Examining the quality of care across the continuum of maternal care (antenatal, perinatal and postnatal care) under the expanded free maternity policy (Linda Mama Policy) in Kenya: a mixed-methods study.

BACKGROUND: Kenya still faces the challenge of mothers and neonates dying from preventable pregnancy-related complications. The free maternity policy (FMP), implemented in 2013 and expanded in 2017 (Linda Mama Policy (LMP)), sought to address this challenge. This study examines the quality of care (QoC) across the continuum of maternal care under the LMP in Kenya. METHODS: We conducted a convergent parallel mixed-methods study across multiple levels of the Kenyan health system, involving key informant interviews with national stakeholders (n=15), in-depth interviews with county officials and healthcare workers (HCWs) (n=21), exit interview survey with mothers (n=553) who utilised the LMP delivery services, and focus group discussions (n=9) with mothers who returned for postnatal visits (at 6, 10 and 14 weeks). Quantitative data were analysed descriptively, while qualitative data were analysed thematically. All the data were triangulated at the analysis and discussion stage using a framework approach guided by the QoC for maternal and newborns. RESULTS: The results showed that the expanded FMP enhanced maternal care access: geographical, financial and service utilisation. However, the facilities and HCWs bore the brunt of the increased workload and burnout. There was a longer waiting time for the initial visit by the pregnant women because of the enhanced antenatal care package of the LMP. The availability and standards of equipment, supplies and infrastructure still posed challenges. Nurses were multitasking and motivated despite the human resources challenge. Mothers were happy to have received care information; however, there were challenges regarding respect and dignity they received (inadequate food, over-crowding, bed-sharing and lack of privacy), and they experienced physical, verbal and emotional abuse and a lack of attention/care. CONCLUSIONS: Addressing the negative aspects of QoC while strengthening the positives is necessary to achieve the Universal Health Coverage goals through better quality service for every woman.

Asistencia del recién nacido con hernia diafragmática congénita / Care of newborns with congenital diaphragmatic hernia / Cuidados ao recém-nascido com hérnia diafragmática congênita

La hernia diafragmática congénita es un defecto en el diafragma que lleva a la herniación del contenido abdominal a la cavidad torácica durante el período intrauterino. La morbimortalidad está determinada por la asociación con otras malformaciones, el grado de hipoplasia pulmonar y la presencia de hipertensión pulmonar secundaria. Presenta una incidencia estimada de 1 cada 2.500-3.000 recién nacidos vivos, constituyendo en un 60% una malformación aislada. Es una patología evolutiva que puede ser diagnosticada a partir de la semana 20-24, la ubicación más habitual es la posterolateral izquierda. Se trata de una patología que requiere ingreso a cuidados intensivos al nacimiento y luego de lograda la estabilización del paciente es de sanción quirúrgica. Los objetivos de este trabajo son conocer las características generales de la patología para sistematizar el manejo logrando así un óptimo asesoramiento de los padres a nivel prenatal y seguimiento postnatal del recién nacido.

Congenital diaphragmatic hernia is a defect in the diaphragm that leads to herniation of theabdominal contents of the thoracic cavity during the intrauterine period. Morbidity and mortality are determined by the association with other malformations, the degree ofpulmonary hypoplasia and the presence of secondary pulmonary hypertension.It has an estimated incidence of 1 every 2,500-3,000 live newborns, and in 60% of the cases it is an isolated malformation. It is an evolutionary pathology that can be diagnosed from week 20-24; it is most commonly located in the left posterolateral. It is a pathology that requires intensive care at birth and after delivery and once the patient has been stabilized, surgical action is required. The objectives of this work are to understand the general characteristics of the pathology in order to refine its manipulation and achieve optimal counseling for parents at the newborn's prenatal and postnatal stages.

