Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study.

OBJECTIVE: Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. STUDY DESIGN: This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. RESULTS: During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. CONCLUSION: This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. KEY POINTS: · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..

Postpartum care in a cardio-obstetric clinic after preterm preeclampsia: patient and healthcare provider perspectives.

BACKGROUND: Despite the significant disruption and health implications of preterm preeclampsia with severe features for birthing people, little is known about how the system of postpartum care might be strengthened for affected families. Multidisciplinary cardio-obstetric clinics are emerging; however, there is limited research on patient and healthcare provider perspectives. OBJECTIVE: To describe patient and healthcare provider perspectives of services in a cardio-obstetric clinic following preterm preeclampsia with severe features. STUDY DESIGN: Individuals who experienced preterm preeclampsia with severe features and presented to a cardio-obstetric clinic were approached for study participation. Providers were approached if they provided postpartum care to patients with preterm preeclampsia with severe features and considered a referral to the cardio-obstetric clinic. Participants completed a remotely conducted, semistructured interview between March 2022 and April 2023. The interviews were audio-recorded, professionally transcribed, and checked for accuracy. Responses were inductively coded for content analysis around the study questions of clinical referrals, patient education, visit expectations, and care coordination in relation to ambulatory clinical services. RESULTS: Twenty participants (n=10 patients and n=10 providers) completed interviews. Healthcare system navigation was difficult, particularly in the context of postpartum needs. When patients are informed about their diagnosis, the information could both increase anxiety and be useful for long-term healthcare planning. Language concordant care did not always occur, and both patients and providers described gaps in quality services. Within the theme of responsibility, patients described needing to be vigilant, and providers recognized the gaps in referral and care coordination systems. Comprehensible patient education provided with birthing parents' companions and enhanced systems for care coordination were areas for further improvement in providing postpartum cardio-obstetric care following preterm preeclampsia. CONCLUSION: This qualitative study identified patients' struggles with a confusing postpartum healthcare system and captured providers' concerns about maintaining consistent care and improving access to long-term healthcare services to improve outcomes for patients at risk of cardiovascular disease.

Development and implementation of a pregnancy heart team at a Southeastern United States tertiary hospital: a qualitative study.

BACKGROUND: The United States has seen a significant rise in maternal mortality and morbidity associated with cardiovascular disease over the past 4 decades. Contributing factors may include an increasing number of parturients with comorbid conditions, a higher rate of pregnancy among women of advanced maternal age, and more patients with congenital heart disease who survive into childbearing age and experiencing pregnancy. In response, national medical organizations have recommended the creation of multidisciplinary obstetric-cardiac teams, also known as pregnancy heart teams, to provide comprehensive preconception counseling and coordinated pregnancy management that extend through the postpartum period. OBJECTIVE: We sought to describe the development and implementation of a pregnancy heart team for parturients with cardiac disease at a southeastern United States tertiary hospital. STUDY DESIGN: This was a qualitative study that was conducted among healthcare team members involved during the pregnancy heart team formation. Semi-structured interviews were conducted between April and May 2022, professionally transcribed, and the responses were thematically coded for categories and themes using constructs from The Consolidated Framework for Implementation Research. RESULTS: Themes identified included intentional collaboration to improve outpatient and inpatient coordination through earlier awareness of patients who meet the criteria and via documented care planning. The pregnancy heart team united clinicians around best practices and coordination to promote the success and safety of pregnancies and not only to minimize maternal health risks. Developing longitudinal care plans was critical among the pathway team to build on collective expertise and to provide clarity for those on shift to reduce hesitancy and achieve timely, vetted practices without additional consults. Establishing a proactive approach of specialists offering their perspectives was viewed as positively contributing to a culture of speaking up. Barriers to the successful development and sustainability of the pregnancy heart team included unmet administrative needs and clinician turnover within a context of shortages in staffing and high workload. CONCLUSION: This study described the process of developing and implementing a pregnancy heart team at 1 institution, thereby offering insights for future multidisciplinary care for maternal cardiac patients. Establishing pregnancy heart teams can enhance quality care for high-risk patients, foster learning and collaboration among physician and nursing specialties, and improve coordination to manage complex maternal cardiac cases.

