Background: Freestanding birth centers (FSBCs) are appropriate settings for the care of individuals with low-risk pregnancies. Studies have demonstrated improved outcomes, including reduced rates of preterm birth, low birth weight, gestational diabetes, and cesareans, among diverse publicly-insured mothers. Disparities in utilization of FSBCs exist by insurance status and race. The present study can inform efforts to increase equitable access to and utilization of FSBCs.

Methods: Twelve publicly-insured mothers of color shared the decision-making processes they engaged in when choosing a birth setting, as well as their perceived care experiences. Participants received maternity care in one of three FSBCs included in a larger embedded-unit case study. Semi-structured in-depth interviews were digitally recorded and professionally transcribed. Qualitative analysis methods were used to identify themes.

Findings: Anticipated birth experiences were paramount, both attributes participants desired and those they wished to avoid: history of poor maternity care experiences, avoidance of unnecessary interventions, preference for un-medicated vaginal birth, and gender-concordant and relationship-based care. Participants’ decisions were also influenced by external factors including: geographic proximity, lack of affordability of home birth, in- vs. out-of-network coverage of collaborating hospitals, and familial influences. Satisfaction with their birth experiences was deep. Participants highlighted restoration of trust in one’s own body and power, and appreciation for education-intensive care.

Conclusions: Midwifery-led FSBC care can improve the experience and outcomes of maternity care among eligible publicly-insured patients of color. Understanding decision-making processes and motivations for seeking FSBC care may inform efforts aimed at increasing equitable access to, demand for, and utilization of FSBCs.

background: Little is known about how many Labor and Delivery units in U.S. hospitals have adopted doula policies. Our aim was to determine the prevalence of doula policies, analyze their content and make evidence based recommendations.

methods: We studied a random sample of labor and delivery units in the U.S. stratified into urban and rural areas. Analysis of public and intradepartmental doula policies for similarities and differences, negative and positive language, and for adherence to evidence about doulas as labor support was performed

results: 89.7% (n=252) reported no public policy and 87.7% (n=242) reported no internal policy. 10.3% (n=29) had public policies, 12.3% (n=34) had internal policies used by staff and 2.5% (n=7) had both. Rural hospitals were more likely to have both public (8.0% difference [95% CI: -0.22 to 19.1; p=0.057]) and internal policies (2.0% difference [95% CI: -6.15 to 12.9; p=0.67]) compared to urban hospitals. Thematic analysis revealed themes relating to how doulas are defined, restrictions on practice, contractual obligations & formality and clauses for doula removal from the labor support role.

conclusions: All Hospitals with L&D units should have a doula policy. Doula policies should be publicly available. Doula defined in professional terms. Policies should reflect informed consent documents. No contractual obligation should be created between the doula and the hospital. Policies should contain a Doula Scope of Practice. Access to doulas should be unrestricted. Removal clauses should be removed.

keywords: doulas, hospital policy, labor and delivery, pregnancy, informed consent, patient rights

Introduction: Each year, 2% to 10% of pregnancies in the United States are impacted by gestational diabetes mellitus (GDM). Of the women affected, half will develop type 2 diabetes within five years. The study aimed to improve prevention and self-management approaches for women with a recent diagnosis of GDM by understanding barriers to follow-up care, particularly for racial and ethnic minorities, from the provider perspective.

Methods: Semi-structured interviews were conducted by a trained interviewer. Participants included providers of various positions (physicians, nurses, diabetes health educators, etc.) who deliver care to patients with GDM during and/or after pregnancy. Participants were asked about their interactions with patients, knowledge of clinical guidelines, and perceived barriers to providing follow-up care for GDM women. Through thematic analysis of the data, barriers to obtaining postpartum care were identified.

Results: A total of seven providers caring for a racially and ethnic diverse group of patients with GDM were interviewed. Four key barriers were identified:1) lack of perceived value for postpartum visit and glucose screening; 2) decrease in mothers’ available time; 3) difficulties contacting patient following delivery, and; 4) inconvenience of glucose testing.

Conclusions: Clinical structures and programs to address the perceived lack of value in guideline-based care as well as barriers to accessing care must be addressed to adequately treat women with GDM, particularly racial and ethnic minorities. Themes identified from this study guided enhancement of an established clinical referral and clinical care delivery system and informed the development of new diabetes prevention efforts for this high-risk population.

Medical-legal partnerships (MLP) integrate civil legal aid attorneys as part of health care teams to collaboratively address root causes of poor health. MLPs are currently located in 46 states in a range of health care settings. A growing body of research shows that MLPs have positive impacts on client outcomes, including reductions in stress; however, few studies exist documenting the impact MLPs have specifically in maternal and child health (MCH) settings and on MCH staff.

