Measuring EQ-5D-5L utility values in parents who have experienced perinatal death.

BACKGROUND: Policymakers use clinical and cost-effectiveness evidence to support decisions about health service commissioning. In England, the National Institute for Health and Care Excellence (NICE) recommend that in cost-effectiveness analyses "effectiveness" is measured as quality-adjusted life years (QALYs), derived from health utility values. The impact of perinatal death (stillbirth/neonatal death) on parents' health utility is currently unknown. This knowledge would improve the robustness of cost-effectiveness evidence for policymakers. OBJECTIVE: This study aimed to estimate the impact of perinatal death on parents' health utility. METHODS: An online survey conducted with mothers and fathers in England who experienced a perinatal death. Participants reported how long ago their baby died and whether they/their partner subsequently became pregnant again. They were asked to rate their health on the EQ-5D-5L instrument (generic health measure). EQ-5D-5L responses were used to calculate health utility values. These were compared with age-matched values for the general population to estimate a utility shortfall (i.e. health loss) associated with perinatal death. RESULTS: There were 256 survey respondents with a median age of 40 years (IQR 26-40). Median time since death was 27 months (IQR 8-71). The mean utility value of the sample was 0.774 (95% CI 0.752-0.796). Utility values in the sample were 13% lower than general population values (p < 0.05). Over 10 years, this equated to a loss of 1.1 QALYs. This reduction in health utility was driven by anxiety and depression. CONCLUSIONS: Perinatal death has important and long-lasting health impacts on parents. Mental health support following perinatal bereavement is especially important.

Gaps in Stillbirth Bereavement Care: A Cross-Sectional Survey of U.S. Hospitals by Birth Volume.

OBJECTIVES: The quality and scope of perinatal bereavement care in the United States has been evaluated by surveying bereaved parents, but little is known about how care varies across hospitals. We sought to survey clinicians about stillbirth bereavement care practices at U.S. hospitals and to evaluate care by hospital birth volume. METHODS: Using American Hospital Association data, we employed stratified random sampling to select 300 hospitals from all centers with at least 100 annual deliveries. Within each state, we divided all hospitals into size quartiles and randomly selected from each until we reached the goal number per state. We then identified a staff member knowledgeable about typical bereavement care on labor and delivery at each hospital and sent an on-line survey about care. We linked survey data with hospital characteristics and used summary statistics, Chi squared, and Fisher's Exact test to compare care by hospital birth volume. RESULTS: We reached an eligible respondent at 429/551 hospitals and 396 of the 429 (73%) agreed to participate. We received 289 usable surveys for an overall response rate of 67%. Only one third of hospitals (n = 96, 33%) reported staff protected time for perinatal bereavement care. Of 17 bereavement topics, just six were routinely offered by at least two-thirds of the hospitals. Financial limitations and staff shortages were the most commonly identified barriers to care and were most pronounced at small-volume hospitals. CONCLUSIONS FOR PRACTICE: This study offers a snapshot in bereavement care and identified important gaps for both large and small hospitals.

"Three Good Things" Digital Intervention Among Health Care Workers: A Randomized Controlled Trial.

PURPOSE: Positive psychology shows promise in improving positive affect and happiness. We tested a digital version of a positive psychology intervention called Three Good Things (3GT) among health care workers to assess whether gratitude practice improved well-being. METHODS: All members of a large academic medicine department were invited. Participants were randomized to an immediate intervention group or control group (delayed intervention). Participants completed outcome measures surveys (demographics, depression, positive affect, gratitude, and life satisfaction) at baseline, and at 1 month and 3 months post-intervention. Controls completed additional surveys at 4 and 6 months (completion of the delayed intervention). During the intervention, we sent 3 text messages per week asking for 3GT that occurred that day. We used linear mixed models to compare the groups and to look at the effects of department role, sex, age, and time on outcomes. RESULTS: Of 468 eligible individuals, 223 (48%) enrolled and were randomized with high retention through the end of the study. Most (87%) identified as female. For the intervention group, positive affect improved slightly at 1 month, then declined slightly but remained significantly improved at 3 months. Depression, gratitude, and life satisfaction scores showed a similar trend but were not statistically different between groups. CONCLUSIONS: Our research showed adherence to a positive psychology intervention for health care workers created small positive improvements immediately post-intervention but were not sustained. Further work should evaluate whether utilizing different duration or intensity of the intervention improves benefits.

