Rebekah E. Gee

Partner support and impact on birth outcomes among teen pregnancies in the United States

PURPOSE Despite hypothesized relationships between lack of partner support during a womans pregnancy and adverse birth outcomes, few studies have examined partner support among teens. We examined a potential proxy measure of partner support and its impact on adverse birth outcomes (low birth weight (LBW), preterm birth (PTB) and pregnancy loss) among women who have had a teenage pregnancy in the United States. METHODS In a secondary data analysis utilizing cross-sectional data from 5609 women who experienced a teen pregnancy from the 2006-2010 National Survey of Family Growth (NSFG), we examined an alternative measure of partner support and its impact on adverse birth outcomes. Bivariate and multivariable logistic regression were used to assess differences in women who were teens at time of conception who had partner support during their pregnancy and those who did not, and their birth outcomes. RESULTS Even after controlling for potential confounding factors, women with a supportive partner were 63% less likely to experience LBW [aOR: 0.37, 95% CI: (0.26-0.54)] and nearly 2 times less likely to have pregnancy loss [aOR: 0.48, 95% CI: (0.32-0.72)] compared to those with no partner support. CONCLUSIONS Having partner support or involvement during a teenagers pregnancy may reduce the likelihood of having a poor birth outcome.

The balance between stress and personal capital during pregnancy and the relationship with adverse obstetric outcomes: findings from the 2007 Los Angeles Mommy and Baby (LAMB) study.

Stress during pregnancy is a salient risk factor for adverse obstetric outcomes. Personal capital during pregnancy, defined as internal and social resources that help women cope with or decrease their exposure to stress, may reduce the risk of poor obstetric outcomes. Using data from the 2007 Los Angeles Mommy and Baby study (N = 3,353), we examined the relationships between the balance of stress and personal capital during pregnancy, or the stress-to-capital ratio (SCR), and adverse obstetric outcomes (i.e., pregnancy complications, preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA)). Women with a higher SCR (i.e., greater stress relative to personal capital during pregnancy) were significantly more likely to experience at least one pregnancy complication, PTB, and lower gestational age, but not LBW or SGA. Accounting for pregnancy complications completely mediated the association between the SCR and PTB. Our findings indicate that experiencing greater stress relative to personal capital during pregnancy is associated with an increased risk for pregnancy complications, PTB, and lower gestational age and that pregnancy complications may be a mechanism by which the SCR is related to adverse obstetric outcomes.

Effect of maternal height and weight on risk of preterm birth in singleton and twin births resulting from in vitro fertilization: a retrospective cohort study using the Society for Assisted Reproductive Technology Clinic Outcome Reporting System

OBJECTIVE To examine the effect of height, weight, and body mass index (BMI) on the risk of preterm birth of singleton and twin pregnancies conceived by vitro fertilization (IVF). DESIGN Retrospective cohort study using 2006-2008 data from the Society for Reproductive Technology Clinic Outcome Reporting System (SART CORS). SETTING SART-associated assisted reproductive technology programs. PATIENT(S) 56,556 singleton and 23,804 twin live births resulting from fresh nondonor IVF cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Rates of very early preterm (VEPTB; <28 weeks), very preterm (VPTB; <32 weeks), and preterm birth (<37 weeks) births. RESULT(S) In both singleton and twin births, increased maternal height was associated with a decreased risk of preterm birth. Maternal overweight and obesity were associated with significantly increased risk of VEPTB and VPTB in twin pregnancies. For very obese women (BMI > 35 kg/m(2)) twins were associated with a threefold increased risk of VEPTB (6.1% vs. 2.0%) and a twofold increased risk of VPTB (11.5% vs. 5.9%) compared with women of normal weight (BMI 18.4-24.9 kg/m(2)). CONCLUSION(S) Obesity and short stature significantly increase the risk of VEPTB and VPTB in twins conceived by IVF.

Recommendations of the IOM clinical preventive services for women committee: implications for obstetricians and gynecologists.

PURPOSE OF REVIEW In July 2011, in response to language in the Affordable Care Act (ACA) the Office of the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services (HHS) tasked the Institute of Medicine (IOM) to develop a report on the clinical preventive services necessary for women. The committee proposed eight new clinical preventive service recommendations aimed at closing significant gaps in preventive healthcare. This article reviews the process, findings, and the implications for obstetrician gynecologists and other primary care clinicians. Obstetricians and gynecologists play a major role in delivering primary care to women and many of the services recommended by the Committee are part of the core set of obstetrics and gynecology services. RECENT FINDINGS The womens health amendment to the ACA (Federal Register, 2010) requires that new private health plans cover - with no cost-sharing requirements - preventive healthcare services for women. Congress requested that a review be conducted to ascertain whether there were any additional needed preventive services specific to womens health that should be included. SUMMARY The IOM Committee on Preventive Services for Women recommended eight clinical measures specific to womens health that should be considered for coverage without co-payment. The US Department of HHS reviewed and adopted these recommendations, and, as a result, new health plans will need to include these services as part of insurance policies with plan years beginning on or after 1 August 2012. The authors discuss the implications of the IOM recommendations on practicing clinicians and on their potential impact on womens health and well being.

