Pooja Mehta

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment.

Purpose of the ReviewOpioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population.Recent FindingsWe review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal (“detoxification”) is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad.SummaryFurther research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.

Deaths From Unintentional Injury, Homicide, and Suicide During or Within 1 Year of Pregnancy in Philadelphia

OBJECTIVES To understand the effect of unintentional injuries (e.g., drug overdose), suicide, and homicide on pregnancy-associated death (death during or within 1 year of pregnancy). METHODS We analyzed all cases of pregnancy-associated death among Philadelphia, Pennsylvania, residents from 2010 to 2014, examining cause of death, contributing factors, and history of health care use. RESULTS Approximately half (49%; 42 of 85) of pregnancy-associated deaths were from unintentional injuries (n = 31), homicide (n = 8), or suicide (n = 3); drug overdose was the leading cause (n = 18). Substance use was noted during or around events leading to death in 46% (31 of 67) of nonoverdose deaths. A history of serious mental illness was noted in 39% (32 of 82) of nonsuicide deaths. History of intimate partner violence (IPV) was documented in 19% (15 of 77) of nonhomicide deaths. Regardless of cause of death, approximately half of all decedents had an unscheduled hospital visit documented within a month of death. CONCLUSIONS Unintentional injury, homicide, and suicide contribute to many deaths among pregnant and recently pregnant women. Interventions focused on substance use, mental health, and IPV may reduce pregnancy-associated and pregnancy-related deaths.

Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act.

Purpose of review To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities. Recent findings Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities. Summary The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.

Fathers’ intentions to accept human papillomavirus vaccination for sons and daughters: exploratory findings from rural Honduras

ObjectivesLittle is known about fathers’ attitudes toward human papillomavirus (HPV) vaccination in low-resource settings. We sought to determine the awareness of HPV vaccination among Honduran fathers, and to assess their intention to accept HPV vaccination for their sons and daughters.MethodsWe conducted 100 structured interviews of fathers recruited from medical and business settings between May 2007 and June 2008. After assessing baseline knowledge, fathers received a brief explanation of HPV infection, cervical cancer, genital warts, and HPV vaccination. They were then asked whether they would accept HPV vaccination for their sons and daughters.ResultsPrior to receiving information about HPV, 85% of fathers believed that cervical cancer was preventable, over two-thirds could correctly name some form of prevention, 22% of fathers had heard of HPV, and 17% had heard of HPV vaccination. After receiving HPV-related information, 100% of fathers intended to accept HPV vaccination for their sons and 94% intended to accept HPV vaccination for their daughters.ConclusionsFew Honduran fathers were aware of HPV or HPV vaccination, but after receiving information, most would accept HPV vaccination for their sons and daughters.

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.

Learning from UJAMBO: Perspectives on Gynecologic Care in African Immigrant and Refugee Women in Boston, Massachusetts

African-born immigrant women, and particularly refugees and asylum seekers, are at risk for reproductive health disparities but inadequately use relevant gynecologic services. We sought to elucidate perspectives on gynecologic care in a population of Congolese and Somali immigrants. We conducted a secondary qualitative analysis of focus group data using a grounded theory approach and the Integrated Behavioral Model as our theoretical framework. Thirty one women participated in six focus groups. Participant beliefs included the states of pregnancy and/or pain as triggers for care, preferences included having female providers and those with familiarity with female genital cutting. Barriers included stigma, lack of partner support, and lack of resources to access care. Experiential attitudes, normative beliefs, and environmental constraints significantly mediated care preferences for/barriers to gynecologic health service utilization in this population. Centering of patient perspectives to adapt delivery of gynecologic care to immigrants and refugees may improve utilization and reduce disparities.

Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy among Pregnant Women in Specialty Treatment

Background: Opioid agonist therapy (OAT) is the standard of care for pregnant women with opioid use disorder (OUD). Medicaid coverage policies may strongly influence OAT use in this group. Objective: To examine the association between Medicaid coverage of methadone maintenance and planned use of OAT in the publicly funded treatment system. Research Design: Retrospective cross-sectional analysis of treatment admissions in 30 states extracted from the Treatment Episode Data Set (2013 and 2014). Subjects: Medicaid-insured pregnant women with OUD (n=3354 treatment admissions). Measures: The main outcome measure was planned use of OAT on admission. The main exposure was state Medicaid coverage of methadone maintenance. Using multivariable logistic regression models adjusting for sociodemographic, substance use, and treatment characteristics, we compared the probability of planned OAT use in states with Medicaid coverage of methadone maintenance versus states without coverage. Results: A total of 71% of pregnant women admitted to OUD treatment were 18–29 years old, 85% were white non-Hispanic, and 56% used heroin. Overall, 74% of admissions occurred in the 18 states with Medicaid coverage of methadone maintenance and 53% of admissions involved planned use of OAT. Compared with states without Medicaid coverage of methadone maintenance, admissions in states with coverage were significantly more likely to involve planned OAT use (adjusted difference: 32.9 percentage points, 95% confidence interval, 19.2–46.7). Conclusions: Including methadone maintenance in the Medicaid benefit is essential to increasing OAT among pregnant women with OUD and should be considered a key policy strategy to enhance outcomes for mothers and newborns.

