Ebony B. Carter

Group Prenatal Care Compared With Traditional Prenatal Care: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of group prenatal care on perinatal outcomes compared with traditional prenatal care. DATA SOURCES: We searched MEDLINE through PubMed, EMBASE, Scopus, Cumulative Index of Nursing and Allied Health literature, the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We searched electronic databases for randomized controlled trials and observational studies comparing group care with traditional prenatal care. The primary outcome was preterm birth. Secondary outcomes were low birth weight, neonatal intensive care unit admission, and breastfeeding initiation. Heterogeneity was assessed using the Q test and I2 statistic. Pooled relative risks (RRs) and weighted mean differences were calculated using random-effects models. TABULATIONS, INTEGRATION, AND RESULTS: Four randomized controlled trials and 10 observational studies met inclusion criteria. The rate of preterm birth was not significantly different with group care compared with traditional care (11 studies: pooled rates 7.9% compared with 9.3%, pooled RR 0.87, 95% confidence interval [CI] 0.70–1.09). Group care was associated with a decreased rate of low birth weight overall (nine studies: pooled rate 7.5% group care compared with 9.5% traditional care; pooled RR 0.81, 95% CI 0.69–0.96), but not among randomized controlled trials (four studies: 7.9% group care compared with 8.7% traditional care, pooled RR 0.92, 95% CI 0.73–1.16). There were no significant differences in neonatal intensive care unit admission or breastfeeding initiation. CONCLUSION: Available data suggest that women who participate in group care have similar rates of preterm birth, neonatal intensive care unit admission, and breastfeeding.

Maternal marijuana use and neonatal morbidity

OBJECTIVE Marijuana use is becoming increasingly common in the obstetric population; however, it is unknown whether it is associated with poor neonatal outcomes. We sought to determine the prevalence and risk factors for marijuana use in pregnancy and to evaluate whether marijuana use is independently associated with poor neonatal outcomes. STUDY DESIGN This was a retrospective cohort study of all consecutive, nonanomalous, term deliveries at 1 institution over a 4-year study period. Women with marijuana use during pregnancy, either by self-report or positive urine drug screen, were compared with women who did not use marijuana. The primary outcome was a composite neonatal morbidity including birthweight less than 2500 g, neonatal intensive care unit admission, 5-minute Apgar score less than 7, and umbilical artery pH less than 7.10. Univariate, bivariate, and multiple logistic regression analyses were performed. RESULTS Among the 8138 women in the cohort, 680 (8.4%) used marijuana during pregnancy. Women who used marijuana were younger; more likely to be of African American race; have inadequate prenatal care; and use tobacco, alcohol, and other drugs. Medical comorbidities did not differ between groups. After adjusting for smoking, other drug use, and African American race, the composite and all individual markers of poor neonatal outcome were not significantly higher among women who used marijuana during pregnancy. CONCLUSION Marijuana use is common in pregnancy but may not be an independent risk factor for poor neonatal outcomes in term pregnancies.

The impact of chorionicity on maternal pregnancy outcomes

OBJECTIVE Women carrying twin pregnancies often receive similar counseling, regardless of chorionicity, with the notable exception of twin-twin transfusion syndrome (TTTS); however, little is known about whether the presence of 1 vs 2 placentas confers dissimilar maternal risks. We sought to determine differences in maternal and neonatal outcomes based on chorionicity. STUDY DESIGN This was a retrospective cohort study of all twin pregnancies at our institution undergoing routine second-trimester ultrasound for anatomic survey from 1990 through 2010. Secondary outcomes included other adverse maternal and neonatal outcomes. Relative risks and adjusted odds ratios (aORs) were calculated. Cluster analysis was used to account for nonindependence of twin pairs. RESULTS Of 2301 pregnancies, 1747 (75.9%) were dichorionic and 554 (24.1%) were monochorionic. Rates of preeclampsia, gestational diabetes, placental abruption, placenta previa, preterm labor, and preterm premature rupture of membranes (PPROM) were not significantly different in dichorionic vs monochorionic pregnancies. Early preterm delivery less than 34 weeks (aOR, 1.47; 95% confidence interval [CI], 1.17-1.86) and less than 28 weeks (aOR, 2.58; 95% CI, 1.58-4.20) were more likely in monochorionic twins, as was neonatal intensive care unit admission (aOR, 1.41; 95% CI, 1.12-1.78). Monochorionic twins delivered earlier at a mean gestational age of 34.2 weeks vs 35.0 weeks for dichorionic twins (P < .001). Hospital length of stay was significantly longer for monochorionic twins with a mean of 13.7 days vs 10.8 days for dichorionic twins (P = .01). CONCLUSION There are no significant differences in maternal outcomes by chorionicity; however, monochorionicity is associated with increased fetal risks. This information may be helpful in guiding more targeted counseling to expectant parents of twins that, although the presence of an additional placenta does not confer additional maternal risks, monochorionic infants tend to deliver earlier and require longer hospital stays.