Racial and ethnic disparities in maternal morbidity and mortality.

Maternal mortality or pregnancy-related mortality provides one of the starkest examples of women’s health disparities. In the United States, black women are three to four times more likely to die due to pregnancy-related complications than are white women. The five main causes of pregnancy-related mortality are venous thromboembolism, hemorrhage, preeclampsia, infection, and cardiomyopathy. Black women are more likely to die from each of these top causes of maternal death than their white counterparts. Moreover, pregnant black women when compared with their white counterparts are more likely to have preventable deaths (44% compared with 30%). Health equity refers to circumstances in which every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health disparities have been defined by the Centers for Disease Control and Prevention as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” Understanding racial and ethnic variation in maternal health indicators and recognizing contributors to inequity are important first steps toward achieving health equity and eliminating health disparities. For the first time in U.S. history, the pregnancyrelated mortality ratio is increasing. The ratio increased from 9.1 per 100,000 in 1987–1990 to 11.5 per 100,000 in 1991–1997, sparking widespread concern. The most recent estimates indicate that the maternal mortality ratio continues to increase, with an overall ratio of 16 per 100,000 live births in 2006–2010. The increase in pregnancy-related mortality in the United States is believed to be in part due to enhanced documentation and a change in case definition capturing more true cases of pregnancy-related mortality. Even after accounting for improved data collection, there appears to be an actual increase in pregnancy-related morbidity. Factors thought to contribute to this rise include health disparities, increasing rates of obesity, delayed childbearing, increased cesarean delivery rates, emerging infections (such as influenza H1N1), and untreated underlying medical conditions. Review of each maternal death as a sentinel event has provided abundant opportunity for improving obstetric health systems. Reviewing severe maternal morbidity, which occurs much more frequently than pregnancy-related mortality, has the potential to be even more informative. To simplify the identification of severe maternal morbidity, Callaghan and colleagues proposed to define it using 1 of 25 specific International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes that capture potentially life-threatening illness and indicators of organ-system failure that likely represent severe events (Box 1). In 2008–2009, the occurrence of severe maternal morbidity was 129 per 10,000 and represented a 75% increase over the estimates in 1998–1999. This ratio continues to increase. NonHispanic blacks are twice as likely to experience severe maternal morbidities than their white counterparts, and rates of 22 of the 25 indicators of severe maternal morbidity, including eclampsia, heart failure, and need for ventilation, are higher among blacks. From the Divisions of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Morsani College of Medicine and College of Public Health, University of South Florida, Tampa, Florida, and University of North Carolina, Chapel Hill, North Carolina; and Louisiana State University Departments of Health Policy and Management and Obstetrics and Gynecology, Schools of Public Health and Medicine, New Orleans, Louisiana.

17α-Hydroxyprogesterone Caproate Access in the Louisiana Medicaid Population

Preterm birth and its associated neonatal morbidities remain pertinent health care and economic issues in the United States. Progesterone supplementation in the form of 17α-hydroxyprogesterone caproate has been reported to reduce the risk for recurrent preterm birth in women with a prior spontaneous preterm delivery, but several barriers contribute to its underutilization. The Affordable Care Act has increased the number of women receiving insurance coverage for pre- and perinatal care. However, the increase in insurance coverage has not necessarily facilitated access to standard therapies such as progesterone for the prevention of preterm birth. Data from Louisiana illustrate this point, and the state has responded by developing educational programs and the nations first pay-for-performance strategy targeting the initiation of progesterone therapy.

Quality measurement: what it means for obstetricians and gynecologists.