Erratum to: Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment

The original paper of this article unfortunately contains error. Dr. Pooja Mehta’s Conflict of Interest information was incorrectly listed in the publication. Her correct COI information is as follows: Dr. Pooja Mehta declares grant funding from American College of Obstetricians & Gynecologists Warren H. Pearse Research Award for Women’s Health Policy, and from the HRSA Maternal Child Health Bureau R20 Secondary Data Analysis, both unrelated to the submission.

Understanding High Utilization of Emergency Obstetric Care in Pregnant Women of Low Socioeconomic Status [170].

INTRODUCTION: Drivers and impact of low-value care use in pregnant women with high levels of emergency care utilization are poorly understood. METHODS: Deidentified records of all obstetric triage visits from October 2013 to August 2014 at an urban academic medical center were analyzed for utilization trends and clinical outcome. We conducted semistructured interviews with 40 low-income women presenting to obstetric triage after 16 weeks of gestation, purposively sampling those presenting for a fourth or higher visit (high utilizers) or a first visit at term (low utilizers). Interviews were recorded and coded by theme. RESULTS: Six thousand seven hundred and ninety-four triage visits representing 3,539 patients occurred during the study period with 1.9 mean visits per patient. High utilizers made up 10.9% of the sample and were more likely than other triage users to report prior psychosocial trauma (17.8% compared with 7.7%, P<.001) and medical illness (64.0% compared with 47.5%, P<.001). High utilizers were less likely than other triage users to deliver at our center (16% compared with 42%, P<.001); those who did were more likely to deliver preterm (22.6% compared with 12.3%, P=.02). Interview participants perceived triage care to be of higher quality and more accessible than outpatient prenatal care. High utilizers reported social dysfunction and difficulty coping with pregnancy. Low utilizers reported social stability and self-efficacy. CONCLUSION: High emergency utilization can be a signal of unmet need. Interventions targeting perinatal disparities should incorporate low-income patient perspectives by leveraging emergency visits, addressing social determinants, and promoting access to quality prenatal care.

Single vs Multiple Embryo Transfer Comparative Costs and a Call for Change

The equivalent efficacy and superior safety of elective single embryo transfer (SET) compared with elective multiple embryo transfer (MET) after in vitro fertilization (IVF) has been established in recent medical literature. The transfer of a single high-quality embryo selected from a larger number of available embryos after IVF does not decrease implantationratescomparedwithMETanddecreases the rateof twins from 30% to between 1% and 2%.1 To reduce the complications associated with twin and higher-order multiple births—including medical and delivery complications for mothers, infant low birth weight, preterm birth, stillbirth, neonatal and infant mortality, and cerebral palsy2—practice guidelines have urged health care professionals to recommend SET in women younger than 35 years who have more than 1 top-quality embryo, who may have had a previous successful IVF cycle, and who are on a first or second treatment cycle.3 There has been a resulting decrease in the proportion of transfers of 3 or more embryos from 70% to 39%. However, the United States has lagged behind the rest of the world in adoption of SET, with rates of twin pregnancy due to MET after IVF actually increasing in recent years.4 Until recently, cost-effectiveness studies comparing electiveSETwithMEThave focusedontheeasier-to-measurecosts of achieving pregnancy and medical costs up to 4 to 6 weeks postpartum,withconflicting results.5-7Toourknowledge, longer-termexaminations of the relative cost ofMET to families, payers, and society, aswell as studies thatmore directly elicit patient perspectives, are lacking. The study by Chambers et al8 in this issue of JAMA Pediatrics attempts to fill this gap by assessing the contribution of assisted reproductive technology to the frequency, duration, and cost of hospitalization in singleton, twin, and higher-order multiple children up to 5 years of life in Western Australia. The authors were able to take advantage of a validated linkage system between a regional birth registry, a reproductive technology registry, death certificates, and an inpatient hospital admission database to perform one of the largest population assessments of costs attributable to SET vs MET to date.8 The study’s authors demonstrated that, compared with singletons, twins andhigher-ordermultiple childrenwere 3.4 and 9.6 timesmore likely to be stillborn, respectively, and 6.4 and 36.7 times more likely to die during the neonatal period, respectively. Twins and higher-ordermultipleswere 18.7 and 525.1 more times likely to be preterm and small for gestational age, respectively. The average hospital cost of singleton, twin, and higher-order multiple children to 5 years was