A hérnia diafragmática congênita é um defeito no diafragma que leva à herniação doconteúdo abdominal para a cavidade torácica durante o período intrauterino. A morbimortalidade é determinada pela associação com outras malformações, pelo grau de hipoplasia pulmonar e pela presença de hipertensão pulmonar secundária. Apresenta uma incidência estimada de 1 a cada 2.500-3.000 nascidos vivos, constituindo-se em 60% uma malformação isolada. É uma patologia evolutiva que pode ser diagnosticada a partir da semana 20-24 e a localização mais comum é o póstero-lateral esquerdo. É uma patologia que requer internação em terapia intensiva ao nascimento e após o parto. Uma vez que o paciente for estabilizado, é necessária ação cirúrgica. Os objetivos deste paper são conhecer as características gerais da patologia para melhorar o seu manejo, obtendo assim um aconselhamento ideal para os pais no nível pré-natal e no acompanhamento do crescimento pós-natal do recém-nascido.

Association of Insurance Status With Provision of Recommended Services During Comprehensive Postpartum Visits.

Importance: Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits. Objective: To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type. Design, Setting, and Participants: This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020. Exposures: Visit paid by Medicaid vs other payment types. Main Outcomes and Measures: Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use. Results: A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02). Conclusions and Relevance: These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

Evaluation of an Inpatient Postpartum Human Papillomavirus Immunization Program.

OBJECTIVE: To evaluate the result of an inpatient postpartum human papillomavirus (HPV) immunization pilot program in a diverse, low-income patient population from an urban, hospital-based obstetrics and gynecology clinic. METHODS: In this cohort study, we present results from the first 2 years of the inpatient postpartum HPV immunization program, in which vaccine-eligible postpartum women were identified and immunized during their hospital stays. The program was implemented after educational outreach with prenatal and postpartum clinicians and nurses. Associations between receipt of the HPV vaccine as an inpatient and the characteristics of patients, and the likelihood of and missed opportunities for receiving a subsequent dose of the HPV vaccine as an outpatient were determined using logistic regression, time-to-event analyses, chi-squared tests and t-tests. RESULTS: From April 11, 2017, to April 10, 2019, 394 (59.2%) of 666 postpartum women were eligible for the inpatient postpartum HPV immunization program. The majority (265/394, 67.3%) received the immunization pilot program HPV dose; 36 of those 265 (13.6%) completed the series with that dose. Among women due for additional doses after hospital discharge, those who received the inpatient dose were more likely to receive a subsequent outpatient dose (138/229) than were those who did not receive an inpatient dose (39/129; hazard ratio 2.51, 95% CI 1.76-3.58). On average, there were 30.7 fewer (95% CI 5.8-55.6, P<.02) missed opportunities for subsequent outpatient doses for every 100 eligible visits among women who received the inpatient dose, compared with women who did not. By the end of the study, the proportion of women who had completed the vaccine series was higher among women who received the inpatient dose (95/265, 35.8%) than in those who did not (12 out 129, 9.3%; odds ratio 5.45, 95% CI 2.86-10.38). CONCLUSION: The inpatient postpartum HPV immunization program was associated with increased rates of immunization and addressed a previously missed opportunity. Inpatient immunization programs can serve as a critical way to address gaps in vaccine uptake.

Development and Implementation of a Postpartum Depression Screening Program in the NICU.

Postpartum depression (PPD) is higher among NICU mothers compared to mothers without infants in the NICU. Routine screening improves early PPD identification and treatment for mothers. Key national women and infant organizations endorse facility-based policies that address PPD screening. In addition to PPD screening, the key national organizations recommend facilities providing care to women and infants develop a method of referral for maternal PPD evaluation, treatment, and follow-up. Due to the timing, onset, and maternal predisposition to PPD, the NICU is a prime setting for PPD screening. Despite recommendations, PPD screening is not routine in the NICU. This article describes the development and assessment of a PPD screening program implemented in the NICU. Data analysis of 30 NICU mothers evaluated the risk of PPD based on screening tool scores, maternal diagnostic evaluation compliance, and documentation of maternal follow-up with designated NICU staff.

Perineorrhaphy Compared With Pelvic Floor Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree Perineal Tear: A Randomized Controlled Trial.

OBJECTIVE: To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree obstetric injury diagnosed at least 6 months postpartum. METHODS: We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited. RESULTS: From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% [95% CI 42-78%], odds ratio 19 [95% CI 5-69]). The surgery group was superior to physical therapy regarding all secondary endpoints. CONCLUSION: Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02545218.

