Factors Associated With Postprocedure Opioid Prescribing and Persistent Opioid Use Among Opioid-naive Patients: A Nationally Representative Sample.

OBJECTIVE: Examine factors associated with postprocedure opioid receipt and persistent opioid use among opioid-naive patients in a nationally representative sample. SUMMARY BACKGROUND DATA: We used panels 18-20 in the Medical Expenditures Panel Survey (MEPS) between the years 2013 and 2015. Respondents ages 18 and over with any self-reported procedure in the previous year with complete data on the outcome variables for the remainder of the 2-year study period. METHODS: This prospective observational study used multivariable regression to determine factors associated with postprocedure opioid receipt and persistent opioid use among opioid-naive patients, adjusting for sociodemographic, health, and procedure-related characteristics. RESULTS: Adjusted models showed younger age, Western location (AOR = 1.38; 95% CI = 1.02, 1.86), and high-school degree (AOR = 1.60; CI = 1.14, 2.26) were associated with higher odds of postprocedure opioid receipt. Patients who had procedures in an inpatient (AOR: 5.71; CI: 4.31-7.56), outpatient (AOR = 3.77; CI = 2.87,4.95), and dental setting (AOR = 2.86; CI = 1.45, 5.63), and musculoskeletal diagnoses (AOR = 2.23; CI = 1.39, 3.58) and injuries (AOR = 2.04; CI = 1.29, 3.23) were more likely to have postprocedure opioid receipt. Persistent opioid use was associated with Midwest (AOR = 2.06; CI = 1.08, 3.95) and Northeast location (AOR = 2.45; CI = 1.03, 3.95), musculoskeletal diagnosis (AOR = 3.91; CI = 1.23, 8.31), public insurance (AOR = 2.07; CI = 1.23-3.49), and positive depression screener (AOR = 3.36; CI = 2.04, 5.55). CONCLUSIONS: Procedures account for a large portion of opioid prescriptions among opioid-naive patients. This study provides evidence to inform national guidelines for opioid prescribing and postprocedure pain management.

Is LARC for Everyone? A Qualitative Study of Sociocultural Perceptions of Family Planning and Contraception Among Refugees in Ethiopia.

Objective Ethiopia is home to an increasingly large refugee population. Reproductive health care is a critical issue for these groups because refugee women are at high risk for unmet family planning needs. Efforts to expand contraceptive use, particularly long acting reversible contraceptive (LARC) methods are currently underway in several Ethiopian refugee camps. Despite availability of LARC methods, few refugee women opt to use them. The purpose of this study was to explore how culture influences contraceptive attitudes and behaviors, particularly towards LARC methods, among Ethiopia's refugee populations. Methods Focus group discussions and individual interviews were conducted with Eritrean and Somali refugees living in Ethiopia. The qualitative data was analyzed to identify important themes highlighting the relationship between cultural values and contraceptive attitudes and behaviors. Results Childbearing was highly valued among participants in both study groups. Eritreans reported desire to limit family size and attributed this to constraints related to refugee status. Somalis used cultural and religious faith to deal with economic scarcity and were less likely to feel the need to adapt contraceptive behaviors to reduce family size. Participants held overall positive views of the contraceptive implant. Attitudes toward the intrauterine device (IUD) were overwhelmingly negative due to its long-acting nature. Conclusions Culture, religion and refugee status form a complex interplay with family planning attitudes and behaviors among Eritrean and Somali refugees. For these populations, the three-year implant appears to be a more acceptable contraceptive method than the longer-acting IUD because it is in line with their reproductive plans.

A Qualitative Study to Understand Nativity Differences in Breastfeeding Behaviors Among Middle-Class African American and African-Born Women.