Postpartum Hospital Discharge: Birthing Parent Perspectives on Supportive Practices and Areas for Improvement.

BACKGROUND: Postpartum hospital care and individualized discharge preparedness should be part of person-focused health services. Yet, there are limited descriptions of birthing parents' experiences to identify clinical practice strengths and opportunities to improve systems of care. OBJECTIVE: To explore birthing parents' perspectives on supportive healthcare practices and areas for improvement around postpartum hospital discharge. METHODS: In this mixed-methods study, participants completed an online questionnaire and a semistructured, telephone interview at 2 to 3 weeks postpartum. Researchers summarized responses to 2 quantitative questions and conducted a thematic content analysis of interview data. RESULTS: Forty birthing parents participated (90% non-White). According to quantitative responses, most birthing parents were prepared to be discharged (82.5%). Responses to the interview generated 6 broad factors related to postpartum hospital discharge preparedness: inpatient postpartum support, physical and emotional health, patient priorities and agency, clear and relevant information, holistic care, and scheduling and continuity of care. Researchers further identified themes around specific healthcare practices participants described to be supportive and opportunities for improvement. CONCLUSION: Birthing parents articulated multiple contributors to their preparation for postpartum hospital discharge. These perspectives offer insights for strengthening systems of perinatal care and inform measures of quality postpartum care.

Examination of Social Determinants of Health Characteristics Influencing Maternal Postpartum Symptom Experiences.

Postpartum women experience multiple, co-occurring postpartum symptoms. It is unknown if social determinants of health (SDOH) influence postpartum symptom typologies. This secondary analysis used the Community and Child Health Network study data. Participants included for analysis varied depending on the availability of the SDOH data (N = 851 to 1784). Bivariate and multiple regression analyses were conducted to examine the association between SDOH and previously identified postpartum symptom typologies. Area under the receiver operating characteristics curve (AUROC) was calculated to examine if adding SDOH variables contributes to predicting postpartum symptom typologies. The adjusted odds (aOR) of being in high symptom severity or occurrence typologies were greater for participants who had less than high school education (aOR = 2.29), experienced healthcare discrimination (aOR = 2.21), used governmental aid (aOR = 2.11), or were food insecure (aOR = 2.04). AUROC improved after adding SDOH. Considering experiences of different social-economic hardships influence postpartum symptom typologies, future practice and research should address SDOH to improve postpartum symptom experiences.

Hemoglobin on Admission for Childbirth and Postpartum Acute Care Use in a Southeastern Health Care System.

OBJECTIVE: Our objective was to evaluate whether hemoglobin on admission for childbirth is associated with postpartum acute care use (ACU). STUDY DESIGN: We conducted a retrospective cohort study of patients giving birth at a southeastern quaternary care hospital from January 2018 through June 2021 using electronic health records. Predelivery hemoglobin was categorized as <9, 9- < 10, 10- < 11, 11- < 12, and ≥12 g/dL. Acute care was defined as a visit to obstetric triage, the emergency department, or inpatient admission within 90 days postpartum. Generalized estimating equations quantified the crude and multivariable-adjusted association between predelivery hemoglobin and ACU. RESULTS: Among 8,677 pregnancies, 1,467 (17%) used acute care in the system within 90 days postpartum. In unadjusted models, those with predelivery hemoglobin <9 had twice the risk of postpartum ACU compared to those with hemoglobin ≥12 (95% confidence interval [CI]: 1.59-2.69), with a decrease in risk for each increase in hemoglobin category (9- < 10 g/dL: risk ratio [RR]: 1.47, CI: 1.21-1.79; 10- < 11 g/dL: RR: 1.44, CI: 1.26-1.64; 11- < 12 g/dL: RR: 1.20, CI: 1.07-1.34). The adjusted model showed a similar trend with smaller effect estimates (<9 g/dL: RR: 1.50, CI: 1.14-1.98; 9- < 10 g/dL: RR: 1.22, CI: 1.00-1.48; 10- < 11 g/dL: RR: 1.22, CI: 1.07-1.40; 11- < 12 g/dL: RR: 1.09, CI: 0.98-1.22). CONCLUSION: Low hemoglobin at childbirth admission was associated with increased postpartum ACU. Low hemoglobin on admission could signal to providers that additional follow-up, resources, and ongoing support are warranted to identify and address underlying health needs. Because hemoglobin is routinely assessed during the childbirth hospitalization, this indicator may be especially valuable for risk assessment among patients with limited prior engagement in health care. KEY POINTS: · Low hemoglobin on admission for birth is associated with postpartum acute care use.. · Hemoglobin on admission may aid in risk-stratification during childbirth hospitalization.. · Point-of-care metrics may help identify high-risk patients with limited preventive health care..

