Urania Magriples

Group prenatal care and perinatal outcomes: a randomized controlled trial.

OBJECTIVE: To determine whether group prenatal care improves pregnancy outcomes, psychosocial function, and patient satisfaction and to examine potential cost differences. METHODS: A multisite randomized controlled trial was conducted at two university-affiliated hospital prenatal clinics. Pregnant women aged 14–25 years (n=1,047) were randomly assigned to either standard or group care. Women with medical conditions requiring individualized care were excluded from randomization. Group participants received care in a group setting with women having the same expected delivery month. Timing and content of visits followed obstetric guidelines from week 18 through delivery. Each 2-hour prenatal care session included physical assessment, education and skills building, and support through facilitated group discussion. Structured interviews were conducted at study entry, during the third trimester, and postpartum. RESULTS: Mean age of participants was 20.4 years; 80% were African American. Using intent-to-treat analyses, women assigned to group care were significantly less likely to have preterm births compared with those in standard care: 9.8% compared with 13.8%, with no differences in age, parity, education, or income between study conditions. This is equivalent to a risk reduction of 33% (odds ratio 0.67, 95% confidence interval 0.44–0.99, P=.045), or 40 per 1,000 births. Effects were strengthened for African-American women: 10.0% compared with 15.8% (odds ratio 0.59, 95% confidence interval 0.38–0.92, P=.02). Women in group sessions were less likely to have suboptimal prenatal care (P<.01), had significantly better prenatal knowledge (P<.001), felt more ready for labor and delivery (P<.001), and had greater satisfaction with care (P<.001). Breastfeeding initiation was higher in group care: 66.5% compared with 54.6%, P<.001. There were no differences in birth weight nor in costs associated with prenatal care or delivery. CONCLUSION: Group prenatal care resulted in equal or improved perinatal outcomes at no added cost. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00271960 LEVEL OF EVIDENCE: I

High-grade endometrial carcinoma in tamoxifen-treated breast cancer patients.

PURPOSE Several reports have associated tamoxifen administration with endometrial carcinoma. A retrospective study of the histologic features of uterine cancer in patients with a history of breast carcinoma was undertaken to determine the effect of treatment with tamoxifen. MATERIALS AND METHODS A computer search of the Yale-New Haven Hospital Tumor Registry from 1980 to 1990 identified 53 patients with a history of breast carcinoma who subsequently developed a malignant tumor of the uterine corpus. RESULTS Fifteen patients received tamoxifen for breast carcinoma and 38 did not. The mean ages of the two groups were not significantly different. The mean interval between detection of breast and endometrial cancers was 5 years in the tamoxifen group and 12 years in the nontreated group (P = .0023). Sixty-seven percent of patients in the tamoxifen group had poorly differentiated endometrioid carcinomas (including adenosquamous carcinoma) or carcinomas associated with poor outcome (eg, uterine papillary serous carcinoma, clear-cell carcinoma, or mixed müllerian tumor), as compared with 24% in the nontreated group (P = .03). Patients in the tamoxifen group were much more likely to die of endometrial cancer (33.3% v 2.6% of the nontreated group, P = .005). CONCLUSION From this retrospective study, it appears that women receiving tamoxifen as treatment for breast cancer who subsequently develop uterine cancer are at risk for high-grade endometrial cancers that have a poor prognosis. These findings also indicate that tamoxifen-associated uterine cancers may have a different basis from those associated with steroidal estrogen treatment.

