Reproductive care in community health centers: Multi-method evaluation of the Illinois Contraceptive Access Now (ICAN!) demonstration program.

OBJECTIVES: Nearly one-third of low-income women of reproductive age in the U.S. receive care in federally qualified community health centers, but comprehensive reproductive care is not consistently provided. Illinois Contraceptive Access Now (ICAN!) is an initiative addressing the access gap to high-quality contraceptive care with a focus on normalizing reproductive health screening for patients in federally qualified community health centers (FQHCs). STUDY DESIGN: This multi-method program evaluation used the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, with retrospective and prospective data collection from three Illinois FQHCs who participated as Quality Hubs, and from a Community Advisory Board. We conducted descriptive analysis of patient surveys using the Person-Centered Contraceptive Counseling (PCCC) measure (n = 142); clinician and staff pre-and post-training surveys (n = 210); and Community Advisory Board surveys (n = 8) collecting quantitative and qualitative feedback. We ran logistic regression on claims data from 15- to 49-year-old patients identified as female at birth (n = 103,756). RESULTS: Reach assessment showed patients receiving contraceptive or preconception care increased from 1063 per month in 2020 to 1236 per month in 2021 (16% increase), while general volume increased 2%. Effectiveness showed most patients (78%) described the quality of contraceptive counseling as "excellent" on the PCCC. Adoption assessment showed knowledge increases after clinical training on Modern Contraception (85% pre-training, 95% post-training) and Reproductive Justice (RJ) (58% pre-training, 70% post-training). Implementation assessment found that most Community Advisory Board members felt ICAN! was responsive to community needs. CONCLUSIONS: The ICAN! demonstration year increased provider knowledge and volume of reproductive care at three Illinois FQHCs. IMPLICATIONS: Contraceptive access initiatives that operationalize same day access to birth control methods while training FQHC providers on RJ and modern contraception, show promise on several measures. Early evidence from ICAN! indicates increased reproductive health service provision, as well as increases in provider knowledge of RJ and modern contraceptive care.

Closing the contraceptive coverage gap: A multipronged approach to advancing reproductive equity in Illinois.

Despite Illinois' progress in the area of reproductive health, Black, Indigenous, and People of Color, young people, and people with low resources face persistent barriers to high-quality contraceptive care and experience inequities in reproductive health outcomes. Illinois Contraceptive Access Now (ICAN!) is a 5-year initiative that aims to improve the quality and coverage of contraceptive care at community health centers statewide. By leveraging state policies, a robust community health infrastructure, digital innovation, and with a focus on sustainability, ICAN! seeks to cut the "contraceptive coverage gap" in Illinois in half by 2025. As Illinois democratizes access to contraceptive care, this initiative can serve as a model for advancing reproductive equity nationwide.

Maternal socioeconomic disadvantage is associated with transcriptional indications of greater immune activation and slower tissue maturation in placental biopsies and newborn cord blood.

Children from economically disadvantaged families experience worse cognitive, psychiatric, and medical outcomes compared to more affluent youth. Preclinical models suggest some of the adverse influence of disadvantage could be transmitted during gestation via maternal immune activation, but this hypothesis has not been tested in humans. It also remains unclear whether prenatal interventions can mitigate such effects. To fill these gaps, we conducted two studies. Study 1 characterized the socioeconomic conditions of 79 women during pregnancy. At delivery, placenta biopsies and umbilical blood were collected for transcriptional profiling. Maternal disadvantage was associated with a transcriptional profile indicative of higher immune activation and slower fetal maturation, particularly in pathways related to brain, heart, and immune development. Cord blood cells of disadvantaged newborns also showed indications of immaturity, as reflected in down-regulation of pathways that coordinate myeloid cell development. These associations were independent of fetal sex, and characteristics of mothers (age, race, adiposity, diabetes, pre-eclampsia) and babies (delivery method, gestational age). Study 2 performed the same transcriptional analyses in specimens from 20 women participating in CenteringPregnancy, a group-based psychosocial intervention, and 20 women in traditional prenatal care. In both placenta biopsies and cord blood, women in CenteringPregnancy showed up-regulation of transcripts found in Study 1 to be most down-regulated in conjunction with disadvantage. Collectively, these results suggest socioeconomic disparities in placental biology are evident at birth, and provide clues about the mechanistic origins of health disparities. They also suggest the possibility that psychosocial interventions could have mitigating influences.

Using item response theory to optimize measurement of chronic stress in pregnancy.

OBJECTIVE: Utilize Rasch analysis to develop an optimized self-reported measure of stress in pregnancy and examine the association with patient demographics and biologic measures of stress. STUDY DESIGN: Measured self-reported stress in pregnant women using 12 existing scales. Collected blood for biologic measures of stress (Epstein Barr Virus [EBV], C-Reactive Protein [CRP], Corticotropin Reactive Hormone [pCRH], and Adenocorticotropin Hormone [ACTH]). Used multidimensional scaling and Rasch analysis to produce an item reduced self-report measure. RESULTS: Enrolled 112 women. Survey items reduced to two factors: perceived stressors and buffers of stress. Women with a domestic partner had lower perceived stress (p = 0.003). Caucasian women reported higher buffers of stress (p = 0.045), as did women with private insurance (p < 0.001), a planned pregnancy (p < 0.01), and a domestic partner (p < 0.001). Women with higher buffers of stress had lower levels of pCRH (adjusted p = 0.01). CONCLUSION: Item reduced, optimized measures of stress were associated with significant differences in patient demographics and biologic measures of stress.