Pregnancy Complications as Markers for Subsequent Maternal Cardiovascular Disease: Validation of a Maternal Recall Questionnaire

BACKGROUND We designed and tested the validity of a questionnaire to characterize maternal recall of pregnancy complications associated with increased future cardiovascular disease risk, based on the 2011 American Heart Association (AHA) guidelines. METHODS A maternal recall questionnaire of pregnancy history was administered to 971 patients who had participated in a previous cohort study of 1,608 pregnant women. Medical records from the study pregnancy served as the gold standard. Prevalence, sensitivity (sens), specificity (spec), positive predictive value (PPV), negative predictive value (NPV), and/or Spearmans correlation coefficients (r) were calculated for each question. RESULTS A total of 526 (54%) individuals recontacted responded. Respondents were more likely to be older, white, educated, and nulliparous and were less likely to deliver low-birthweight infants in the study pregnancy than were individuals who did not respond. Mean length of recall was 4.35 years (standard deviation [SD] 0.46) postpartum. Maternal recall was most accurate for gestational diabetes (sens: 92%, spec: 98%, PPV: 79%, NPV: 99%), infant birthweight (r=0.95), and gestation length (r=0.85). Maternal recall was modest for preeclampsia (sens: 79%, spec: 97%, PPV: 68%, NPV: 98%) and pregnancy-associated hypertension, including preeclampsia or gestational hypertension (sens: 60%, spec: 95%, PPV: 64%, NPV: 94%). CONCLUSIONS This validation study demonstrated that the majority of women could accurately recall a history of gestational diabetes, infant birthweight, and gestational age at delivery, 4 years postpartum on average. Recall of preeclampsia and pregnancy-associated hypertension overall was modest. Maternal report of these pregnancy conditions may help clinicians identify women at increased risk for cardiovascular disease.

Group prenatal care

Patients participating in group prenatal care gather together with women of similar gestational ages and 2 providers who cofacilitate an educational session after a brief medical assessment. The model was first described in the 1990s by a midwife for low-risk patients and is now practiced by midwives and physicians for both low-risk patients and some high-risk patients, such as those with diabetes. The majority of literature on group prenatal care uses CenteringPregnancy, the most popular model. The first randomized controlled trial of CenteringPregnancy showed that it reduced the risk of preterm birth in low-risk women. However, recent meta-analyses have shown similar rates of preterm birth, low birthweight, and neonatal intensive care unit admission between women participating in group prenatal care and individual prenatal care. There may be subgroups, such as African Americans, who benefit from this type of prenatal care with significantly lower rates of preterm birth. Group prenatal care seems to result in increased patient satisfaction and knowledge and use of postpartum family planning as well as improved weight gain parameters. The literature is inconclusive regarding breast-feeding, stress, depression, and positive health behaviors, although it is theorized that group prenatal care positively affects these outcomes. It is unclear whether group prenatal care results in cost savings, although it may in large-volume practices if each group consists of approximately 8-10 women. Group prenatal care requires a significant paradigm shift. It can be difficult to implement and sustain. More randomized trials are needed to ascertain the true benefits of the model, best practices for implementation, and subgroups who may benefit most from this innovative way to provide prenatal care. In short, group prenatal care is an innovative and promising model with comparable pregnancy outcomes to individual prenatal care in the general population and improved outcomes in some demographic groups.

Number of prenatal visits and pregnancy outcomes in low-risk women

Objective:We investigated the association between number of prenatal visits (PNV) and pregnancy outcomes.Study Design:A retrospective cohort of 12 092 consecutive, uncomplicated term births was included. Exclusion criteria included unknown or third trimester pregnancy dating, pre-existing medical conditions and common pregnancy complications. Patients with ⩽10 PNV were compared with those with >10. The primary outcome was a neonatal composite including neonatal intensive-care unit admission, low APGAR score (<7), low umbilical cord pH (<7.10) and neonatal demise. Secondary outcomes included components of the composite as well as vaginal delivery, induction and cesarean delivery. Logistic regression was used to adjust for potential confounders.Result:Of 7256 patients in the cohort meeting inclusion criteria, 30% (N=2163) had >10 PNV and the remaining 70% (N=5093) had ⩽10, respectively. There was no difference in the neonatal composite between the two groups. However, women with>10 PNV were more likely to undergo induction of labor and cesarean delivery.Conclusion:Low-risk women with ⩾10 PNV had higher rates of pregnancy interventions without improvement in neonatal outcomes.

Evaluating the Optimal Definition of Abnormal First-Trimester Uterine Artery Doppler Parameters to Predict Adverse Pregnancy Outcomes

To investigate the optimal definition of abnormal first‐trimester uterine artery Doppler parameters associated with adverse pregnancy outcomes.

