Health Care Use by Commercially Insured Postpartum and Nonpostpartum Women in the United States.

OBJECTIVE: To compare the type, frequency, and timing of health care use among commercially insured postpartum and nonpostpartum women. METHODS: This retrospective cohort study used data from a large national commercial claims database. Women between 18 and 44 years of age who gave birth in 2016 (n=149,563) and women who were neither pregnant nor postpartum between 2015 and 2017 (n=2,048,831) (nonpostpartum) were included. We examined hospitalization, and preventive visits, problem visits, and emergency department (ED) visits among postpartum women during the early postpartum period (less than 21 days after childbirth), the postpartum period (21-60 days postpartum), and extended postpartum period (61-365 days after childbirth). Visits among nonpostpartum women were assessed during time periods of equivalent duration. RESULTS: Almost 24% of postpartum women had a problem visit in the early postpartum period, compared with 19.7% of nonpostpartum women (adjusted difference 4.8 percentage points [95% CI 4.6-5.0]). Approximately 3% of postpartum women had an early ED visit, more than double the percentage among nonpostpartum women (adjusted difference 2.3 percentage points [95% CI 2.2-2.4]). Both problem visits and ED visits among postpartum women remained elevated relative to nonpostpartum women during the postpartum and extended postpartum periods. Although postpartum women were more likely than nonpostpartum women to receive preventive care during the early and postpartum periods, only 43% of postpartum women had a preventive visit during the extended postpartum period, a rate 1.8 (95% CI -2.1 to -1.5) percentage points lower than that of nonpostpartum women. Adjusted hospitalization rates among postpartum women in the early (0.8%), postpartum (0.3%), and extended postpartum (1.4%) periods were higher than those of nonpostpartum women (0.1%, 0.2%, and 1.6%, respectively). CONCLUSIONS: Commercially insured postpartum women use more health care than nonpostpartum women, including inpatient care. Differences are largest in the early postpartum period and persist beyond 60 days postpartum.

Protocol for a quasi-experimental study of the effectiveness and cost-effectiveness of mother and baby units compared with general psychiatric inpatient wards and crisis resolution team services (The ESMI study) in the provision of care for women in the postpartum period.

INTRODUCTION: Research into what constitutes the best and most effective care for women with an acute severe postpartum mental disorder is lacking. The effectiveness and cost-effectiveness of psychiatric mother and baby units (MBUs) has not been investigated systematically and there has been no direct comparison of the outcomes of mothers and infants admitted to these units, compared with those accessing generic acute psychiatric wards or crisis resolution teams (CRTs). Our primary hypothesis is that women with an acute psychiatric disorder, in the first year after giving birth, admitted to MBUs are significantly less likely to be readmitted to acute care (an MBU, CRTs or generic acute ward) in the year following discharge than women admitted to generic acute wards or cared for by CRTs. METHODS AND ANALYSIS: Quasi-experimental study of women accessing different types of acute psychiatric services in the first year after childbirth. Analysis of the primary outcome will be compared across the three service types, at 1-year postdischarge. Cost-effectiveness will be compared across the three service types, at 1-month and 1-year postdischarge; explored in terms of quality-adjusted life years. Secondary outcomes include unmet needs, service satisfaction, maternal adjustment, quality of mother-infant interaction. Outcomes will be analysed using propensity scoring to account for systematic differences between MBU and non-MBU participants. Analyses will take place separately within strata, defined by the propensity score, and estimates pooled to produce an average treatment effect with weights to account for cohort attrition. ETHICS AND DISSEMINATION: The study has National Health Service (NHS) Ethics Approval and NHS Trust Research and Development approvals. The study has produced protocols on safeguarding maternal/child welfare. With input from our lived experience group, we have developed a dissemination strategy for academics/policy-makers/public.

[Delays related to maternal mortality in the department of Santander from 2012 to 2015]. / Demoras en mortalidad materna en el departamento de Santander 2012 a 2015.