Quality problems in health care can be described as underuse (when proven, evidence-based practices are not followed), misuse (failure to provide appropriate care or use of inappropriate care, including medical errors), and overuse (the provision of medical services with no benefit or for which harms outweigh benefits). When policymakers, employers, purchasers of health care, and consumers look at the quality of health care delivery in the United States, the picture is not reassuring. Numerous studies have shown that patients receive little more than half of recommended evidence-based care. Variation in care in different communities, states, and regions is vast, and too often care results in adverse outcomes. Purchasers, policymakers, and patients are demanding greater accountability for the dollars spent and the quality of care provided. Quality measures are widely used locally and nationally as tools for accountability and for information sharing on caregiver and health system quality and performance. They are used for public reporting, payment incentives, accreditation, maintenance of certification, and value-based purchasing. The Institute of Medicine has called for health systems “to do their work openly; to make their results known to the public and professionals alike; and to build trust through disclosure, even of the systems’ own problems.” A wide variety of organizations have embraced the Institute of Medicine’s challenge outlined in the 2001 Crossing the Quality Chasm report, with resulting greater transparency of health care systems’ performance.

The Affordable Care Act: an overview for obstetricians and gynecologists.

The Patient Protection and Affordable Care Act was passed in March 2010, and the U.S. Supreme Court affirmed the constitutionality of the individual mandate in June 2012. The individual mandate and employer responsibility provisions, insurance subsidies, and state health insurance exchanges will take effect when full implementation occurs in January 2014. The Affordable Care Act represents the greatest single expansion in coverage since the 1965 enactment of Medicare and Medicaid. If fully implemented, the Act has the potential to reduce the number of uninsured Americans by more than half and result in coverage for up to 94% of Americans. Although the changes are sweeping, many of the provisions of the Affordable Care Act have taken effect or states and employers have already begun preparing for the changes. Provisions of the Affordable Care Act already in effect include coverage of young adults up to 26 years of age under their parents’ plans and a ban on preexisting-condition exclusions for those under 19 years of age. In addition to these provisions, coverage of preventive services benefits without cost-sharing; a ban against lifetime coverage limits and restrictions on annual limits; annual premium rate-increase controls; and patient protections such as direct access to obstetric and gynecologic care, pediatric care, and fairer and stronger appeals rights have been implemented. By September 2012, the Act’s preventive service expansions had improved coverage for an estimated 47 million women. Sixteen states from diverse regions of the nation are in the process of establishing health insurance exchanges that will offer affordable coverage to millions of low-income and moderateincome individuals and families as well as small employers. Pre-existing-condition plans have been established in all states to offer affordable, subsidized coverage in advance of the full health insurance and Medicaid reforms that begin in 2014. These reforms consist of a ban on the use of pre-existing-condition exclusions, prohibition against discriminatory pricing on the basis of health, and guaranteed issuance of health insurance and guaranteed renewal of coverage. In addition, the Act also invests in public health and prevention, primary health care access, and initiatives to strengthen the primary health care workforce. The central purpose of the Affordable Care Act was to extend coverage to nearly all Americans under age 65. Although the Act establishes the broad contours of this coverage arrangement (employer plans for those with workplace benefits, Medicaid for the poorest Americans, and subsidized private insurance for low-income and moderate-income individuals and families through state exchange marketplaces), states have flexibility to design their insurance marketplaces and may choose to have the federal government set up and operate exchanges on behalf of state residents. Exchanges will certify qualified health plans for sale, determine whether individuals and families have incomes greater than 138% and up to 400% of the federal poverty level (up to

Improving maternal and infant health outcomes in Medicaid and the Children's Health Insurance Program.

92,200 for a family of four in 2012) and thus qualify for premium tax credits and cost-sharing assistance, facilitate enrollment and renewal of coverage, coordinate with state Medicaid programs and the Children’s Health Insurance Program, and oversee the quality of coverage offered by participating plans. As of September 2012, states are in the process of deciding whether to administer their own exchanges, work in partnership with the federal government, or rely on federal administration. The deadline for states to show operational readiness to administer their own exchanges without federal support is January 2013. Exchanges may be state agencies, public corporations, or private nonprofit entities. From the Louisiana State University Departments of Health Policy and Management and Obstetrics and Gynecology, Schools of Public Health and Medicine, New Orleans, Louisiana; and the George Washington University School of Public Health and Health Services, Washington, DC.

Improving Medicaid: three decades of change to better serve women of childbearing age.

Maternal and infant health is critical to our nations health. Disparities remain unacceptably high, particularly in the areas of prematurity and infant mortality. In 2012, traditionally distant partners such as federal and state governments, Medicaid and commercial payers, patients, public health and private clinicians, and multiple advocacy groups collaborated to focus on improving birth outcomes. To catalyze the alignment, the Centers for Medicare and Medicaid Services convened an Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and the Childrens Health Insurance Program. Over a years time, the Expert Panel assimilated the best available evidence in clinical science and policy from content leaders and patients. These recommendations culminated in the present report, which challenges us as a nation to implement strategies to help all children have the best chance to survive and thrive comparable to that of other westernized nations.