Supine sleep positioning in preterm and term infants after hospital discharge from 2000 to 2011.

OBJECTIVE: Supine sleep positioning (SSP) has been shown to reduce the risk of sudden infant death syndrome (SIDS) and preterm infants are at higher risk for SIDS. Population-based estimates of SSP are lacking for the preterm population. The objectives of this study are: (1) compare the prevalence of SSP after hospital discharge for preterm and term infants in the United States; and (2) assess racial/ethnic disparities in SSP for preterm and term infants. STUDY DESIGN: We analyzed the 2000 to 2011 data from the Pregnancy Risk Assessment Monitoring System of Centers for Disease Control and Prevention from 35 states. We measured prevalence of SSP by preterm and term gestational age (GA) categories. We calculated adjusted prevalence ratios (APR) to evaluate the likelihood of SSP for each GA category compared with term infants and the likelihood of SSP for non-Hispanic black (NHB) and Hispanic infants compared with non-Hispanic white (NHW) infants. RESULTS: Prevalence of SSP varied by GA: ⩽27, 59.7%; 28 0/7 to 33 6/7, 63.7%; 34 0/7 to 36 6/7 (late preterm), 63.6%; and 37 0/7 to 42 6/7 (term) weeks, 66.8% (P<0.001). In the adjusted analyses, late preterm infants were slightly less likely to be placed in SSP compared with term infants (APR: 0.96, confidence interval: 0.95 to 0.98). There were racial/ethnic disparities in SSP for all GA categories when NHB and Hispanic infants were compared with NHW infants. CONCLUSIONS: All infants had suboptimal adherence to SSP indicating a continued need to better engage families about SSP. Parents of late preterm infants and families of NHB and Hispanic infants will also require greater attention given their decreased likelihood of SSP.

United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement.

OBJECTIVE: Summarize policies that support maternal and neonatal transport among states and territories. STUDY DESIGN: Systematic review of publicly available, web-based information on maternal and neonatal transport for each state and territory in 2014. Information was abstracted from published rules, statutes, regulations, planning documents and program descriptions. Abstracted information was summarized within two categories: transport and reimbursement. RESULTS: Sixty-eight percent of states and 25% of territories had a policy for neonatal transport; 60% of states and one territory had a policy for maternal transport. Sixty-two percent of states had a reimbursement policy for neonatal transport, whereas 20% reimbursed for maternal transport. Thirty-two percent of states had an infant back-transport policy while 16% included back-transport for both. No territories had reimbursement or back-transport policies. CONCLUSION: The lack of development of maternal transport reimbursement and neonatal back-transport policies negatively impacts the achievements of risk-appropriate care, a strategy focused on improving perinatal outcomes.

Home care practices for preterm and term infants after hospital discharge in Massachusetts, 2007 to 2010.

OBJECTIVE: The objective of this study was to compare the prevalence of home care practices in very to moderately preterm (VPT), late preterm (LPT) and term infants born in Massachusetts. STUDY DESIGN: Using 2007 to 2010 Massachusetts Pregnancy Risk Assessment Monitoring System data, births were categorized by gestational age (VPT: 23 to 33 weeks; LPT: 34 to 36 weeks; term: 37 to 42 weeks). Home care practices included breastfeeding initiation and continuation, and infant sleep practices (supine sleep position, sleeping in a crib, cosleeping in an adult bed). We developed multivariate models to examine the association of infant sleep practices and breastfeeding with preterm status, controlling for maternal sociodemographic characteristics. RESULTS: Supine sleep position was more prevalent among term infants compared with VPT and LPT infants (77.1%, 71.5%, 64.4%; P=0.02). In the adjusted model, LPT infants were less likely to be placed in supine sleep position compared with term infants (adjusted prevalence ratio=0.86; 95% confidence interval: 0.75 to 0.97). Breastfeeding initiation and continuation did not differ among preterm and term groups. Nearly 16% of VPT and 18% of LPT and term infants were not sleeping in cribs and 14% of LPT and term infants were cosleeping on an adult bed. CONCLUSION: Compared with term infants, LPT infants were less likely to be placed in supine sleep position after hospital discharge. A significant percent of preterm and term infants were cosleeping on an adult bed. Hospitals may consider improving their safe sleep education, particularly to mothers of LPT infants.

Racial disparities in outcomes of military and civilian births in California.