OBJECTIVE: To characterize maternal deaths in the department of Santander, Colombia, and the delays that contributed to these deaths during the period 2012-2015, through a systematic review of health care, in order to offer an input that allows proposing actions that contribute to reduce these fatal outcomes. MATERIALS AND METHODS: Descriptive, retrospective, cross-sectional study that determines the characteristics of maternal mortality in pregnant or postpartum women who were administered complete analysis units and whose death was not caused by external or violent causes. RESULTS: The most frequent delay in the 49 cases of maternal deaths was type IV, which refers to the delay in receiving adequate and timely medical treatment (87.8%), mainly due to deficiencies in promotion and prevention strategies (63.2%). The majority of the deaths were avoidable (61.2%) in the puerperium (84%), and in users of the subsidized insurance scheme (57.1%). CONCLUSIONS: Although 98% of mothers were affiliated to the health system (subsidized, contributory, special or exceptional schemes), it was possible to demonstrate that women who were affiliated to the subsidized regime showed a greater frequency of the event, which reflects that there are important opportunities for improvement in the care provided to pregnant women in this type of scheme.

OBJETIVO: Caracterizar las muertes maternas en el departamento de Santander y las demoras que contribuyeron a dichas muertes, durante los años 2012 a 2015, mediante los análisis de las atenciones en salud, con el fin de ofrecer un insumo que permita plantear acciones para disminuir desenlaces fatales. MATERIALES Y MÉTODOS: Estudio descriptivo, retrospectivo, de corte transversal, en el cual se determinaron las características de la mortalidad materna en las mujeres gestantes o en puerperio a quienes se les realizaron unidades de análisis completas y que no fueron por causas externas o violentas. RESULTADOS: La demora que más se presentó en los 49 casos de muertes maternas fue la tipo IV relacionada con recibir un tratamiento médico adecuado y oportuno (87,8%), debido principalmente a deficiencias en los servicios de promoción y prevención (63,2%). La mayor parte de las muertes fueron evitables (61,2%), en el puerperio (84%) y en usuarias del régimen subsidiado (57,1%). CONCLUSIONES: Las mujeres afiliadas al régimen subsidiado presentaron mayor frecuencia del evento, lo cual refleja que existen importantes oportunidades de mejora en la atención que se brinda a las gestantes en el régimen subsidiado.

Clinical characteristics of patients from the worldwide registry on peripartum cardiomyopathy (PPCM): EURObservational Research Programme in conjunction with the Heart Failure Association of the European Society of Cardiology Study Group on PPCM.

AIMS: The purpose of this study is to describe disease presentation, co-morbidities, diagnosis and initial therapeutic management of patients with peripartum cardiomyopathy (PPCM) living in countries belonging to the European Society of Cardiology (ESC) vs. non-ESC countries. METHODS AND RESULTS: Out of 500 patients with PPCM entered by 31 March 2016, we report on data of the first 411 patients with completed case record forms (from 43 countries) entered into this ongoing registry. There were marked differences in socio-demographic parameters such as Human Development Index, GINI index on inequality, and Health Expenditure in PPCM patients from ESC vs. non-ESC countries (P < 0.001 each). Ethnicity was Caucasian (34%), Black African (25.8%), Asian (21.8%), and Middle Eastern backgrounds (16.4%). Despite the huge disparities in socio-demographic factors and ethnic backgrounds, baseline characteristics are remarkably similar. Drug therapy initiated post-partum included ACE inhibitors/ARBs and mineralocorticoid receptor antagonists with identical frequencies in ESC vs. non-ESC countries. However, in non-ESC countries, there was significantly less use of beta-blockers (70.3% vs. 91.9%) and ivabradine (1.4% vs. 17.1%), but more use of diuretics (91.3% vs. 68.8%), digoxin (37.0% vs. 18.0%), and bromocriptine (32.6% vs. 7.1%) (P < 0.001). More patients in non-ESC vs. ESC countries continued to have symptomatic heart failure after 1 month (92.3% vs. 81.3%, P < 0.001). Venous thrombo-embolic events, arterial embolizations, and cerebrovascular accidents were documented in 28 of 411 patients (6.8%). Neonatal death rate was 3.1%. CONCLUSION: PPCM occurs in women from different ethnic backgrounds globally. Despite marked differences in socio-economic background, mode of presentation was largely similar. Embolic events and persistent heart failure were common within 1 month post-diagnosis and required intensive, multidisciplinary management.

Protocol for economic evaluation alongside a cluster-randomised controlled trial of a psychoeducational intervention for the primary prevention of postnatal mental health problems in first-time mothers.

