Maternal health equity in Georgia: a Delphi consensus approach to definition and research priorities.

BACKGROUND: Pregnancy-related mortality in the United States is the greatest among all high-income countries, and Georgia has one of the highest maternal mortality rates-almost twice the national rate. Furthermore, inequities exist in rates of pregnancy-related deaths. In Georgia, non-Hispanic Black women are nearly 3 times more likely to die from pregnancy-related complications than non-Hispanic White women. Unlike health equity, a clear definition of maternal health equity is lacking, overall and in Georgia specifically, but is needed to reach consensus and align stakeholders for action. Therefore, we used a modified Delphi method to define maternal health equity in Georgia and to determine research priorities based on gaps in understanding of maternal health in Georgia. METHODS: Thirteen expert members of the Georgia Maternal Health Research for Action Steering Committee (GMHRA-SC) participated in an iterative, consensus-driven, modified Delphi study comprised of 3 rounds of anonymous surveys. In round 1 (web-based survey), experts generated open-ended concepts of maternal health equity and listed research priorities. In rounds 2 (web-based meeting) and 3 (web-based survey), the definition and research priorities suggested during round 1 were categorized into concepts for ranking based on relevance, importance, and feasibility. Final concepts were subjected to a conventional content analysis to identify general themes. RESULTS: The consensus definition of maternal health equity created after undergoing the Delphi method is: maternal health equity is the ultimate goal and ongoing process of ensuring optimal perinatal experiences and outcomes for everyone as the result of practices and policies free of interpersonal or structural bias that tackle current and historical injustices, including social, structural, and political determinants of health impacting the perinatal period and life course. This definition highlights addressing the current and historical injustices manifested in the social determinants of health, and the structural and political structures that impact the perinatal experience. CONCLUSION: The maternal health equity definition and identified research priorities will guide the GMHRA-SC and the broader maternal health community for research, practice, and advocacy in Georgia.

Prevalence of Home Births and Associated Risk Profile and Maternal Characteristics, 2016-2018.

OBJECTIVE: To estimate the prevalence of pregnancies that meet the low-risk criteria for planned home births and describe geographic and maternal characteristics of home births compared with hospital births. METHODS: Data from the 2016-2018 Pregnancy Risk Assessment Monitoring System (PRAMS), a survey among women with recent live births, and linked birth certificate variables were used to calculate the prevalence of home births that were considered low-risk. We defined low-risk pregnancy as a term (between 37 and 42 weeks of gestation), singleton gestation with a birth weight within the 10th-90th percentile mean for gestational age (as a proxy for estimated fetal size appropriate for gestational age), without prepregnancy or gestational diabetes or hypertension, and no vaginal birth after cesarean (VBAC). We also calculated the prevalence of home and hospital births by site and maternal characteristics. Weighted prevalence estimates are presented with 95% CIs to identify differences. RESULTS: The prevalence of home births was 1.1% (unweighted n=1,034), ranging from 0.1% (Alabama) to 2.6% (Montana); 64.9% of the pregnancies were low-risk. Among the 35.1% high-risk home births, 39.5% of neonates were large for gestational age, 20.5% of neonates were small for gestational age, 17.1% of the women had diabetes, 16.9% of the women had hypertension, 10.6% of the deliveries were VBACs, and 10.1% of the deliveries were preterm. A significantly higher percentage of women with home births than hospital births were non-Hispanic White (83.9% vs 56.5%), aged 35 years or older (24.0% vs 18.1%), with less than a high school-level of education (24.6% vs 12.2%), and reported no health insurance (27.0% vs 1.9%). A significantly lower percentage of women with home births than hospital births initiated prenatal visits in the first trimester (66.9% vs 87.1%), attended a postpartum visit (80.1% vs 90.0%), and most often laid their infants on their backs for sleep (59.3% vs 79.5%). CONCLUSIONS: Understanding the risk profile, geographic distribution, and characteristics of women with home births can guide efforts around safe birthing practices.

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes.

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

The National Network of State Perinatal Quality Collaboratives: A Growing Movement to Improve Maternal and Infant Health.

State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention (CDC), in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

The National Network of State Perinatal Quality Collaboratives: A Growing Movement to Improve Maternal and Infant Health.

State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention, in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of PQCs National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

State-based perinatal quality collaboratives: Pursuing improvements in perinatal health outcomes for all mothers and newborns.

State-based perinatal quality collaboratives (SPQC) have become increasingly widespread in the United States. Whereas the first was launched in 1997, today over 40 states have SPQCs that are actively working or are in development. Despite great variability in the structure and function of SPQCs among states, many have seen their efforts lead to significant improvements in the care of mothers and newborns. Clinical topics targeted by SPQCs have included nosocomial infection in newborns, human milk use, neonatal abstinence syndrome, early term deliveries without a medical indication, maternal hemorrhage, and maternal hypertension, among others. While each SPQC uses approaches suited to its own context, several themes are common to the goals of all SPQCs, including developing obstetric and neonatal partnerships; including families as partners; striving for participation by all providers; utilizing rigorous quality improvement science; maintaining close partnerships with public health departments; and seeking population-level improvements in health outcomes.

