Michelle H. Moniz

Influenza immunization in pregnancy: overcoming patient and health care provider barriers

Seasonal influenza imparts disproportionate morbidity and death to pregnant women. Immunization against influenza is the most effective intervention to mitigate the burden of influenza disease during pregnancy; nevertheless, immunization rates remain suboptimal in this patient population. Therefore, there is a clear need for strategies to optimize influenza vaccination among pregnant women. We reviewed potential patient and health care provider barriers to influenza immunization and propose effective strategies for overcoming them.

Improving influenza vaccination rates in pregnancy through text messaging: a randomized controlled trial.

OBJECTIVE: To estimate whether text messages sent to ambulatory pregnant women could improve influenza vaccine uptake. METHODS: Obstetric patients at less than 28 weeks of gestation were enrolled in a randomized controlled trial from an academic centers outpatient clinic during two consecutive influenza seasons (2010–2011 and 2011–2012). Potential participants were excluded if they had already received that seasons influenza vaccine. Participants were randomized to receive 12 weekly text messages encouraging general pregnancy health (General) or general pregnancy health plus influenza vaccination (Flu). Study participants completed preintervention and postintervention surveys about preventive health beliefs. Influenza vaccine receipt was assessed using prenatal record review. The study was powered to detect a 55% increase in the vaccination rate in the intervention group. RESULTS: Two hundred sixteen women were enrolled, 204 of whom were available for intention-to-treat analysis (n=100 General, n=104 Flu). Participants were primarily African American (66%) with low educational attainment (90% equivalent to or less than high school education) and predominantly with either public or no insurance (88%). The overall influenza vaccination rate among participants was 32% with no difference between participants in the General (31% [n=31]) compared with Flu (33% [n=34]) groups (difference 1.7%, 95% confidence interval −11.1 to 14.5%). CONCLUSION: Text messaging prompts were not effective at increasing influenza vaccination rates among a low-income, urban, ambulatory obstetric population. Ongoing efforts are needed to improve vaccine uptake among pregnant women unsure about or unwilling to receive influenza vaccination. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01248520. LEVEL OF EVIDENCE: I

Characterization of Medicaid policy for immediate postpartum contraception

OBJECTIVE Long-acting reversible contraception (LARC) is safe, effective and cost-saving when provided immediately postpartum but currently underutilized due to nonreimbursement by Medicaid and other insurers. The objectives of this study were to (a) determine which state Medicaid agencies provide specific reimbursement for immediate postpartum LARC and (b) identify modifiable policy-level barriers and facilitators of immediate postpartum LARC access. STUDY DESIGN We conducted semistructured telephone interviews with representatives of 40 Medicaid agencies to characterize payment methodology for immediate postpartum LARC. We coded transcripts using grounded theory and content analysis principles. RESULTS Three categories of immediate postpartum LARC payment methodology emerged: state Medicaid agency (a) provides separate or increased bundled payment (n=15), (b) is considering providing enhanced payment (n=9) or (c) is not considering enhanced payment (n=16). Two major themes emerged related to Medicaid decision-making about immediate postpartum LARC coverage: (a) Health effects: States with payment for immediate postpartum LARC frequently cited improved maternal/child health outcomes as motivating their reimbursements. Conversely, states without payment expressed misinformation about LARCs clinical effects and lack of advocacy from local providers about clinical need for this service. (b) Financial implications: States providing payment emphasized overall cost savings. Conversely, states without reimbursement expressed concern about immediate budget constraints and potential adverse impact on existing global payment methodology for inpatient care. CONCLUSIONS Many states have recently provided Medicaid coverage of immediate postpartum LARC, and several other states are considering such coverage. Addressing misinformation about clinical effects and concerns about cost-effectiveness of immediate postpartum LARC may promote adoption of immediate postpartum LARC reimbursement in Medicaid agencies currently without it. IMPLICATIONS Medicaid policy for reimbursement of immediate postpartum LARC is evolving rapidly across the US. Our findings suggest several concrete strategies to remove policy-level barriers and promote facilitators of immediate postpartum LARC.

Maternal immunization: Clinical experiences, challenges, and opportunities in vaccine acceptance

Maternal immunization holds tremendous promise to improve maternal and neonatal health for a number of infectious conditions. The unique susceptibilities of pregnant women to infectious conditions, as well as the ability of maternally-derived antibody to offer vital neonatal protection (via placental transfer), together have produced the recent increased attention on maternal immunization. The Advisory Committee on Immunization Practices (ACIP) currently recommends 2 immunizations for all pregnant women lacking contraindication, inactivated Influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap). Given ongoing research the number of vaccines recommended during pregnancy is likely to increase. Thus, achieving high vaccination coverage of pregnant women for all recommended immunizations is a key public health enterprise. This review will focus on the present state of vaccine acceptance in pregnancy, with attention to currently identified barriers and determinants of vaccine acceptance. Additionally, opportunities for improvement will be considered.

Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the United States, 2008-2013

OBJECTIVE To measure rates of long-acting reversible contraception (LARC), including intrauterine devices and contraceptive implants, and tubal sterilization during delivery hospitalizations and correlates of their use. METHODS This retrospective cohort study used the 2008-2013 National Inpatient Sample, a publicly available all-payer database. We identified delivery hospitalizations with the International Classification of Diseases, 9th Revision, Clinical Modification codes for intrauterine device insertion, contraceptive implant insertion, and tubal sterilization. We used weighted multivariable logistic regression to examine associations between predictors (age, delivery mode, medical comorbidity, payer, hospital type, geographic region, and year) and likelihood of LARC and sterilization and to compare characteristics of LARC and sterilization users. RESULTS Our sample included 4,691,683 discharges, representing 22,667,204 delivery hospitalizations. Long-acting reversible contraception insertion increased from 1.86 per 10,000 deliveries (2008-2009) to 13.5 per 10,000 deliveries (2012-2013; P<.001); tubal sterilization remained stable (711-683 per 10,000 deliveries; P=.24). In multivariable analysis adjusting for all predictors, compared with neither LARC nor sterilization, LARC use was highest among women with medical comorbidities (count per 10,000 deliveries: 15.04, standard error 2.11, adjusted odds ratio [OR] 1.92, 95% confidence interval [CI] 1.72-2.13), nonprivate payer (13.50, standard error 2.14, adjusted OR 5.23, 95% CI 3.82-7.16), and at urban teaching hospitals (14.92, standard error 2.25, adjusted OR 20.85, 95% CI 12.73-34.15). Sterilization was least likely among women aged 24 years or younger (251.04, standard error 4.88, adjusted OR 0.12 95% CI 0.12-0.13, compared with 35 years or older) and most likely with cesarean delivery (1,568.74, standard error 20.81, adjusted OR 6.25, 95% CI 5.88-6.63). Comparing only LARC and sterilization users, LARC users tended to have nonprivate insurance (84.95% compared with 57.17%, adjusted OR 1.90, 95% CI 1.38-2.63) and deliver at urban teaching hospitals (94.65% compared with 45.47%, adjusted OR 38.39, 23.52-62.64) in later study years (2012-2013; 55.72% compared with 32.18%, adjusted OR 8.26, 95% CI 4.42-15.44, compared with 2008-2009). CONCLUSION Long-acting reversible contraception insertion increased from 1.86 to 13.5 per 10,000 deliveries but remained less than 2% of the sterilization rate. Inpatient postpartum LARC insertion is more likely among sicker, poorer women delivering at urban teaching hospitals.

Recruiting pregnant patients for survey research: A head to head comparison of social media-based versus clinic-based approaches

Background Recruiting a diverse sample of pregnant women for clinical research is a challenging but crucial task for improving obstetric services and maternal and child health outcomes. Objective To compare the feasibility and cost of recruiting pregnant women for survey research using social media-based and clinic-based approaches. Methods Advertisements were used to recruit pregnant women from the social media website Facebook. In-person methods were used to recruit pregnant women from the outpatient clinic of a large, tertiary care center. In both approaches, potential respondents were invited to participate in a 15-minute Web-based survey. Each recruitment method was monitored for 1 month. Using bivariate statistics, we compared the number, demographic characteristics, and health characteristics of women recruited and the cost per completed survey for each recruitment method. Results The social media-based approach recruited 1178 women and the clinic-based approach recruited 219 women. A higher proportion of subjects recruited through social media identified as African American (29.4%, 207/705 vs 11.2%, 20/179), reported household incomes <US

Immediate postpartum long-acting reversible contraception: the time is now

30,000 per year (56.8%, 409/720 vs 25.8%, 47/182), reported being in early pregnancy (18.6%, 135/726 vs 10.4%, 19/183 first trimester), and rated their health as fair or poor (22.2%, 160/722 vs 8.2%, 15/183; all P<.001). A smaller proportion of subjects recruited through social media had earned a college degree (21.3%, 153/717 vs 62.3%, 114/183) and were married or in a domestic partnership (45.7%, 330/722 vs 72.1%, 132/183; all P<.001). Social media-based recruitment costs were US

Text messages for influenza vaccination among pregnant women: A randomized controlled trial

14.63 per completed survey, compared with US

Attitudes About Required Coverage of Mental Health Care in a U.S. National Sample

23.51 for clinic-based recruitment. Conclusions Web-based recruitment through a social networking platform is a feasible, inexpensive, and rapid means of recruiting a large, diverse sample of pregnant women for survey research.

Disparities in Chronic Conditions Among Women Hospitalized for Delivery in the United States, 2005–2014

Immediate postpartum long-acting reversible contraception: the time is now Michelle Moniz⁎, Tammy Chang, Michele Heisler , Vanessa K. Dalton Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA School of Public Health, University of Michigan, Ann Arbor, MI, USA