Maternal and Child Health

Increase in Contraceptive Counseling by Primary Care Clinicians After Implementation of One Key Question® at an Urban Community Health Center Abstract Introduction To provide quality family planning services and reduce racial and socioeconomic disparities in unintended pregnancy and pregnancy outcomes, primary care clinicians should routinely assess women’s reproductive health needs and provide patient-centered contraceptive and preconception counseling. One Key Question® asks women if they would like to become pregnant in the next year and prompts clinicians to provide counseling appropriate to each patient. We conducted a pilot study to assess if implementing One Key Question® in the Electronic Medical Record (EMR) of an urban community health center, coupled with brief clinician training, would increase rates of contraceptive and preconception counseling. Methods We incorporated One Key Question® into a new EMR form and provided a brief training to primary care clinicians on reproductive life plan assessment, preconception counseling, and contraception. We surveyed women patients, ages 18–49, after their visit and compared pre- vsersus post-intervention rates of patient-reported contraceptive and preconception counseling. Results After One Key Question® was introduced in the clinic EMR and clinicians underwent brief training on its use, patients reported significantly higher rates of their clinician counseling them about contraception (52% vs. 76%, p = 0.040) and recommending a long-acting reversible contraceptive (LARC) method (10% vs. 32%, p = 0.035). There were no significant changes in preconception counseling. Discussion After EMR integration of One Key Question® coupled with brief clinician training, rates of contraceptive counseling and LARC recommendations increased in this community health center pilot study. Future research should compare One Key Question® to standard care in a prospective randomized trial.

Early Childhood Nutritional Implications of the Rise in Factory Employed Mothers in Rural Cambodia: A Qualitative Study Abstract Objectives Limited research has been conducted on the maternal and child health situation of garment factory workers in Cambodia. This qualitative study investigated the health-seeking behaviours for maternal and infant care of female garment factory workers in Kampong Tralach district, Cambodia. Methods We conducted 54 in-depth interviews, six focus group discussions and observed two factories. Participants were pregnant women and mothers of infants who have worked in factories, young women currently working in factories, caregivers of children, village leaders, healthcare workers, and factory managers. Deductive and inductive thematic analysis was performed. Results The women were accessing regular antenatal and facility-based delivery care. Most factory managers provided maternity leave, and some also provided leave for regular antenatal (ANC) visits. Women often returned to work 2 months post-delivery and this triggered the cessation of exclusive breastfeeding. Feeding was also compromised for the 6–12 months old children as carers, delayed the introduction of complementary feeds. Factories were equipped with childcare and breastfeeding spaces, however these were not used due to both feasibility issues and distrust of factory management. Instead, grandmothers were the preferred childcare providers. Conclusions for Practice Current factory policies regarding ANC, maternity leave and childcare provisions are context insensitive to rural workers who live far from the workplace to avail themselves of mandated ANC leave or breastfeeding breaks. Our study suggest that the increasing number of young women working in garment factories is compromising the early nutrition of their children, with a reduction in exclusive breastfeeding and inadequate complementary feeding.

Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India Abstract Introduction India aims to achieve universal health coverage, with a focus on equitable delivery of services. There is significant evidence on extent of inequities by income status, gender and caste. In this paper, we report geographic inequities in coverage of reproductive, maternal and child health (MCH) services in Haryana state of India. Methods Cross-sectional data on utilization of maternal, child health and family planning services were collected from 12,191 women who had delivered a child in the last one year, 10314 women with 12–23 months old child, and 45864 eligible couples across all districts in Haryana state. Service coverage was assessed based on eight indicators − 6 for maternal health, one for child health and one for family planning. Inter- and intra-district inequalities were compared based on four and three indicators respectively. Results Difference in coverage of full ante-natal care, full immunization and contraceptive prevalence rate between districts performing best and worst was found to be 54%, 65% and 63% respectively. More than one-thirds of the sub-centres (SCs) in Panchkula, Ambala, Gurgaon and Mewat districts had their ante-natal care coverage less than 50% of the respective district average. Similarly, a significant proportion of SCs in Mewat, Panipat and Hisar districts had full immunization rate below 50% of the district average. Conclusion Widespread inter- and intra-district inequities in utilization of MCH services exist. A comprehensive geographical targeting to identify poor performing districts, community development blocks and SCs could result in significant equity gains, besides contributing to quick achievement of sustainable development goals.

Health Care Provider Attitudes Toward Safety of Selected Hormonal Contraceptives in Breastfeeding Women Abstract Objectives Little is known about provider attitudes regarding safety of selected hormonal contraceptives among breastfeeding women. Methods Using a nationwide survey, associations were analyzed between provider characteristics and perception of safety of combined oral contraceptives (COCs) in breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors and depot medroxyprogesterone acetate (DMPA) in breastfeeding women < 1 month postpartum and ≥ 1 month postpartum. Results Approximately 68% of public-sector providers considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among non-physicians versus physicians (adjusted odds ratios [aOR] range 0.34–0.51) and those with a focus on adolescent health/pediatrics versus reproductive health (aOR 0.68, 95% confidence interval [CI] 0.47–0.99). Most public-sector providers considered DMPA safe for breastfeeding women during any time postpartum, with lower odds among non-physicians versus physicians (aOR range 0.20–0.54) and those with primary clinical focus other than reproductive health (aOR range 0.26–0.65). The majority of office-based physicians considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among those who did not use, versus those who used, CDC’s contraceptive guidance (aOR 0.40, 95% CI 0.21–0.77). Most office-based physicians also considered DMPA safe for breastfeeding women during any time postpartum. Conclusions for Practice A high proportion of providers considered use of selected hormonal contraceptives safe for breastfeeding women, consistent with evidence-based guidelines. However, certain provider groups might benefit from education regarding the safety of these methods for breastfeeding women.

