Laura B. Attanasio

Hospital care and early breastfeeding outcomes among late preterm, early-term, and term infants.

BACKGROUND Compared with term infants (39-41 weeks), early-term (37-38 weeks) and late preterm (34-36 weeks) infants have increased breastfeeding difficulties. We evaluated how hospital practices affect breastfeeding by gestational age. METHODS This Listening to Mothers III survey cohort included 1,860 mothers who delivered a 34-41-week singleton from July 2011 to June 2012. High hospital support was defined as at least seven practices consistent with the Baby-Friendly Hospital Initiatives Ten Steps for United States hospitals. Logistic regression tested mediating effects of hospital support on the relationship between gestational age and breastfeeding at 1 week postpartum. RESULTS High hospital support was associated with increased exclusive breastfeeding (AOR 2.21 [95% CI 1.58-3.09]). Just 16.4 percent of late preterm infants experienced such support, compared with early-term (37.9%) and term (30.7%) infants (p = 0.004). Although overall breastfeeding rates among late preterm, early-term, and term infants were 87, 88, and 92 percent, respectively, (p = 0.21), late preterm versus term infants were less likely to exclusively breastfeed (39.8 vs. 62.3%, p = 0.002). Inclusion of hospital support in multivariable modeling did not attenuate the effect of late preterm gestation. DISCUSSION Differences in practices do not account for decreased exclusive breastfeeding among late preterm infants. Hospital supportive practices increase the likelihood of any breastfeeding.

Patient-reported communication quality and perceived discrimination in maternity care

Background:High-quality communication and a positive patient-provider relationship are aspects of patient-centered care, a crucial component of quality. We assessed racial/ethnic disparities in patient-reported communication problems and perceived discrimination in maternity care among women nationally and measured racial/ethnic variation in the correlates of these outcomes. Methods:Data for this analysis came from the Listening to Mothers III survey, a national sample of women who gave birth to a singleton baby in a US hospital in 2011–2012. Outcomes were reluctance to ask questions and barriers to open discussion in prenatal care, and perceived discrimination during the birth hospitalization, assessed using multinomial and logistic regression. We also estimated models stratified by race/ethnicity. Results:Over 40% of women reported communication problems in prenatal care, and 24% perceived discrimination during their hospitalization for birth. Having hypertension or diabetes was associated with higher levels of reluctance to ask questions and higher odds of reporting each type of perceived discrimination. Black and Hispanic (vs. white) women had higher odds of perceived discrimination due to race/ethnicity. Higher education was associated with more reported communication problems among black women only. Although having diabetes was associated with perceptions of discrimination among all women, associations were stronger for black women. Conclusions:Race/ethnicity was associated with perceived racial discrimination, but diabetes and hypertension were consistent predictors of communication problems and perceptions of discrimination. Efforts to improve communication and reduce perceived discrimination are an important area of focus for improving patient-centered care in maternity services.

Medically complex pregnancies and early breastfeeding behaviors: a retrospective analysis.

Background Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices. Methods We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011–2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status. Results More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52–0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with >30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47–0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81–8.94; and AOR = 2.68; 95% CI, 1.70–4.23, respectively). Conclusions Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants.

Women's Experiences with Neuraxial Labor Analgesia in the Listening to Mothers II Survey: A Content Analysis of Open-Ended Responses.

BACKGROUND: Most women who give birth in United States hospitals receive neuraxial analgesia to manage pain during labor. In this analysis, we examined themes of the patient experience of neuraxial analgesia among a national sample of U.S. mothers. METHODS: Data are from the Listening to Mothers II survey, conducted among a national sample of women who delivered a singleton baby in a U.S. hospital in 2005 (N = 1,573). Our study population consisted of women who experienced labor, did not deliver by planned cesarean, and who reported neuraxial analgesia use (n = 914). We analyzed open-ended responses about the best and worst parts of women’s birth experiences for themes related to neuraxial analgesia using qualitative content analysis. RESULTS: Thirty-three percent of women (n = 300) mentioned neuraxial analgesia in their open-ended responses. We found that effective pain relief was frequently spontaneously mentioned as a key positive theme in women’s experiences with neuraxial analgesia. However, some women perceived timing-related challenges with neuraxial analgesia, including waiting in pain for neuraxial analgesia, receiving neuraxial analgesia too late in labor, or feeling that the pain relief from neuraxial analgesia wore off too soon, as negative aspects. Other themes in women’s experiences with neuraxial analgesia were information and consent, adverse effects of neuraxial analgesia, and plans and expectations. CONCLUSIONS: The findings from this analysis underscored the fact that women appreciate the effective pain relief that neuraxial analgesia provides during childbirth. Although pain control was 1 important facet of women’s experiences with neuraxial analgesia, their experiences were also influenced by other factors. Anesthesiologists can work with obstetric clinicians, nurses, childbirth educators, and pregnant and laboring patients to help mitigate some of the challenges with timing, communication, neuraxial analgesia administration, or expectations that may have contributed to negative aspects of women’s birth experiences.