OBJECTIVE: To examine racial disparities in prenatal care utilization, birth weight, and fetal and neonatal mortality in a population for whom financial barriers to health care services are minimal. STUDY-DESIGN: Using linked birth, fetal death, and infant death certificate files, we examined prenatal care utilization, birth weight distribution, and fetal and neonatal mortality rates for all white and black births occurring in military hospitals in California from January 1, 1981, to December 31, 1985. These patterns were compared with the experience of their civilian counterparts during the same time period. RESULTS: Black mothers had higher percentages of births occurring in teenaged and unmarried mothers than did white mothers in military and civilian populations. First-trimester prenatal care initiation was lower for blacks in the military (relative risk, 0.79; 95% confidence interval, 0.75-0.82) and civilian (relative risk, 0.51; 95% confidence interval, 0.50-0.52) populations. However, the scale of the disparity in prenatal care utilization was significantly smaller (P < .001) in the military group. Rates of low birth weight and fetal and neonatal mortality among blacks were elevated in the military and civilian groups. However, the racial disparity in low birth weight was significantly smaller in the military group (P < .01 and P < .001, respectively). CONCLUSIONS: In populations with decreased financial barriers to health care, racial disparities in prenatal care use and low birth weight were reduced. However, the persistence of significant disparities suggests that more comprehensive strategies will be required to ensure equity in birth and neonatal outcome.

Evaluation of an early discharge program for infants after childbirth in a military population.

The objective of this study was to evaluate the outcome of an early discharge program for infants with regard to length of stay, patient safety, maternal satisfaction, and hospital expense in a military population. The study consisted of a retrospective analysis of data from two 6-month periods--March to August 1994 (before early discharge) and March to August 1996 (after early discharge)--in a military, tertiary care, teaching hospital. The criteria for early discharge included healthy term singleton newborns delivered by uncomplicated vaginal delivery with maternal support systems, transportation, and phone access. The interventions included maternal education regarding maternal and infant care and telephone follow-up at 48 hours and 5 days after discharge. The main outcome measures included length of hospital stay, inpatient cost, infant health services utilization, and maternal satisfaction (measured by survey). During the 6-month study periods in 1994 and 1996, a total of 1,911 deliveries were examined. The mean number (+/- SD) of hospital days per infant was 2.54 +/- 0.83 in 1994 compared with 1.88 +/- 1.03 in 1996. There was not a statistically significant difference in the number of readmissions between 1994 (9 of 1042, 0.86%) and 1996 (12 of 869, 1.38%) (odds ratio = 1.61, 95% confidence interval = 0.67, 3.83). A review of the infant health services utilization revealed a statistically significant increase in the total number of clinic visits (scheduled and unscheduled) before the 2-week well-child visit for the 1996 group. However, that group did not experience a change in the number of emergency room visits. Seventy-five percent of mothers were satisfied with the program as assessed by questionnaire. In addition, the program was able to save 599 inpatient hospital days, for a total cost savings of $442,903.23 in 1996. This reduction in inpatient hospital days netted an average cost savings of $509.67 per infant. By following strict discharge criteria, increasing parent education before discharge, implementing a phone follow-up system, and ensuring easy access to care, an early discharge program in our military population was not associated with increased adverse newborn outcomes and reduced costs.

Hospital neonatal services in the United States: variation in definitions, criteria, and regulatory status, 2008.

OBJECTIVE: The purpose of this study was to describe variation among states in designations of hospital neonatal services levels. STUDY DESIGN: We systematically searched all 50 states and District of Columbia governmental web sites and extracted definitions and levels terminology, functional and utilization criteria, regulatory compliance and funding measures, and citation of American Academy of Pediatrics (AAP) documents on levels of neonatal care. RESULT: Thirty-three states designate multiple graduated levels of neonatal services. Two to six levels were designated by numbers, titles, or both. Regulatory sources include hospital licensure, Certificate of Need or State Health Plan (CON/SHP), State Health Department, or an affiliated non-governmental entity (SHD/affiliate). Twenty-four states have a single source and nine have two or more. Functional criteria include population characteristics, respiratory care capabilities, and neonatal and cardiac surgery in 25 states. Utilization criteria include capacity, volume, occupancy, or case mix. Compliance mechanisms include license renewal, CON/SHP approval, and/or SHD/affiliate certification. Thirteen states link funding for the highest level of care through Medicaid, Maternal Child Health Title V funds or regional programs. AAP documents are cited or incorporated by reference in 22 states. CONCLUSION: All states regulate health care services and facilities. Definitions, criteria, compliance mechanisms, and regulatory source and status of neonatal levels of service vary widely. A consistent national approach would facilitate comparisons in neonatal outcomes and resource use and be informative to parents, providers, and policy makers. AAP documents could serve as a mechanism to foster such consistency.