Tiffany Blake-Lamb

Intensive Prenatal Nutrition Counseling in a Community Health Setting: A Randomized Controlled Trial

OBJECTIVE To assess the effect of a culturally appropriate nutritional intervention delivered to overweight and obese patients in a community health setting on gestational weight gain and postpartum weight retention. MATERIALS AND METHODS We conducted a randomized controlled trial of an intensive nutrition counseling intervention for overweight and obese women by a registered dietitian throughout pregnancy and 6 months postpartum. The primary outcome was likelihood of gestational weight gain within Institute of Medicine (IOM, now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) guidelines. Secondary outcomes included birth weight and maternal and neonatal complications. RESULTS Three hundred patients were randomized. In intent-to-treat analyses, assignment to the intervention group did not have a significant effect on maintenance of gestational weight gain within IOM guidelines (34.2% compared with 27.5%, odds ratio [OR] 1.4, 95% CI 0.8-2.4). Among obese women, assignment to the intervention group was associated with fewer large-for-gestational-age (LGA) neonates (7% compared with 17%; OR 0.3, 95% CI 0.1-0.99). Neither primary nor secondary outcomes were significantly different among overweight women in the intervention group in intent-to-treat analyses. In as-treated analyses, women in the intervention group had lower neonatal birth weights (3,343 g compared with 3,500 g; difference -157.4 g, 95% CI -298.4 to -16.5) and lower likelihood of LGA (6% compared with 14%; OR 0.4, 95% CI 0.2-0.96). Among overweight women, participation in the intervention was associated with lower gestational weight gain (26.1 pounds compared with 31.4 pounds; difference -5.3 pounds, 95% CI -10.0 to -0.6), lower neonatal birth weights (3,237 g compared with 3,467 g; difference -230, 95% CI -452.8 to -7.8), and lower percent of initial body mass index at 6 months postpartum (101% compared with 106%; difference -4.9, 95% CI -8.8 to -0.9). CONCLUSION Our intervention did not result in a significant improvement in our primary outcome, the proportion of obese and overweight women who had gestational weight gain within IOM guidelines. However, intensive prenatal nutrition counseling offered in an urban community health setting may decrease LGA births among a group of overweight and obese women from culturally diverse backgrounds at risk for adverse maternal and neonatal outcomes. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT01056406.

Strengthening integration of clinical and public health systems to prevent maternal-child obesity in the First 1,000 Days: A Collective Impact approach

INTRODUCTION Obesity interventions may be most effective if they begin in the earliest stages of life, support changes across family, clinical, and public health systems, and address socio-contextual factors. METHODS The First 1000Days is a systematic program starting in early pregnancy lasting through the first 24months of infancy to prevent obesity among low-income mother-infant pairs in three community health centers in Massachusetts. The program uses a Collective Impact approach to create the infrastructure for sustained, system-wide changes for obesity prevention across early life clinical and public health services, including Obstetrics, Pediatrics, Adult Medicine, Behavioral Health, Nutrition, Community Health, the Women, Infants and Children (WIC) program, and the Maternal, Infant and Childhood Home Visiting program. Program components include 1) staff and provider training; 2) enhanced gestational weight gain and infant overweight tracking; 3) universal screening of adverse health behaviors and socio-contextual factors; 4) universal patient navigation to support individual behavior change and social needs, while strengthening integration of clinical and public health services; 5) individualized health coaching for mother-infant pairs at high risk of obesity; and 6) educational materials to support behavior change. RESULTS A quasi-experimental evaluation design will examine changes, between 2015 and 2019, in gestational weight gain and prevalence of infant overweight from 0 to 24months of age. CONCLUSIONS The First 1000Days program will examine the effectiveness of an early life obesity prevention program for mother-infant pairs. If successful, the program could provide a model for chronic disease prevention and health promotion among vulnerable families starting in early life.

