Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules.

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative.

BACKGROUND: We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. METHODS: We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. RESULTS: Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). DISCUSSION: Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.

Delivery Strategies for Postpartum Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the effects of postpartum health care-delivery strategies on health care utilization and maternal outcomes. DATA SOURCES: We searched Medline, EMBASE, CENTRAL, CINAHL, and ClinicalTrials.gov for studies in the United States or Canada from inception to November 16, 2022. METHODS OF STUDY SELECTION: We used duplicate screening for studies comparing health care-delivery strategies for routine postpartum care on health care utilization and maternal outcomes. We selected health care utilization, clinical, and harm outcomes prioritized by stakeholder panels. TABULATION, INTEGRATION, AND RESULTS: We found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480). For general postpartum care, care location (clinic, at home, by telephone) did not affect depression or anxiety symptoms (low strength of evidence), and care integration (by multiple types of health care professionals) did not affect depression symptoms or substance use (low strength of evidence). Providing contraceptive care earlier (compared with later) was associated with greater implant use at 6 months (summary effect size 1.36, 95% CI 1.13-1.64) (moderate strength of evidence). Location of breastfeeding care did not affect hospitalization, other unplanned care utilization, or mental health symptoms (all low strength of evidence). Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month and any breastfeeding at 3-6 months (summary effect size 1.10-1.22) but not other breastfeeding measures (all moderate strength of evidence). Care by a lactation consultant was associated with higher breastfeeding rates at 6 months (summary effect size 1.43, 95% CI 1.07-1.91) but not exclusive breastfeeding (all moderate strength of evidence). Use and nonuse of information technology for breastfeeding care were associated with comparable rates of breastfeeding (moderate strength of evidence). Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing but not random glucose or hemoglobin A 1c testing (moderate strength of evidence). CONCLUSION: Various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022309756 .

Retrospective Use of Patients' Characteristics to Assess Variation in Prenatal Care Utilization.

OBJECTIVE: We used patients' medical and psychosocial risk factors to explore prenatal care utilization and health outcomes to inform prenatal care tailoring. STUDY DESIGN: This retrospective cohort study assessed patients who gave birth at an academic institution from January 1 to December 31, 2018, using electronic health record (EHR) data. Patients were categorized into four phenotypes based on medical/psychosocial risk factors available in the EHR: Completely low risk; High psychosocial risk only; High medical risk only; and Completely high risk. We examined patient characteristics, visit utilization, nonvisit utilization (e.g., phone calls), and outcomes (e.g., preterm birth, preeclampsia) across groups. RESULTS: Of 4,681 patients, the majority were age 18 to 35 (3,697, 79.0%), White (3,326, 70.9%), multiparous (3,263, 69.7%), and Completely high risk (2,752, 58.8%). More Black and Hispanic patients had psychosocial risk factors than White patients. Patients with psychosocial risk factors had fewer prenatal visits (10, interquartile range [IQR]: 8-12) than those without (11, IQR: 9-12). Patients with psychosocial risk factors experienced less time in prenatal care, more phone calls, and fewer EHR messages across the same medical risk group. Rates of preterm birth and gestational hypertension were incrementally higher with additional medical/psychosocial risk factors. CONCLUSION: Data readily available in the EHR can assess the compounding influence of medical/psychosocial risk factor on patients' care utilization and outcomes. KEY POINTS: · Medical and psychosocial needs in pregnancy can inform patient phenotypes and are associated with prenatal care use and outcomes.. · Patient phenotypes are associated with prenatal care use and outcomes.. · Patients with high psychosocial risk spent less time in prenatal care and had more phone calls in pregnancy.. · Tailored prenatal care models may proactively address differences in patient's needs..

Routine Prenatal Care.

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Reduced Compared With Traditional Schedules for Routine Antenatal Visits: A Systematic Review.

