Supporting reproductive health among birthing persons with chronic conditions in the United States: A qualitative multilevel study using systems thinking to inform action.

OBJECTIVE (STUDY QUESTION): To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross-system actions that can improve identified problems in the United States. DATA SOURCES/STUDY SETTING: Data were collected from six groups of system actors via online focus groups. STUDY DESIGN: This is a qualitative multilevel study using the iceberg systems thinking framework. DATA COLLECTION/EXTRACTION METHODS: Data were collected by note-taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas. PRINCIPAL FINDINGS: Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders. CONCLUSIONS: By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.

Postpartum Health Experiences of Women with Newborns in Intensive Care: The Desire to Be by the Infant Bedside as a Driver of Postpartum Health.

INTRODUCTION: Women with infants in a neonatal intensive care unit (NICU) encounter multiple challenges following childbirth, including greater burden of chronic disease and increased risk for depression, compared with women with well infants. At the same time, they are confronted with the trauma of a hospitalized infant while also managing their postpartum recovery. Limited research exists describing the health needs of these women, despite the many numbers living this experience daily. This study aimed to better understand postpartum health needs of women with infants in the NICU in the 90 days following birth and to propose actionable system improvements to address identified needs. METHODS: The authors conducted in-depth individual interviews with 50 postpartum women of infants admitted to the NICU at a quaternary care hospital. Eligible women were aged at least 18 years, spoke English or Spanish, and had infants in the NICU longer than 3 days. Interview topics included NICU experience, recommended and desired health care, and suggestions for improvement. Interviews were audiotaped and transcribed verbatim. The authors used qualitative description techniques including memo-writing, coding, matrices, diagramming, and team discussion to analyze the data. RESULTS: Women reported significant intrapartum health conditions and concerns (eg, preeclampsia, emergency cesarean birth, anxiety) and described unmet social, emotional, mental, and physical health needs. Unmet practical needs while in the NICU (eg, a place to rest, affordable parking, access to food, childcare) caused considerable burden. Despite disease burden and emergent health needs, few women reported regular monitoring of their postpartum health by maternal health care providers. Women frequently minimized and delayed care for their health needs so as to remain by the infant bedside. DISCUSSION: Women with infants in the NICU would benefit from patient-centered care that provides greater attention to their postpartum health and recovery while also supporting their drive to remain close to their hospitalized infant.

Perinatal morbidity and health utilization among mothers of medically fragile infants.

OBJECTIVE: To determine the burden of perinatal morbidity among mothers of medically fragile infants. STUDY DESIGN: We conducted a retrospective cohort study of 6849 mothers who delivered liveborn infants at a quaternary care hospital during a two-year period. We compared mothers of well babies with mothers of infants admitted to the Neonatal Intensive Care Unit (NICU), and we used logistic regression to model predictors of postpartum acute care utilization among NICU mothers. RESULTS: Rates of obstetric morbidity were highest for mothers of infants staying ≥72 h in the NICU; 54.2% underwent cesarean birth, 7.5% experienced severe maternal morbidity, and 6.6% required a blood transfusion. Factors independently associated with postpartum acute care use included gestational age <28 weeks, ever smoking, non-Hispanic Black race, temperature >38 °C and receiving psychiatric medication during the birth hospitalization. CONCLUSION: Focused support for mothers of NICU infants has the potential to reduce maternal morbidity and improve health.

Health Needs of Mothers of Infants in a Neonatal Intensive Care Unit : A Mixed-Methods Study.

