Stay Home, Stay Connected: Providing Supplemental Education and Psychosocial Support for Pregnant People

INTRODUCTION: The traditional medical model of prenatal care may miss opportunities for anticipatory guidance and psychosocial support for pregnant people. We describe Stay Home, Stay Connected (SHSC), a virtual, service-learning, pregnancy support group that supplements routine prenatal care. METHODS: Stay Home, Stay Connected was implemented during the acute COVID-19 pandemic and updated in January 2022 in keeping with relaxation of COVID-19 restrictions. The program consists of monthly small-group sessions with 8–10 pregnant people at similar gestational age, led by an obstetric provider (eg, physician, midwife) and medical, midwifery, and social work students. Recorded group classes on mental health and wellness are available on-demand. In our IRB-exempt assessment of SHSC patients from January 2022 to October 2022, we obtained consent and collected surveys at enrollment and after sessions to assess participants' reasons for joining and overall satisfaction. RESULTS: Since program updates, 80 patients have participated in 5 small groups, led by 4 providers and 8 students. Of the 80 patients registered for SHSC, 65 (81%) completed the enrollment survey. The top reasons for joining SHSC were desire for extra support, more information about pregnancy, and connection with other patients. The majority of participants who completed satisfaction surveys, reported sessions were helpful to their learning (32/34, 94%) and feeling supported (25/26, 96%). All participants surveyed reported they would recommend SHSC to other pregnant patients. CONCLUSION: A virtual service-learning pregnancy support group remains feasible and acceptable for participants after the acute COVID-19 pandemic. We are continuing to expand and develop SHSC to fulfill unmet needs in pregnancy. [ FROM AUTHOR] Copyright of Obstetrics & Gynecology is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Frequency of Prenatal Care Visits: Protocol to Develop a Core Outcome Set for Prenatal Care Schedules.

BACKGROUND: Prenatal care, one of the most common preventive care services in the United States, endeavors to improve pregnancy outcomes through evidence-based screenings and interventions. Despite the prevalence of prenatal care and its importance to maternal and infant health, there are several debates about the best methods of prenatal care delivery, including the most appropriate schedule frequency and content of prenatal visits. Current US national guidelines recommend that low-risk individuals receive a standard schedule of 12 to 14 in-office visits, a care delivery model that has remained unchanged for almost a century. OBJECTIVE: In early 2020, to mitigate individuals' exposure to the SARS-CoV-2 virus, prenatal care providers implemented new paradigms that altered the schedule frequency, interval, and modality (eg, telemedicine) of how prenatal care services were offered. In this paper, we describe the development of a core outcome set (COS) that can be used to evaluate the effect of the frequency of prenatal care schedules on maternal and infant outcomes. METHODS: We will systematically review the literature to identify previously reported outcomes important to individuals who receive prenatal care and the people who care for them. Stakeholders with expertise in prenatal care delivery (ie, patients or family members, health care providers, and public health professionals and policy makers) will rate the importance of identified outcomes in a web-based survey using a 3-round Delphi process. A digital consensus meeting will be held for a group of stakeholder representatives to discuss and vote on the outcomes to include in the final COS. RESULTS: The Delphi survey was initiated in July 2022 with invited 71 stakeholders. A digital consensus conference was conducted on October 11, 2022. Data are currently under analysis with plans to submit them in a subsequent manuscript. CONCLUSIONS: More research about the optimal schedule frequency and modality for prenatal care delivery is needed. Standardizing outcomes that are measured and reported in evaluations of the recommended prenatal care schedules will assist evidence synthesis and results reported in systematic reviews and meta-analyses. Overall, this COS will expand the consistency and patient-centeredness of reported outcomes for various prenatal care delivery schedules and modalities, hopefully improving the overall efficacy of recommended care delivery for pregnant people and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43962.

Televisits Compared With In-Person Visits for Routine Antenatal Care: A Systematic Review.