OBJECTIVE: To assess differences in maternal and child outcomes in studies comparing reduced routine antenatal visit schedules with traditional schedules. DATA SOURCES: A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, searching for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries. METHODS OF STUDY SELECTION: Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher. TABULATION, INTEGRATION, AND RESULTS: Five randomized controlled trials and five nonrandomized comparative studies compared reduced routine antenatal visit schedules with traditional schedules. Studies did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight. There was insufficient evidence for numerous prioritized outcomes of interest, including completion of the American College of Obstetricians and Gynecologists-recommended services and patient experience measures. CONCLUSION: The evidence base is limited and heterogeneous and allowed few specific conclusions. Reported outcomes included, for the most part, standard birth outcomes that do not have strong plausible biological connection to structural aspects of antenatal care. The evidence did not find negative effects of reduced routine antenatal visit schedules, which may support implementation of fewer routine antenatal visits. However, to enhance confidence in this conclusion, future research is needed, particularly research that includes outcomes of most importance and relevance to changing antenatal care visits. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021272287.

Televisits Compared With In-Person Visits for Routine Antenatal Care: A Systematic Review.

OBJECTIVE: To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care. DATA SOURCES: A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries. METHODS OF STUDY SELECTION: Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher. TABULATION, INTEGRATION, AND RESULTS: Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82-1.28) or preterm births (summary OR 0.93, 95% CI 0.84-1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported. CONCLUSION: People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021272287.

Use of Opioid-Sparing Protocols and Perceived Postpartum Pain in Patients with Opioid Use Disorder and Chronic Prenatal Opioid Exposure.

INTRODUCTION: Opioid-sparing protocols reduce postpartum opioid prescribing in opioid-naïve patients; however, patients with opioid use disorder (OUD) and complex pain needs who may benefit from these protocols are typically excluded from them. We assessed postpartum pain experiences of patients with OUD and chronic prenatal opioid exposure after implementation of an opioid-sparing protocol. METHODS: A phone survey assessed postpartum pain experiences for people with chronic prenatal opioid exposure who delivered between January 2020 and August 2021 at an academic hospital. Analyses included descriptive statistics, qualitative content analysis, and a joint display comparing themes. RESULTS: Of 25 patients, 18 (72%) participated; most were non-Hispanic White (100%, 18/18), publicly insured (78%, 14/18), multiparous (78%, 14/18), with OUD (100%, 18/18). No patients with a vaginal birth received an opioid prescription; half (4/8) with a cesarean birth received one at discharge. Over one-third (7/18, 39%) reported poor pain control (≥ 5/10) in the hospital and one week post-discharge; scores were higher for cesarean versus vaginal birth. Qualitative sub-analyses of open-ended responses revealed patient perceptions of postpartum pain and treatment. The most effective strategies, stratified by birth type and pain level, ranged from non-opioid medications for vaginal births and minor pain to prescription opioids for cesarean births and moderate-to-intense pain. DISCUSSION: Postpartum opioid prescribing for patients with chronic prenatal opioid use was low for vaginal and cesarean birth following implementation of an opioid-sparing protocol. Patients with OUD reported good pain management with opioid-sparing pain regimens; however, many reported poorly controlled pain immediately postpartum. Future work should assess approaches to postpartum pain management that minimize the risks of opioid medication-particularly in at-risk groups.

What is already known on this subject? Opioid-sparing protocols can reduce postpartum opioid prescribing in opioid-naïve patients; however, there are currently no clear guidelines for opioid prescribing for people with opioid use disorder (OUD) in the postpartum period.What this study adds?Postpartum opioid prescribing for patients with chronic prenatal opioid use was less than the national average and one-third of patients reported poor pain control. Opioid-sparing protocols postpartum should be expanded to patients with OUD to improve pain control and minimize risks associated with opioid medication.

Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review.

Importance: Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. Objective: To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum. Evidence Review: Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide. Findings: A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits. Conclusions and Relevance: The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

Frequency of Prenatal Care Visits: Protocol to Develop a Core Outcome Set for Prenatal Care Schedules.

