Society for Maternal-Fetal Medicine Special Statement: Prophylactic low-dose aspirin for preeclampsia prevention-quality metric and opportunities for quality improvement.

Prophylactic low-dose aspirin reduces the rates of preeclampsia, preterm birth, fetal growth restriction, and perinatal death in patients with risk factors for preeclampsia. Despite recommendations from the US Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine, low-dose aspirin use is reported in <50% of patients with high-risk factors and <25% of patients with >1 moderate-risk factor. These low use rates represent an important "quality gap" and demonstrate the need for quality improvement activities. In this article, we outline the specifications for a process metric to standardize the measurement of the rate of aspirin use. Furthermore, we outline an approach to conducting a quality improvement project to increase the use of aspirin by patients with risk factors for preeclampsia.

Association of Social Determinants of Health and Clinical Factors with Postpartum Hospital Readmissions among Nulliparous Individuals.

OBJECTIVE: Prior data suggest that there are racial and ethnic disparities in postpartum readmission among individuals, especially among those with hypertensive disorders of pregnancy. Existing reports commonly lack granular information on social determinants of health. The objective of this study was to investigate factors associated with postpartum readmission for individuals and address whether such risk factors differed by whether an individual had an antecedent diagnosis of a hypertensive disorder of pregnancy (HDP). STUDY DESIGN: This is a secondary analysis of a large, multicenter prospective cohort study of 10,038 nulliparous participants. The primary outcome of this analysis was postpartum readmission. A priori, participants were analyzed separately based on whether they had HDP. Participant characteristics previously associated with a greater risk of perinatal morbidity or readmission (including social determinants of health, preexisting and chronic comorbidities, and intrapartum characteristics) were compared with bivariable analyses and retained in multivariable models if p < 0.05. Social determinants of health evaluated in this analysis included insurance status, self-identified race and ethnicity (as a proxy for structural racism), income, marital status, primary language, and educational attainment. RESULTS: Of 9,457 participants eligible for inclusion, 1.7% (n = 165) were readmitted following initial hospital discharge. A higher proportion of individuals with HDP were readmitted compared with individuals without HDP (3.4 vs 1.3%, p < 0.001). Among participants without HDP, the only factors associated with postpartum readmission were chorioamnionitis and cesarean delivery. Among participants with HDP, gestational diabetes and postpartum hemorrhage requiring transfusion were associated with postpartum readmission. While the number of postpartum readmissions included in our analysis was relatively small, social determinants of health that we examined were not associated with postpartum readmission for either group. CONCLUSION: In this diverse cohort of nulliparous pregnant individuals, there was a higher frequency of postpartum readmission among participants with HDP. Preexisting comorbidity and intrapartum complications were associated with postpartum readmission among this population engaged in a longitudinal study. KEY POINTS: · Non-HDP patients had higher odds of PPR with chorioamnionitis or cesarean.. · HDP patients had higher odds of PPR if they had GDM or PPH.. · Characterizing PPR may identify and highlight modifiable factors..

Assessing the impact of telehealth implementation on postpartum outcomes for Black birthing people.

BACKGROUND: The COVID-19 pandemic led to the rapid uptake of telemedicine services, which have been shown to be potentially cost-saving and of comparable quality to in-person care for certain populations. However, there are some concerns regarding the feasibility of implementation for marginalized populations, and the impact of widespread implementation of these services on health disparities has not been well studied. OBJECTIVE: This study aimed to assess the impact of telehealth implementation on postpartum care during the COVID-19 pandemic on racial disparities in visit attendance and completion of postpartum care goals. STUDY DESIGN: In this retrospective cohort study at a single tertiary care center, differences in outcomes between all Black and non-Black patients who had scheduled postpartum visits before and after telehealth implementation for postpartum care were compared. The primary outcome was postpartum visit attendance. The secondary outcomes included postpartum depression screening, contraception selection, breastfeeding status, completion of postpartum 2-hour glucose tolerance test, and cardiology follow-up for hypertensive disorders of pregnancy. In multivariable analysis, interaction terms were used to evaluate the differential impact of telehealth implementation by race. RESULTS: Of 1579 patients meeting the inclusion criteria (780 in the preimplementation group and 799 in the postimplementation group), 995 (63%) self-identified as Black. In the preimplementation period, Black patients were less likely to attend a postpartum visit than non-Black patients (63.9% in Black patients vs 88.7% in non-Black patients; adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.79). In the postimplementation period, there was no difference in postpartum visit attendance by race (79.1% in Black patients vs 88.6% in non-Black patients; adjusted odds ratio, 0.74; 95% confidence interval, 0.45-1.21). In addition, significant differences across races in postpartum depression screening during the preimplementation period became nonsignificant in the postimplementation period. Telehealth implementation for postpartum care significantly reduced racial disparities in postpartum visit attendance (interaction P=.005). CONCLUSION: Telehealth implementation for postpartum care during the COVID-19 pandemic was associated with decreased racial disparities in postpartum visit attendance.