CDC Grand Rounds: Public Health Strategies to Prevent Preterm Birth.

Preterm birth (delivery before 37 weeks and 0/7 days of gestation) is a leading cause of infant morbidity and mortality in the United States. In 2013, 11.4% of the nearly 4 million U.S. live births were preterm; however, 36% of the 8,470 infant deaths were attributed to preterm birth (1). Infants born at earlier gestational ages, especially <32 0/7 weeks, have the highest mortality (Figure) and morbidity rates. Morbidity associated with preterm birth includes respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage; longer-term consequences include developmental delay and decreased school performance. Risk factors for preterm delivery include social, behavioral, clinical, and biologic characteristics (Box). Despite advances in medical care, racial and ethnic disparities associated with preterm birth persist. Reducing preterm birth, a national public health priority (2), can be accomplished by implementing and monitoring strategies that target modifiable risk factors and populations at highest risk, and by providing improved quality and access to preconception, prenatal, and interconception care through implementation of strategies with potentially high impact.

Perinatal quality collaboratives: improving care for mothers and infants.

Perinatal morbidity and mortality are key indicators of a nation's health status. These measures of our nation's health are influenced by decisions made in health care facilities and by health care providers. As our health systems and health care for women and infants can be improved, there is an expectation that these measures of health will also improve. State-based perinatal quality collaboratives (PQCs) are networks of perinatal care providers including hospitals, clinicians, and public health professionals working to improve pregnancy outcomes for women and newborns through continuous quality improvement. Members of the collaborative are healthcare facilities, primarily hospitals, which identify processes of care that require improvement and then use the best available methods to effect change and improve outcomes as quickly as possible. The Division of Reproductive Health at the Centers for Disease Control and Prevention is collaborating with state-based PQCs to enhance their ability to improve perinatal care by expanding the range of neonatal and maternal health issues addressed and including higher proportions of participating hospitals in their state PQC. The work of PQCs is cross-cutting and demonstrates how partnerships can act to translate evidence-based science to clinical care.

Attitudes and practices regarding late preterm birth among American obstetrician-gynecologists.

BACKGROUND: Late preterm birth (LPTB) accounts for most preterm births and has been increasing, associated with increases in cesarean sections and inductions at this gestational age. METHODS: A self-administered survey, consisting of questions about opinions, knowledge, and practices regarding LPTB, was mailed to 1232 American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in Practice in May-July 2010. RESULTS: Surveys were returned by 520 practicing obstetricians.Two thirds of respondents defined LPTB as either 34­36 or 34­37 weeks gestation [corrected].Most responding physicians (87%) were aware of the evidence regarding morbidity and mortality of infants born at 34-36 weeks; 81% considered such evidence sufficient to make a clinical judgment. Although 84% were concerned about long-term health problems in these infants, many disagreed that LPTB infants were at increased risk of long-term neurodevelopmental outcomes. Most agreed that the increase in LPTB in the United States is due to increasing rates and complications of multifetal pregnancies and maternal disorders. Almost all responding physicians agreed that certain clinical indications (e.g., severe preeclampsia, placental abruption, premature rupture of the membranes [PROM]) were appropriate reasons for early delivery, and most disagreed with delivering late preterm infants for logistical reasons or convenience. Half of responding physicians reported that concerns about malpractice risks contribute to their decision to induce labor or perform a cesarean section at 34-36 weeks. CONCLUSIONS: Many obstetricians underestimate long-term neurodevelopmental outcomes among infants born late preterm and may have a lower threshold to deliver some infants late preterm for indications that are not evidence based. Additional educational efforts regarding LPTB are needed.

The rates of abnormal glucose challenge tests and gestational diabetes in women receiving 17α-hydroxyprogesterone caproate.

We compared the rates of abnormal 1-hour glucose challenge tests (GCT) and gestational diabetes (GDM) between women receiving 17α-hydroxyprogesterone caproate (17-P) and women who did not receive 17-P to determine if the effect varies based on the number of doses received or in a group of high-risk obese women. We performed a secondary analysis of a prospective cohort study where women with a history of a previous preterm delivery in the antecedent pregnancy followed at a high-risk clinic were offered 17-P. GCT was performed after the initiation of 17-P, and doses given prior to testing were recorded. Rates of abnormal GCT and GDM were compared between those receiving 17-P ( N = 67) and controls ( N = 140). Mean glucose values (112.4 versus 111.3, P = 0.8), rate of abnormal GCT (23.9% versus 20%, adjusted odds ratio 1.45, 95% confidence interval 0.7 to 3.0), and rate of GDM (6% versus 8.6%, adjusted odds ratio 1.21, 95% confidence interval 0.3 to 4.5) were similar between groups. In this prospective study, 17-P administration to women at risk of recurrent preterm delivery did not significantly affect glucose tolerance.