BACKGROUND: Prenatal care, one of the most common preventive care services in the United States, endeavors to improve pregnancy outcomes through evidence-based screenings and interventions. Despite the prevalence of prenatal care and its importance to maternal and infant health, there are several debates about the best methods of prenatal care delivery, including the most appropriate schedule frequency and content of prenatal visits. Current US national guidelines recommend that low-risk individuals receive a standard schedule of 12 to 14 in-office visits, a care delivery model that has remained unchanged for almost a century. OBJECTIVE: In early 2020, to mitigate individuals' exposure to the SARS-CoV-2 virus, prenatal care providers implemented new paradigms that altered the schedule frequency, interval, and modality (eg, telemedicine) of how prenatal care services were offered. In this paper, we describe the development of a core outcome set (COS) that can be used to evaluate the effect of the frequency of prenatal care schedules on maternal and infant outcomes. METHODS: We will systematically review the literature to identify previously reported outcomes important to individuals who receive prenatal care and the people who care for them. Stakeholders with expertise in prenatal care delivery (ie, patients or family members, health care providers, and public health professionals and policy makers) will rate the importance of identified outcomes in a web-based survey using a 3-round Delphi process. A digital consensus meeting will be held for a group of stakeholder representatives to discuss and vote on the outcomes to include in the final COS. RESULTS: The Delphi survey was initiated in July 2022 with invited 71 stakeholders. A digital consensus conference was conducted on October 11, 2022. Data are currently under analysis with plans to submit them in a subsequent manuscript. CONCLUSIONS: More research about the optimal schedule frequency and modality for prenatal care delivery is needed. Standardizing outcomes that are measured and reported in evaluations of the recommended prenatal care schedules will assist evidence synthesis and results reported in systematic reviews and meta-analyses. Overall, this COS will expand the consistency and patient-centeredness of reported outcomes for various prenatal care delivery schedules and modalities, hopefully improving the overall efficacy of recommended care delivery for pregnant people and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43962.

Barriers to Telemedicine Use: Qualitative Analysis of Provider Perspectives During the COVID-19 Pandemic.

BACKGROUND: Though telemedicine is a promising approach for removing barriers to care and improving access for patients, telemedicine use for many medical specialties has decreased from its peak during the acute COVID-19 public health crisis. Understanding the barriers and facilitators to the maintenance of web-based visits-one key component of telemedicine-is critical for ensuring the continuous availability of this service for patients. OBJECTIVE: The purpose of this study is to describe medical providers' perceived barriers and facilitators to the continued use of web-based visits to inform quality improvement efforts and promote sustainability. METHODS: We performed a qualitative content analysis of free-text responses from a survey of medical providers administered from February 5-14, 2021, at a large, midwestern academic institution, including all providers from medical professions that offered telemedicine (eg, physicians, residents or fellows, nurse practitioners, physicians assistants, or nurses) who completed at least 1 web-based visit from March 20, 2020, to February 14, 2021. The primary outcome was the experience of providing web-based visits, including barriers and facilitators to continued usage of web-based visits. Survey questions included 3 major domains: quality of care, technology, and satisfaction. Responses were coded using qualitative content analysis and further analyzed through a matrix analysis to understand the providers' perspectives and elucidate key barriers and facilitators of web-based visit usage. RESULTS: Of 2692 eligible providers, 1040 (38.6%) completed the survey, of whom 702 were providers from medical professions that offered telemedicine. These providers spanned 7 health care professions and 47 clinical departments. The most common professions represented were physicians (486/702, 46.7%), residents or fellows (85/702, 8.2%), and nurse practitioners (81/702, 7.8%), while the most common clinical departments were internal medicine (69/702, 6.6%), psychiatry (69/702, 6.6%), and physical medicine and rehabilitation (67/702, 6.4%). The following 4 overarching categories of provider experience with web-based visits emerged: quality of care, patient rapport, visit flow, and equity. Though many providers saw web-based visits as a tool for improving care access, quality, and equity, others shared how appropriate selection of web-based visits, support (eg, patient training, home devices, and broadband access), and institutional and nationwide optimization (eg, relaxation of licensing requirements across state borders and reimbursement for phone-only modalities) were needed to sustain web-based visits. CONCLUSIONS: Our findings demonstrate key barriers to the maintenance of telemedicine services following the acute public health crisis. These findings can help prioritize the most impactful methods of sustaining and expanding telemedicine availability for patients who prefer this method of care delivery.