Thyroid nodules and cancer during pregnancy, post-partum and preconception planning: Addressing the uncertainties and challenges.

Thyroid nodules and thyroid cancer have become increasingly common worldwide. When discovered during pregnancy, they pose unique diagnostic and therapeutic challenges for both the treating physician and the patient. The benefits of treatment should be carefully weighed against risks that may adversely impact maternal and fetal health. In this review, we present current knowledge and controversies surrounding the management of thyroid nodules and thyroid cancer in pregnancy, in the post-partum period and during preconception planning.

Outcomes of hypoplastic left heart syndrome and fetal aortic valvuloplasty in a country with suboptimal postnatal management.

BACKGROUND: Fetal aortic stenosis (AoS) may progress to hypoplastic left heart syndrome (HLHS) in utero. There are currently no data, prenatal or postnatal, describing survival of fetuses or neonates with AoS or HLHS in a country with suboptimal postnatal management. STUDY DESIGN: Prospective cohort study performed in Mexico, including cases diagnosed with AoS and HLHS within a 6-year period. AoS patients fulfilling previously published criteria for evolving HLHS (eHLHS) were offered fetal aortic valvuloplasty. Outcome variables were perinatal mortality, postnatal management, type of postnatal circulation, and overall survival. RESULTS: Fifty-four patients were included: 16 AoS and 38 HLHS. Eighteen patients had associated anomalies and/or an abnormal karyotype. Seventy-four percent of HLHS received comfort measures, with only three cases reporting an attempt at surgical palliation, and one survivor of the first stage. Fetal aortic valvuloplasty was performed successfully in nine cases of eHLHS. Overall postnatal survival was 44% in AoS with fetal aortic valvuloplasty, and one case (ongoing) in the HLHS group. CONCLUSIONS: HLHS in Mexico carries more than a 95% risk of postnatal death, with little or no experience at surgical palliation in most centers. Fetal aortic valvuloplasty in AoS may prevent progression to HLHS and in this small cohort was associated with ≈50% survival.

Fetal endoscopic tracheal occlusion reduces pulmonary hypertension in severe congenital diaphragmatic hernia.

OBJECTIVE: Fetal endoscopic tracheal occlusion (FETO) is associated with increased perinatal survival and reduced need for extracorporeal membrane oxygenation (ECMO) in fetuses with severe congenital diaphragmatic hernia (CDH). This study evaluates the impact of FETO on the resolution of pulmonary hypertension (PH) in fetuses with isolated CDH. METHODS: We reviewed retrospectively the medical records of all fetuses evaluated for CDH between January 2004 and July 2017 at a single institution. Fetuses with additional major structural or chromosomal abnormalities were excluded. CDH cases were classified retrospectively into mild, moderate and severe groups based on prenatal magnetic resonance imaging indices (observed-to-expected total fetal lung volume and percentage of intrathoracic liver herniation). Presence of PH was determined based on postnatal echocardiograms. Logistic regression analyses were performed to evaluate the relationship between FETO and resolution of PH by 1 year of age while controlling for side of the CDH, use of ECMO, gestational age at diagnosis, gestational age at delivery, fetal gender, sildenafil use at discharge and CDH severity. Resolution of PH by 1 year of age was compared between a cohort of fetuses with severe CDH that underwent FETO and a cohort that did not have the procedure (non-FETO). A subanalysis was performed restricting the analysis to isolated left CDH. Parametric and non-parametric tests were used for comparisons. RESULTS: Of 257 CDH cases evaluated, 72% (n = 184) had no major structural or chromosomal anomalies of which 58% (n = 107) met the study inclusion criteria. The FETO cohort consisted of 19 CDH cases and the non-FETO cohort (n = 88) consisted of 31 (35%) mild, 32 (36%) moderate and 25 (28%) severe CDH cases. All infants with severe CDH, regardless of whether they underwent FETO, had evidence of neonatal PH. FETO (OR, 3.57; 95% CI, 1.05-12.10; P = 0.041) and ECMO (OR, 5.01; 95% CI, 2.10-11.96; P < 0.001) were independent predictors of resolution of PH by 1 year of age. A higher proportion of infants with severe CDH that underwent FETO had resolution of PH by 1 year after birth compared with infants with severe CDH in the non-FETO cohort (69% (11/16) vs 28% (7/25); P = 0.017). Similar results were observed when the analysis was restricted to cases with left-sided CDH (PH resolution in 69% (11/16) vs 28% (5/18); P = 0.032). CONCLUSION: In infants with severe CDH, FETO and ECMO are independently associated with increased resolution of PH by 1 year of age. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Psychometric properties of the hospital birth satisfaction scale: Birth in Brazil survey / Propriedades psicométricas da escala de satisfação com a assistência hospitalar no parto: estudo Nascer no Brasil / Propiedades psicométricas de la escala de satisfacción sobre cuidados hospitalarios durante el parto: encuesta Nacer en Brasil

