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.

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.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity.

OBJECTIVE: This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants. STUDY DESIGN: This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races. RESULTS: The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model. CONCLUSION: This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709). KEY POINTS: · Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Federal Direction + Local Implementation as a Strategy for Improving Infant Health: The Founding and Evolution of the Infant Welfare Society of Evanston.

While the role of the US federal government in improving Maternal and Child Health (MCH) is often seen as a history of opportunities and tensions between the federal bureaucracy and state implementation, less is known about how federal governmental policies to improve MCH have been implemented at the local level, and the nature of the dynamic between local implementation and federal adoption of locally generated strategies. By describing the emergence of the Infant Welfare Society of Evanston in the first part of the 20th century and describing its evolution until 1971, we showcase the forces that shaped the emergence of an MCH institution at the local level in the early part of the history of MCH in the US.  This article highlights the interaction of a progressive maternalistic frame and the growth of local public health infrastructure as fundamental to the basis of action to address infant health during this period. However, this history also highlights the complex relationship of institutions dominated by White women and their relationship to the populations served in the development of the field of MCH and elucidates the need for more explicit attention to understanding the role of Black social institutions in the development of the field of MCH.

The history of Maternal and Child Health (MCH) in the US is often seen through the lens of federal-state relations; however, less is known about how federal governmental policies to improve MCH have been implemented at the local level, and the nature of the dynamic between local implementation and federal adoption of locally generated strategies. To address this gap in our historical knowledge, we tell the story of the Infant Welfare Society of Evanston (IWSE), a community-based organization, whose activities to address infant health beginning in the second decade of the 20th century directly parallel and in some circumstances influenced federal MCH efforts. Examining this history enables us to also explore issues of racial equity in the development of the field of MCH in the US.

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.

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.

Rural Cancer Disparities: Understanding Implications for Breast and Cervical Cancer Diagnoses.

BACKGROUND: Rural populations experience several disparities, influenced by structural-, community-, and individual-level barriers, across the breast and cervical cancer continuum. OBJECTIVES: This study seeks to identify structural-, community-, and individual-level barriers that affect rural populations across the cancer continuum, understand the role of nurses serving rural populations in breast and cervical cancer screening and diagnostics, and provide recommendations for working with rural patients. METHODS: This is a secondary analysis of qualitative interviews conducted with public health nurses serving rural populations. FINDINGS: Emergent themes indicate that rural populations experience barriers that affect disparities across the breast and cervical cancer continuum, including a changing healthcare landscape, access to cancer-focused care, access to insurance, collective poverty, and demographic factors. Nurses working with rural communities can address these disparities as they fulfill multiple roles and responsibilities.

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.

Interpregnancy Interval and Severe Maternal Morbidity in Iowa, 2009 to 2014.

INTRODUCTION: Maternal mortality and morbidity rates have risen significantly, yet little research has focused on how severe maternal morbidity (SMM) is associated with future reproductive health, such as birth spacing or the likelihood of subsequent SMM. This study focuses on the risk of SMM recurrence and the association of interpregnancy intervals with SMM. METHODS: This population-based, retrospective cohort study used Iowa hospital discharge data longitudinally linked to birth certificate data between 2009 and 2014. To examine recurrence of SMM, crude and adjusted multivariable logistic regression models were generated. The associations between varying interpregnancy intervals and subsequent SMM were examined. Crude, stratified, and adjusted risk ratios and their associated 95% confidence intervals were estimated. RESULTS: A total of 36,190 women were included in this study. Women with SMM in the index delivery had significantly higher odds of SMM in the subsequent delivery (adjusted odds ratio, 8.16; 95% confidence interval, 5.45-12.24) compared with women without SMM. Women with an interpregnancy interval of less than 6 months compared with 18 months or longer were more likely to experience SMM during their subsequent delivery, although the difference was not statistically significant (adjusted odds ratio, 1.41; 95% confidence interval, 0.99, 2.03). CONCLUSIONS: This study demonstrates that women who experience SMM are at markedly increased risk of subsequent SMM. Further investigation is necessary to inform optimal interpregnancy interval recommendations based on prior maternal health outcomes.