INTRODUCTION: Postnatal mental health problems, which are an international public health priority, are a suitable target for preventive approaches. The financial burden of these disorders is borne across sectors in society, including health, early childhood, education, justice and the workforce. This paper describes the planned economic evaluation of What Were We Thinking, a psychoeducational intervention for the prevention of postnatal mental health problems in first-time mothers. METHODS AND ANALYSIS: The evaluation will be conducted alongside a cluster-randomised controlled trial of its clinical effectiveness. Cost-effectiveness and costs-utility analyses will be conducted, resulting in estimates of cost per percentage point reduction in combined 30-day prevalence of depression, anxiety and adjustment disorders and cost per quality-adjusted life year gained. Uncertainty surrounding these estimates will be addressed using non-parametric bootstrapping and represented using cost-effectiveness acceptability curves. Additional cost analyses relevant for implementation will also be conducted. Modelling will be employed to estimate longer term cost-effectiveness if the intervention is found to be clinically effective during the period of the trial. ETHICS AND DISSEMINATION: Approval to conduct the study was granted by the Southern Health (now Monash Health) Human Research Ethics Committee (24 April 2013; 11388B). The study was registered with the Monash University Human Research Ethics Committee (30 April 2013; CF12/1022-2012000474). The Education and Policy Research Committee, Victorian Government Department of Education and Early Childhood Development approved the study (22 March 2012; 2012_001472). Use of the EuroQol was registered with the EuroQol Group; 16 August 2012. TRIAL REGISTRATION NUMBER: The trial was registered with the Australian New Zealand Clinical Trials Registry on 7 May 2012 (registration number ACTRN12613000506796).

A nationwide descriptive study of obstetric claims for compensation in Norway.

OBJECTIVE: To describe causes of substandard care in obstetric compensation claims. DESIGN AND SETTING: A nationwide descriptive study in Norway. POPULATION: All obstetric patients who believed themselves inflicted with injuries by the Health Service and applying for compensation. METHODS: Data were collected from 871 claims to The Norwegian System of Compensation to Patients during 1994-2008, of which 278 were awarded compensation. MAIN OUTCOME MEASURES: Type of injury and cause of substandard care. RESULTS: Of 871 cases, 278 (31.9%) resulted in compensation. Of those, asphyxia was the most common type of injury to the child (83.4%). Anal sphincter tear (29.9%) and infection (23.0%) were the most common types of injury to the mother. Human error, both by midwives (37.1% of all cases given compensation) and obstetricians (51.2%), was an important contributing factor in inadequate obstetric care. Neglecting signs of fetal distress (28.1%), more competent health workers not being called when appropriate (26.3%) and inadequate fetal monitoring (17.3%) were often observed. System errors such as time conflicts, neglecting written guidelines and poor organization of the department were infrequent causes of injury (8.3%). CONCLUSIONS: Fetal asphyxia is the most common reason for compensation, resulting in large financial expenses to society. Human error contributes to inadequate health care in 92% of obstetric compensation claims, although underlying system errors may also be present.

Is African descent an independent risk factor of peripartum cardiomyopathy?

Risk factors for peripartum cardiomyopathy (PPCM) are controversial. PPCM seems to be more prevalent in women of African descent, the highest observed incidence is in Haiti (1 per 300 live births). Our retrospective study conducted in Martinique showed an incidence of 1 per 5500 live births. This incidence is significantly lower than in Haiti. Women from Martinique and Haiti do not differ for most classical risk factors: African descent, age, pregnancy-associated hypertension, multiple pregnancy and pre-eclampsia. However, the parity rate and the socioeconomic level are different. Thus, African descent could be confounded by high parity rate and socioeconomic status.

Postpartum thromboembolism: severe events might be preventable using a new risk score model.

BACKGROUND: Pregnancy-related venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality. A new risk assessment model for VTE in relation to pregnancy has been introduced in Sweden. We wished to determine the proportion of preventable VTE cases if the model had been in use and make a brief cost-benefit analysis. METHODS: A hospital-based retrospective case-control study of all postpartum thromboembolic instances of deep venous thrombosis and pulmonary embolisms during a 16-year period. Large anamnestic risk factors at the time of delivery were assessed. We correlated the findings with the new Swedish guidelines for thromboprophylaxis. RESULTS: We found 37 cases of postpartum VTE during the study period. Nineteen of all VTE cases (51%) and eight out of eleven of cases of pulmonary embolism (73%) had two or more large anamnestic risk factors, ie, they would have been subjected to thromboprophylaxis if the new guidelines had been used. The cost of each preventable VTE was lower than treating a VTE. CONCLUSION: Approximately one-half of postpartum VTE cases and 70% of pulmonary emboli cases have at least two large risk factors and might be preventable using the new algorithm. From the perspective of the health care system the new recommendations appears to be cost-effective.