Social Support and Social Conflict as Predictors of Prenatal Depression

OBJECTIVE: To estimate how social support and social conflict relate to prenatal depressive symptoms and to generate a brief clinical tool to identify women at increased psychosocial risk. METHODS: This is a prospective study following 1,047 pregnant women receiving care at two university-affiliated clinics from early pregnancy through 1 year postpartum. Structured interviews were conducted in the second trimester of pregnancy. Hierarchical and logistic regressions were used to examine potential direct and interactive effects of social support and conflict on prenatal depressive symptoms measured by the Center for Epidemiologic Studies-Depression Scale. RESULTS: Thirty-three percent of the sample reported elevated levels of depressive symptoms predicted from sociodemographic factors, social support, and social conflict. Social support and conflict had independent effects on depressive symptoms although social conflict was a stronger predictor. There was a “dose–response,” with each increase in interpersonal risk factor resulting in consequent risk for probable depression based on symptom reports (Center for Epidemiologic Studies-Scale greater than or equal to 16). A composite of one social support and three conflict items were identified to be used by clinicians to identify interpersonal risk factors for depression in pregnancy. Seventy-six percent of women with a composite score of three or more high-risk responses reported depressive symptoms. CONCLUSION: Increased assessment of social support and social conflict by clinicians during pregnancy can identify women who could benefit from group or individual interventions to enhance supportive and reduce negative social interactions. LEVEL OF EVIDENCE: II

Effects of group prenatal care on psychosocial risk in pregnancy: Results from a randomised controlled trial

Few interventions have succeeded in reducing psychosocial risk among pregnant women. The objective of this study was to determine whether an integrated group prenatal care intervention already shown to improve perinatal and sexual risk outcomes can also improve psychosocial outcomes compared to standard individual care. This randomised controlled trial included pregnant women ages 14–25 from two public hospitals (N = 1047) who were randomly assigned to standard individual care, group prenatal care or integrated group prenatal care intervention (CenteringPregnancy Plus, CP+). Timing and content of visits followed obstetrical guidelines, from 18-week gestation through birth. Each 2-h group prenatal care session included physical assessment, education/skills building and support via facilitated discussion. Using intention-to-treat models, there were no significant differences in psychosocial function; yet, women in the top tertile of psychosocial stress at study entry did benefit from integrated group care. High-stress women randomly assigned to CP+ reported significantly increased self-esteem, decreased stress and social conflict in the third trimester of pregnancy; social conflict and depression were significantly lower 1-year postpartum (all p-values < 0.02). CP+ improved psychosocial outcomes for high-stress women. This ‘bundled’ intervention has promise for improving psychosocial outcomes, especially for young pregnant women who are traditionally more vulnerable and underserved.

Gestational weight gain and subsequent postpartum weight loss among young, low-income, ethnic minority women

OBJECTIVE Document weight change trajectories that lead to gestational weight gain or postpartum weight loss outside clinical recommendations established by the Institute of Medicine. STUDY DESIGN Women aged 14-25 receiving prenatal care and delivering singleton infants at term (n = 427). Medical record review and 4 structured interviews conducted: second and third trimester, 6- and 12-months postpartum. Longitudinal mixed modeling to evaluate weight change trajectories. RESULTS Only 22% of participants gained gestational weight within Institute of Medicine guidelines. There were 62% that exceeded maximum recommendations-more common among those overweight/obese (body mass index ≥25.0; P < .0001). 52% retained ≥10 lb 1-year postpartum. Increased weight gain and retention documented among smokers and women with pregnancy-induced hypertension; breastfeeding promoted postpartum weight loss (all P < .02). Body mass index by race interaction suggested healthier outcomes for Latinas (P = .02). CONCLUSION Excessive pregnancy weight gain and inadequate postpartum weight loss are highly prevalent among young low-income ethnic minority women. Pregnancy and postpartum are critical junctures for weight management interventions.

Pregnancy as a Window of Opportunity for HIV Prevention: Effects of an HIV Intervention Delivered Within Prenatal Care

OBJECTIVES We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks. METHODS We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N = 1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum. RESULTS Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Subanalyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents. CONCLUSION HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV.

Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers

OBJECTIVES We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes. METHODS We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008-2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys. RESULTS In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks. CONCLUSIONS CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.

