Streamlining Universal Prenatal Screening for Risk for Adverse Birth Outcomes.

OBJECTIVE: Many of the medical risk factors for adverse birth outcomes (e.g., preeclampsia) are regularly monitored in prenatal care. However, many of the psychosocial risk factors associated with adverse birth outcomes (e.g., maternal stress, anxiety, depression, intimate partner violence) are not regularly addressed during routine prenatal care. Comprehensive prenatal screening for psychosocial risk factors for adverse birth outcomes can improve maternal and neonatal outcomes. In this study, we examine an existing tool for opportunities to streamline and improve screening. METHODS: We reviewed medical records for 528 mother-infant dyads, recording maternal responses to a 21-item prenatal risk screening tool, and gestational age/birth weight of infants. Multiple approaches to scoring were used to predict likelihood of adverse birth outcome. RESULTS: Women who answered yes to any of the top four interrelated items were 3.32 times more likely to have an adverse birth outcome. Sensitivity and specificity were 68% and 65%, respectively. CONCLUSION FOR PRACTICE: We identified a short surveillance tool to identify women who are at highest risk and require more in-depth screening, and to rule out women who are at very low risk of an adverse birth outcome.

Variation in Tdap and Influenza Vaccination Coverage Among Pregnant Women by Insurance Type - Florida, 2016-2018.

Infants are at increased risk for pertussis-associated morbidity and mortality, and pregnant women and their infants are more likely than other patient populations to experience severe influenza-related illness (1,2). The Advisory Committee on Immunization Practices (ACIP) recommends that all women receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during each pregnancy, preferably during the early part of gestational weeks 27-36 (3). ACIP also recommends that women who are or might be pregnant during the influenza season receive the inactivated influenza vaccine at any time during pregnancy (4). Despite these recommendations, coverage with Tdap and influenza vaccines during pregnancy has been low, with approximately one half of women receiving each vaccine and only one third receiving both, based on a survey during March-April 2019 (5). Data obtained through a retrospective chart review of randomly selected pregnant women who delivered at the University of Florida Health Shands Hospital in Gainesville, Florida, from January 1, 2016, to December 31, 2018, were analyzed to assess vaccination coverage by insurance type. Because the Florida Medicaid policy at that time did not cover these vaccines during pregnancy, the hospital system offered Tdap and influenza vaccines at no additional cost to mothers during the immediate postpartum hospital stay. Among 341 women, 68.6% of privately insured and 13.4% with Medicaid received Tdap during pregnancy, and among 316 women, 70.4% of privately insured and 35.6% with Medicaid received influenza vaccine during pregnancy. Many women, especially those with Medicaid, were vaccinated in the immediate postpartum period, when vaccination was available at no cost, increasing Tdap vaccination rates to 79.3% for privately insured and 51.7% for women with Medicaid; influenza vaccination rates rose to 72.0% for privately insured and 43.5% for women with Medicaid. These data suggest that the state Medicaid policy to not cover these vaccines during pregnancy might have significantly reduced coverage among its enrollees.

Validation of algorithms to estimate gestational age at birth in the Medicaid Analytic eXtract-Quantifying the misclassification of maternal drug exposure during pregnancy.

PURPOSE: Accurate ascertainment of gestational age (GA) has been a challenge in perinatal epidemiologic research. To date, no study has validated GA algorithms in Medicaid Analytic eXtract (MAX). METHODS: We linked livebirths of mothers enrolled in Medicaid ≥30 days after delivery in 1999-2010 MAX to state birth certificates. We used clinical/obstetric estimate of gestation on the birth certificates as gold standard to validate claims-based GA algorithms. We calculated the proportions of deliveries with algorithm-estimated GA within 1-/2-weeks of the gold standard, the sensitivity, specificity, and positive/negative predictive value (PPV/NPV) of exposure to select medications during specific gestation windows, and quantified the impact of exposure misclassification on hypothetical relative risk (RR) estimates. RESULTS: We linked 1 336 495 eligible deliveries. Within 1-week agreement was 77%-80% overall and 47%-56% for preterm deliveries. The trimester-specific drug exposure status had high sensitivities and PPVs (88.5%-98.5%), and specificities and NPVs (>99.0%). Assuming a hypothetical RR of 2.0, bias associated with exposure misclassification during first trimester ranged from 10% to 40% under non-differential/differential misclassification assumptions. CONCLUSIONS: Claims-based GA algorithms had good agreement with the gold standard overall, but lower agreement among preterm deliveries, potentially resulting in biased risk estimated for pregnancy exposure evaluations.