Quality Improvement Initiative for Aspirin Screening and Prescription Rates for Preeclampsia Prevention in an Outpatient Obstetric Clinic.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) impact 10% of pregnancies in the United States and cause adverse maternal and neonatal outcomes such as prematurity and low birth weight. Aspirin administration to at-risk individuals during pregnancy can reduce risk of HDP. STUDY DESIGN: Define-Measure-Assess-Improve-Control methodology was utilized to improve aspirin screening in an outpatient obstetric clinic. Retrospective cohort analysis compared outcome metrics pre- and postimplementation by using logistic regression models, adjusting for race and insurance. Key informant interviews and process mapping identified barriers to aspirin screening. A multidisciplinary team implemented low-cost strategies such as provider education, additional screening by ancillary staff, automated electronic reminders, and standardized patient counseling. RESULTS: Over 6 months, the screening rate improved from 62.5 to 92.0% (adjusted odds ratio [aOR] = 6.89, 95% confidence interval [CI]: 3.30-14.43). The prescription rate for patients correctly identified to be eligible for aspirin improved from 66.7 to 82.4% (aOR = 1.96, 95% CI: 0.88-4.35). CONCLUSION: Comprehensive, tailored quality improvement efforts can significantly increase aspirin screening and prescription, which may decrease maternal and neonatal morbidity due to HDP. KEY POINTS: · Initiative improved overall and correct screening rates.. · Initiative increased provider knowledge of eligibility.. · Low-cost interventions can have high impact over short time interval..

Examining changes in clinical management and postpartum readmissions for hypertensive disorders of pregnancy over time.

OBJECTIVE: In response to 2013 guidelines for hypertensive disorders of pregnancy (HDP), our study examined changes in antenatal management and postpartum readmission (PPR) over time. STUDY DESIGN: This is a retrospective cohort study of individuals diagnosed antenatally with HDP who delivered at a tertiary care center from 2012 to 2017. MAIN OUTCOME MEASURES: The primary outcome was postpartum readmission for HDP in 2012-2013 vs 2014-2017. Secondary outcomes included intravenous magnesium administration and prescription for oral (PO) antihypertensive medication during delivery admission. Multivariable logistic regression models assessed differences in outcomes over time, adjusted for age, race, and payer status, for HDP with and without severe features, defined by ACOG criteria. RESULTS: Of 5,300 eligible individuals, 73.5 % had HDP without severe features and 26.5 % had severe features. The PPR frequency in this cohort was 1.1 % (N = 59). There was no difference in PPR for individuals with HDP without severe features (aOR 0.73; 95 % CI 0.28-1.88) or with severe features (aOR 1.30; 95 % CI 0.50-3.39) by epoch. Magnesium administration for HDP with severe features remained below 80 % over time. Magnesium administration for HDP without severe features and discharge prescriptions for PO medications for HDP with severe features were lower after 2013. Neither magnesium administration nor discharge prescriptions were associated with decreased odds of PPR. CONCLUSION: Although there was no difference in PPR for HDP after 2013, there were changes in antenatal management of HDP, including decreased magnesium administration for individuals with HDP without severe features and PO medication for individuals with severe features.

Evaluating the maternal and perinatal sequelae of severe gestational hypertension.