Human-centered design in the context of social determinants of health in maternity care: methods for meaningful stakeholder engagement.

PURPOSE: The screening process for social determinants of health (SDoH) includes questions regarding life circumstances and barriers to accessing health care. For patients, these questions may be intrusive, biased, and potentially risky. This article describes human-centered design methods to engage birthing parents and health care team members around SDoH screening and referral in maternity care. METHODS: Three phases of qualitative research with birthing parents, health care teams, and hospital administrators were conducted in the United States. Shadowing, interviews, focus groups, and participatory workshops addressed the explicit and tacit concerns of the stakeholders regarding SDoH during maternity care. RESULTS: Birthing parents wanted to be informed of the purpose of the clinic collecting SDoH information and how this information is used. Health care teams want to feel they are providing reliable and quality resources to their patients. They would like greater transparency that administrators are acting on SDoH data and the information is reaching people that can assist patients. CONCLUSION: As clinics implement patient-centered strategies for addressing SDoH in maternity care, it is important to include patients' perspectives. This human-centered design approach advances understanding of knowledge and emotional needs around SDoH and offers insights to meaningful engagement around sensitive health data.

Institution-Specific Perinatal Emergency Checklists: Multicenter Report on Development, Implementation, and Sustainability.

OBJECTIVE: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse checklist use to improve obstetric care. However, there is limited research into development, implementation, and sustained use of perinatal emergency checklists to inform individual institutions. This study aimed to investigate the development and implementation of perinatal emergency checklists in diverse hospital settings in the United States. STUDY DESIGN: A qualitative study was conducted individually with clinicians from three health care systems. The participants developed and implemented institution-tailored perinatal emergency checklists. Interview transcriptions were coded using the Consolidated Framework for Implementation Research. RESULTS: The study sites included two health care systems and one individual hospital. Delivery volumes ranged from 3,500 to 48,000 deliveries a year. Interviews were conducted with all 10 participants approached. Checklists for 19 perinatal emergencies were developed at the three health care systems. Ten of the checklist topics were the same at all three institutions. Participants described the checklists as improving patient care during crises. The tools were viewed as opportunities to promote a shared mental model across clinical roles, to reduce redundancy and coordinate obstetric crisis management. Checklist were developed in small groups. Implementation was facilitated by those who developed the checklists. Participants agreed that simulation was essential for checklist refinement and effective use by response teams. Barriers to implementation included limited clinician availability. There was also an opportunity to strengthen integration of checklists workflow early in perinatal emergencies. Participants articulated that culture change took time, active practice, persistence, reinforcement, and process measurement. CONCLUSION: This study outlines processes to develop, implement, and sustain perinatal emergency checklists at three institutions. Participants agreed that multiple, parallel implementation tactics created the culture shift for integration. The overview and specific Consolidated Framework for Implementation Research components may be used to inform adaptation and sustainability for others considering implementing perinatal emergency checklists. KEY POINTS: · Perinatal emergency checklists reduce redundancy and coordinate obstetric crisis management.. · Perinatal emergency simulation is essential for checklist refinement and effective team use.. · Integrations of perinatal emergency checklists requires culture change and process measurement..

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records.

Introduction: The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs). Materials and Methods: A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery. Results: Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers. Conclusions: Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

Evaluation of Patient Access to Spanish-Language-Concordant Care on a Postpartum Unit.