Adult-Oriented Health Reform and Children’s Insurance and Access to Care: Evidence from Massachusetts Health Reform Abstract Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)—the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0–17 years in Massachusetts compared to children in other New England states. The National Survey of Children’s Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts’s enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = − 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.

Association Between Motor Skills and Musculoskeletal Physical Fitness Among Preschoolers Abstract Objective Previous work is conflicted regarding the relationship between motor skill development and physical activity. One potential explanation for this equivocality is the difficulty and lack of precision in physical activity measurement, particularly within preschool populations. Our exploration of plank performance as a proxy measure for fitness addresses a void in the literature, as few studies have investigated the role of motor skill development on fitness. The purpose of this study was to evaluate the potential relationship between motor skill level and musculoskeletal endurance (via the plank test). Methods Data from the 2012 National Youth Fitness Survey were used, which included 224 preschool-aged children (3–5 years). Motor skill level was assessed from the Test of Gross Motor Development-Second Edition (TGMD2). Motor skill parameters included general motor skills, locomotor skills, and object control skills. Results Within this nationally representative sample of preschoolers, increased motor skills were positively associated with plank performance [General Motor Skills (β = 0.45; 95% CI 0.31–0.59), locomotor skills (β = 1.88; 95% CI 1.15–2.61), and object control skills (β = 2.05; 95% CI 1.11–2.98)]. Conclusion Motor skill level in this national preschool sample was associated with musculoskeletal endurance. Thus, future interventions should aim to develop and refine motor skills among preschoolers.

Evaluating the Whoops Proof S.C . Campaign: A Pair-Matched Group Pretest–Posttest Quasi-experimental Study Abstract Introduction: In South Carolina, 50% of all pregnancies are unintended. Intrauterine devices (IUDs) and the implant are recommended as top-tier contraceptive options for all women and adolescents. The Whoops Proof S.C. campaign was evaluated to determine if women (ages 18 to 29) who do not intend to become pregnant in the next year report greater awareness of and positive regard for IUDs and the implant after exposure to a multi-channel campaign. Methods: A pair-matched group pretest–posttest quasi-experimental design was utilized. A total of 1,439 women responded to the pretest survey (May–July 2016) and 1,534 responded to the posttest survey (October–November 2016) in four South Carolina counties. Statistical analysis include paired-sample and independent t-tests and one-way ANOVA tests for variance. Results: At posttest, intervention county participants were significantly more likely to recall messaging and to report receiving contraceptive information from Whoops Proof S.C (t(1533)= − 8.466, p < .0001). Participants who saw ads more than once per week reported a significant increase in awareness of IUDs and the implant (F(6,1532) = 5.571; p < .001). Participants in intervention counties reported a significant increase in positive attitudes toward IUDs (t(616) = − 1.740; p = .041) and the implant (t(603)= − 1.665; p = .048). Discussion: The Whoops Proof S.C. campaign offers strategies to campaign planners and health care providers to optimize exposure and recall frequency to increase awareness of and positive regard for highly effective contraceptive methods. Campaign planners should test messages and focus on communication channels to increase engagement and avoid saturation.

Reproductive and Pregnancy Experiences of Diverse Sexual Minority Women: A Descriptive Exploratory Study Abstract Objectives This study sought to explore how sexual minority women (SMW) and heterosexual women compare in terms of reproductive history, with a particular focus on examining within-group differences among SMW. Methods Women were predominantly recruited through consecutive sampling during presentation for prenatal care in Toronto Canada, and Massachusetts, USA. In total, 96 partnered pregnant women (62 SMW, 34 heterosexual) completed an internet survey during 2013-2015. Results We found few significant differences in reproductive history outcomes when comparing SMW and heterosexual groups. However, when we compared male-partnered SMW to female-partnered SMW, we found potentially important differences in rates of miscarriage and pregnancy complications, indicating that partner gender may be an important contributor to differences in reproductive history among SMW. Conclusions for Practice These findings highlight the need to recognize the unique health risks with which male-partnered SMW may present. Considering that this group is often invisible in clinical practice, the findings from this exploratory study have important implications for providers who treat women during the transition to parenthood. Future research should further examine the differences in social and health access within larger samples of SMW groups, as well as seek to understand the complex relationships between sexual identity and perinatal health for this understudied group of women.

Effect of Parity on Pregnancy-Associated Hypertension Among Asian American Women in the United States Abstract Objectives Pregnancy-associated hypertension (PAH) includes gestational hypertension, preeclampsia and eclampsia. Although a protective effect of multi-parity on PAH has been reported in previous studies, the association has not been examined among Asian American women in the U.S. Methods Using data from 2014 U.S. National Vital Statistics System, we examined the prevalence of PAH among Asian American women who had singleton live births (N = 235,303), and its association with parity (number of previous pregnancies including live births and fetal deaths) controlling for potential confounders. We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CI) using multivariable logistic regression analysis. Results Overall, 2.72% (95% CI 2.66%, 2.79%) of Asian American women were recorded to have PAH during pregnancy. Parity was inversely associated with PAH in our study, where Asian American women who had 1–2 and 3 or more previous pregnancies had significantly lower odds of PAH (aOR 0.61, 95% CI 0.58, 0.65; and aOR 0.62, 95% CI 0.57, 0.68, respectively) compared to nulliparous women, after controlling for potential confounders. Conclusions Recent U.S. vital statistics data revealed that nulliparity is significantly associated with PAH among Asian American women. Future studies should identify specific factors that are associated with PAH and factors contributing to disparities in PAH risk among Asian American women.

Severe Maternal Morbidity, A Tale of 2 States Using Data for Action—Ohio and Massachusetts Abstract Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008–2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.