The objective of this study was to analyze the psychometric properties of the hospital birth satisfaction scale with data from the first follow-up interview of the Birth in Brazil survey. The 11 questions of the scale were asked by telephone up to six months after discharge in a stratified random sample of 16,109 women residing in all five regions of the country. The sample was randomly divided into two halves. Exploratory factor analysis (EFA) was applied to the first half in order to identify the scale's factorial structure. The scree plot suggested the scale to be one-dimensional. The EFA demonstrated a good fit of the one-dimensional model. Factor loadings were greater than 0.5 for all items, except for the mean time transpired between leaving the home and arriving at the maternity hospital, which was excluded from the next analysis. The confirmatory factor analysis applied to the sample's second half with the remaining ten items had a good fit and the factor loadings were > 0.50 with p-values < 0.001. The associations between birth satisfaction and the external variables, the mother's education level (standardized coefficient = 0.073; p = 0.035), private insurance (SC = 0.183; p < 0.001) and having a companion at some point during the hospitalization for labor (SC = 0.193; p = 0.001) were all as expected. There was evidence of configural and metric invariance according to type of hospital (private or public) and type of delivery (cesarean or vaginal). These results showed that the hospital birth satisfaction scale in Brazil is a one-dimensional instrument composed of ten items.

O estudo teve como objetivo analisar as propriedades psicométricas da escala de satisfação com a assistência hospitalar no parto, a partir dos dados da primeira entrevista de seguimento do estudo Nascer no Brasil. As 11 perguntas da escala foram endereçadas via telefone dentro de seis meses depois da alta hospitalar em uma amostra aleatória estratificada de 16.109 mulheres residentes nas cinco macrorregiões brasileiras. A amostra foi dividida aleatoriamente em duas metades. Na primeira metade, foi realizada análise fatorial exploratória (AFE) para identificar a estrutura fatorial da escala. O gráfico de declividade sugeriu que a escala era unidimensional. A AFE demonstrou bom ajuste do modelo unidimensional. As cargas fatoriais foram maiores de 0,50 para todos os itens, exceto para o tempo médio de viagem da residência da parturiente até a maternidade, que foi excluído da análise subsequente. A análise fatorial confirmatória realizada com os dez itens remanescentes na segunda metade da amostra mostrou bom ajuste, com cargas fatoriais > 0,50 e valores de p < 0,001. As associações entre a satisfação com a assistência hospitalar no parto e as variáveis externas de escolaridade materna (coeficiente padronizado = 0,073; p = 0,035), plano de saúde privado (CP = 0,183; p < 0,001) e ter acompanhante em algum momento durante a internação para o parto (CP = 0,193; p = 0,001) foram na direção esperada. Houve evidências de invariância configural e métrica de acordo com o tipo de hospital (privado vs. público) e tipo de parto (cesáreo vs. vaginal). Os resultados mostram que a escala de satisfação com a assistência hospitalar no parto no Brasil é um instrumento unidimensional constituído de dez itens.