Economic efficacy of anthelmintic treatments in dairy sheep naturally infected by gastrointestinal strongyles.

The aim of the present paper was to assess benefit of strategic anthelmintic treatments on milk production in six commercial dairy sheep farms, located in southern Italy, whose animals were naturally infected with gastrointestinal strongyles. On each farm, two similar groups were formed, one untreated control group and one treated group. In all the treated groups, the strategic anthelmintic schemes were based on: (i) only one treatment with moxidectin in the periparturient period (February, Farm No. 6), or; (ii) two treatments, i.e. the first with moxidectin performed in the periparturient period (February, Farms Nos. 1, 2, 3 and 4) or in the postparturient period (April, Farm No. 5), and the second with netobimin at the mid/end of lactation (June, Farms Nos. 1, 2, 3, 4 and 5). Faecal egg count reduction (FECR) tests were performed on each farm in order to asses the anthelmintic efficacy of the drugs used. In addition, milk yield measurements for each animal fortnightly in each farm for the lactation period were performed. In terms of FECR, both moxidectin and netobimin were effective in all the 6 studied farms. Regarding milk production, overall in the 6 study farms the mean daily milk productions of the treated groups were higher than those of the control group. However, there were important differences between the 6 farms, i.e. the increase of milk production in the treated groups versus the control groups was as follows: +18.9% (Farm 1), +30.4% (Farm 2), +4.0% (Farm 3), +37.0% (Farm 4), +5.5% (Farm 5) and +40.8% (Farm 6). The results of the study showed that the economic efficacy of an anthelmintic treatment is not a cause-effect issue, but is a multifactorial issue which depends upon the quali-quantitative parasitological status of the animals, the pathogenesis of the species of parasites, the virulence of the strains of parasites, the local epidemiology, the timing of treatment, the breed of animal in terms of genetics and production types, nutrient supply.

[Cesarean section on demand--an equivalent alternative to spontaneous delivery?]. / Die Wunschsectio--Eine gleichwertige Alternative zur Spontangeburt?

Due to advances in perioperative management, surgical techniques as well as anaesthesia, caesarean section has become a very safe intervention for mother and child. In certain high-risk situations, an early delivery by caesarean section can prevent serous morbidity and mortality of the fetus and newborn. It has been postulated that a planned caesarean section is a true alternative to vaginal birth, and in the absence of a specific medical reason the woman's demand may be an indication for the operation. A critical review of studies based on large regional perinatal datasets shows that the risk for minor as well as serious complications in the mother and the newborn is increased after planned caesarean section. Serious consequences for subsequent pregnancies like uterine rupture or placenta praevia, which may be associated with accreta or abruptio of the placenta, are of major concern. On the other hand, trauma to the pelvic floor with urinary or anal incontinence is more frequent after vaginal birth. The balance of these risks including the very rare cases of severe intrapartal asphyxia, which might be prevented by a planned caesarean section, must be carefully evaluated together with the patient on an individual basis. These risks must be carefully balanced and the final decision about the type of delivery requires a detailed informed consent.critical review of studies based on large regional perinatal datasets shows that the risk for minor as well as serious complications in the mother and the newborn is increased after planned caesarean section. Serious consequences for subsequent pregnancies like uterine rupture or placenta praevia, which may be associated with accreta or abruptio of the placenta, are of major concern. On the other hand, trauma to the pelvic floor with urinary or anal incontinence is more frequent after vaginal birth. The balance of these risks including the very rare cases of severe intrapartal asphyxia, which might be prevented by a planned caesarean section, must be carefully evaluated together with the patient on an individual basis. These risks must be carefully balanced and the final decision about the type of delivery requires a detailed informed consent.

Evaluation of a systemic antibiotic treatment of toxic puerperal metritis in dairy cows.