Postpartum Home Blood Pressure Monitoring: A Systematic Review.

OBJECTIVE: To assess the effectiveness of postpartum home blood pressure (BP) monitoring compared with clinic-based follow-up and the comparative effectiveness of alternative home BP-monitoring regimens. DATA SOURCES: Search of Medline, Cochrane, EMBASE, CINAHL, and ClinicalTrials.gov from inception to December 1, 2022, searching for home BP monitoring in postpartum individuals. METHODS OF STUDY SELECTION: We included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm studies that evaluated the effects of postpartum home BP monitoring (up to 1 year), with or without telemonitoring, on postpartum maternal and infant outcomes, health care utilization, and harm outcomes. After double screening, we extracted demographics and outcomes to SRDR+. TABULATION, INTEGRATION, AND RESULTS: Thirteen studies (three RCTs, two nonrandomized comparative studies, and eight single-arm studies) met eligibility criteria. All comparative studies enrolled participants with a diagnosis of hypertensive disorders of pregnancy. One RCT compared home BP monitoring with bidirectional text messaging with scheduled clinic-based BP visits, finding an increased likelihood that at least one BP measurement was ascertained during the first 10 days postpartum for participants in the home BP-monitoring arm (relative risk 2.11, 95% CI 1.68-2.65). One nonrandomized comparative study reported a similar effect (adjusted relative risk [aRR] 1.59, 95% CI 1.36-1.77). Home BP monitoring was not associated with the rate of BP treatment initiation (aRR 1.03, 95% CI 0.74-1.44) but was associated with reduced unplanned hypertension-related hospital admissions (aRR 0.12, 95% CI 0.01-0.96). Most patients (83.3-87.0%) were satisfied with management related to home BP monitoring. Home BP monitoring, compared with office-based follow-up, was associated with reduced racial disparities in BP ascertainment by approximately 50%. CONCLUSION: Home BP monitoring likely improves ascertainment of BP, which is necessary for early recognition of hypertension in postpartum individuals, and may compensate for racial disparities in office-based follow-up. There is insufficient evidence to conclude that home BP monitoring reduces severe maternal morbidity or mortality or reduces racial disparities in clinical outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022313075.

Association Between the Use of a Digital Health Platform During Pregnancy and Helping Users Avoid Emergency and In-Person Care: Retrospective Observational Study.

BACKGROUND: Almost one-third of pregnant people visit the emergency room during pregnancy. Although some emergency care is necessary, gaps in patient education and inaccessibility of preventive services have been identified as key reasons for high-cost, low-value care in pregnancy. Digital platforms present a promising solution for providing resources to supplement routine prenatal care, thereby reducing the use of low-value in-person services. OBJECTIVE: This study aimed to describe the relationship between the use of Maven and in-person care avoidance (emergency room or office visits) during pregnancy. Maven is a digital prenatal health platform that supplements routine prenatal care. Maven offers educational content (articles, videos, and classes), care coordination (through a care advocate), and provider services (web-based appointments and communication with providers) designed to complement prenatal care. Specifically, the aims of this study were to examine whether the use of Maven is associated with in-person care avoidance overall and whether improvements in pregnancy-related knowledge facilitate in-person care avoidance. To assess aim 2, we tested if the use of Maven is associated with improvements in self-reported understanding of warning signs and medically accurate information and if self-reported understanding of medically accurate information and warning signs is associated with in-person care avoidance in a population of Maven users. METHODS: In this retrospective study, we used adjusted logistic regression to examine the relationship between digital platform use, avoidance of in-person care, and the platform's influence on pregnancy-related knowledge (learning medically accurate information and recognizing warning signs). Demographics, medical history, and in-person care avoidance were self-reported. RESULTS: Of the 5263 users, 280 (5.32%) reported that Maven helped them avoid in-person care during pregnancy. More users who reported avoiding in-person care also reported that the digital platform helped them understand warning signs (231/280, 82.5%) and learned medically accurate information (185/280, 66.1%). In the adjusted models, all modes of digital service use (assessed as quartiles) were associated with avoiding in-person care in a dose-response manner (eg, web-based provider appointments: Q2 adjusted odds ratio [aOR] 1.57, 95% CI 1.00-2.41; Q3 aOR 2.53, 95% CI 1.72-3.72; Q4 aOR 5.26, 95% CI 3.76-7.42). Users were more likely to avoid in-person care if they reported that Maven helped them recognize warning signs (aOR 3.55, 95% CI 2.60-4.94) or learn medically accurate information (aOR 2.05, 95% CI 1.59-2.67). CONCLUSIONS: These results suggest that digital platforms can be effective in helping patients to avoid in-person care. The educational pathway suggests that digital platforms can be particularly effective in helping patients recognize warning signs and learn medically accurate information, which may help them avoid in-person care by recognizing when in-person care is medically appropriate. Future work is needed to assess other pathways through which digital resources can support pregnant people and improve perinatal care use.