Association Between Breastfeeding Discouragement and Breastfeeding Behaviors.

OBJECTIVE: To examine the association between subjective norms and breastfeeding behaviors and to assess whether individual characteristics modify this association. DESIGN: Retrospective cohort study. SETTING: Florida, 2004 to 2005; Louisiana, 2004; and Ohio, 2009 to 2010. PARTICIPANTS: Stratified systematic sample of respondents who completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey from three states (N = 5,378). METHODS: We used PRAMS data to examine the associations between three independent variables (breastfeeding discouragement by others and number and type of normative referents) and three breastfeeding behaviors (breastfeeding initiation and breastfeeding duration at 4 weeks and 10 weeks after birth) using multivariable log binomial regression. We also examined whether maternal characteristics modified the association between breastfeeding discouragement by others and breastfeeding behaviors. RESULTS: Respondents who reported that others discouraged them from breastfeeding were more likely to initiate breastfeeding (adjusted relative risk (RR) = 0.78, 95% confidence interval [CI] [0.64, 0.96]) than those who were not discouraged. Furthermore, in the total sample, breastfeeding discouragement from others was not associated with breastfeeding discontinuation by 4 weeks and 10 weeks after birth. Breastfeeding discouragement from health care providers was associated with a greater incidence of noninitiation among respondents who reported breastfeeding discouragement from others (adjusted RR = 2.82, 95% CI [1.88, 4.22]). CONCLUSIONS: Findings suggest that women may be motivated to initiate breastfeeding because of their beliefs and emotions despite being discouraged by others. However, discouragement by health care providers was associated with decreased initiation. This underscores a need for the continued implementation and scale-up of evidence-based maternity care practices and education of providers and the public to support breastfeeding.

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.

A two-generation approach to postpartum care: Building on the well-baby visit.

BACKGROUND: Although postpartum (PP) care is essential for the health and well-being of women and their infants, many women in the United States do not receive PP care. In order to ensure that women's PP needs are met, it is essential to develop delivery models that address their barriers to care. The objective of the current study was to obtain women's feedback and perspectives about delivering women's health care at the well-baby visit (WBV) using a modified mixed-methods approach including open-ended interviews and surveys. METHODS: Twenty brief open-ended interviews were conducted with PP women at a large urban medical center in Chicago. The interviews were recorded, transcribed, and coded following a mixed deductive and inductive approach and analyzed using Dedoose. Following the interview analysis, surveys with 50 immediate PP women and 50 who were 2-4 months PP were conducted. Statistical analyses included frequencies and chi-square tests to determine differences between participants interviewed at the two time periods. RESULTS: Key themes that emerged from the open-ended interviews include the tension between the desire for continuity of care (prenatal to PP) and the desire for convenient care. The surveys found that 86%-94% of women would be interested in receiving PP care at the same clinic site and time as their new baby. CONCLUSIONS: One approach to addressing women's PP health and need for convenient care is the provision of components of women's health care at the WBV. Therefore, we present an innovative two-generation model for PP care focusing on needs of both the woman and infant.

Comparing Postpartum Care Utilization from Medicaid Claims and the Pregnancy Risk Assessment Monitoring System in Wisconsin, 2011-2015.

OBJECTIVE: To compare two data sources from Wisconsin-Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) surveys-for measuring postpartum care utilization and to better understand the incongruence between the sources. METHODS: We used linked Medicaid claims and PRAMS surveys of Wisconsin residents who delivered a live birth during 2011-2015 to assess women's postpartum care utilization. Three different definitions of postpartum care from Medicaid claims were employed to better examine bundled service codes and timing of care. We used one question from the PRAMS survey that asks women if they have had a postpartum checkup. Concordance between the two data sources was examined using Cohen's Kappa value. For women who reported having a postpartum checkup on PRAMS but did not have a Medicaid claim for a traditional postpartum visit, we determined the other types of health care visits these women had after delivery documented in the Medicaid claims. RESULTS: Among the 2313 women with a Medicaid-paid delivery and who completed a PRAMS survey, 86.6% had claims for a postpartum visit during the first 12 weeks postpartum and 90.5% self-reported a postpartum checkup on PRAMS (percent agreement = 79.9%, Kappa = 0.015). The percent agreement and Kappa values varied based on the definition of postpartum care derived from the Medicaid claims data. CONCLUSIONS: There was slight agreement between Medicaid claims and PRAMS data. Most women had Medicaid claims for postpartum care at some point in the first 12 weeks postpartum, although the timing of these visits was somewhat unclear due to the use of bundled service codes.