Objective To explore nativity differences and the role of attitudes, social norms, and behavioral control perceptions surrounding breastfeeding initiation and duration among middle-class African-American (AA) and African-born (AB) mothers in the US. Methods Semi-structured individual interviews were conducted with 20 middle-class AA and AB mothers in central Ohio from December 2012 to February 2013. Interview questions were developed based on the Theory of Planned Behavior (TPB). Interviews were analyzed for salient themes by TPB constructs. Differences in themes were examined by nativity status. Results All study participants had initiated breastfeeding or bottle-feeding with expressed breast milk, noting the benefits it conferred as well as the persuasive encouragement they received from others. Persistent encouragement was often cited as a factor for sustaining breastfeeding. More AA mothers had discontinued breastfeeding by the time of the interview, which was often attributed to health, lactation, and work challenges. Inconsistent support from health providers, dissuasive remarks from others, ambivalent breastfeeding attitudes, and diminished family support led some mothers to begin formula supplementation. Analysis of maternal narratives revealed nativity differences across sources of encouragement. Specifically, important sources of encouragement were health providers for AA mothers and family, friends, partners and culture for AB mothers. Only AB mothers expressed concerns about difficulty they encountered with breastfeeding due to the lack of proximal family support. Conclusions Findings reveal that both groups of mothers may be susceptible to unsupportive breastfeeding norms in the US and also highlight the need for intervention in health care settings and workplaces to improve AA women's breastfeeding rates.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Anxiety among Black and Latina Mothers of Premature Infants at Social-Environmental Risk.

Anxiety is heightened for mothers of premature infants, potentially interfering with early mothering. This study describes relationships among race/ethnicity, language, and anxiety for women at social-environmental risk who deliver a premature infant. Postnatal baseline interview data from a randomized trial testing a behavioral intervention for mothers and infants (29-34 weeks gestational age) were used to examine maternal state (STAI-Y1) and trait (STAI-Y2) anxiety among blacks and Latinas, and by language preference. Latinas (n = 97) had an elevated prevalence of high (≥ 40) state anxiety compared to blacks (n = 97), with Latinas preferring a Spanish to an English interview reporting the highest levels of state anxiety. Trait anxiety did not differ across groups. Culturally appropriate interventions are needed to reduce anxiety among Latina mothers delivering premature infants, especially among those with limited English language proficiency. A racially/ethnically diverse workforce, bilingual healthcare providers, and trained medical interpreters may help to ensure better outcomes.

Comparison of two health-promotion programs for older workers.

OBJECTIVES: We examined the effects of 2 worksite health-promotion interventions (compared with a health-education control) on older workers' healthy behaviors and health outcomes. METHODS: We conducted a prospective, randomized controlled trial with 423 participants aged 40 years and older. Participants were categorized into 3 study arms: the COACH intervention combined Web-based risk assessments with personal coaching support, the RealAge intervention used a Web-based risk assessment and behavior-specific modules, and a control group received printed health-promotion materials. Participants were assessed at baseline, 6 months, and 12 months. Random-effects modeling controlled for baseline stage of change for all behaviors of interest in all groups. RESULTS: At 6 and 12 months, COACH participants showed significantly increased fruit and vegetable consumption (P = .026; P < .001) and participation in physical activity (P = .05; P = .013), and at 12 months they showed decreased percentage of energy from fat (P = .027). RealAge participants showed significantly decreased waist circumference at 6 and 12 months (P = .05; P = .018). CONCLUSIONS: COACH participants were twice as likely to use the COACH intervention as RealAge participants were to use the RealAge intervention. COACH participants experienced twice the number of positive outcomes that control participants experienced.

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.

Postpartum Health Care Use After Gestational Diabetes and Hypertensive Disorders of Pregnancy.