Maternal Income during Pregnancy is Associated with Chronic Placental Inflammation at Birth.

Objective This study aims to examine whether maternal household income is associated with histological evidence of chronic placental inflammation. Study Design A total of 152 participants completed surveys of household income and consented to placenta collection at delivery and postpartum chart review for birth outcomes. Placental inflammatory lesions were evaluated via histological examination of the membranes, basal plate, and villous parenchyma by a single, experienced pathologist. Associations between household income and the presence of inflammatory lesions were adjusted for known perinatal risk factors. Results Overall, 45% of participants reporting household income below $30,000/y had chronic placental inflammation, compared with 25% of participants reporting income above $100,000 annually (odds ratio [OR] = 4.23, 95% confidence interval [CI] = 1.25, 14.28; p = 0.02). Middle-income groups showed intermediate rates of chronic inflammatory lesions, at 40% for those reporting $30,000 and 50,000 (OR = 3.60, 95% CI = 1.05, 12.53; p = 0.04) and 38% for those reporting $50,000 to 100,000 (OR = 1.57, 95% CI = 0.60, 4.14; p = 0.36). Results remained significant after adjustment for maternal age, race, and marital status. Conclusion Chronic placental inflammation is associated with maternal household income. Greater occurrence of placental lesions in low-income mothers may arise from a systemic inflammatory response to social and physical environmental factors.

Close relationship qualities and maternal peripheral inflammation during pregnancy.

OBJECTIVE: Close relationships are associated with pregnancy outcomes, but little is known about the mechanisms involved. This paper examines whether quality of women's close relationships, specifically with romantic partner (RP) and closest friend or family member (CF), is associated with inflammatory biomarkers during the third trimester of pregnancy. METHODS: 90 pregnant women were assessed during the second and third trimester. At both visits they completed self-reports describing the positive and negative aspects of their RP and CF relationships. Peripheral blood was collected during these visits, and used to measure systemic levels of cytokines, including IFNγ, IL10, IL6, IL8 and IL13. An index of inflammatory regulation, as reflected by the ratio of IL6:IL10, was also computed. RESULTS: Positive (e.g. support, intimacy) and negative (e.g. conflict) aspects of the RP relationship interacted to predict third trimester cytokine values. Specifically, RP relationships relatively low in both positive and negative aspects were associated with lower third trimester anti-inflammatory (IL10, IL13) and anti-viral (IFNγ) cytokines, and a higher IL6:IL10 ratio, controlling for second trimester levels. These associations were independent of demographics, gestational age, weeks between assessment, parity, pre-pregnancy body mass index, maternal stress, distress, depressed mood and RP cohabitation. CF relationship aspects were not associated with inflammatory markers. CONCLUSIONS: RP relationships relatively low in both positive, e.g. support and intimacy, and negative, e.g. conflict, aspects were associated with a less anti- and more pro-inflammatory cytokine profile during the third trimester. These findings have implications for understanding the associations amongst close relationships, inflammation, and potentially pregnancy outcomes.

Patterns of peripheral cytokine expression during pregnancy in two cohorts and associations with inflammatory markers in cord blood.

PROBLEM: Maternal inflammation undergoes adaptations during pregnancy, and excessive inflammation has been associated with adverse outcomes. One mechanism may be maternal inflammation transmission to the fetal compartment. Links between maternal pregnancy inflammation and fetal inflammation are poorly characterized. METHOD: Principal components analysis was used to extract underlying inflammation components across cytokines (IFN-γ, IL-10, IL-13, IL-6, IL-8, TNF-α) in two pregnancy cohorts (SPAH N=87, MOMS N=539) assessed during the second and third trimesters. Links between maternal inflammation over pregnancy and fetal (cord blood) inflammation were assessed. RESULTS: Substantial cytokine rank-order stability was observed in both cohorts, ß's range .47-.96, P's <.001. Two consistent inflammatory components were extracted: a pro-inflammatory (IL-10, IL-6, IL-8, TNF-α, IFN-γ) component and anti-inflammatory (IL-13) component. Higher maternal pro-inflammatory and lower anti-inflammatory indices during pregnancy were associated with higher cord blood inflammation, P's>.04. CONCLUSION: Maternal inflammation indices over pregnancy were associated with inflammation in cord blood at birth. Results have implications for understanding pregnancy inflammatory processes and how maternal inflammation may be transmitted to fetal circulation.

Stress and stress reduction.

Chronic stress contributes to preterm birth (PTB), through direct physiological mechanisms or behavioral pathways. This review identified interventions to prevent PTB through decreased maternal stress. Studies were grouped according to intervention: group prenatal care (11 studies), care coordination (8 studies), health insurance expansion (4 studies), expanded prenatal education/support in the clinic (8 studies), home visitation (9 studies), telephone contact (2 studies), or stress-reduction strategies (5 studies). Group prenatal care had the most evidence for PTB prevention. Comparative studies of PTB prevention through different models of prenatal care and maternal support, education, empowerment, stress-reduction, and coping strategies are needed.