and led to a decrease in overall insurance, depending on the point in pregnancy considered and the time period of the study, with the largest effects found in coverage after the birth of a child. These findings have particular implications for the increasing emphasis on preconception and interconception care as a strategy to improve women's and infant's health.

The Well-Woman Project: Listening to Women's Voices.

Purpose: The U.S. Affordable Care Act (ACA) of 2010 included the Well-Woman Visit (WWV) as one of the preventive services, which must be covered without cost sharing. Despite concerted efforts to increase access to the WWV, data from the early years of the ACA demonstrated ongoing barriers, including insufficient consumer and provider awareness of the ACA's no cost-sharing provision for preventive services. As such, 2 years after full implementation of the ACA, the Well-Woman Project (WWP) used qualitative methods to learn about women's perceptions of the WWV and barriers that affect their ability to be healthy and seek well-woman care. Methods: Women's voices were captured by Listening Sessions in eight cities and through stories from women across the United States posted to a WWP Website, or reported over a WWP toll-free phone line. Thematic analysis of Listening Sessions and stories was conducted using Dedoose software. Results: In 2016, Listening Sessions (17) were held with 156 women; in addition, stories were collected from 102 women across the United States. Women are aware of the importance of preventive care, but report multiple barriers to seeking such care. However, they are able to articulate a variety of system and policy strategies that mitigate the complexity of navigating the health care system; help women prioritize their health and accessing health care; promote positive relationships with providers; empower women to advocate for themselves and others; promote positive mental health as well as access to safe environments, healthy food, and social support systems; decrease barriers related to lack of transportation and childcare; and support the provision of trauma informed care in the health care delivery system. Conclusion: To improve women's health status and reduce inequities, making the preventive well-care visit available without cost-sharing is necessary, but not a sufficient strategy.

Hospital factors and nontransfer of small babies: a marker of deregionalized perinatal care?

OBJECTIVES: Our purpose was to examine the contribution of hospital factors (e.g., reimbursement sources, teaching status) to the rate of nontransfer of <1250 g infants born in nontertiary hospitals in Illinois. We chose nontransfer as a marker of the extent to which there have been structural changes in the regionalized perinatal care system in Illinois. STUDY DESIGN: Using data from live birth certificates (1989-1996), from the American Hospital Association's Annual Survey of Hospitals (1990 to 1996), and Illinois hospital discharge records (1992 to 1996), we simultaneously assessed the effect of hospital and individual factors on nontransfer of infants <1250 g (n=2904). RESULTS: When adjusted for individual risk factors, several hospital factors were associated with nontransfer. These include birth in a Level II+hospital (odds ratios(OR) 3.75; 95% CI 2.29, 5.29), high Medicaid revenues (OR 1.97; 95% CI 1.58, 2.47), high HMO revenues (OR 1.39; 95% CI 1.11, 2.28), and status as a teaching hospital (OR 1.63; 95% CI 1.30, 2.09). CONCLUSIONS: This study suggests that there should be careful consideration of the role of hospital factors in perinatal deregionalization in order to preserve the improvements in maternal and infant outcomes associated with regionalized perinatal care.

A review of prenatal home-visiting effectiveness for improving birth outcomes.

OBJECTIVE: To determine the effectiveness of prenatal home visiting for improving prenatal care utilization and preventing preterm birth and low birth weight. DATA SOURCES: Medline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Social Work Abstract databases were searched for articles that examined prenatal home-visiting and prenatal care utilization or neonatal outcomes, with additional ascendancy and descendancy searches. Listservs were also used to identify unpublished evaluations. STUDY SELECTION: Quantitative studies meeting the following criteria were included in the analyses: published between 1985 and 2009, published in English, reported providing prenatal home visiting, and reported on prenatal care utilization or a neonatal outcome. DATA EXTRACTION: Study characteristics and findings related to prenatal care utilization, gestational age, and birth weight were abstracted independently by at least two authors. Study quality was assessed across five domains. DATA SYNTHESIS: The search yielded 28 studies comparing outcomes for women who did and did not receive prenatal home visiting, with 14 (59%) using an RCT design. Five (17%) studies reporting on prenatal care utilization found a statistically significant improvement in use of prenatal care for women with home visiting. Of 24 studies reporting an effect on birth outcomes, five (21%) found a significant positive effect on gestational age, and seven of 17 (41%) found a significant positive effect on birth weight. CONCLUSIONS: More evidence suggests that prenatal home visiting may improve the use of prenatal care, whereas less evidence exists that it improves neonatal birth weight or gestational age. These findings have implications for implementing Title II of the Affordable Care Act.