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.

Prenatal exposure to multiple metals and birth outcomes: An observational study within the National Children's Study cohort.

BACKGROUND: Prenatal exposure to metals may play an important role in fetal growth. However, the epidemiologic evidence for certain metals is sparse, and most of the existing research has focused on evaluating single metals in highly exposed target populations. OBJECTIVES: We evaluated associations of cadmium, lead, manganese, selenium, and total mercury exposures during pregnancy with fetal growth using data from mother-infant pairs participating in the National Children's Study. METHODS: Prenatal metal exposures were measured using maternal blood collected from 6 to 32 weeks of gestation. Birth outcomes, including gestational age, birthweight, birth length, head circumference, and ponderal index, were ascertained through physical measurement at birth or abstraction from medical records. Regression coefficients and their 95% confidence intervals were estimated from multivariable linear regression models in the overall study population as well as among male and female infants. We further evaluated pairwise metal-metal interactions. RESULTS: Sex-specific associations were observed for lead, with inverse associations for birthweight, birth length, head circumference, and gestational age observed only among female infants. Sex-specific associations were also observed for selenium, with a positive association for birthweight observed among male infants; selenium was also positively associated with ponderal index and inversely associated with birth length among female infants. Overall, total mercury was inversely associated with birthweight and ponderal index, and the association with birthweight was stronger among female infants. No significant associations were observed with cadmium and manganese. In the metal-metal interaction analyses, we found evidence of a synergistic interaction between lead and total mercury and antagonistic interaction between selenium and total mercury with selected birth outcomes. CONCLUSIONS: Our findings suggest that prenatal exposure to metals may be related to birth outcomes, and infant sex may modify these associations.

The Effect of Continuous Versus Pregnancy-Only Medicaid Eligibility on Routine Postpartum Care in Wisconsin, 2011-2015.

OBJECTIVE: To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. RESULTS: Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). CONCLUSIONS FOR PRACTICE: Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

A Novel Approach to Postpartum Contraception Provision Combined with Infant Care: A Randomized, Controlled Trial.

BACKGROUND: Unintended pregnancy among women with short interpregnancy intervals remains common. Women's attendance at the 4- to 6-week postpartum visit, when contraception provision often occurs, is low, whereas their attendance at well-baby visits is high. We aimed to evaluate if offering co-located contraceptive services to mothers at well-baby visits increases use of long-acting reversible contraception (LARC) at 5 months postpartum compared with usual care in a randomized, controlled trial. METHODS: Women with infants aged 4.5 months or younger who were not using a LARC method and had not undergone sterilization were eligible. Generalized linear models were used to estimate risk ratios. Likability and satisfaction of the contraception visit were assessed. RESULTS: Between January 2015 and January 2017, 446 women were randomized. LARC use at 5 months was 19.1% and 20.9% for the intervention and control groups, respectively, and was not significantly different after controlling for weeks postpartum (risk ratio, 0.85; 95% confidence interval, 0.59-1.23). Uptake of the co-located visit was low (17.7%), but the concept was liked; insufficient time to stay for the visit was the biggest barrier to uptake. Women who accepted the visit were more likely to use a LARC method at 5 months compared with women in the control group (risk ratio, 1.97; 95% confidence interval, 1.26-3.07). CONCLUSIONS: Women perceived co-located care favorably and LARC use was higher among those who completed a visit; however, uptake was low for reasons including inability to stay after the infant visit. Intervention effects were possibly diluted. Future research should test a version of this intervention designed to overcome barriers that participants reported.

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.