OBJECTIVE: To compare benefits and harms of televisits and in-person visits in people receiving routine antenatal care. DATA SOURCES: A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries. METHODS OF STUDY SELECTION: Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher. TABULATION, INTEGRATION, AND RESULTS: Two randomized controlled trials, four nonrandomized comparative studies, and one survey compared visit types between 2004 and 2020, three of which were conducted during the coronavirus disease 2019 (COVID-19) pandemic. Number, timing, and mode of televisits and who provided care varied across studies. Low-strength evidence from studies comparing hybrid (televisits and in-person visits) and all in-person visits did not indicate differences in rates of neonatal intensive care unit admission of the newborn (summary odds ratio [OR] 1.02, 95% CI 0.82-1.28) or preterm births (summary OR 0.93, 95% CI 0.84-1.03). However, the studies with stronger, although still statistically nonsignificant, associations between use of hybrid visits and preterm birth compared the COVID-19 pandemic and prepandemic eras, confounding the association. There is low-strength evidence that satisfaction with overall antenatal care was greater in people who were pregnant and receiving hybrid visits. Other outcomes were sparsely reported. CONCLUSION: People who are pregnant may prefer hybrid televisits and in-person visits. Although there is no evidence of differences in clinical outcomes between hybrid visits and in-person visits, the evidence is insufficient to evaluate most outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021272287.

Associations Among Postpartum Posttraumatic Stress Disorder Symptoms and COVID-19 Pandemic-Related Stressors.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) pandemic-related stressors (eg, exposure, infection worry, self-quarantining) can result in heightened levels of distress and symptoms of postpartum posttraumatic stress disorder (PTSD). METHODS: Using a cross-sectional descriptive design, we collected survey data from a convenience sample of 670 postpartum persons who gave birth to a newborn during the first 6 months of the COVID-19 pandemic in the United States. The presence of PTSD symptoms was measured using the 21-item Birth Memories And Recall Questionnaire (BirthMARQ) and defined as an affirmative rating for each item (score of 5 to 7 on a 1 to 7 agreement scale). Symptoms counts were computed for each of the 6 BirthMARQ domains, 2 symptom clusters (intrusive; mood and cognition alterations), and the total number of symptoms. Symptom counts were analyzed using descriptive statistics. We explored associations among COVID-19 experiences (self-quarantine behaviors, infection worry, exposure) and counts of PTSD symptoms using negative binomial regression models while controlling for postpartum depression screening scores, neonatal intensive care unit admissions, number of weeks postpartum, race, and marital status. RESULTS: Almost 99% of participants reported experiencing at least one of 21 PTSD symptoms (mean, 8.32; SD, 3.63). Exposure to COVID-19 was associated with a 34% greater risk for experiencing intrusive symptoms, specifically, symptoms of reliving the birthing experience as if it were happening now (47% greater risk). Worry surrounding COVID-19 infection was associated with a 26% increased risk for experiencing intrusive recall symptoms in which birth memories came up unexpectantly. COVID-19 quarantining behaviors were not significantly related to increasing PTSD symptoms. Many of the demographic variables included were associated with increasing PTSD symptoms. DISCUSSION: Screening perinatal persons for PTSD is critically important, especially during public health crises like the COVID-19 pandemic. The integration of comprehensive mental health screening, including specific screening for trauma and symptoms of PTSD, across health care settings can help improve delivery of quality, patient-centered care to postpartum persons.

Postpartum depression and associated risk factors during the COVID-19 pandemic.

OBJECTIVE: To describe postpartum depression and associated risk factors among postpartum patients in the United States (US) between February and July 2020. This study used a cross-sectional descriptive design to collect survey data from a convenience sample of postpartum patients who lived in the US and delivered a live infant after the US declared COVID-19 a public health emergency. RESULTS: Our sample included 670 postpartum patients who completed an online survey inclusive of the Edinburgh Postnatal Depression Scale (EPDS) and selected demographic items (e.g. NICU admission status, infant gestational age, infant feeding method). In our sample, 1 in 3 participants screened positive for postpartum depression and 1 in 5 had major depressive symptoms. Participants who fed their infants formula had 92% greater odds of screening positive for postpartum depression and were 73% more likely to screen positive for major depressive symptoms compared to those who breastfed or bottle-fed with their own human milk. Participants with infants admitted to a NICU had 74% greater odds of screening positive. Each 1 week increase in weeks postpartum increased the odds of screening positive by 4%. Participants who worried about themselves and their infants contracting COVID-19 had 71% greater odds of screening positive.

Designing your patient's prenatal care "PATH": Recommendations for maternity care professionals based on MiPATH

The article provides recommendations for maternity care professionals when designing their patient's prenatal care Plan for Appropriate Tailored Healthcare (PATH). Topics discussed include evidence supporting prenatal care recommendations, information on Michigan PATH (MiPATH) panel process, and MiPATH panel recommendations which includes screening for medical, social, and structural determinants of health, telemedicine, and supporting for social and structural determinants.

"Mourning the Experience of What Should Have Been": Experiences of Peripartum Women During the COVID-19 Pandemic.