BACKGROUND: Hypertensive disorders of pregnancy are widespread and have long-standing implications for women's health. Historically, the management of "severe gestational hypertension," or the presence of severely elevated blood pressures without any other signs or symptoms of end-organ damage meeting the criteria for preeclampsia, has been unclear. The new American College of Obstetricians and Gynecologists guidelines based on expert opinion recommend that severe gestational hypertension be treated similarly to preeclampsia with severe features, but data regarding outcomes for women with this diagnosis have been limited. OBJECTIVE: This study aimed to compare the maternal and perinatal sequelae of severe gestational hypertension with that of other types of hypertensive disorders of pregnancy. STUDY DESIGN: This is a retrospective cohort study of women with hypertensive disease of pregnancy who delivered at a single tertiary care center between February and December 2018. Women with chronic hypertension; hemolysis, elevated liver enzymes, and low platelet count syndrome; preexisting kidney, liver, rheumatologic, or hematologic disorders; or multifetal pregnancies were excluded. Women were categorized as having severe gestational hypertension if they had a sustained systolic blood pressure of >160 mm Hg or a diastolic blood pressure of >110 mm Hg without other criteria for preeclampsia. The primary comparison was between women with severe gestational hypertension and women with preeclampsia without severe features. Secondary comparisons included women with severe gestational hypertension vs women with other types of hypertensive disease of pregnancy. The primary outcome for this analysis was small-for-gestational-age birth. We also evaluated other maternal and neonatal morbidities including but not limited to pulmonary embolism, stroke, eclampsia, blood transfusion, mechanical ventilation, intensive care unit admission, death, 5-minute Apgar score of ≤4, umbilical cord pH, neonatal intensive care unit admission of >2 days, respiratory distress syndrome, and neonatal death. Bivariate analyses using chi-square tests and logistic regressions adjusting for race, ethnicity, age, body mass index, parity, and insurance status were performed to compare frequencies of outcomes for each type of hypertensive disease of pregnancy with those of severe gestational hypertension. RESULTS: Of 2076 women eligible for inclusion, 12.2% (n=254) had severe gestational hypertension and 379 (18.2%) had preeclampsia without severe features. Although there was no difference in the odds of small-for-gestational-age birth between women with severe gestational hypertension and women with preeclampsia without severe features (14.7% vs 9.8%; adjusted odds ratio, 0.72; 95% confidence interval, 0.44-1.21), the latter were significantly less likely to receive a prescription for antihypertensive medication at discharge (OR 0.11, 95% CI 0.06-0.22) or to be readmitted postpartum (OR 0.14, 95% CI 0.04-0.50). CONCLUSION: There was no difference in the primary outcome, that is, rate of small-for-gestational-age birth, between women with severe gestational hypertension and women with preeclampsia without severe features. However, women with severe gestational hypertension had greater odds of other maternal and neonatal morbidities than women with preeclampsia without severe features or mild gestational hypertension. These findings support recent recommendations regarding the management of women with severe gestational hypertension.

Evaluating the Impact of a Student-Run Women's Clinic on Access to Gynecologic Care for Uninsured Women in Rhode Island.

Clinica Esperanza/Hope Clinic (CEHC) is a free clinic providing primary care to a predominantly Spanish-speaking, uninsured patient population in Rhode Island with limited access to gynecologic care. In 2015, medical students at the Alpert Medical School of Brown University started the Women's Clinic of Clinica Esperanza (WCCE), a "clinic within the clinic," recruiting physician preceptors and obtaining funding to support WCCE operations. For complex issues, clinic services were supplemented by a subspecialty referral system at a local hospital. Interim results over a two-year period ending in May 2017 are reported here. Medical students organized 48 women's clinics and provided 83 Pap smears, 138 breast exams, 42 mammogram referrals, 35 STI tests, and 19 vaginitis screens, among other activities. As the example of WCCE shows, student-run clinics can utilize medical students' relationships with providers and unique funding sources to expand access to specialty care for uninsured patients.

Characterizing Social Determinants of Health for Adolescent Mothers during the Prenatal and Postpartum Periods.

PURPOSE: Significant racial disparities and continuing poor birth outcomes make adolescent pregnancy a significant public health concern in the United States despite declining pregnancy rates. Social determinants of health are associated with increased likelihood of pregnancy and poor maternal and child health outcomes. This study aims to characterize specific elements of social determinants of health in a cohort of predominantly Latina adolescent mothers. METHODS: Between February 2007 and August 2008, 106 pregnant adolescents participated in a study with assessments at 20 to 24 weeks of gestation, and at 3 and 6 months postpartum. Survey questions addressed residential mobility, financial support and childcare, and perceived need for and use of community resources. Comparative analysis assessed differences between adolescents by age (<16 vs. ≥16 years old) and ethnicity (Latina vs. non-Latina). FINDINGS: Adolescent mothers experienced high rates of residential mobility, with 59.4% moving at least once in the year before their prenatal survey. Participants relied primarily on public aid (94-96%) and their parents (81-85%) for financial support. Latina participants were more likely than non-Latinas to rely on public aid. Although many participants reported needing financial support and housing, few used available services. Younger adolescents relied less often on the father of the baby for support than older adolescents. CONCLUSIONS: Adolescent mothers' high rates of residential mobility and increasing reliance on public assistance highlight resource gaps that potentially put them and their children at risk for poor outcomes. Targeted efforts to augment systemic support in these domains are a critical component of addressing health disparities for this population.