The objective of this study was to evaluate the efficacy and economic efficiency of a systemic treatment of toxic puerperal metritis in dairy cows with ceftiofur. Cows with abnormal vaginal discharge at a postpartum examination (d 4 to 6 after calving) and a rectal temperature > or = 39.5 degrees C were assigned to three treatment groups. Cows in group 1 (n = 70) received 600 mg of ceftiofur intramuscularly (i.m.) on 3 consecutive days. Cows in group 2 (n = 79) received an intrauterine treatment with antibiotic pills consisting of 2500 mg of ampicillin and 2500 mg of cloxacillin and an additional 6000 mg (i.m.) of ampicillin. This treatment was performed on 3 consecutive days. Cows in group 3 (n = 78) received the same intrauterine treatment as in group 2. In addition, 600 mg of ceftiofur was administered i.m. on 3 consecutive days. Body temperature was recorded daily for 6 d after first treatment. There were no significant differences among the groups regarding clinical efficacy at d 6 after first treatment. The cure rates based on rectal temperatures declining to below 39.5 degrees C on d 6 after treatment were 82.9, 84.8, and 84.6% for groups 1, 2, and 3, respectively. Reproductive performance did not differ significantly between group 1 and groups 2 and 3 for any of the measures tested. A financial analysis with 87 different cost scenarios demonstrated that a systemic treatment of toxic puerperal metritis in cattle with ceftiofur is an effective alternative to the combination of local and systemic treatments.

Implementation of early discharges after uncomplicated vaginal deliveries: maternal and infant complications.

BACKGROUND: Short-stay obstetric stays have been the recent focus of many social and medical debates. We did a retrospective study of a large community teaching hospital's experience in making a safe transition to short-stay obstetrics. METHODS: Over a 10-month period, a multidisciplinary committee developed an intrapartum and postpartum education program to allow short hospital stays after uncomplicated vaginal deliveries. Computerized data were then retrieved on all uncomplicated spontaneous vaginal deliveries (DRG 373) from January 1994 to March 1995. RESULTS: During the study period, 554 women were discharged on the first postpartum day, resulting in three maternal readmissions and nine pediatric readmissions (combined readmission rate of 2.2%). This low readmission rate compared favorably with our experience with 2,563 uncomplicated vaginal deliveries from January 1991 to December 1993, immediately before the institution of the short-stay obstetrics program (combined readmission rate of 3.9%). The average hospital cost for a 1-day stay was $1,714 compared with $2,477 for a 2- to 3-day stay, representing a saving of only 31%. CONCLUSIONS: Early obstetric discharges after an uncomplicated spontaneous vaginal delivery can be safe and effective with appropriate patient selection and support.

Health and economic consequences of septic induced abortion.

Over a period of 7 years, 230 cases of illegally induced abortions complicated by sepsis were treated at the University College Hospital, Ibadan, Nigeria. The number of terminations complicated by sepsis doubled from 25.4 (between 1981 and 1985) to 51.0 (between 1986 and 1987) cases per year. Peritonitis was the commonest associated complication while maternal mortality was 8.3%. The average cost of treatment was US$223.11, while the average monthly earnings was US$45.00. Legalization of abortion would have resulted in a saving of US$50,022.28. Provision of legal abortion would reduce the incidence of sepsis after termination while reproductive health education and information dissemination and provision of easily accessible family planning services would greatly reduce the number of unwanted pregnancies.

Veterinary and nonveterinary costs of disease in 29 California dairies participating in the National Animal Health Monitoring System from 1988 to 1989.

Twenty-nine California dairy herds were studied over a 12-month period from 1988 to 1989 as part of the National Animal Health Monitoring System. Monthly interviews administered to dairy producers were used to measure the costs of all health-related expenditures and disease incidence in these herds. Of the total $1,523,558 reported, $1,355,467 (89%) was attributed to cost of disease events and $168,091 (11%) to cost of disease prevention. Most (78%) of the cost of disease events was attributable to death and culling losses. Veterinary services accounted for only $54,099 (4%) of total costs, 64% of which was used for disease prevention, compared with 36% for disease treatment. Udder disease was the most costly category of diseases reported at an average of $49.85/head at risk annually, followed by reproductive problems at $38.05. Through the use of sampling strategies less biased than those used in other surveys, the National Animal Health Monitoring System is designed to provide statistically-valid estimates of disease incidence and costs across broad geographic areas, potentially benefiting all those interested in the economics of livestock diseases in the United States.