Postpartum Opioid Prescribing in Patients with Opioid Use Prior to Birth.

OBJECTIVE: This study aimed to describe opioid prescribing patterns for pregnant patients with a history of or active opioid use to inform postpartum pain management strategies. STUDY DESIGN: We conducted a retrospective cohort analysis of all patients with a history of opioid use disorder (OUD) or chronic pain seen at a single outpatient clinic specializing in opioid use and OUD in pregnancy from January 2019 to August 2021. Patient characteristics, delivery outcomes, and opioid prescribing information were collected through electronic health record fields. We used descriptive statistics to characterize differences in receipt of an opioid prescription, prescription size, and receipt of a prescription refill across three patient groups: patients with OUD on medication, patients with OUD maintaining abstinence, and patients with chronic pain using opioids. In the study period, the institutional average rate of opioid prescribing after cesarean and vaginal birth were 80.0 and 2.8%, respectively. RESULTS: Of the 69 patients included in this study, 46 (66.7%) had a history of OUD on medication, 14 (20.3%) had a history of OUD maintaining abstinence, and 9 (13.0%) had a history of chronic pain. Receipt of an opioid prescription after childbirth was more common after cesarean birth (12/23, 52.2%) than vaginal birth (3/46, 6.5%). Refills were common in patients who received an opioid proscription (cesarean: 5/12, 41.7%; vaginal: 1/3, 33.3%). CONCLUSION: Compared with institutional averages, postpartum opioid prescribing rates for people with a history of OUD or chronic pain were 50 to 60% lower for cesarean birth and three times higher for vaginal birth. Future work is needed to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations. KEY POINTS: · Opioid prescribing rates for patients with OUD/chronic pain were 60% lower for cesarean birth than institutional averages.. · Opioid prescribing rates for patients with OUD/chronic pain were three times higher for vaginal birth than institutional averages.. · Refill rates following birth were high overall for cesarean (40%) and vaginal (33%) birth.. · More work is needed to balance opioid prescribing with adequate pain control in high-risk patients..

Utilization of digital prenatal services and management of depression and anxiety during pregnancy: A retrospective observational study.

Introduction: We examined how utilization of Maven, a digital healthcare platform that provides virtual prenatal services, is associated with improvements in perceived management of anxiety and depression during pregnancy, and how medical knowledge and support may influence this association. Materials and Methods: In this retrospective study we used adjusted logistic regression to examine the relationship between digital platform use in pregnancy and perceived mental health management, and how perceived management of mental health is affected by user-reported improvements in medical knowledge and feeling supported by the platform. Effects were evaluated separately among users with and without a mental health condition. Demographics, medical history, and mental health management were self-reported. Results: Of 5,659 users, 705 (12.5%) reported that Maven helped them manage anxiety and/or depression in the prenatal period. In adjusted models, users who read more articles, sent more messages to care advocates, or had more appointments with providers were more likely to report improved management of mental health in a dose-response manner (e.g., articles read: Q2 aOR 1.31 (95% CI 1.01-1.70), Q3 aOR 1.68 (95% CI 1.30-2.17), Q4 1.99 (95% CI 1.54-2.59)). Improvements in medical knowledge and high perceived support were both associated with better perceived mental health management. Results were similar in users with and without a mental health condition. Discussion: These results suggest that access to a diverse set of digital resources provides multiple pathways to managing depression and anxiety during pregnancy for those with and without a diagnosed mental health condition.