OBJECTIVE: To evaluate patient access to Spanish-language-concordant care on a postpartum unit and to identify facilitators and barriers to the use of interpretation services. DESIGN: Mixed-methods research study, comprising a cross-sectional chart review from September to December 2019 and semistructured interviews from June to December 2020. SETTING/LOCAL PROBLEM: A tertiary academic medical center in the southeastern United States where individuals with limited English proficiency are at risk for poor health outcomes when they are unable to communicate with clinicians in their preferred language. PARTICIPANTS: We conducted a chart review of 50 randomly selected birthing parent-newborn couplets and interviews with 14 inpatient health care team members. MEASUREMENTS: The chart review examined patient characteristics, health care team composition including Spanish language proficiency, length of stay, number of interpreter requests, and time between clinician interpreter requests and interpreter arrival on the unit. Interviews evaluated facilitators and barriers to interpreter use. RESULTS: Access to a clinician certified in medical Spanish or an interpreter was offered to 12 of 50 (24%) couplets upon admission to the unit and to 7 of 50 (14%) of couplets for daily maternal and newborn medical rounds. Clinicians reported long and unpredictable wait times to access interpreters, which led them to rely on hand gestures, broken Spanish, and smartphone apps to "get by" when communicating with patients without certified interpretation services. Participants described low usage of interpreters for "noncritical" encounters. CONCLUSION: Interpreters and other forms of Spanish-language-concordant care were underused on the postpartum unit. This deviation from national standards may put families at risk for harm. Recommendations from this study include advancing a culture of respectful care, improving the interpreter request workflow, addressing safe staffing, facilitating direct patient access to interpreters, and providing ongoing evaluation and support.

Welcoming, supportive care in US birthing facilities and realization of breastfeeding goals.

BACKGROUND: Emotional and physical support for birthing parents is positively associated with realization of their breastfeeding goals. However, few studies have investigated maternal descriptions of their postnatal unit experience of these domains. RESEARCH AIM: The objective was to investigate maternal report of their birthing facility experiences and quantify the extent to which accounts of postpartum support were associated with meeting their breastfeeding goals. METHODS: After IRB review, data were obtained through an online survey distributed from November 2016-May 2017. This analysis utilizes data from 2,771 birthing parents who were at least 18 years of age, experienced maternity care in the United States within five years, and reported that they had intended to breastfeed. Bivariate analysis was followed by logistic regression controlling for significant covariates. RESULTS: In this sample of primarily non-Hispanic white birthing parents with intent to exclusively breastfeed, the following postnatal unit variables were associated with higher odds of meeting their breastfeeding goals, birthing parents feeling: welcomed (adjusted OR=1.36), that health care promoted their physical health (adjusted OR=1.41), that care promoted their emotional health (adjusted OR=1.38), that they were supported (adjusted OR=1.56), and that they were recognized by their health care team (adjusted OR=1.30). All the measured postnatal unit support variables were significantly correlated with each other, with correlation coefficients ranging from 0.15 to 0.81. CONCLUSIONS: Before the COVID-19 pandemic, birthing parents' experiences on the postnatal unit were interrelated and associated with meeting their breastfeeding goals. As health care services are reviewed and prioritized during the COVID-19 pandemic and as part of ongoing strengthening of systems, qualitative and observational research can address the mechanisms underlying breastfeeding outcomes to inform the provision of more holistic and effective support.

Systematic Review of the Effect of Technology-Mediated Education Intervention on Maternal Outcomes in the First Year After Birth.

OBJECTIVE: To synthesize the findings on the effect of technology-mediated education intervention in the first year after birth on maternal health outcomes and to evaluate interventions for participant perspectives and health equity. DATA SOURCES: We conducted a systematic review of the literature using the electronic databases PubMed, Embase, and CINAHL for articles published between 2010 and 2020. The search strategy was developed by a health sciences librarian. STUDY SELECTION: We included articles if the following criteria were met: they reported studies conducted in the United States or a resource-similar nation on the evaluation of a technology-mediated education intervention within the first year after birth and they included the assessment of at least one maternal health outcome. DATA EXTRACTION: The lead author extracted data from the full-text articles and entered them into Microsoft Excel. We assessed the quality and risk of bias using the Cochrane Collaboration's tool for examining the potential risk of bias. DATA SYNTHESIS: We identified 21 articles that met the inclusion criteria. Videos were the most commonly reported technology-mediated education intervention, followed by text messages, phone calls, and websites. Maternal health outcomes addressed in the included articles were mental health, weight loss, breastfeeding, general postpartum education, perineal care, and substance use. Technology-mediated education interventions positively affected mental health, weight loss, and breastfeeding outcomes. CONCLUSION: The current evidence suggests that technology-mediated education intervention is beneficial for the physical and mental health outcomes of women during the first year after birth. Future work may benefit from more attention to health equity and design in collaboration with women to gain a better understanding of the information needs and desired technology features.