Usability of encounter data for Medicaid comprehensive managed care vs traditional Medicaid fee-for-service claims among pregnant women.

BACKGROUND: The completeness of medical encounters capture among Medicaid enrollees in comprehensive managed care (CMC) has been shown to vary across states and years. CMC penetration has grown, and CMC encounter capture specific to pregnancy care is understudied. OBJECTIVES: To compare the completeness of encounter data for pregnant beneficiaries in CMC versus traditional fee-for-service (FFS) in Texas and Florida between 2007 and 2010. METHODS: Using Medicaid Analytic eXtract (MAX) data linked to Florida and Texas birth certificate records, for each state and study year, we compared proportions using seven themes: (a) delivery; (b) prenatal visits; (c) dispensed prescriptions during pregnancy; (d) gestational diabetes and blood glucose testing; (e) antidiabetics and diagnosis of diabetes mellitus; (f) antibiotics for urinary tract infection and outpatient encounter; and (g) bacterial vaginosis and dispensing for metronidazole or clindamycin. We considered CMC data to be acceptable if proportions were no less than 10% below the corresponding (2007 to 2010) FFS control values. RESULTS: Pregnancy-related characteristics of FFS vs CMC denominators were comparable. Proportions for the seven measures among FFS controls ranged from 26% to 98%. In Texas, CMC encounter data met the thresholds for all measures between 2007 and 2010. Florida had usable CMC encounter data starting from 2009 with incomplete medical and pharmacy records in 2007 and 2008. CONCLUSIONS: The quality of CMC encounter data in MAX files for pregnant women varied in Florida and Texas and improved over time. Use of pregnancy-specific measures can aid researchers in selecting states and years with acceptable encounter data quality.

Impact of an on-site perinatal mood disorders clinic in the diagnosis and management of perinatal mood disorders.

Objectives To assess change in Edinburgh Postnatal Depression Scale (EPDS) scores in women treated at the Perinatal Mood Disorders Clinic (PMDC) as a measure of improvement in perinatal mood disorders (primary outcome), and treatment disposition at final visit. Methods Chart review was performed for all PMDC patients between March 1, 2017 and June 1, 2018 (n=120), as a self-controlled case series design. Two-tailed t-tests compared initial and final EPDS scores for all patients with >1 visit (n=64), where EPDS score of ≥13 indicated a positive screen for depression. A multivariable linear regression model with robust standard errors estimated the relationship between patient characteristics and final EPDS scores. Results Of 120 patients, n=56 had one visit and n=64 had >1 visit. Of these 64, mean final score (11.04) was lower than mean initial score (16.54; p<0.001). Additionally, certain patient characteristics were associated with higher final EPDS score, including history of mood disorder and treatment with both pharmacotherapy and psychotherapy. Conclusions Women treated at the PMDC showed improved EPDS scores when receiving at least two separate care visits. Therefore, the clinic may be filling a gap in access to timely care for women with perinatal mood disorders.

Assessing the utility of the Healthy Start Screen to predict an elevated Edinburgh Postnatal Depression Scale score.

Objective To examine the utility of the Healthy Start Screen (HSS), which is an assessment of health, environment, and behavioral risk factors offered to all pregnant women in the state of Florida, in identifying women at risk for developing postpartum depression (PPD). Methods The sample for this Institutional Review Board (IRB)-approved, retrospective study consisted of patients who presented to a women's clinic for a new prenatal visit. Those patients who completed both the HSS at their prenatal visit and the Edinburgh Postnatal Depression Scale (EPDS) at their postpartum visit were included. We focused on items 1-10 of the HSS, where patients could respond with either "yes" or "no", and identified a positive EPDS as any score greater than or equal to 12. Results Women who identified as feeling down, depressed or hopeless, feeling alone when facing problems, to having ever received mental health services, or to having any trouble paying bills were more likely to have an EPDS score greater than or equal to 12. Conclusion The HSS, currently mandated by the state of Florida to be offered to all pregnant women, is a useful tool for identifying women at increased risk of developing PPD.

Increased Tdap and Influenza Vaccination Acquisition Among Patients Participating in Group Prenatal Care.