Prenatal visit utilization and outcomes in pregnant women with type II and gestational diabetes

Objective:To investigate the association between the number of prenatal visits (PNVs) and pregnancy outcomes in women with gestational diabetes (GDM) and Type 2 diabetes mellitus (DM).Study Design:A 4-year prospective cohort study of women with GDM and DM and was conducted. Patients ⩾75th percentile for number of PNVs were compared with those ⩽25th percentile. The primary outcomes were large for gestational age (LGA) with birth weight >90% and neonatal intensive care unit (NICU) admission for >24 h. Secondary neonatal outcomes included severe LGA (>95%), shoulder dystocia, hyperbilirubinemia requiring phototherapy, neonatal hypoglycemia, low 5 min APGAR score (<7) and preterm birth (prior to 37 weeks). Secondary maternal outcomes included mean third trimester fasting blood glucose, hemoglobin A1c (Hgb A1c) in labor, preeclampsia, gestational weight gain over Institute of Medicine recommendations, mode of delivery and maternal readmission within 30 days. Logistic regression was used to adjust for maternal race, nulliparity and body mass index.Results:Of the 305 women, 4 were excluded for unknown number of PNVs. Among the 301 included, the average number of visits was 12. Rates of LGA were similar between the high (28%) compared with low (18%) utilization groups (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 0.81–3.54). The high utilization group was 85% less likely to deliver an infant requiring NICU admission (aOR 0.15; 95% CI 0.04–0.53) and 59% less likely to have a preterm birth (aOR 0.41; 95% CI 0.21–0.80). A time-to-event analysis to account for the fact that patients who delivered earlier had fewer weeks to experience PNVs showed that the risk for NICU admission was still significantly lower in the high PNV utilization group (hazard ratio 0.15; 95% CI 0.04–0.51) after adjusting for confounders in a Cox proportional hazard model. The mean Hgb A1c at the time of delivery was significantly better in the high (6.4%) compared with low (6.9%) utilization groups (P=0.01). There were no differences in other maternal outcomes based on prenatal care utilization.Conclusions:Diabetic women with high PNV utilization have better glycemic control in the 3 months prior to delivery and are significantly less likely to deliver preterm infants or infants requiring NICU admission. There may be innovative ways to provide prenatal care for GDM and DM to optimize maternal and neonatal outcomes.

Impact of evidence-based interventions on wound complications after cesarean delivery

BACKGROUND: A number of evidence‐based interventions have been proposed to reduce post–cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE: We sought to estimate the impact of a group of evidence‐based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine‐alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN: We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine‐alcohol vs iodine‐alcohol for skin antisepsis at cesarean delivery from 2011–2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence‐based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine‐alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence‐based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS: Of 1082 patients with follow‐up data, 349 (32.3%) received all the evidence‐based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence‐based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58–0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence‐based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12–2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18–11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence‐based measures. CONCLUSION: Implementation of evidence‐based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence‐based measures.

Group versus traditional prenatal care in low-risk women delivering at term: a retrospective cohort study

Objective:Group prenatal care (GC) models are receiving increasing attention as a means of preventing preterm birth; yet, there are limited data on whether group care improves perinatal outcomes in women who deliver at term. The purpose of this study was to evaluate our institutional experience with GC over the past decade and test the hypothesis that GC, compared with traditional individual care (TC), improves perinatal outcomes in women who deliver at term.Study Design:We performed a retrospective cohort study of women delivering at term who participated in GC compared with TC. A group of 207 GC patients who delivered at term from 2004 to 2014 were matched in a 1:2 ratio to 414 patients with term singleton pregnancies who delivered at our institution during the same period by delivery year, maternal age, race and insurance status. The primary outcome was low birth weight (<2500 g). Secondary outcomes included early term birth (37.0 to 38 6/7 weeks), 5 min APGAR score <7, special care nursery admission, neonatal intensive care unit (NICU) admission, neonatal demise, cesarean section and number of prenatal visits. Outcomes were compared between the two groups using univariable statistics.Results:Baseline characteristics were similar between the two matched groups. GC was associated with a significant reduction in low birth weight infants compared with TC (11.1% vs 19.6%; relative risk (RR) 0.57; 95% confidence interval (CI) 0.37 to 0.87). Patients in GC were significantly less likely than controls to require cesarean delivery, have low 5 min APGAR scores and need higher-level neonatal care (NICU: 1.5% vs 6.5%; RR 0.22; 95% CI 0.07 to 0.72). There were no significant differences in rates of early term birth and neonatal demise.Conclusions:Low-risk women participating in GC and delivering at term had a lower risk of low birth weight and other adverse perinatal outcomes compared with women in TC. This suggests GC is a promising alternative to individual prenatal care to improve perinatal outcomes in addition to preterm birth.