The Postpartum Visit: Predictors, Disparities and Opportunities [6I]

INTRODUCTION: We determined the proportion of women receiving obstetric and non-obstetric care in the 2 months following delivery and explored whether sociodemographic, clinical or practice variables were associated with adherence to the obstetrical postpartum visit (OBPPV), hypothesizing increased visit completion among women with obstetric or medical comorbidities. METHODS: Encounter data from a large, academic institution were examined for all women who delivered from 2006–2010. Univariate and multivariable models were built to identify independent predictors of adherence to the OBPPV. Secondarily, we describe health care utilization during this period for non-obstetric visits. RESULTS: Of 14,220, women, 84% completed an OBPPV. 3% of women had no OBPPV but were seen elsewhere. Independent predictors of adherence to the OBPPV include nulliparity, Asian race, Hispanic ethnicity, and care in a health center setting. Obese women were less likely to return for an OBPPV. Predictors did not differ among women with a preterm birth in the preceding pregnancy, nor did having an obstetric complication increase the likelihood of return. During the OBPPV period, 9% of women were additionally seen by primary care providers, 13% by other, non-obstetrical providers, 2% utilized the emergency department and 2% had inpatient admissions. CONCLUSION: The most common visit in the postpartum period is the OBPPV, though many women access other care during this time. Increased BMI is associated with poorer compliance with postpartum follow-up. For women at risk of adverse obstetrical and womens health outcomes, understanding patterns of postpartum health care utilization is valuable for improving care quality and reducing inequities.

Postpartum Health Care Utilization at an Academic Center and Affiliated Community Health Centers [19M]

INTRODUCTION: Optimizing womens health after pregnancy holds potential to beneficially impact subsequent pregnancy outcomes. We compare postpartum care utilization for women at an academic medical center and affiliated community health centers. METHODS: Administrative encounter data were examined for women who received prenatal care and delivered from 2006–2010 to identify health care encounters within 2 months after delivery, and among women who enrolled in hospital-affiliated primary care practices prior to delivery to examine utilization in the 2 years after delivery. Univariate and multivariate models were built to identify predictors of care utilization. RESULTS: Among 8,749 and 4,439 women receiving prenatal care at the academic center and affiliated health centers, respectively, most returned for an obstetric postpartum visit (86% vs 79%, P<.0001), and additionally some had encounters with primary care (7% vs 12%, P<.0001), other outpatient clinics (13% vs 14%, P=.094), the emergency department (2% vs 3%, P<.0001), or hospital admissions (1.7% vs 1.9%, P=.41) during the initial 2 months postpartum. Among the 3,743 and 2,034 women with previously established primary care, the majority sought primary care (79% vs. 84%, P<.0001) and other outpatient services (71% vs 74%, P=.019) in the 2 years after delivery—with increasing age, having a chronic health condition, and accessing care at a community health center increasing the odds of utilizing postpartum primary care. CONCLUSION: After pregnancy most women utilize the obstetric postpartum visit and primary care, emphasizing the opportunity to optimize preconception health care at these encounters. A community-based care delivery model may facilitate primary care utilization after pregnancy.

Does the Addition of a Specialized Postpartum Clinic Improve the Care of Women With Preeclampsia

INTRODUCTION: Women with antepartum preeclampsia are at higher risk of developing cardiovascular disease. We sought to assess if the introduction of a specialized postpartum clinic decreases the rate of readmission and triage visits and increases the rate of primary care provider follow-up for women who had antepartum preeclampsia. METHODS: This is a retrospective comparative cohort study of women who had antepartum preeclampsia: 69 women who delivered in 2008 were compared with 69 women who followed in a specialized postpartum clinic from October 2011 to March 2013. &khgr;2 testing was used to compare the rate of readmission, triage visits, and primary care provider follow-up. RESULTS: There was no difference in the baseline characteristics between the two groups. There was a higher combined rate of readmission and triage visits after the introduction of the clinic, 8.7% compared with 21.7% (P<.039). A total of 85.7% of the readmissions and 62.5% of the triage visits occurred before the specialized postpartum clinic appointments. Furthermore, 66.7% of the readmissions and triage visits occurred within 10 days from delivery. There was a trend toward better primary care provider follow-up, 37.7% compared with 46.4% (P<.302). CONCLUSIONS: Our study shows that after the introduction of a specialized postpartum clinic, the rate of readmission and triage visits increased. This likely reflects a growing awareness surrounding preeclampsia and its associated long-term cardiovascular risks. Our study supports that earlier access to postpartum care, within 10 days, may reduce the rate of hospitalization and provide better access to clinical care. A trend toward increased primary care provider follow-up requires further investigation.