Objective: To examine postpartum health care utilization after a pregnancy complicated by gestational diabetes (GD) and hypertensive disorders of pregnancy (HDP) using nationally representative data. Materials and Methods: We examined longitudinal pooled panel data from the 1996-2007 Medical Expenditure Panel Survey with linked data from Pregnancy Detail Files on adult women (>18) with singleton pregnancies who reported an infant delivery. Multivariable weighted logistic regression analyses, including interactions, examined the associations between pregnancy complications (GD/HDP) and three postpartum health care utilization outcomes, adjusting for demographic characteristics. Results: The unweighted sample size included 304 women. Overall, 32% did not report an office visit within 12 weeks postpartum, and 15% did not report an office visit within 1 year postpartum. In addition, 15% had ≥1 emergency room (ER) visit 1 year postpartum. Women with GD/HDP compared with those with neither complication had more ER visits 1 year postpartum (unadjusted mean 4.9 vs. 2.3; p < 0.01). In multivariable analyses, GD and HDP were not independently associated with outcomes. However, education marginally modified the pregnancy complication-office visit 1 year postpartum relationship (p = 0.06). Other demographic characteristics were independently associated with each postpartum health care utilization outcome after adjustment. Conclusions: Women with GD/HDP did not differ from women with neither complication on postpartum utilization outcomes. Less educated women with GD/HDP were more likely to miss an office visit within 1 year postpartum than less educated women with neither complication. Certain subgroups of women were more likely to forego timely and appropriate postpartum care. Efforts to improve care coordination and insurance coverage access during the postpartum period are needed.

Maternal Characteristics Associated With Social Support in At-Risk Mothers of Premature Infants.

OBJECTIVE: To identify maternal characteristics associated with social support among new mothers of premature infants who are at social-environmental risk. DESIGN: Cross-sectional analysis of intake interview data from a larger randomized controlled trial of a mother-premature infant developmentally based intervention. SETTING: Two urban community-based hospitals. PARTICIPANTS: One hundred ninety-four women (50% Black, 50% Hispanic) who recently gave birth to otherwise healthy, premature (29-34 weeks gestational age) infants. Participants had at least 2 of 10 social-environmental risks (e.g., poverty). METHODS: In-hospital interviews were conducted to obtain data on sociodemographic characteristics, prior mental health problems, and social support through the use of the Personal Resources Questionnaire 2000. Bivariate and multivariable linear regression analyses were performed to identify factors associated with social support. RESULTS: Mean Personal Resources Questionnaire 2000 scores were significantly lower for Hispanic than Black participants (92.0 vs. 96.0, respectively), those interviewed in Spanish versus English (89.8 vs. 96.1), those with low versus age-appropriate education levels (89.7 vs. 95.3), multiparous versus primiparous women (92.7 vs. 96.0), and those reporting versus not reporting histories of mental health problems (84.7 vs. 94.8). After multivariable adjustment, only younger age, Spanish language preference, multiparity, and a history of mental health problems were associated with significantly lower levels of social support (R2 = 0.18). CONCLUSION: More programs should be made available to provide social support to at-risk mothers, especially younger mothers, and those with limited English ability, other children at home, or histories of mental health problems. Nurses should target these mothers for additional support during their premature infants' NICU stay.

Describing abortion attitudes among young, African American men.

OBJECTIVES: This paper describes African American teenaged males' attitudes and perspectives on abortion. METHODS: Data were derived from a larger cross-sectional survey of African American males aged 14-19, living in the south side of Chicago. RESULTS: Acceptability of abortion varied by partner type, such that 60% of teenagers felt abortion was acceptable with a casual partner while 37% found it acceptable with committed partners (p<.001). Acceptability also varied by sociocontextual factors, and with overarching uncertainty or inconsistency. CONCLUSIONS: Teenaged African American males have uniquely complex attitudes toward abortion.

Variation in Pregnancy Options Counseling and Referrals, And Reported Proximity to Abortion Services, Among Publicly Funded Family Planning Facilities.

CONTEXT: As frontline providers, publicly funded family planning clinics represent a critical link in the health system for women seeking information about pregnancy options, yet scant information exists on their provision of relevant services. Understanding their practices is important for gauging how well these facilities serve patients' needs. METHODS: A 2012 survey of 567 publicly funded family planning facilities in 16 states gathered information on referral-making for adoption and abortion services, and perceived proximity to abortion services. Chi-square, multivariable logistic regression and multinomial logistic regression analyses were performed to assess differences among facilities in referral-making and reported proximity to abortion services. RESULTS: Abortion referrals were provided by a significantly smaller proportion of providers than were adoption referrals (84% vs. 97%). Health departments and community health centers were significantly less likely than comprehensive reproductive health centers to refer for abortion services and to have a list of abortion providers available (odds ratios, 0.1-0.2). Rural facilities were more likely than urban ones to report a distance of more than 100 miles to the closest first-trimester abortion provider (relative risk ratio, 11.4), second-trimester abortion provider (8.7) and medication abortion provider (8.0). Health departments were more likely than comprehensive reproductive health centers not to know the location of the closest first-trimester, second-trimester or medication abortion provider (2.5-3.5). CONCLUSION: A better understanding of disparities in provision of pregnancy options counseling and referrals at publicly funded family planning clinics is needed to ensure that women get timely care.

