Brownsyne Tucker Edmonds

Understanding low-income African American women's expectations, preferences, and priorities in prenatal care

We aimed to explore factors affecting prenatal care attendance and preferences for prenatal care experiences among low-income black women by conducting a focus group study using a community-based participatory research framework and nominal group technique. Discussions were audiorecorded, transcribed, and coded by trained reviewers. Friends/family and babys health were the top attendance motivators. Greatest barriers were insurance, transportation, and ambivalence. Facilitators included transportation services, social support, and resource education. In a “perfect system,” women wanted continuity of care, personal connection, and caring/respect from providers. Relationship-centered maternity care models may mitigate disparities. Group prenatal care may provide the continuity and support system desired.

Using simulation to assess the influence of race and insurer on shared decision making in periviable counseling.

Introduction Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling. Methods We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semistructured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance. Results Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P < 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = <0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients. Conclusions This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients’ sociodemographic characteristics and deserves further study.

Current practice patterns in cervical cancer screening in Indiana

OBJECTIVE The purpose of this study is to describe current health care provider cervical cancer screening practice patterns for average-risk women in the state of Indiana in comparison to the 2012 guidelines as well as earlier guidelines. We also aim to describe what factors are associated with increased adherence to guidelines, and what factors may impede adherence. STUDY DESIGN We conducted a vignette-based survey among a convenience sample of obstetricians, gynecologists, midwives, nurse practitioners, and physician assistants attending the Indiana American Congress of Obstetricians and Gynecologists Section meeting in January 2013. RESULTS Questionnaires were returned by 51% (112/218) of attendants. Of the 111 providers with completed surveys, 42 (38%) follow current guidelines. Of providers, 86% start screening at age 21 years. Of providers, 33% screen women aged 21-29 years every 3 years. Of providers, 33% follow recommendations for cotesting every 5 years for patients 30-65 years of age. The majority of providers follow guidelines to stop screening after a benign hysterectomy or age 65 years (75% and 51%, respectively). CONCLUSION The majority of providers follow the 2012 guidelines for the initiation and cessation of cervical screening; however, most providers screen more frequently than currently recommended for patients between ages 21-65 years.

Predictors of cesarean delivery for periviable neonates.

OBJECTIVE: To test for racial or ethnic disparities or both in periviable cesarean delivery and describe sociodemographic and clinical characteristics associated with periviable cesarean delivery. METHODS: This was a retrospective cohort study of state-level maternal and neonatal hospital discharge data linked to vital statistics data for deliveries occurring between 23.0 and 24.6 weeks of gestation in California, Missouri, and Pennsylvania from 1995 to 2005 (N=8,290). RESULTS: Approximately 79% of the population was aged 18–35 years, and almost half were nulliparous. Almost 20% of the women were African American, 36.4% were Hispanic, and 33.6% were white. Overall, 33.6% of periviable neonates were delivered by cesarean. In multivariable analyses adjusting for sociodemographic and clinical characteristics, cesarean delivery did not differ among African American and Hispanic women compared with white women (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.76–1.05; and OR 0.95, 95% CI 0.83–1.09, respectively). Women presenting with preterm labor were significantly less likely to undergo cesarean delivery (OR 0.84, 95% CI 0.73–0.96), whereas women presenting with preterm premature rupture of membranes (OR 1.29, 95% CI 1.14–1.45) or abruption (OR 2.43, 95% CI 2.09–2.81) were more likely to have cesarean deliveries. The strongest predictor of periviable cesarean delivery was pregnancy-induced hypertension (OR 15.6.4, 95% CI 12.3–19.7). CONCLUSION: Unlike disparities observed at later gestational ages, cesarean delivery did not differ by race and ethnicity among this periviable cohort. Instead, medical indications such as pregnancy-induced hypertension, preterm premature rupture of membranes, or abruption were associated with a higher likelihood of cesarean delivery. Periviable deliveries represent a subset of deliveries, wherein race and ethnicity do not influence mode of delivery; the acuity of the clinical encounter dictates the course of care. LEVEL OF EVIDENCE: II

Comparing neonatal morbidity and mortality estimates across specialty in periviable counseling

Abstract Objective: To describe and compare estimates of neonatal morbidity and mortality communicated by neonatologists and obstetricians in simulated periviable counseling encounters. Methods: A simulation-based study of 16 obstetricians (OBs) and 15 neonatologists counseling standardized patients portraying pregnant women with ruptured membranes at 23 weeks gestation. Two investigators tabulated all instances of numerically-described risk estimates across individuals and by specialty. Results: Overall, 12/15 (80%) neonatologists utilized numeric estimates of survival; 6/16 (38%) OBs did. OBs frequently deferred the discussion of “exact numbers” to neonatologists. The 12 neonatologists provided 13 unique numeric estimates, ranging from 3% to 50% survival. Half of those neonatologists provided two to three different estimates in a single encounter. By comparison, six OBs provided four unique survival estimates (“50%”, “30–40%”, “1/3–1/2”, “<10%”). Only 2/15 (13%) neonatologists provided numeric estimates of survival without impairment. None of the neonatologists used the term “intact” survival, while five OBs did. Three neonatologists gave numeric estimates of long-term disability and one OB did. Conclusion: We found substantial variation in estimates and noteworthy omissions of discussions related to long-term morbidity. Across specialties, we noted inconsistencies in the use and meaning of terms like “intact survival.” More tools and training are needed to improve the quality and consistency of periviable risk-communication.