Pregnancy-related mortality in the United States, 1998 to 2005.

OBJECTIVE: To estimate the risk of women dying from pregnancy complications in the United States and to examine the risk factors for and changes in the medical causes of these deaths. METHODS: De-identified copies of death certificates for women who died during or within 1 year of pregnancy and matching birth or fetal death certificates for 1998 through 2005 were received by the Pregnancy Mortality Surveillance System from the 50 states, New York City, and Washington, DC. Causes of death and factors associated with them were identified, and pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated. RESULTS: The aggregate pregnancy-related mortality ratio for the 8-year period was 14.5 per 100,000 live births, which is higher than any period in the previous 20 years of the Pregnancy Mortality Surveillance System. African-American women continued to have a three- to four-fold higher risk of pregnancy-related death. The proportion of deaths attributable to hemorrhage and hypertensive disorders declined from previous years, whereas the proportion from medical conditions, particularly cardiovascular, increased. Seven causes of death--hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions--each contributed 10% to 13% of deaths. CONCLUSION: The reasons for the reported increase in pregnancy-related mortality are unclear; possible factors include an increase in the risk of women dying, changed coding with the International Classification of Diseases, 10th Revision, and the addition by states of pregnancy checkboxes to the death certificate. State-based maternal death reviews and maternal quality collaboratives have the potential to identify deaths, review the factors associated with them, and take action on the findings.

Pandemic influenza and pregnant women: summary of a meeting of experts.

Pandemic Influenza: Special Considerations for Pregnant Women was a meeting convened by the Centers for Disease Control and Prevention in 2008 to obtain input from experts and key partners regarding clinical management of pregnant women and related public health actions to be taken during a pandemic. Meeting goals were to discuss issues specific to pregnant women, identify gaps in knowledge, and develop a public health approach for pregnant women in the event of a pandemic. The meeting focused on 4 main topics: prophylaxis and treatment with influenza antiviral and other medications, vaccine use, nonpharmaceutical interventions and health care planning, and communications. Participants reviewed the available evidence to guide action in each of these areas and identified areas of critical needs for future research.

Attitudes and practices regarding use of progesterone to prevent preterm births.

We sought to describe current attitudes and practices of obstetrician-gynecologists regarding use of progesterone and prevention of preterm birth. A self-administered survey was mailed to American College of Obstetricians and Gynecologists Fellows and Junior Fellows in Practice in March to May 2007. The survey consisted of 36 questions, including respondents' demographic characteristics, preterm birth risk factor knowledge and screening practices, and use of progesterone for the prevention of preterm birth. The response rate was 52% ( N = 345); most respondents were general obstetrician-gynecologists (89%). Many (74%) reported recommending or offering progesterone for prevention of preterm birth. Almost all (93%) reported use for the indication of previous spontaneous preterm birth. However, many also reported use for other indications such as dilated/effaced cervix (37%), short cervix on ultrasound (34%), and cerclage (26%). These results suggest that most obstetricians recommend or offer progesterone to prevent preterm birth for women with a previous spontaneous preterm birth and many also offer it for women with other high-risk obstetric conditions.

Current research in preterm birth.

Preterm birth is one of the leading causes of infant mortality and the leading cause of infant morbidity in the United States. It accounts for >70% of neonatal deaths and almost half of long-term neurological disabilities. The Centers for Disease Control and Prevention (CDC) is collaborating with state health departments, universities, communities, and healthcare providers to understand why preterm births occur and how to address preterm birth risk factors. These collaborations include identification of genetic and other biological markers for the early detection of women at high risk of preterm birth; improving understanding of the relationships among psychosocial stress, immune and inflammatory responses, and preterm risk; and designing community strategies to improve the health of pregnant women. By conducting public health research activities that explore the genetic, biological, clinical, behavioral, social, and community determinants of preterm birth, CDC will continue to elucidate the complex interactions of these factors and how they influence preterm birth.

Anogenital warts knowledge and counseling practices of US clinicians: results from a national survey.

OBJECTIVES: To examine messages US clinicians use when counseling patients diagnosed with anogenital warts. STUDY DESIGN: In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts. RESULTS: After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement. CONCLUSIONS: Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Sexually transmitted disease care in managed care organizations.

Most STD cases in the United States are managed in health sectors dominated by commercial and Medicaid MCOs. To sustain the recent declines in bacterial STD incidence in the United States and to control expansion of the prevalent viral STD, MCOs will need to contribute substantially to control efforts. Applied researchers and quality improvement specialists must work with clinicians, patients, and health systems to develop and scale-up interventions to improve STD prevention and control.