The Association of Low Social Support with Breast Milk Expression in Low-Income Mother-Preterm Infant Dyads.

BACKGROUND: Premature infants benefit from receiving expressed breast milk (BM), but expressing breast milk is difficult for new mothers. Little is known about mothers' social support and BM expression during the premature infant's hospital stay. OBJECTIVE: We examined whether low maternal social support was associated with breast milk expression initiation and low breast milk expression among low-income mothers of premature infants. METHODS: Maternal intake interview data and daily infant data on proportion of nutrition from BM during hospitalization were analyzed from a larger randomized trial testing a developmental intervention on 181 mother-premature infant dyads with at least 2 of 10 social-environmental risks. Multivariable modified Poisson regression was used to examine the relationship between social support (Personal Resources Questionnaire 2000; dichotomized as low for lowest quartile), initiation (any breast milk expressed vs none), and low breast milk expression (if BM was < 30% of infant total milk/formula intake during hospitalization). RESULTS: Breast milk expression was initiated by 70.2% of mothers, and 32.3% of those mothers had low breast milk expression. In adjusted multivariable analyses, social support did not relate to the initiation of breast milk expression but was significantly associated with low breast milk expression among mothers who initiated (adjusted relative risk = 1.57; 95% confidence interval, 1.00-2.47). CONCLUSION: Low social support was not associated with initiation but was associated with low breast milk expression during hospitalization. Interventions to enhance social support for mothers of premature infants, especially those reporting low social support from family and friends, may increase in-hospital expression and long-term breastfeeding.

Mother-infant interaction improves with a developmental intervention for mother-preterm infant dyads.

While premature infants have a high need for positive interactions, both infants and their mothers are challenged by the infant's biological immaturity. This randomized clinical trial of 198 premature infants born at 29-34 weeks gestation and their mothers examined the impact of the H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention on mother-premature infant interaction patterns at 6-weeks corrected age (CA). Mothers had at least 2 social environmental risk factors such as minority status or less than high school education. Mother-infant dyads were randomly assigned to the H-HOPE intervention group or an attention control group. H-HOPE is an integrated intervention that included (1) twice-daily infant stimulation using the ATVV (auditory, tactile, visual, and vestibular-rocking stimulation) and (2) four maternal participatory guidance sessions plus two telephone calls by a nurse-community advocate team. Mother-infant interaction was assessed at 6-weeks CA using the Nursing Child Assessment Satellite Training-Feeding Scale (NCAST, 76 items) and the Dyadic Mutuality Code (DMC, 6-item contingency scale during a 5-min play session). NCAST and DMC scores for the Control and H-HOPE groups were compared using t-tests, chi-square tests and multivariable analysis. Compared with the Control group (n = 76), the H-HOPE group (n = 66) had higher overall NCAST scores and higher maternal Social-Emotional Growth Fostering Subscale scores. The H-HOPE group also had significantly higher scores for the overall infant subscale and the Infant Clarity of Cues Subscale (p < 0.05). H-HOPE dyads were also more likely to have high responsiveness during play as measured by the DMC (67.6% versus 58.1% of controls). After adjustment for significant maternal and infant characteristics, H-HOPE dyads had marginally higher scores during feeding on overall mother-infant interaction (ß = 2.03, p = 0.06) and significantly higher scores on the infant subscale (ß = 0.75, p = 0.05) when compared to controls. In the adjusted analysis, H-HOPE dyads had increased odds of high versus low mutual responsiveness during play (OR = 2.37, 95% CI = 0.97, 5.80). Intervening with both mother and infant is a promising approach to help premature infants achieve the social interaction patterns essential for optimal development.