Doctor, What Would You Do? An ANSWER for Patients Requesting Advice About Value-Laden Decisions

This article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients.

Women’s opinions of legal requirements for drug testing in prenatal care

Abstract Purpose: To explore women’s attitudes and perceptions regarding legal requirements for prenatal drug testing. Methods: Web-based survey of 500 US women (age 18–45) recruited from a market research survey panel. A 24-item questionnaire assessed their opinion of laws requiring doctors to routinely verbal screen and urine drug test patients during pregnancy; recommendations for consequences for positive drug tests during pregnancy; and opinion of laws requiring routine drug testing of newborns. Additional questions asked participants about the influence of such laws on their own care-seeking behaviors. Data were analyzed for associations between participant characteristics and survey responses using Pearson’s chi-squared test. Results: The majority of respondents (86%) stated they would support a law requiring verbal screening of all pregnant patients and 73% would support a law requiring universal urine drug testing in pregnancy. Fewer respondents were willing to support laws that required verbal screening or urine drug testing (68% and 61%, respectively) targeting only Medicaid recipients. Twenty-one percent of respondents indicated they would be offended if their doctors asked them about drug use and 14% indicated that mandatory drug testing would discourage prenatal care attendance. Conclusion: Women would be more supportive of policies requiring universal rather than targeted screening and testing for prenatal drug use. However, a noteworthy proportion of women would be discouraged from attending prenatal care – a reminder that drug testing policies may have detrimental effects on maternal child health.

Prospective parents’ perspectives on antenatal decision making for the anticipated birth of a periviable infant

Abstract Objective: To examine prospective parents’ perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period. Study design: Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases). Results: Participants most often recalled being involved in resuscitation, cerclage, and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like “brain damage”, “disability”, and “handicap”. The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a “fighting chance”; others voiced concerns about “best interest”, a “healthy baby”, “pain and suffering”, and religious faith. Conclusions: Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.Objective: To examine prospective parents’ perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions d...

Maternal-Fetal Medicine physicians’ practice patterns for 22-week delivery management

Abstract Objective: To describe Maternal-Fetal Medicine (MFM) physicians’ practice patterns for 22-week delivery management. Mehods: Surveyed 750 randomly-sampled members of the Society of Maternal-Fetal Medicine, querying MFMs’ practices and policies guiding 22-week delivery management. Results: Three hundred and twenty-five (43%) MFMs responded. Nearly all (87%) would offer induction. Twenty-eight percent would order steroids, and 12% would perform cesarean for a patient desiring resuscitation. Offering induction differed significantly based on the provider’s practice setting, region, religious service attendance and political affiliation. In multivariable analyses, political affiliation remained a significant predictor of offering induction (p = 0.03). Conclusions: Most MFMs offer induction for PPROM at 22 weeks. A noteworthy proportion is willing to order steroids and perform cesarean. Personal beliefs and practice characteristics may contribute to these decisions. While little is known about the efficacy of these interventions at 22 weeks, some MFMs will offer obstetrical intervention if resuscitation is intended.

Patient knowledge and attitudes toward cervical cancer screening after the 2012 screening guidelines

OBJECTIVE To assess womens attitudes and preferences related to recent changes in cervical cancer screening guidelines. METHODS We distributed 380 surveys in three University based and Community clinics. Study participants anonymously completed surveys, which included questions related to demographics, cervical cancer, screening practices, risk perception and attitudes towards changing practices. RESULTS 315 women agreed to participate (83%). 60% (185/310) of participants had some college education or higher and 12% (36/305) worked in the medical field. On average, participants answered 4.1 (SD = 1.3) of the 8 knowledge questions correctly. Knowledge scores significantly increased with education level (Kruskal-Wallis test p-value < 0.001). The majority (72%, n = 228) reported that they should be screened annually, and that screening should be initiated with the onset of sexual activity (63%, n = 197). Participants that were more knowledgeable of current screening practices were more comfortable extending screening intervals (Kruskal-Wallis test p < 0.001). CONCLUSION Even among a relatively highly educated population of women, participants had limited knowledge of cervical cancer and current screening guidelines. Many participants reported discomfort with less frequent screening intervals. PRACTICE IMPLICATIONS This study supports the need for improvement in cervical cancer prevention education especially with regards to the new screening guidelines.