Understanding social needs in pregnancy: Prospective validation of a digital short-form screening tool and patient survey.

BACKGROUND: Social determinants of health significantly affect health outcomes, yet are infrequently addressed in prenatal care. OBJECTIVE: This study aimed to improve the efficiency and experience of addressing social needs in pregnancy through: (1) testing a digital short-form screening tool; and (2) characterizing pregnant people's preferences for social needs screening and management. STUDY DESIGN: We developed a digital short-form social determinants of health screening tool from PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences), and a survey to query patients' preferences for addressing social needs. Instruments were administered online to peripartum participants, with equal representation of patients with public and private insurance. We calculated the sensitivity and specificity of the short-form tool vs PRAPARE. Quantitative responses were characterized using descriptive statistics. Free-text responses were analyzed with matrix and thematic coding. Survey data were analyzed by subgroups of historically marginalized populations. RESULTS: A total of 215 people completed the survey. Participants were predominantly White (167; 77.7%) and multiparous (145; 67.4%). Unmet social needs were prevalent with both the short-form tool (77.7%) and PRAPARE (96.7%). The sensitivity (79.3%) and specificity (71.4%) of the short-form screener were high for detecting any social need. Most participants believed that it was important for their pregnancy care team to know their social needs (material: 173, 80.5%; support: 200, 93.0%), and over half felt comfortable sharing their needs through in-person or digital modalities if assistance was or was not available (material: 117, 54.4%; support: 122, 56.7%). Free-text themes reflected considerations for integrating social needs in routine prenatal care. Acceptability of addressing social needs in pregnancy was high among all groups. CONCLUSION: A digital short-form social determinants of health screening tool performs well when compared with the gold standard. Pregnant people accept social needs as a part of routine pregnancy care. Future work is needed to operationalize efficient, effective, patient-centered approaches to addressing social needs in pregnancy.

Elevating the patient voice in contraceptive care quality improvement: A qualitative study of patient preferences for peripartum contraceptive care.

OBJECTIVE: Patient-centeredness is an important indicator of peripartum contraceptive care quality. Prior work demonstrates how care fragmentation, provider biases, and other factors sometimes undermine the patient-centeredness and quality of this care. To guide the design of future quality improvement interventions, we explored patient preferences for peripartum contraceptive care. STUDY DESIGN: For this qualitative study, we recruited a convenience sample of individuals receiving prenatal care at the study site and participating in an online survey about their experience of peripartum contraceptive care during February-July 2020. We conducted individual, in-depth, semistructured interviews to assess patients' preferences for peripartum contraceptive care. Using inductive and deductive qualitative content analysis, we evaluated interview data for patient preferences for peripartum contraceptive counseling and organized preferences into domains to inform future quality measurement. RESULTS: Interviews (lasting 7-26 min) included 21 postpartum individuals, who were largely White with high levels of formal education. Many participants described suboptimal care experiences characterized by insufficient information, inadequate centering of patient values, and, occasionally, disrespectful care. We identified four key themes describing patients' desire for (1) comprehensive, anticipatory information from one's peripartum provider; (2) counseling and decision-making that (a) prioritize patient preferences and values and (b) avoid pressure; (3) care that respects patient feelings and wishes; and (4) provider responsiveness to individual patient preferences regarding timing and frequency of counseling. CONCLUSIONS: We newly identify four key domains of patient preferences for peripartum contraceptive care. Additional research is needed to understand peripartum contraceptive care preferences among diverse patient populations. Future research should develop validated measures for evaluating the patient experience of peripartum contraceptive care at scale, as part of ongoing efforts to improve the quality and respectfulness of peripartum care. IMPLICATIONS: Patients want peripartum contraceptive care to provide comprehensive, anticipatory information; elicit and respond to their counseling and decision-making preferences; and demonstrate respect for their wishes.