Breastfeeding Behavior Among Adolescents: Initiation, Duration, and Exclusivity

PURPOSE Despite a substantial amount of evidence on breastfeeding among non-adolescent mothers, research and strategies uniquely designed to target adolescent mothers are critical because their rates of breastfeeding are disproportionately low and their transition to parenthood is often unlike that of older mothers. Literature to date, however, offers limited evidence for designing effective interventions. Therefore, we aimed to fill this gap in the literature by examining breastfeeding behaviors among a cohort of female adolescents as they transition to parenthood. METHODS Data were derived from a longitudinal cohort of pregnant adolescent females (ages 14-21 years) and their male partners, observed from pregnancy through 6 months postpartum. Means and frequencies were used to describe breastfeeding experiences, breastfeeding behaviors, and sociodemographic characteristics. We used multivariate logistic regression and Cox proportional hazards models to identify factors independently associated with breastfeeding initiation, exclusive breastfeeding, and breastfeeding duration. RESULTS Approximately 71% initiated breastfeeding. Intending to breastfeed, having had complications in labor and delivery, and lower social support were associated with greater odds of breastfeeding initiation. Of the adolescent mothers who initiated breastfeeding, 84% had stopped by 6 months postpartum; among those, average breastfeeding duration was 5 weeks. Participants who exclusively breastfed had longer breastfeeding duration, and participants who had experienced intimate partner violence had shorter breastfeeding duration. Obese women and women who had more difficulty breastfeeding had lower odds of exclusive breastfeeding. CONCLUSIONS Enhanced clinical support and the promotion of exclusive breastfeeding should be considered when designing interventions to improve breastfeeding rates among adolescent mothers.

Depression during Pregnancy among Young Couples: The Effect of Personal and Partner Experiences of Stressors and the Buffering Effects of Social Relationships

STUDY OBJECTIVE To assess the relationship between personal and romantic partners experiences of stressful life events and depression during pregnancy, and the social moderators of this relationship, among 296 young couples with low incomes from urban areas. PARTICIPANTS AND SETTING We recruited couples who were expecting a baby from four ob/gyn and ultrasound clinics in southern Connecticut; women were ages 14-21 and male partners were 14+. DESIGN AND OUTCOME MEASURES We analyzed self-reports of stressful events in the previous six months, depression in the past week and current interpersonal social supports. To determine the influence of personal and partner experiences of stressful events on depression, we used multilevel dyadic models and incorporated interaction terms. We also used this model to determine whether social support, family functioning and relationship satisfaction moderated the association between stressful events and depression. RESULTS Experiences of stressful life events were common; 91.2% of couples had at least one member report an event. Money, employment problems, and moving were the most common events. Personal experiences of stressful life events had the strongest association with depression among men and women; although partner experiences of stressful life events were also significantly associated with depression among women. Social support, family functioning, and romantic relationship satisfaction significantly buffered the association between personal and partner stressful events and depression. CONCLUSION Interventions that improve relationships, support systems, and family functioning may reduce the negative impact of stressors, experienced both personally and by a romantic partner, on the emotional well-being of young expectant parents.

Prevalence of post-traumatic stress disorder in pregnant women with prior pregnancy complications

Objective. To assess the prevalence of post-traumatic stress disorder (PTSD) in pregnant women with prior pregnancy complications. Methods. Seventy-six pregnant women at a maternal–fetal medicine referral clinic were asked to complete an anonymous questionnaire. Fifty-six women had a prior pregnancy complication (study group), and the remaining 20 had none (comparison group). Subjects were assessed with a questionnaire consisting of a modified patient-rated version of the Clinician Administered PTSD Scale (CAPS). The modified CAPS was used to approximate the prevalence of full or partial PTSD related to a prior pregnancy complication using two scoring rules, the rule-of-3 (original rule) and rule-of-4 (more stringent rule). Results. The prevalence of full PTSD among women with prior pregnancy complications was 12.5% and 8.9% based on the rule-of-3 and rule-of-4, respectively. For partial PTSD, the prevalence was 28.6% based on the rule-of-3 versus 17.9% based on the rule-of-4. The most common type of complication was miscarriage, accounting for 73.5% of the reported complications. None of the women in the comparison group met criteria for full or partial PTSD. Conclusions. The prevalence of PTSD in pregnant women with a prior pregnancy-related complication is considerable. These findings provide additional evidence that pregnancy complications can be experienced as traumatic, and as such lead to partial or full PTSD symptoms.