The impact of prenatal employment on breastfeeding intentions and breastfeeding status at 1 week postpartum

Background: Postpartum employment is associated with non-initiation and early cessation of breastfeeding, but less is known about the relationship between prenatal employment and breastfeeding intentions and behaviors. Objective: This study aimed to estimate the relationship between prenatal employment status, a strong predictor of postpartum return to work, and breastfeeding intentions and behaviors. Methods: Using data from the Listening to Mothers II national survey (N = 1573), we used propensity score matching methods to account for non-random selection into employment patterns and to measure the impact of prenatal employment status on breastfeeding intentions and behaviors. We also examined whether hospital practices consistent with the Baby-Friendly Hospital Initiative (BFHI), assessed based on maternal perception, were differentially associated with breastfeeding by employment status. Results: Women who were employed (vs unemployed) during pregnancy were older, were more educated, were less likely to have had a previous cesarean delivery, and had fewer children. After matching, these differences were eliminated. Although breastfeeding intention did not differ by employment, full-time employment (vs no employment) during pregnancy was associated with decreased odds of exclusive breastfeeding 1 week postpartum (adjusted odds ratio = 0.48; 95% confidence interval, 0.25-0.92; P = .028). Higher BFHI scores were associated with higher odds of breastfeeding at 1 week but did not differentially impact women by employment status. Conclusion: Women employed full-time during pregnancy were less likely to fulfill their intention to exclusively breastfeed, compared to women who were not employed during pregnancy. Clinicians should be aware that employment circumstances may impact women’s breastfeeding decisions; this may help guide discussions during clinical encounters.

Reevaluating the relationship between prenatal employment and birth outcomes: a policy-relevant application of propensity score matching.

BACKGROUND Prior research shows an association between prenatal employment characteristics and adverse birth outcomes, but suffers methodological challenges in disentangling womens employment choices from birth outcomes, and little U.S.-based prior research compares outcomes for employed women with those not employed. This study assessed the effect of prenatal employment status on birth outcomes. METHODS With data from the Listening to Mothers II survey, conducted among a nationally representative sample of women who delivered a singleton baby in a U.S. hospital in 2005 (n = 1,573), we used propensity score matching to reduce potential selection bias. Primary outcomes were low birth weight (<2,500 g) and preterm birth (gestational age <37 weeks). Exposure was prenatal employment status (full time, part time, not employed). We conducted separate outcomes analyses for each matched cohort using multivariable regression models. FINDINGS Comparing full-time employees with women who were not employed, full-time employment was not causally associated with preterm birth (adjusted odds ratio [AOR], 1.37; p = .47) or low birth weight (AOR, 0.73; p = .41). Results were similar comparing full- and part-time workers. Consistent with prior research, Black women, regardless of employment status, had increased odds of low birth weight compared with White women (AOR, 5.07; p = .002). CONCLUSIONS Prenatal employment does not independently contribute to preterm births or low birth weight after accounting for characteristics of women with different employment statuses. Efforts to improve birth outcomes should focus on the characteristics of pregnant women (employed or not) that render them vulnerable.

Relationship Between Hospital-Level Percentage of Midwife-Attended Births and Obstetric Procedure Utilization

INTRODUCTION Research has shown good outcomes among individual low-risk women who receive perinatal care from midwives, yet little is known about how hospital-level variation in midwifery care relates to procedure use and maternal health. This study aimed to document the association between the hospital-level proportion of midwife-attended births and obstetric procedure utilization. METHODS This analysis used 2 data sources: Healthcare Cost and Utilization Project State Inpatient Database data for New York in 2014, and New York State Department of Health data on the percentage of midwife-attended births at hospitals in the state in 2014. Using logistic regression, we estimated the association between the hospital-level percentage of midwife-attended births and 4 outcomes among low-risk women: labor induction, cesarean birth, episiotomy, and severe maternal morbidity. RESULTS Hospital-level percentage of midwife-attended births was not associated with reduced odds of labor induction or severe maternal morbidity. Women who gave births at hospitals with more midwife-attended births had lower odds of giving birth by cesarean (eg, adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.59-0.82 at a hospital with 15% to 40% of births attended by midwives, compared to no midwife-attended births) and lower odds of episiotomy (eg, aOR, 0.41; 95% CI, 0.23-0.74 at a hospital with more than 40% of births attended by midwives, compared to no midwife-attended births). DISCUSSION Our results indicate that hospitals with more midwife-attended births have lower utilization of some obstetric procedures among low-risk women; this raises the possibility of improving value in maternity care through greater access to midwifery care.