El objetivo de este estudio fue analizar las propiedades psicométricas de la escala de satisfacción sobre cuidados hospitalarios durante el parto, con datos procedentes de la primera entrevista de seguimiento, pertenecientes a la encuesta Nacer en Brasil. Se hicieron 11 preguntas de esta escala por teléfono hasta seis meses después del parto, mediante un muestreo aleatorio estratificado a 16.109 mujeres, residentes en las cinco regiones del país. Se dividió el mismo aleatoriamente en dos mitades. En la primera, se realizó un análisis factorial exploratorio (AFE) para identificar la estructura factorial de la escala. El gráfico de sedimentación indicó que la escala era unidimensional. El AFE demostró un buen ajuste al modelo unidimensional. Las cargas factoriales fueron superiores al 0,5 en todos los ítems, excepto en el tiempo empleado en ir de casa al hospital materno-infantil, que se excluyó del siguiente análisis. En la segunda mitad de la muestra se realizó un análisis factorial confirmatorio con los diez ítems restantes que tuvo un buen ajuste y cuyas cargas factoriales fueron > 0,50 con p-valor < 0,001. Las asociaciones entre la satisfacción con los cuidados hospitalarios recibidos para el parto, las variables externas, escolaridad maternal (coeficiente estandarizado = 0,073; p = 0,035), seguro privado (CE = 0,183; p < 0,001) y contar con pareja en algún momento durante la hospitalización para el parto (CE = 0,193; p = 0,001), estuvieron en línea con lo esperado. Hubo evidencia de invarianza métrica y de configuración, según el tipo de hospital (privado o público), y tipo de parto (cesárea o vaginal). Estos resultados mostraron que la escala de satisfacción sobre cuidados hospitalarios durante el parto en Brasil es un instrumento unidimensional compuesto de diez ítems.

Cuidados del recién nacido en la sala de partos / Care of the newborn in the delivery room

El nacimiento de un niño es uno de los momentos más maravillosos de la vida. Pocas experiencias pueden compararse con este suceso. Los recién nacidos tienen capacidades sorprendentes y, sin embargo, dependen por completo de los demás en todos los aspectos: alimentación, calor y bienestar. Si existen señales que indican que hay algún problema, puede administrarse el tratamiento indicado en la sala de partos misma. El médico o la partera y otros miembros del equipo del cuidado de la salud trabajan juntos para ayudar a que el bebé elimine el exceso de fluido y comience a respirar. El objetivo general de este trabajo es conocer el estado actual de la producción científica enfermera sobre los cuidados de enfermería al Recién Nacido en la sala de partos. Se ha realizado una búsqueda bibliográfica de la producción científica enfermera hasta el momento actual en las siguientes bases de datos: Cuiden, Pubmed y Liliacs. Un adecuado Plan de Cuidados de Enfermería al Recién Nacido en la Sala de Partos deberá ir encaminado a Secar, estimular y reposicionar, colocar piel con piel con la madre si es posible, cuidados del cordón umbilical y la placenta.

The birth of a child is one of the most wonderful moments of life. Few experiences can be compared with this event. Newborns have surprising abilities and, nevertheless, depend completely on others in all aspects: food, heat and well-being. If there are signs indicating that there is a problem, the treatment indicated in the delivery room itself can be administered. The doctor or midwife and other members of the health care team work together to help the baby remove excess fluid and start breathing. The general objective of this work is to know the current state of nursing scientific production on nursing care for the Newborn in the delivery room. A bibliographic search of nursing scientific production has been carried out up to the present time in the following databases: Cuiden, Pubmed and Liliacs. An adequate Nursing Care Plan for the Newborn in the Delivery Room should be aimed at drying, stimulating and repositioning, placing skin with skin with the mother if possible, care of the umbilical cord and the placenta.

European guidelines on perioperative venous thromboembolism prophylaxis: Surgery during pregnancy and the immediate postpartum period.