In 2018, data was collected through a series of qualitative interviews with 25 MCH nurse home visitors and case managers to assess the impact MLP integration has on staff satisfaction, ability to address social determinants of health, client outcomes, and changes to knowledge and practice. Data was collected from two MLP sites in the greater Philadelphia, PA region through semi-structured in-person and telephonic interviews. Data was coded and analyzed using NVivo 12 and Microsoft Excel software.

Major themes identified through qualitative analyses related to MLP integration include increased job effectiveness, increased knowledge on and capability to address social determinants of health, improved job satisfaction, decreased stress, and increased self-efficacy. Interviewees also identified challenges, including screening and referral processes and a need for increased resources. Study findings provide valuable insight on MCH provider perceptions on integrating legal services as part of care. Recommendations for future research include the impact that MLP integration has on workforce retention within MCH settings.

The preterm birth (PTB) rate has risen in the U.S. for the third straight year and racial disparities persist. In Los Angeles County, the PTB rate for Black mothers is nearly 50% higher than other groups and the infant mortality rate for Black babies is more than three times higher than White babies. The Community Birth Plan (CBP) is a collaborative between California public health agencies, March of Dimes, clinicians, hospitals, and community members and organizations to develop a community-informed toolkit that improves Black maternal and infant health in LA County. One aim of the collaborative is to improve Black women's access and utilization of evidence-based clinical interventions to prevent PTB. These include: progesterone shots for women with a prior preterm birth, low-dose aspirin for women at risk for preeclampsia, group prenatal care, and interpregnancy interval of 18-months. Increase access and use of these interventions will improve equity in maternal and infant outcomes.

March of Dimes is conducting focus groups/listening sessions in LA County with Black women with prior PTB experience, clinical providers, and community organizations to better understand patient experiences, barriers to clinical care, and identify strategies to improve equity in access and utilization of interventions. We anticipate 40 participants in the focus groups/ listening sessions.

The results of the focus groups will inform the CBP toolkit content and activities. We will use results/recommendations from the groups to collaborate with clinical partners to develop systems that improve access to PTB prevention interventions and quality prenatal care for all women.

Chronic health conditions such as obesity, diabetes, hypertension and cardiovascular disease are associated with obstetric morbidity and mortality and poor birth outcomes. These conditions are becoming more prevalent among women of reproductive age in the United States. To mitigate risks associated with chronic health conditions during pregnancy, Merck for Mothers is supporting three innovative CHW models in the Eastern United States aimed at linking pregnant women with chronic conditions to the care and support services they need to have safe pregnancies and healthy lives. This study identified specific features of the CHW-client relationship that facilitate these goals and examined the impact of the program on clients. We conducted focus groups and semi-structured interviews with 18 CHWS and 40 clients. Using a grounded theory-informed thematic approach, we identified three sub-themes related to “building trust-based relationships”: emotional attendance, authenticity, and priority. These qualities enabled the creation of relationships with CHWs that acted as conduits for improved engagement with the healthcare system, behavioral change, and reduced stress. This study contributes to a growing body of literature demonstrating that support provided by CHWs and other lay health workers is beneficial to pregnant women, and provides insights into the mechanisms by which CHWs are effective. Evaluations of the effectiveness of CHW interventions targeting pregnant and postpartum women should include metrics to assess the quality of CHW-client interactions to ensure their greatest potential impact, and additional resources should be devoted to expanding these programs to provide vulnerable mothers with comprehensive care.

BACKGROUND: Preterm birth and low birthweight are the second leading cause of US infant mortality and cost $38 billion annually. Preterm birth rates have been rising for three consecutive years. Only one-third of preterm births have a known etiology, requiring population based approaches.

METHOD: We developed and evaluated a new model of group prenatal care that integrates an IT platform to increase patient engagement. Expect With Me provides complete prenatal care that meets ACOG and ACNM guidelines with a curriculum that focuses on nutrition, physical activity, mental health/stress, and sexual risk. We evaluated Expect With Me through a prospective longitudinal cohort study in three clinical sites in two US cities. We compared birth outcomes for 2,402 women who received Expect With Me or standard individual prenatal care. Participants entered care before 24 weeks gestation, had no history of prior preterm, and bore singletons. The average treatment effect of Expect With Me compared to individual care was estimated by using augmented inverse probability weights using propensity scores.