Postnatal Unit Experiences Associated With Exclusive Breastfeeding During the Inpatient Stay: A Cross-Sectional Online Survey.

BACKGROUND: Efforts to provide accessible and effective infant feeding support are advancing to set up new families to meeting their goals. However, data continue to be limited for understanding how inpatient postpartum support and experiences contribute to exclusive breastfeeding during hospitalization. RESEARCH AIMS: To explore postnatal unit experiences including skin-to-skin contact, overnight support, rooming-in, responsive clinicians, and understandable communication that correlate with early infant feeding outcomes among a sample of mothers who intended to breastfeed. METHODS: This was a prospective cross-sectional survey study. Through secure online survey, participants submitted (N = 2,401) responses from November 2016 to May 2017 about their experiences with maternity healthcare and offered thoughts on the postnatal unit environment. Descriptive statistics were used to examine distributions of maternal characteristics, postpartum experience, and birthing facility characteristics. RESULTS: Exclusive breastfeeding was positively correlated with the following postnatal unit experiences: mother did not ask that her infant be taken out of the postnatal unit room; infant staying in postnatal unit room except for treatment(s); mother got help from clinical staff when needed after pressing the call button; and nurse, midwife, and/or doctor always explained information to mother in ways that they understood. CONCLUSION: Postnatal unit experiences associated with exclusive breastfeeding during postpartum hospitalization were rooming in; parents who did not ask for their infant to be taken out of the unit room; whether mothers received timely help from clinical staff; and information was explained in a way they could understand.

Screening and Referral for Social Determinants of Health: Maternity Patient and Health Care Team Perspectives.

Objective: To identify patient and health care team perspectives on screening and referral for Social Determinants of Health (SDoH) in maternity care. Methods: This human-centered design study was conducted in a prenatal clinic and in the surrounding community of a university teaching hospital in the Southeastern United States. Qualitative data were collected through semistructured interviews and focus groups between March 2019 and February 2020, with findings shared in-person with participants for feedback. Results: A total of 19 English- and Spanish-speaking patients and 11 health care team members participated. Participants suggested that all patients should be screened as part of integrated health assessments, early in care and periodically, but only when protocols are in place for addressing needs-immediate or ongoing. They expressed concerns that disclosure of SDoH screening data might exacerbate already existing biases, negatively impact care, or be used to harm them. Patients wanted proactive transparency about the purpose of SDoH screening, and to know who would have access to their data, when and how it would be used, and how long it would be stored. Patients expressed concern about confidentiality and stigma, and wanted their health care team to normalize seeking help, and acknowledge that birthing people's circumstances change over time. Patients and health care team responded that patient-provider communication should be respectful, be antiracist, and demonstrate respect for patient autonomy. Conclusion: Patients and health care team members recommended that SDoH resource information be accessible to all patients regardless of endorsed needs.

Social Determinants of Health in Maternity Care: A Quality Improvement Project for Food Insecurity Screening and Health Care Provider Referral.

Purpose: This quality improvement project evaluated implementation of social determinants of health screening and referral for food insecurity. Methods: Four obstetric providers used study-developed resources to screen and refer English-speaking patients (n=14) during clinic visits. Providers and patients completed post-visit questionnaires. Provider feedback informed improvements to the intervention approach for consecutive study shifts. Results: Providers and patients reported high satisfaction with encounters. Referrals were made for four patients. Challenges to implementation included resource organization, time constraints, and integration into clinic workflow. Conclusion: Processes for universal screening and tailored information provision are areas to continue to strengthen for establishing equitable health care.

Associations between mother-infant bed-sharing practices and infant affect and behavior during the still-face paradigm.