OBJECTIVES: The ongoing COVID-19 pandemic may significantly affect the peripartum experience; however, little is known about the perceptions of women who gave birth during the COVID-19 pandemic. Thus, the purpose of our study was to describe the peripartum experiences of women who gave birth during the COVID-19 pandemic in the United States. METHODS: Using a cross-sectional design, we collected survey data from a convenience sample of postpartum women recruited through social media. Participants were 18 years of age or older, lived in the United States, gave birth after February 1, 2020, and could read English. This study was part of the COVID-19 Maternal Attachment, Mood, Ability, and Support study, which was a larger study that collected survey data describing maternal mental health and breastfeeding during the COVID-19 pandemic. This paper presents findings from the two free-text items describing peripartum experiences. Using the constant comparative method, responses were thematically analyzed to identify and collate major and minor themes. RESULTS: 371 participants responded to at least one free-text item. Five major themes emerged: (1) Heightened emotional distress; (2) Adverse breastfeeding experiences; (3) Unanticipated hospital policy changes shifted birthing plans; (4) Expectation vs. reality: "mourning what the experience should have been;" and (5) Surprising benefits of the COVID-19 pandemic to the delivery and postpartum experience. CONCLUSIONS FOR PRACTICE: Peripartum women are vulnerable to heightened stress induced by COVID-19 pandemic sequalae. During public health crises, peripartum women may need additional resources and support to improve their mental health, wellbeing, and breastfeeding experiences.

A Review of Prenatal Care Delivery to Inform the Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Panel.

OBJECTIVE: To perform a literature review of key aspects of prenatal care delivery to inform new guidelines. DATA SOURCES: A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov. METHODS OF STUDY SELECTION: We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction. TABULATION, INTEGRATION, AND RESULTS: Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth. CONCLUSION: Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

The evolution of prenatal care delivery guidelines in the United States.

The coronavirus disease 2019 pandemic led to some of the most drastic changes in clinical care delivery ever seen in the United States. Almost overnight, providers of prenatal care adopted virtual visits and reduced visit schedules. These changes stood in stark contrast to the 12 to 14 in-person prenatal visit schedule that had been previously recommended for almost a century. As maternity care providers consider what prenatal care delivery changes we should maintain following the acute pandemic, we may gain insight from understanding the evolution of prenatal care delivery guidelines. In this paper, we start by sketching out the relatively unstructured beginnings of prenatal care in the 19th century. Most medical care fell within the domain of laypeople, and childbirth was a central feature of female domestic culture. We explore how early discoveries about "toxemia" created the groundwork for future prenatal care interventions, including screening of urine and blood pressure-which in turn created a need for routine prenatal care visits. We then discuss the organization of the medical profession, including the field of obstetrics and gynecology. In the early 20th century, new data increasingly revealed high rates of both infant and maternal mortalities, leading to a greater emphasis on prenatal care. These discoveries culminated in the first codification of a prenatal visit schedule in 1930 by the Children's Bureau. Surprisingly, this schedule remained essentially unchanged for almost a century. Through the founding of the American College of Obstetricians and Gynecologists, significant technological advancements in laboratory testing and ultrasonography, and calls of the National Institutes of Health Task Force for changes in prenatal care delivery in 1989, prenatal care recommendations continued to be the same as they had been in 1930-monthly visits until 28 weeks' gestation, bimonthly visits until 36 weeks' gestation, and weekly visits until delivery. However, coronavirus disease 2019 forced us to change, to reconsider both the need for in-person visits and frequency of visits. Currently, as we transition from the acute pandemic, we should consider how to use what we have learned in this unprecedented time to shape future prenatal care. Lessons from a century of prenatal care provide valuable insights to inform the next generation of prenatal care delivery.

Patient and provider perspectives of a new prenatal care model introduced in response to the coronavirus disease 2019 pandemic.