BACKGROUND: Mothers with babies in the neonatal intensive care unit (NICU) face a host of challenges following childbirth. Limited information is available on these mothers' postpartum health needs and access to services. OBJECTIVE: To identify health needs of NICU mothers, access to services, and potential service improvements. DESIGN: A mixed-methods study including a retrospective cohort study, in-depth interviews, and focus groups. SETTING: Large, Level IV, regional referral, university-affiliated hospital in the United States. PARTICIPANTS: Mothers of live-born infants born from 1 July 2014 to 30 June 2016 (n = 6849). Interviews included 50 NICU mothers and 59 stakeholders who provide services to these mothers or their infants. MEASUREMENTS: Severe maternal morbidity, chronic health conditions, health care encounters from discharge through 12 weeks postpartum, maternal health needs, care access, and system improvements. RESULTS: Compared with mothers of well babies, NICU mothers had more chronic diseases, experienced more perinatal complications, and utilized more acute care postpartum. Qualitative analyses revealed the desire to be at the baby's bedside as a driver of maternal health-seeking behaviors, with women not seeking or delaying medical care so as to stay by their infant. Stakeholders acknowledged the unique needs of NICU mothers and cited system challenges, lack of clarity about provider roles, and reimbursement policies as barriers to meeting needs. LIMITATIONS: The study was conducted within a single health care system, which may limit generalizability. Qualitative analyses did not explore the influence of fathers, other children in the home, or length of NICU stay. CONCLUSION: Universal screening and convenient access to maternal health services for NICU mothers should be explored to reduce adverse maternal health outcomes. PRIMARY FUNDING SOURCE: Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.

Addressing Unmet Maternal Health Needs at a Pediatric Specialty Infant Care Clinic.

OBJECTIVE: The objective of this intervention was to evaluate the feasibility of screening mothers of medically fragile infants in the domains of 1) depression, 2) tobacco exposure, and 3) family planning at a post-neonatal intensive care unit (NICU) developmental pediatric visit. Additionally, we sought to estimate the percentage who met criteria for further evaluation in the three domains assessed. METHODS: A cross-sectional questionnaire was administered to 100 caregivers of medically fragile infants at a specialty, post-NICU clinic visit. Participants' responses in three domains were evaluated and appropriate referrals were provided. Analysis was then restricted to the 87 biological mothers who completed the screening. Study staff contacted the mothers 2 months later to determine whether services had been accessed and to assess overall satisfaction with the screening within the pediatric visit. Qualitative interviews were conducted with pediatric clinic staff. RESULTS: Screening questionnaires were completed by 87 biological mothers. Twenty-two mothers (25%) met referral criteria. Pediatric clinic staff and providers were comfortable administering the screening instrument, and there was minimal disruption to clinic flow. CONCLUSIONS: Mothers of medically fragile infants are likely to have unmet health care needs that can be identified at a specialty pediatric clinic visit. A screening and referral intervention can be implemented with minimal interruption in pediatric clinic flow and is acceptable to mothers and pediatric providers.

Advancing preconception health in the United States: strategies for change.

In January 2015, the US Preconception Health and Health Care Initiative (PCHHC) established a new national vision that all women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have. Achieving this vision presents both challenges and opportunities. This manuscript describes the reasons why the US needs to prioritize preconception health as well as its efforts historically to advance change. The authors share lessons from past work and current strategies in the US to reach this ambitious goal.

Postpartum Health Services Requested by Mothers with Newborns Receiving Intensive Care.

Objectives Our pilot study aimed to build knowledge of the postpartum health needs of mothers with infants in a newborn intensive care unit (NICU). Methods Between May 2008 and December 2009, a Certified Nurse Midwife was available during workday hours to provide health care services to mothers visiting their infants in the NICU at a large tertiary care center. Results A total of 424 health service encounters were recorded. Maternal requests for services covered a wide variety of needs, with primary care being the most common. Key health concerns included blood pressure monitoring, colds, coughs, sore throats, insomnia and migraines. Mothers also expressed a need for mental health assessment and support, obstetric care, treatment for sexually transmitted infections, tobacco cessation, breastfeeding assistance, postpartum visits, and provision of contraception. Conclusions Our study suggests that mothers with babies in the NICU have a host of health needs. We also found that women were receptive to receiving health services in a critical care pediatric setting. Intensive care nurseries could feasibly partner with in-patient mother-baby units and/or on-site obstetric clinics to increase access to health care for the mothers of the high-risk newborns in their units. Modifications should be made within health care systems that serve high-risk infants to better address the many needs of the mother/baby dyad in the postpartum period.

Systematic review: smoking cessation intervention strategies for adults and adults in special populations.