Parents in the United States increasingly report bed-sharing with their infants (i.e., sleeping on a shared sleep surface), but the relationship between bed-sharing and child socioemotional outcomes are not well understood. The current study examines the links between mother-infant bed-sharing at 3 months and infant affect and behavior during a dyadic challenge task at 6 months. Further, we examine nighttime mother-infant contact at 3 months as a possible mechanism that may mediate linkages between bed-sharing and infant outcomes. Using observational data from a sample of 63 mother-infant dyads, we found that infants who bed-shared for any proportion of the observation period at 3 months displayed significantly more self-regulatory behaviors during the still-face episode of the Still-Face Paradigm (SFP) at 6 months, compared to non-bed-sharing infants. Also, infants of mothers who bed-shared for the entire observation period displayed significantly less negativity during the reunion episode than non-bed-sharing infants. There was no evidence that the relations between mother-infant bed-sharing practices and infant affect and behavior during the SFP were mediated through nighttime mother-infant contact. Results suggest that infant regulation at 6 months postpartum may vary based on early nighttime experiences, with bed-sharing potentially promoting more positive and well-regulated behavior during dyadic interaction.

Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management.

OBJECTIVE: To evaluate whether the frequency of pain assessment and treatment differed by patient race and ethnicity for women after cesarean birth. METHODS: We performed a retrospective cohort study of all women who underwent cesarean birth resulting in a liveborn neonate at a single institution between July 1, 2014, and June 30, 2016. Pain scores documented and medications administered after delivery were grouped into 0-24 and 25-48 hours postpartum time periods. Number of pain scores recorded, whether any pain score was 7 of 10 or greater, and analgesic medication administered were calculated. Models were adjusted for propensity scores incorporating maternal age, body mass index, gestational age, nulliparity, primary compared with repeat cesarean delivery, classical hysterotomy, and admission to the neonatal intensive care unit. RESULTS: A total of 1,987 women were identified, and 1,701 met inclusion criteria. There were 30,984 pain scores documented. Severe pain (7/10 or greater) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%). In the first 24 hours after cesarean birth, non-Hispanic white women had more documented pain assessments (adjusted mean 10.2) than, black, Asian, and Hispanic women (adjusted mean 8.4-9.5; P<.05). Results at 25-48 hours were similar, compared with non-Hispanic white women (adjusted mean 8.3). Black, Asian, and Hispanic women and women who were identified as other all received less narcotic medication at 0-24 hours postpartum (adjusted mean 5.1-7.5 oxycodone tablet equivalents; P<.001-.05), as well as at 25-28 hours postpartum. CONCLUSION: Racial and ethnic inequities in the experience, assessment and treatment of postpartum pain were identified. A limitation of our study is that we were unable to assess the role of patient beliefs about expression of pain, patient preferences with regards to pain medication, and beliefs and potential biases among health care providers.

Evaluation of Ready, Set, BABY: A prenatal breastfeeding education and counseling approach.

BACKGROUND: Comprehensive prenatal education on infant feeding is recommended by many United States health organizations because of the need to maximize maternal preparedness for managing lactation physiology. Ready, Set, BABY (RSB) is a curriculum developed for counseling women about breastfeeding benefits and management including education on optimal maternity care practices. We hypothesized that RSB would be acceptable to mothers and that mothers' strength of breastfeeding intentions would increase, and their comfort with the idea of formula feeding would decrease after educational counseling using the materials. We also hypothesized that mothers' knowledge of optimal maternity care practices would increase after participation. METHODS: Materials were sent to a total of seven sites in the United States and Puerto Rico. Local health care practitioners completed training before counseling mothers with the curriculum. A pre- and postintervention questionnaire was administered to participants. Statistical analysis of results included paired t tests, Wilcoxon signed-rank tests, and McNemar's tests. RESULTS: Four hundred and sixteen expectant women participated. In the pre- and postintervention comparison, maternal participation in RSB significantly improved Infant Feeding Intentions Scale scores (P < 0.001) and knowledge of Baby-Friendly recommended maternity care practices (P < 0.001), while significantly decreasing comfort with the idea of formula feeding (P < 0.001). The education materials were positively rated by participants. CONCLUSIONS: The findings indicate that the approach of using RSB in prenatal counseling group classes or individual sessions improves breastfeeding intentions. Future testing is needed to determine the effectiveness of the materials for impacting breastfeeding outcomes.