RESULTS: Women who received Expect With Me were significantly less likely to have infants born preterm (6.4% vs. 15.1%; rate difference = -0.987; 95% confidence interval = -0.1287, -0.049), infants with low birthweight (< 2500grams; 4.3% vs. 11.6%; rate difference = -0.073; 95% confidence interval = -0.105, -0.042), and infants admitted to the neonatal intensive care unit (9.4% vs. 14.6%; rate difference = -0.052; 95% confidence interval = -0.092, -0.006).

CONCLUSION: Expect With Me resulted in more favorable birth outcomes than traditional individual prenatal care.

background: The Birth Center model of care is one of three prenatal care approaches tested under Strong Start for Mothers and Newborns, a federal initiative to reduce preterm birth among Medicaid/CHIP beneficiaries. Women in Birth Center care and their infants had significantly better outcomes (e.g., lower C-section rates, lower likelihood of being preterm or low birthweight) than risk-matched Medicaid comparators in typical care.

methods:We use Strong Start evaluation data to describe Birth Centers’ experiences participating in Medicaid and identify policies affecting access to Birth Center care. We analyzed data from key informant interviews and focus groups, a survey of Medicaid officials, and a survey of Birth Centers.

results:Women who received Birth Center care had considerable economic and psychosocial needs. The Birth Centers were all freestanding, operated by midwives, and provided comprehensive prenatal care. Many offered planned hospital delivery and all offered a wide range of pain relief measures during labor and delivery.

Strong Start Birth Centers experienced Medicaid-related challenges. Inadequate reimbursement prompted some Centers to limit or stop accepting Medicaid patients. Several Birth Centers struggled with managed care contracting, coverage limitations, and limited ability to participate in delivery reforms. Beyond Medicaid, Birth Centers also experienced challenges related to state regulations.

conclusions: Medicaid beneficiaries do not currently have access to the same range of maternity providers and birth settings as privately-insured women. If progress could be made in addressing barriers identified through the Strong Start evaluation, more Medicaid beneficiaries could access Birth Centers, which could increase positive birth outcomes.

issue: The maternal mortality rate In the United States has more than doubled since 1990 and is the highest of any resource-rich country in the world. Even more alarming are the growing health disparities and mortality rates among minority and low income women.

description: This presentation discusses Safe Start, a community based maternal health program, developed to reduce the risk of maternal morality and improve the health outcomes of high risk pregnant women. Safe Start is a partnership between a community-based maternal-child health agency, a Medicaid managed care organization, and a major urban academic health system. The program employs Community Health Workers (CHWs) and birth doulas who partner with low income, high risk pregnant women to provide case management, care coordination, health education and birth support. The CHWs accompany women to their appointments, link them with resources, develop goals, and provide education about chronic health conditions such as hypertension and diabetes. CHWs partner with medical staff and MCO care managers to bridge gaps in health care and connect women’s systems of support. The CHWs participate in ongoing systematic care reviews that bring the care team together and create a partnership built around support.

conclusions: Systemic barriers related to social determinantes of health impact the quality of prenatal care. This presentation will highlight the multidisciplinary team partnerships and how they provide the necessary support and resources that empower women to manage their health. Integrating CHWs into hospitals, clinics and MCOs can help to improve outcomes and better facilitate a network of care.

Background

Concentrated Disadvantage (CD) provides a community-level look at economic segregation. Economic segregation influences education attainment, safety, and health outcomes. Communities facing CD are at greater risk of infant mortality, low birthweight, child maltreatment, and teen pregnancy compared with less disadvantaged neighborhoods.

Methodology

CD was calculated using 2013-2017 ACS data based upon AMCHP methodology described in the Life Course Indicators Tip Sheet. Percent below the poverty line, percent on public assistance, percent female-headed households, percent unemployed, and household density <18 were used to calculate the proportion of households located in census tracts with CD. Census tracts were labeled disadvantaged if their averaged z-scores fell within the 75th percentile of values in the nation. Data were aggregated to the state level by summing the population of the census tracts labeled as disadvantaged and dividing by the population of all census tracts for each state. Statistical analyses were performed using STATA v15.1.

Results

Nationally, 27.0% of households are located in a census tract with a high level of CD. The percentage of households located in an area of high CD varies widely by state from 2.5% in Vermont to 45.5% in Mississippi. Concentration of CD is highest in Southern states and lowest in Northeast and Midwest states.

Conclusions

Identifying communities with high CD can provide local and state stakeholders with information to improve social capital and ultimately the health and well-being of people living in disadvantaged neighborhoods, especially when addressing issues such as infant mortality, low birthweight and teen pregnancy.