Learning Obstetrical Cervical Exam Skills : Development of a Novel Model to Demystify Blind Procedures.

BACKGROUND AND OBJECTIVES: Obstetric care is a core element in family medicine education. New interns typically learn the sterile cervical exam on the job by examining women in labor. This can be uncomfortable for patients and may increase the risk of infection. Simulated training could minimize these challenges, but manufactured models are expensive and not widely available in residency programs. We sought to evaluate a simple, homemade sewn model using stretchy fabric and pipe cleaners that could improve teaching and acquisition of cervical examination skills and common obstetrical procedures. METHODS: We used the model to teach cervical examination skills to students and new interns and assessed participant satisfaction. We evaluated examination accuracy by grading practice exams on the model before and after a workshop teaching obstetrical procedures including the sterile vaginal exam. We calculated satisfaction using summary statistics. We evaluated pre- and postscores for exam accuracy using paired t tests. RESULTS: Interns demonstrated a significant improvement in cervical exam skills using the model, and participants reported very high satisfaction with the workshop utilizing the model. CONCLUSIONS: We developed a simple, low-cost cervical exam model that was shown to be well-regarded by trainees and could be duplicated by other residency programs. This approach provides a unique and accessible way to offer hands-on simulation during obstetrical training. The model may improve trainees' understanding of the procedures which would lead to better experiences for obstetrical patients.

Online Support Groups for Perinatal Loss: A Pilot Feasibility Study for Women of Color.

We tested use of an online support group for women of color who had experienced stillbirth or early infant loss. We recruited recently bereaved mothers and asked them to participate in an existing online community for pregnancy and infant loss hosted on a commercial platform. Participants were asked to go online at least three times weekly for 6 weeks to read posts. Using a mixed-methods approach, we assessed attitudes toward online support, mental health, and experiences pre- and postintervention using written surveys and a brief phone interview. We used summary statistics for quantitative data and a deductive coding approach for qualitative data. Twenty participants completed the study. We found nonsignificant improvements in all four mental health domains (depression, post-traumatic stress disorder, moderate-severe generalized anxiety, and perinatal grief). Women reported the group allowed them to help others and feel less alone. They also reported that at times, posts could increase the intensity of their loss emotions. This study demonstrated feasibility to recruit, retain, and track participation in an online support group for perinatally-bereaved mothers of color. Although the study was not powered for outcome, all mental health measures showed nonsignificant improvements, suggesting value in further investigating online social support for improving women's mental health after perinatal loss. Clinical Trial Registration: Registered on clinicaltrials.gov [NCT04600076], October 19, 2020.

Medical assistants identify strategies and barriers to clinic efficiency.

This cross-sectional study explored the ways that medical assistants and physicians can work together to ensure that patients receive appropriate care.

Physician Suicide in the United States:Updated Estimates from the National Violent Death Reporting System.

Physician suicide and well-being are critical issues but studies use varying methodologies and suicide is frequently underreported. This study sought to update data on physician suicides in the United States. The National Violent Death Reporting System (NVDRS) at the Centers for Disease Control collects details about violent deaths. The study used 2010-2015 data from 27 NVDRS states to identify suicide deaths among physicians or non-physicians and calculate annual standardized mortality rates (SMR). Of 63,780 victims total, there were 357 physicians identified over 6 years, (307 men and 50 women). If results are extrapolated to all 50 states, there would be approximately 119 physician suicides annually. The SMR for physicians overall was not statistically different from that of non-physicians. This is the first study in 16 years to update estimated physician suicide rates in the United States. The research used strict criteria to identify physicians so results likely represent the lower boundary of physician suicides. Findings show that physician suicide is not significantly lower than that of non-physicians and emphasizes the importance of focusing on structural changes to reduce stigma around mental health in the medical community.

Parents' experiences of care offered after stillbirth: An international online survey of high and middle-income countries.