CenteringPregnancy, an alternative to traditional prenatal care, offers additional time between clinicians and patients with the goal of increasing knowledge, understanding, and autonomy in pregnant participants. We investigated whether these women would be more likely to receive recommended Tdap and influenza vaccinations relative to others who received one-on-one traditional prenatal care. Our study employed a retrospective chart review of all women who participated in CenteringPregnancy group care compared to a group of matched women who received only traditional prenatal care at a large, quaternary care referral academic center. We extracted demographic and clinical characteristics from charts that included maternal age during pregnancy care and parity. Outcome variables of interest were influenza and Tdap vaccination status. Compared with traditional obstetrical care patients, women who participated in CenteringPregnancy were 1.7-2.7 times more likely to obtain the Tdap and influenza vaccines. These findings may be attributable to the increased opportunity for patient education and social support offered by the CenteringPregnancy model.

Case-based care for pre-existing or new-onset mood disorders in patients undergoing infertility therapy.

The inability to conceive is an immensely stressful event in a woman's life. Thus, it is no surprise that women with infertility have twice the rates of depressive symptoms as women without infertility. Incidence of depression in the general female population is approximately 20% compared to almost 40% in infertile females. Based on this information, we expect many individuals with infertility to have pre-existing mood disorders requiring ongoing treatment. In addition, we expect a subset of women to develop a mood disorder during infertility treatment due to related stressors. The reproductive endocrinology team must understand the impact of stress on pregnancy outcomes, the types of treatment options, and the safety and use of various medications. The goal of this case-based commentary is to summarize information on the relationship between stress and infertility and to offer a guide for a range of treatment options that include non-pharmacologic and pharmacologic therapies.

The effects of air pollution on adverse birth outcomes.

BACKGROUND: Air pollution has been shown to have adverse effects on many health outcomes including cardiorespiratory diseases and cancer. However, evidence on the effects of prenatal exposure is still limited. The purpose of this retrospective cohort study is to evaluate the effects of prenatal exposure to air pollutants including particulate matter with aerodynamic diameter less than 2.5 µm (PM2.5) and ozone (O3) on the risk of adverse birth outcomes (ABOs) including term low birth weight (LBW), preterm delivery (PTD) and very PTD (VPTD). METHODS: singleton births from 2004 to 2005 in Florida were included in the study (N=423,719). Trimester-specific exposures to O3 and PM2.5 at maternal residence at delivery were estimated using the National Environmental Public Health Tracking Network data, which were interpolated using Hierarchical Bayesian models. RESULTS: After adjustment for potential confounders such as demographics, medical and lifestyle factors PM2.5 exposures in all trimesters were found to be significantly and positively associated with the risk of all ABOs. Second-trimester exposure had the strongest effects. For an interquartile range (IQR) increase in PM2.5 during the second trimester, the risk of term LBW, PTD and VPTD increased by 3% [95% confidence interval (CI): 1-6%)], 12% (11-14%) and 22% (18-25%), respectively. O3 was also found to be positively associated with PTD and VPTD with the strongest effects over the whole pregnancy period [3% (1-5%) for PTD and 13% (7-19%) for VPTD for each IQR increase]. However, O3 was observed to have protective effects on term LBW. Results were consistent for multi-pollutant models. CONCLUSION: PM2.5 has consistent adverse effects on ABOs whereas O3 has inconsistent effects. These findings warrant further investigation.

An external exposome-wide association study of opioid use disorder diagnosed during pregnancy in Florida.

The prevalence of opioid use disorder (OUD) during pregnancy has quadrupled in recent years and widely varies geographically in the US. However, few studies have examined which environmental factors are associated with OUD during pregnancy. We conducted an external exposome-wide association study (ExWAS) to investigate the associations between external environmental factors and OUD diagnosed during pregnancy. Data were obtained from a unique, statewide database in Florida comprising linked individual-level birth and electronic health records. A total of 255,228 pregnancies with conception dates between 2012 and 2016 were included. We examined 82 exposome measures characterizing seven aspects of the built and social environment and spatiotemporally linked them to each individual record. A two-phase procedure was utilized for the external ExWAS. In Phase 1, we randomly divided the data into a discovery set (50 %) and a replication set (50 %). Associations between exposome measures (normalized and standardized) and OUD initially diagnosed during pregnancy were examined using logistic regression. A total of 15 variables were significant in both the discovery and replication sets. In Phase 2, multivariable logistic regression was used to fit all variables selected from Phase 1. Measures of walkability (the national walkability index, OR: 1.23, 95 % CI: 1.17, 1.29), vacant land (the percent vacant land for 36 months or longer, OR: 1.06, 95 % CI: 1.00, 1.12) and food access (the percentage of low food access population that are seniors at 1/2 mile, OR: 1.47, 95 % CI: 1.38, 1.57) were each associated with diagnosis of OUD during pregnancy. This is the first external ExWAS of OUD during pregnancy, and the results suggest that low food access, high walkability, and high vacant land in under-resourced neighborhoods are associated with diagnosis of OUD during pregnancy. These findings could help develop complementary tools for universal screening for substance use and provide direction for future studies.