: Thromboembolic events in the pregnant and postpartum patient remain rare but potentially fatal complications. The aim of this section was to analyse the few prospective studies addressing the issue of thromboprophylaxis following a surgical procedure during and immediately after pregnancy, as well as national guidelines, and to propose European guidelines on this specific condition. Thromboprophylaxis is broadly recommended due to the combined risks of surgery and pregnancy or the postpartum period, regardless of the mode of delivery. We recommend prophylactic thromboprophylaxis following surgery during pregnancy or the postpartum period when they imply, as a consequence, bed rest, until full mobility is recovered (Grade 1C). Similarly, thromboprophylaxis should be used in cases of perioperative infection during pregnancy or the postpartum period. Concerning thromboprophylaxis following a caesarean section, it seems avoidable only in elective procedures in low-risk patients, after a normal pregnancy, and with an early rehabilitation protocol. The duration of thromboprophylaxis following caesarean section should be at least 6 weeks for high-risk patients, and at least 7 days for the other patients requiring anticoagulation (Grade 1C).

Using a Patient Navigator to Improve Postpartum Care in an Urban Women's Health Clinic.

OBJECTIVE: To estimate whether postpartum visit attendance was improved in women exposed to a postpartum patient navigation program compared with those who received care immediately before the program's initiation and to assess whether other postpartum health behaviors improved during the intervention period. METHODS: This is a prospective observational study of women enrolled in a patient navigation program compared with women receiving care before the program. Navigating New Motherhood was a postpartum patient navigation program for adult, English-speaking women receiving prenatal care at a Medicaid-based university clinic. In 2015, Navigating New Motherhood introduced a clinic-level change in which a navigator was hired and assumed supportive and logistic responsibilities for enrolled patients between delivery and postpartum visit completion. We compared medical record data from women who enrolled in Navigating New Motherhood with those of women receiving care in the same clinic for 1 year immediately before Navigating New Motherhood. The primary outcome was postpartum visit attendance. Secondary outcomes included World Health Organization (WHO) Tier 1 or 2 contraception uptake and other health services measures. We conducted bivariable and multivariable analyses. RESULTS: Of the 225 women approached for Navigating New Motherhood participation after program initiation, 96.9% (n=218) enrolled; these women were compared with 256 women in the historical cohort. Most women in both groups were racial or ethnic minorities and all had Medicaid insurance. There were no important differences in demographic, clinical, or health service characteristics between groups, although women in Navigating New Motherhood were more likely to transfer into the clinic for prenatal care and to deliver neonates admitted to the neonatal intensive care unit. The primary outcome, return for postpartum care, was more common among women in Navigating New Motherhood (88.1% compared with 70.3%, P<.001), a difference that persisted after adjustment for potential confounding factors (adjusted odds ratio [OR] 3.57, 95% confidence interval [CI] 2.11-6.04). Women in Navigating New Motherhood also were more likely to receive a WHO Tier 1 or 2 contraceptive method (adjusted OR 1.56, 95% CI 1.02-2.38), postpartum depression screening (adjusted OR 2.82, 95% CI 1.79-4.43), and influenza (adjusted OR 2.10, 95% CI 1.38-3.19) and human papillomavirus vaccination (adjusted OR 2.33, 95% CI 1.25-4.33). CONCLUSION: Implementation of a postpartum navigation program was associated with improved retention in routine postpartum care and frequency of contraception uptake, depression screening, and vaccination.

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews.

BACKGROUND: The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting. METHODS: Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS). RESULTS: Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate. CONCLUSIONS: Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.

Implementation of Routine Postpartum Depression Screening and Care Initiation Across a Multispecialty Health Care Organization: An 18-Month Retrospective Analysis.

Objectives Postpartum depression (PPD) affects approximately 10-20% of all mothers after giving birth. Adequate screening and follow-up care for the postpartum mother with depression is an essential component of quality care in this population. The purpose of this quality improvement project was to evaluate the quality and quantity of a postnatal PPD screening program and the subsequent initiation of needed PPD treatment in an integrated health system. Methods After implementing a standardized PPD screening process, we conducted an 18-month retrospective study of patient visits that required a PPD screen. Data were abstracted from medical records and analyzed to determine if postnatal PPD screening occurred, what quality of the screening was, and what follow-up measures were taken. Results Within the study timeframe, 28,389 postpartum and well-child visits were eligible for PPD screening. PPD screening occurred at 88% of eligible visits for approximately 5000 unique women. PPD was identified in 8.1% of screened women. Conclusions Of women with PPD, at least 44.8% were prescribed an SSRI and 21.4% attended a visit with a mental health professional, which is consistent with other studies. Screening can be successful through collaboration, although ongoing evaluation and process modification are necessary.