BACKGROUND: Randomized controlled trials document the safety and efficacy of reduced frequency prenatal visit schedules and virtual visits, but real-world data are lacking. Our institution created a prenatal care delivery model incorporating these alternative approaches to continue safely providing prenatal care during the coronavirus disease 2019 pandemic. OBJECTIVE: To evaluate institutional-level adoption and patient and provider experiences with the coronavirus disease 2019 prenatal care model. STUDY DESIGN: We conducted a single-site evaluation of a coronavirus disease 2019 prenatal care model incorporating a reduced frequency visit schedule and virtual visits deployed at a suburban academic institution on March 20, 2020. We used electronic health record data to evaluate institution-level model adoption, defined as changes in overall visit frequency and proportion of virtual visits in the 3 months before and after implementation. To evaluate the patient and provider experience with the coronavirus disease 2019 model, we conducted an online survey of all pregnant patients (>20 weeks' gestation) and providers in May 2020. Of note, 3 domains of care experience were evaluated: (1) access, (2) quality and safety, and (3) satisfaction. Quantitative data were analyzed with basic descriptive statistics. Free-text responses coded by the 3 survey domains elucidated drivers of positive and negative care experiences. RESULTS: After the coronavirus disease 2019 model adoption, average weekly prenatal visit volume fell by 16.1%, from 898 to 761 weekly visits; the average weekly proportion of prenatal visits conducted virtually increased from 10.8% (97 of 898) to 43.3% (330 of 761); and the average visit no-show rate remained stable (preimplementation, 4.3%; postimplementation, 4.2%). Of those eligible, 74.8% of providers (77 of 103) and 15.0% of patients (253 of 1690) participated in the surveys. Patient respondents were largely white (180 of 253; 71.1%) and privately insured (199 of 253; 78.7%), reflecting the study site population. The rates of chronic conditions and pregnancy complications also differed from national prevalence. Provider respondents were predominantly white (44 of 66; 66.7%) and female (50 of 66; 75.8%). Most patients and almost all providers reported that virtual visits improved access to care (patients, 174 of 253 [68.8%]; providers, 74 of 77 [96.1%]). More than half of respondents (patients, 124 of 253 [53.3%]; providers, 41 of 77 [62.1%]) believed that virtual visits were safe. Nearly all believed that home blood pressure cuffs were important for virtual visits (patients, 213 of 231 [92.2%]; providers, 63 of 66 [95.5%]). Most reported satisfaction with the coronavirus disease 2019 model (patients, 196 of 253 [77.5%]; providers, 64 of 77 [83.1%]). In free-text responses, drivers of positive care experiences were similar for patients and providers and included perceived improved access to care through decreased barriers (eg, transportation, childcare), perceived high quality of virtual visits for low-risk patients and increased safety during the pandemic, and improved satisfaction through better patient counseling. Perceived drivers of negative care experience were also similar for patients and providers, but less common. These included concerns that unequal access to virtual visits could deepen existing maternity care inequities, concerns that the lack of home devices (eg, blood pressure cuffs) would affect care quality and safety, and dissatisfaction with poor patient-provider continuity and inadequate expectation setting for the virtual visit experience. CONCLUSION: Reduced visit schedules and virtual visits were rapidly integrated into real-world care, with positive experiences for many patients and providers. Future research is needed to understand the health outcomes and care experience associated with alternative approaches to prenatal care delivery across more diverse patient populations outside of the coronavirus disease 2019 pandemic to inform broader health policy decisions.

Prenatal Care Redesign: Creating Flexible Maternity Care Models Through Virtual Care

Abstract: Each year, over 98% of the almost 4 million pregnant patients in the United States receive prenatal care—a crucial preventive service to improve outcomes for moms and babies. National guidelines currently recommend 12-14 in-person prenatal visits, a schedule unchanged since 1930. In scrutinizing the standard prenatal visit schedule, it quickly becomes clear that prenatal care is overdue for a redesign. We have strong evidence of the benefit of many prenatal services, like screening for gestational diabetes and maternal vaccination. Yet how to deliver these services is much less clear. Studies of prenatal services consistently demonstrate such care can be delivered in fewer than 14 visits, and that we do not need to provide all maternity services in person. Telemedicine has emerged as a promising care delivery option for patients seeking greater flexibility, and early trials leveraging virtual care and remote monitoring have shown positive maternal and fetal outcomes with high patient satisfaction. Our institution has worked for the past year on a new prenatal care pathway. Our initial work assessed the literature, elicited patient perspectives, and captured the insights of experts in patient-centered care delivery. Two key principles emerged to inform prenatal care redesign: 1) design care delivery around essential services, using in-person care for services that cannot be delivered remotely and offering video visits for other essential services;and 2) create flexible services for anticipatory guidance and psychosocial support that allow patients to tailor support to meet their needs through opt-in programs. The rise of COVID-19 prompted us to extend this early work and rapidly implement a redesigned prenatal care pathway. In this paper, we outline our experience rapidly transitioning prenatal care to a new model with 4 in-person visits, 1 ultrasound visit, and 4 virtual visits (the 4-1-4 prenatal plan). We then explore how lessons from this implementation can inform patient-centered prenatal care redesign during and beyond the COVID-19 pandemic.