BACKGROUND: Stillbirth, the death of a baby before birth, is associated with significant psychological and social consequences that can be mitigated by respectful and supportive bereavement care. The absence of high-level evidence to support the broad scope of perinatal bereavement practices means that offering a range of options identified as valued by parents has become an important indicator of care quality. This study aimed to describe bereavement care practices offered to parents across different high-income and middle-income countries. METHODS: An online survey of parents of stillborn babies was conducted between December 2014 and February 2015. Frequencies of nine practices were compared between high-income and middle-income countries. Differences in proportions of reported practices and their associated odds ratios were calculated to compare high-income and middle-income countries. RESULTS: Over three thousand parents (3041) with a self-reported stillbirth in the preceding five years from 40 countries responded. Fifteen countries had atleast 40 responses. Significant differences in the prevalence of offering nine bereavement care practices were reported by women in high-income countries (HICs) compared with women in middle-income countries (MICs). All nine practices were reported to occur significantly more frequently by women in HICs, including opportunity to see and hold their baby (OR = 4.8, 95% CI 4.0-5.9). The widespread occurrence of all nine practices was reported only for The Netherlands. CONCLUSIONS: Bereavement care after stillbirth varies between countries. Future research should look at why these differences occur, their impact on parents, and whether differences should be addressed, particularly how to support effective communication, decision-making, and follow-up care.

Video Visits: Family Physician Experiences With Uptake During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: With the emergence of COVID-19, telemedicine use has increased dramatically as clinicians and patients have looked for alternatives to face-to-face care. Prior research has shown high levels of patient satisfaction and comparable quality of care. Video visits have been hypothesized to be one way to reduce burnout among clinicians, but there has been minimal research on physician views of virtual care. We sought to measure family physician experience with video visits at the start of the COVID-19 pandemic. METHODS: We identified all faculty and resident physicians at a large academic department of family medicine who had conducted a video visit in the prior month and conducted an anonymous online 12-question survey about their experiences, satisfaction, and barriers with care. RESULTS: Most eligible physicians responded (102/109, 94%), of whom half (52%) reported this was their first month trying a video visit. There was very high satisfaction (91% very or somewhat satisfied). The majority of respondents felt that video visits were shorter (54%) or took the same amount of time (38%) as in-person visits. There was concern that many physicians had experienced a visit in which they felt video was not the appropriate platform given patient concerns. CONCLUSIONS: This study is among the first to assess physician experience with video visits. As the visits are perceived as shorter, they may offer a unique opportunity to address clinician burnout. There was a high level of satisfaction at our institution despite multiple technical challenges.

Use of Tablet Video for Delivery of Neonatal Discharge Instructions to First-Time Parents.

BACKGROUND AND OBJECTIVES: While video discharge instructions have been shown to improve retention of information and patient satisfaction, data are limited regarding patient perceptions of video tools. METHODS: We conducted a randomized controlled trial to assess self-rated comprehension and overall satisfaction with video versus face-to-face neonatal discharge instructions in first-time mothers. RESULTS: Video instructions were no different from face-to-face instructions, though there was a nonsignificant increase in confidence in caring for their newborn in the video group. CONCLUSIONS: Broader use of technology may allow for a more standardized approach to patient education and improve efficiency for clinicians, without compromising patient satisfaction and confidence in caring for themselves and their dependents.

MOMSonLINE: Lessons Learned From a Feasibility RCT of Online Support for Mothers Bereaved by Perinatal Loss.

Online support groups are popular for peer support, particularly for uncommon or stigmatized topics including pregnancy and infant loss. We conducted a randomized, controlled, 6-week feasibility study of three groups: an anonymous BabyCenter.com loss support group, a closed Facebook loss group, or a control group. Intervention arm mothers were asked to sign on to their support sites for 6 weeks. Participants completed regular surveys, text message surveys after each log-in, and a final semistructured phone interview. Thirty women were randomized to each arm of the study. Women reported preference for anonymous groups and found it empowering to support others, although many noted an emotional cost to reading postings. Tracking usage online was a major issue despite multiple strategies to collect these data. This pilot demonstrated feasibility of a randomized trial for online perinatal support but noted a critical need for more reliable methods to track usage.

Relationship Between Faculty Characteristics and Emotional Exhaustion in a Large Academic Medical Center.

OBJECTIVE: We evaluated associations between emotional exhaustion (EE), a measure of burnout, among medical school faculty and: demographic and professional characteristics, workplace stressors, coping skills, resilience, sufficient personal time, and depressive symptoms. Respondents completed surveys in November 2017. METHODS: We conducted bivariate and multivariable logistic regression and recycled predictions models to estimate associations between characteristics and probability of EE. RESULTS: Of 1401 respondents, 42% endorsed EE. Faculty with more clinical effort, more workplace stress, less resilience, less personal time, and more depressive symptoms reported statistically significantly higher probabilities of EE compared with their counterparts. Female sex, mid-career stage, and coping skills were no longer associated with EE, after accounting for stress, resilience, personal time, and depressive symptoms. CONCLUSIONS: Coping skills may not mitigate physician EE when coupled with substantial time and mental health burdens.