Antenatal care strengthening for improved health behaviours in Jimma, Ethiopia, 2009-2011: An effectiveness study.

INTRODUCTION: health systems in low-income settings are not sufficiently reaching the poor, and global disparities in reproductive health persist. The frequency and quality of health education during antenatal care is often low. Further studies are needed on how to improve the performance of health systems in low income settings to improve maternal and child health. OBJECTIVES: to assess the effectiveness of a participatory antenatal care intervention on health behaviours and to illuminate how the different socioeconomic groups responded to the intervention in Jimma, Ethiopia. SETTING, INTERVENTION AND MEASUREMENTS: an intervention was designed participatorily and comprised trainings, supervisions, equipment, health education material, and adaption of guidelines. It was implemented at public facilities. Household surveys, before (2008) and after (2010) intervention, were conducted amongst all women who had given birth within the previous 12 months. The effect of the intervention was assessed by comparing the change in health behaviours (number of antenatal visits, health facility delivery, breast feeding, preventive infant health check, and infant immunisation) from before to after the intervention period at intervention sites, relative to control sites, using logistic mixed effect regression. RESULTS: on the basis of 1357 women included before and 2262 after the intervention, there were positive effects of the intervention on breast feeding practices (OR 3.0, 95% CI: 1.4; 3.6) and preventive infant health check (OR 2.4, 95% CI: 1.5; 3.5). There was no effect on infant immunisation coverage and negative effect on number of antenatal visits. The effect on various outcomes was modified by maternal education, and results indicate increased health facility delivery (OR 2.4, 95% CI: 0.8; 6.9) and breast feeding practices (OR 18.2, 95% CI: 5.2;63.6) among women with no education. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the facility based intervention improved some, but not all health behaviours. The improvements indicated amongst the most disadvantaged antenatal care attendants in breast feeding and health facility delivery are encouraging and underline the need to scale up priority of antenatal care in the effort to reduce maternal and child health inequity.

Variation in Postpartum Glycemic Screening in Women With a History of Gestational Diabetes Mellitus.

OBJECTIVE: To assess patterns and predictors of postpartum diabetes screening in a commercially insured, geographically and sociodemographically diverse sample of women with gestational diabetes mellitus. METHODS: Using commercial insurance claims (2000-2012) from all 50 states, we conducted a retrospective cohort study in 447,556 women with at least one delivery and continuous enrollment 1 year before and after delivery. We identified women with a gestational diabetes mellitus pregnancy and examined postpartum diabetes screening type and timing and performed logistic regression to identify screening predictors. RESULTS: Gestational diabetes mellitus was diagnosed in 32,253 (7.2%) women during the study timeframe. Three fourths received no screening within 1 year postpartum. Rates of recommended 75-g oral glucose tolerance testing within 6-12 weeks were low but increased over time (27 [2%] in 2001 compared with 249 [7%] in 2011, adjusted odds ratio [OR] 3.1, 95% confidence interval [CI] 2.0-47). Among women screened, those in the Northeast (19%) and South (18%) were least likely to receive a 75-g oral glucose tolerance test within 0-12 weeks (adjusted OR 0.4 for each, CI 0.4-0.5) compared with the West (36%). Asian women were most likely to receive any screening (18%; adjusted OR 1.5, CI 1.3-1.6) compared with white women (12%). Black women were most likely to receive hemoglobin A1c (21%; adjusted OR 2.0, CI 1.3-3.2) compared with white women (11%). Antepartum antiglycemic medication (21%; adjusted OR 2.1, CI 2.0-2.3) or visit to a nutritionist-diabetes educator (19%; adjusted OR 1.6, CI 1.4-1.7) or endocrinologist (23%; adjusted OR 1.7, CI 1.6-1.9) predicted screening within 12 weeks postpartum. CONCLUSION: Postpartum diabetes screening remains widely underused among commercially insured women with gestational diabetes mellitus. Differences in screening by geography, race, and antepartum care can inform health system and public health interventions to increase diabetes detection in this high-risk population.