Obstetrician-gynecologist perceptions and utilization of prescription drug monitoring programs: A survey study.

ABSTRACT: Query of Prescription Drug Monitoring Programs (PDMPs) is recommended before prescribing opioids by the US Centers for Disease Control and Prevention, to inform clinical practice and aid diversion prevention. Many states mandate prescriber PDMP use; however, little is known about PDMP perception of utility and use among Obstetricians-Gynecologists (OB/GYN), who are the primary provider for most women during pregnancy.This study examined OB/GYN perceptions and utilization of their state PDMP.Survey items were developed by expert consensus. A voluntary anonymous survey was emailed to a random sample of 5000 OB/GYNs (adjusted participants n = 1470, minus unread/refusals). Responses were stratified by state policy environment, where response frequency distributions were compared for OB/GYNs practicing in states with mandatory vs voluntary PDMP query.Adjusted response rate was 27% (n = 397). Most OB/GYNs (78%) were registered with their PDMP. The majority agreed that "…mandating physician use of the PDMP was a good idea" (51.4% mandatory state vs 58.3% voluntary state). Respondents in mandatory states reported that the primary purpose of the PDMP was "to allow the physician to verify medications that the patient is being prescribed" less frequently than those in voluntary states (38.3% vs 52.8%). Several report speaking with patients about controlled substance prescriptions after viewing PDMP reports (27.8% in mandatory vs 26.3% in voluntary states). In qualitative responses, reported frustration with PDMPs was evident.OB/GYNs are diverse in their perceptions regarding the utility and purpose of PDMPs. Tailored education is needed regarding clinical utility of PDMPs for OB/GYN practice.

A survey assessment of clinician perceptions of opioid supply and monitoring requirement policy changes.

OBJECTIVE: Florida-mandated Prescription Drug Monitoring Program (PDMP) use and restricted Schedule II opioid dispensing for acute pain to 3-day supply in 2018. This study assessed physician perception of these policies. DESIGN: A cross-sectional study design. SETTING: Large academic medical center. PATIENTS/PARTICIPANTS: Physicians in inpatient and outpatient practice, as stratified by physician specialty for psychiatry or addiction medicine (Psych/AM), primary care, and others. INTERVENTIONS: A survey was administered electronically from July to September 2019, with survey items adapted from published opioid policy evaluations. MAIN OUTCOME MEASURE: Assessment of physician reason for the use of PDMP and perception of PDMP clinical utility. Responses by specialty were compared via chi square testing. RESULTS: There were N = 214 responses (response rate ~10.9 percent), representing n = 15 from Psych/AM, n = 58 primary care, and n = 143 from other specialties. The most frequently reported reason for PDMP use across specialties was to examine prescribing history for patients currently using opioid analgesics (6.7 percent Psych/AM; 50.1 percent primary care; 38.6 percent others; p = 0.027). Fewer Psych/AM physicians agreed that the policy hinders the clinical work day as compared with primary care physicians (46.7 percent vs. 58.6 percent). More primary care agreed the policy was a good idea relative to Psych/AM (62.1 percent vs. 53.3 percent). More primary care than Psych/AMs agreed that the policy made it more challenging for chronic pain patients to access opioid therapies (77.6 percent vs. 53.3 percent). CONCLUSIONS: The perceived workflow burden and unintended consequence of decreased chronic pain patient access to opioid pharmacotherapies suggest further opportunities for pharmacist-physician collaboration in managing affected patients.

Preventing Traumatic Causes of Maternal Death.

Despite medical advances, maternal deaths in the U.S. are more common than in nearly all other developed nations. In addition, racial disparities have continued to widen. Driving our rates are maternal deaths from trauma such as homicide, suicide, and drug overdose. Here we discuss limitations of existing practices in prenatal and postpartum care in preventing maternal deaths. We then outline three simple yet novel strategies for changing care to prevent traumatic cases of maternal mortality.

Factors associated with opioid prescriptions among women proximal to pregnancy in the United States.