Factors influencing women’s perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth

OBJECTIVE To examine correlates of shared decision making during labor and delivery. METHODS Data were from a cohort of women who gave birth to their first baby in Pennsylvania, 2009-2011 (N = 3006). We used logistic regression models to examine the association between labor induction and mode of delivery in relation to womens perceptions of shared decision making, and to investigate race/ethnicity and SES as potential moderators. RESULTS Women who were Black and who did not have a college degree or private insurance were less likely to report high shared decision making, as well as women who underwent labor induction, instrumental vaginal or cesarean delivery. Models with interaction terms showed that the reduction in odds of shared decision making associated with cesarean delivery was greater for Black women than for White women. CONCLUSIONS Women in marginalized social groups were less likely to report shared decision making during birth and Black women who delivered by cesarean had particularly low odds of shared decision making. PRACTICE IMPLICATIONS Strategies designed to improve the quality of patient-provider communication, information sharing, and shared decision making must be attentive to the needs of vulnerable groups to ensure that such interventions reduce rather than widen disparities.

Health Care Engagement and Follow-up After Perceived Discrimination in Maternity Care

Background: Negative experiences in the health care system, including perceived discrimination, can result in patient disengagement from health care. Four million US women give birth each year, and the perinatal period is a time of sustained interaction with the health care system, but potential consequences of negative experiences have not been examined in this context. We assessed whether perceived discrimination during the birth hospitalization were associated with postpartum follow-up care. Methods: Data were from the Listening to Mothers III survey, a nationally drawn sample of 2400 women with singleton births in US hospitals in 2011–2012. We used multivariate logistic regression to estimate adjusted odds of having a postpartum visit in the 8 weeks following birth by perceptions of discrimination due to (1) race/ethnicity; (2) insurance type; and (3) a difference of opinion with a provider about care. Results: Women who experienced any of the 3 types of perceived discrimination had more than twice the odds of postpartum visit nonattendance (adjusted odds ratio=2.28, P=0.001), after adjusting for socioeconomic and medical characteristics. Conclusions: The postpartum visit is an opportunity for a patient and clinician to address continuing health problems following birth, discuss contraception, and screen for chronic disease. Forgoing this care may have negative health effects. The findings from this study underscore the need to reduce discrimination and improve maternity care experiences.

Employment During Pregnancy and Obstetric Intervention Without Medical Reason: Labor Induction and Cesarean Delivery

BACKGROUND Rising rates of labor induction and cesarean delivery, especially when used without a medical reason, have generated concern among clinicians, women, and policymakers. Whether employment status affects pregnant womens childbirth-related care is not known. We estimated the relationship between prenatal employment and obstetric procedures, distinguishing whether women reported that the induction or cesarean was performed for medical reasons. METHODS Using data from a nationally representative sample of women who gave birth in U.S. hospitals (n = 1,573), we used propensity score matching to reduce potential bias from nonrandom selection into employment. Outcomes were cesarean delivery and labor induction, with and without a self-reported medical reason. Exposure was prenatal employment status (full-time employment, not employed). We conducted separate analyses for unmatched and matched cohorts using multivariable regression models. FINDINGS There were no differences in labor induction based on employment status. In unmatched analyses, employed women had higher odds of cesarean delivery overall (adjusted odds ratio [AOR], 1.45; p = .046) and cesarean delivery without medical reason (AOR, 1.94; p = .024). Adding an interaction term between employment and college education revealed no effects on cesarean delivery without medical reason. There were no differences in cesarean delivery by employment status in the propensity score-matched analysis. CONCLUSIONS Full-time prenatal employment is associated with higher odds of cesarean delivery, but this association was not explained by socioeconomic status and no longer existed after accounting for sociodemographic differences by matching women employed full time with similar women not employed during pregnancy.