A Novel Model for a Free Clinic for Prenatal and Infant Care in Detroit.

PURPOSE: Detroit experiences the highest preterm birth rate and some of the worst birth outcomes in the country. Women and children have extremely high levels of poverty and face numerous barriers to care including lack of trust and racial disparities in care and concrete barriers such as limited transportation and childcare, work hour conflicts, and lack of insurance. DESCRIPTION: We report on a unique model of patient care focused on providing patient-centered care and building trusting relationships. This model is encompassed in a new free, volunteer-run, faith-based clinic which offers prenatal, postpartum, and infant care. ASSESSMENT: In the first 2 years of operation, demand for services rose rapidly and there were stellar clinical outcomes, despite the fact that Luke patients are among the medically and socially highest risk populations in the nation. CONCLUSION: While marginalized populations have worse birth outcomes and far more infant deaths, making care accessible and responsive to patient needs while focusing on building patient relationships is an important strategy to improve outcomes.

An iterative design process to develop a randomized feasibility study and inform recruitment of minority women after stillbirth.

BACKGROUND: Yearly, approximately 25,000 US women experience stillbirth and African American women have a 2.2 fold increased risk of stillbirth compared with white women. After stillbirth, women are subject to a sevenfold increased risk of post-traumatic stress compared with women after a live-birth. This paper presents findings from phase one of a National Institutes of Health funded, two-phase feasibility study to examine an online yoga intervention to reduce symptoms of post-traumatic stress in mothers after stillbirth. An iterative design was used to (1) inform the development of the online yoga intervention and (2) inform recruitment strategies to enroll minority women into phase two. METHODS: Ten mothers (N = 5 stillbirth moms with no yoga experience, N = 5 nonstillbirth moms with yoga experience) participated in a series of online yoga videos (N = 30) and were assessed for self-compassion (SC) and emotional regulation (ER) before and after each video. An independent group of five minority women who had experienced stillbirth were interviewed about cultural barriers to recruitment and perceptions/opinions of yoga. A mean was calculated for SC and ER scores for each video at pre- and post-time points. The percent change of the mean difference between pre-post SC and ER scores were used to select videos for phase two. Videos with a negative change score or that had a 0% change on SC or ER were not used. A combination of deductive and inductive coding was used to organize the interview data, generate categories, and develop themes. RESULTS: Five of the 30 tested yoga videos were not used. An additional 12 videos were developed, filmed, and used in the prescription for phase two. Topics from interview findings included perceived benefits/barriers of and interest in yoga, preferred yoga environment, suggested recruitment methods, content of recruitment material, and recommended incentives. CONCLUSIONS: Online yoga may be beneficial for improving emotional regulation and self-compassion, but further testing is needed. Additionally, minority women express interest in online yoga but suggest that researchers apply culturally specific strategies regarding methods, content of material, and incentives to recruit minority women into a study.

Determining the cause of stillbirth in Kumasi, Ghana.

OBJECTIVE: To classify cause-of-death (COD) for stillbirths occurring in a major referral hospital in Kumasi, Ghana. METHODS: In a retrospective review conducted between June 8, 2011, and June 12, 2012, detailed information was collected on all stillbirths delivered at Komfo Anokye Teaching Hospital in Kumasi, Ghana. Patient records were independently reviewed by investigators using the Perinatal Society of Australia and New Zealand's Perinatal Death Classification system to determine COD for each case. RESULTS: COD was analyzed in 465 stillbirth cases. The leading causes of death were hypoxic interpartum death (105, 22.6%), antepartum hemorrhage (67, 14.4%), hypertension (52, 11.2%), and perinatal infection (32, 6.9%). One hundred and fifty seven (33.8%) stillbirths were classified as unexplained antepartum deaths. CONCLUSIONS: This evaluation of stillbirth in a busy, tertiary care hospital in Kumasi, Ghana provides crucial insight into the high volume of stillbirth in Ghana as well as its medical causes. The study demonstrated the high rate of stillbirth attributed to hypoxic intrapartum events, placental abruption, pre-eclampsia, and unspecified bacterial infections. Yet, our rate of unexplained stillbirths underscores the need for a stillbirth classification system that thoughtfully integrates the needs and limitations of low-resource settings as unexplained stillbirth rates are a common indicator of the effectiveness of a classification system.