BACKGROUND: Pregnant women are a vulnerable population exposed to opioids in the United States. OBJECTIVE: To examine trends and factors associated with opioid prescribing to women proximal to pregnancy. METHODS: The 2011 to 2015 Medical Expenditure Panel Survey (MEPS) was used to identify participants (n = 3020) with self-reported pregnancy or pregnancy-relevant events aged between 18 and 44 years old. To investigate factors associated with opioid prescriptions, we categorized participants into two subgroups: having one or more opioid prescription or having none during the observational period. We used survey multivariable logistic regression to identify factors associated with opioid prescribing accounting for the complex survey design in MEPS. RESULTS: From 2011 to 2015, the prevalence of opioid prescribing among study participants was 31%. Opioids were more likely to be prescribed to women who had psychiatric conditions (odds ratio, 1,76, 95%CI: 1.27-2.44, p < 0.001). Other significant factors included being non-Hispanic white or black, living in the South, active tobacco users, and those with lower Physical Component Summary Scores. CONCLUSION: Receipt of an opioid prescription in the perinatal period is associated with maternal psychiatric disorders in the United States. Study findings add new data to the literature on opioid use among pregnant women and provide evidence for healthcare providers and policy makers to tailor treatment and educational programs to avoid opioid overuse among pregnant women.

OB/GYN perceptions of prescription drug monitoring programs as a primary prevention tool for neonatal abstinence syndrome.

BACKGROUND: The U.S. Centers for Disease Control and Prevention recommend clinicians use Prescription Drug Monitoring Program (PDMPs) as a risk assessment tool for opioid-related harms. This survey assessed perceptions of PDMPs for the purpose of Neonatal Abstinence Syndrome (NAS) prevention among a national sample of obstetricians-gynecologists (OB/GYNs) who are the primary care providers for most pregnancies. METHODS: A survey was emailed to a random sample of active American College of Obstetricians and Gynecologists (ACOG) members. Proxy data for the intensity of the opioid epidemic and state policies related to NAS were added to respondents survey answers. Chi-squared analyses were used to compare response frequencies. RESULTS: Among 397 submitted responses, nearly 70% identified PDMPs having a role in preventing diversion and opioid use disorders but only 25.1% identified PDMPs as a tool to prevent NAS. States with stricter NAS policies (e.g. child abuse, mandatory testing) generally had higher positive responses for PDMPs' role in preventing NAS. States with voluntary PDMP use versus mandatory reported higher positive responses for PDMPs with NAS but differences were not statistically significant (30.6% vs. 23.8%, p = 0.374). State-specific measures of the overall intensity of the opioid epidemic were not associated with perceptions of PDMP. CONCLUSIONS: OB/GYNs do not associate PDMPs as a primary prevention tool against NAS despite endorsements. Tailored educational interventions to this practice environment are needed. Pharmacist engagement with pregnant patients and as champions of PDMP usage may help fill these gaps.

Perception of prescription drug monitoring programs as a prevention tool in primary medical care.

BACKGROUND: Prescription drug monitoring programs (PDMPs) are primary prevention tools to reduce substance use disorders (SUD) and sequelae. Evidence regarding perceptions of PDMPs from different primary care providers, which may impact PDMP utilization for women, is unavailable. OBJECTIVE: To examine perceived PDMP effectiveness among obstetrician-gynecologists (OB/GYNs) compared to primary care physicians (PCPs). METHODS: Independent surveys of PDMP users in Florida, Kentucky, and California were evaluated based on a Likert-type item to assess perception of PDMP effectiveness in reducing prescription drug abuse and diversion. Response distributions of OB/GYNs versus PCPs were compared using chi-square tests. RESULTS: In Florida, there were 41 OB/GYN and 511 PCP respondents; Kentucky, 46 OB/GYNs and 265 PCPs; and California, 41 OB/GYNs and 162 PCPs. In each state OB/GYNs viewed PDMPs as less effective, positive, or useful compared to PCPs (p ≤ 0.01, all states): Florida: 64.1% OB/GYN vs. 83.7% PCP "agree positive impact"; Kentucky: 45.0% OB/GYN vs. 68.5% PCP "effective". California: 73.2% OB/GYN vs. 86.4% PCP "useful". CONCLUSIONS: These results suggest OB/GYNs view their state's PDMP as less effective than do PCPs, which may present barriers to PDMP utilization and decrease opportunities for SUD interventions. Engagement of all healthcare team members is needed to inform future strategies and policies to increase PDMP effectiveness.