BACKGROUND: While smoking cessation interventions have been shown to work, questions remain about how to increase their efficacy. PURPOSE: To examine strategies for effective tobacco treatment in adults and special populations. DATA SOURCES: MEDLINE, Cumulative Index to Nursing and Applied Health (CINAHL), Cochrane Library, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts (1 January 1980 to 10 June 2005). STUDY SELECTION: Systematic reviews; randomized, controlled trials; and observational studies. DATA EXTRACTION: Two reviewers independently abstracted data on study design, population, sample size, treatment, outcomes, and quality. DATA SYNTHESIS: Findings from systematic reviews were summarized and compared with findings from original research published beyond date ranges included in the reviews. Strength of evidence was used to assess the body of evidence. Our review included studies evaluating the efficacy of cessation strategies, such as self-help, counseling, single pharmaceutical agents, combined pharmacotherapies, and pharmacotherapies combined with psychological counseling. Research findings consistent with previous reviews show that self-help strategies alone are ineffective, but counseling and pharmacotherapy used either alone or in combination can improve rates of success with quit attempts. Two studies of self-help materials reported discrepancies across effects. Five studies provided mixed results for counseling interventions. Fourteen studies provided sufficient evidence of the efficacy of single pharmacotherapy, combined pharmacotherapy, and psychological interventions either with or without pharmacotherapy. Few studies focused on ways to reach or treat special populations. Three studies with hospitalized patients had findings consistent with a previous review showing no strong evidence that clinical diagnosis affected the likelihood of quitting. New evidence was insufficient to address the effectiveness of interventions for persons with coexisting psychiatric conditions and substance abuse problems. LIMITATIONS: Previous systematic reviews variably cover the range of issues we addressed. More recent studies do not fill all gaps, especially those for persons with coexisting disease. CONCLUSIONS: Although self-help strategies alone marginally affect quit rates, individual and combined pharmacotherapies and counseling either alone or in combination can significantly increase cessation. Using effective smoking treatments is strongly encouraged for all populations, especially those with high and heavy rates of smoking, such as psychiatric and substance abuse populations.

Tobacco use: prevention, cessation, and control.

OBJECTIVES: The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on (a) the effectiveness of community- and population-based interventions to prevent tobacco use and to increase consumer demand for and implementation of effective cessation interventions; (b) the impacts of smokeless tobacco marketing on smoking, use of those products, and population harm; and (c) the directions for future research. DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Applied Health (CINAHL), Cochrane libraries, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts from January 1980 through June 10, 2005. We included English-language randomized controlled trials, other trials, and observational studies, with sample size and follow-up restrictions. We used 13 Cochrane Collaboration systematic reviews, 5 prior systematic reviews, and 2 meta-analyses as the foundation for this report. REVIEW METHODS: Trained reviewers abstracted detailed data from included articles into evidence tables and completed quality assessments; other senior reviewers confirmed accuracy and resolved disagreements. RESULTS: We identified 1,288 unique abstracts; 642 did not meet inclusion criteria, 156 overlapped with prior reviews, and 2 were not published articles. Of 488 full-text articles retrieved and reviewed, we excluded 298 for several reasons, marked 88 as background, and retained 102. Evidence (consistent with previous reviews) showed that (a) school-based prevention interventions have short-term (but not long-term) effects on adolescents; (b) multicomponent approaches, including telephone counseling, increase the number of users who attempt to quit; (c) self-help strategies alone are ineffective, but counseling and pharmacotherapy used either alone or in combination can improve success rates of quit attempts; and (d) provider training and academic detailing improve provider delivery of cessation treatments, but evidence is insufficient to show that these approaches yield higher quit rates. New evidence was insufficient to address the following: (a) effectiveness of population-based prevention interventions; (b) effectiveness of provider-based interventions to reduce tobacco initiation; (c) effectiveness of community- and provider-based interventions to increase use of proven cessation strategies; (d) effectiveness of marketing campaigns to switch tobacco users from smoking to smokeless tobacco products; and (e) effectiveness of interventions in populations with comorbidities and risk behaviors (e.g., depression, substance and alcohol abuse). No evidence was available on the way in which smokeless tobacco product marketing affects population harm. CONCLUSIONS: The evidence base has notable gaps and numerous study deficiencies. We found little information to address some of the issues that previous authoritative reviews had not covered, some information to substantiate earlier conclusions and recommendations from those reviews, and no evidence that would overturn any previous recommendations.