Piloting a prenatal care smartphone application and care navigation intervention at a federally qualified health center.

BACKGROUND: Given that smartphones are widely used among reproductive-age people of all socioeconomic backgrounds, a smartphone application may be a useful supplement to routine prenatal care. OBJECTIVE: This study aimed to describe the implementation of a smartphone app that offers patient education, depression screening, social determinants of health screening, and care coordination as an adjunct to routine prenatal care at a federally qualified health center. We further sought to characterize app engagement and the association of app use with pregnancy outcomes. STUDY DESIGN: The implementation of the smartphone app was a quality improvement initiative in which the app was made available to all people receiving prenatal care at a designated federally qualified health center between December 2020 and December 2021. Individuals who both initiated prenatal care at this site before 28 weeks of gestation and delivered at our institution during the above-defined period were studied retrospectively after obtaining institutional approval. Summary statistics were used to describe app implementation and information regarding social determinants of health and depression screening. Demographics and maternal and neonatal outcomes were compared between app enrollees and patients receiving prenatal care at the same site who were not enrolled in the app. Data were analyzed using the 2-sample t test to compare continuous variables and the chi-square test to compare categorical variables. RESULTS: Overall, 800 patients receiving prenatal care at the federally qualified health center during the identified period were telephonically approached for enrollment in the smartphone app. A total of 613 people (76.6%) were successfully reached, and of those successfully reached, 538 (87.7%) accepted enrollment in the app; 76.6% of app enrollees (n=412) completed at least 1 social determinants of health screen. Of those, 29.1% (n=120) screened positive for at least 1 need. Of those with positive screens, 51.7% (n=62) accepted referral to resources to address the identified need. Furthermore, 81% of app enrollees (n=443) completed at least 1 depression screen. Of those, 13.1% (n=58) screened positive for depression, and 37.9% (n=22) of those with positive screens accepted a referral to behavioral health services. A total of 483 people met the inclusion criteria for retrospective review: 264 were enrolled in the smartphone app and 219 were not. App enrollees were more likely to speak English (79.9% of app group vs 61.6% of the non-app group; P<.0001), identify as Hispanic (52.7% vs 39.7%; P=.02), and be privately insured (24.6% vs 15.5%; P=.005), and less likely to have a social determinants of health-related need (10.0% vs 21.0%; P=.01). There were no significant differences in mode of delivery or maternal and neonatal outcomes between the 2 groups. CONCLUSION: A high proportion of patients receiving care through our federally qualified health center enrolled in and used the smartphone app and its associated care coordination. This could be a useful tool to screen for depression and adverse social determinants of health in underserved communities. Given that individuals of higher-resource backgrounds seem more likely to enroll in smartphone apps, a more targeted approach is needed to help connect patients of lower-resource backgrounds to smartphone apps and the resources that they offer.

Postpartum Care in the Time of COVID-19: The Use of Telemedicine for Postpartum Care.

Background: Telemedicine was implemented at our institution in response to the COVID-19 pandemic. Data do not currently exist about the use of telemedicine in providing comprehensive postpartum care. Objective: This project aimed to evaluate the impact of telemedicine on postpartum care at an urban Federally Qualified Health Center (FQHC). Study Design: This was a retrospective cohort study of patients who delivered at an urban hospital in New York between September and November 2019 (pre-COVID), February through April 2020 (peak-COVID) and June through August 2020 (ongoing-COVID). The primary outcome was postpartum visit attendance. Secondary outcomes included contraception use, breastfeeding, depression screening, hospital readmission, and emergency department visit rates. Log-binomial regression models were used to estimate relative risk. Results: Telemedicine accounted for 1% of postpartum visits in the pre-COVID cohort, 60% in the peak-COVID cohort, and 48% in the ongoing-COVID cohort. Postpartum visit attendance rates were 52% in the pre-COVID cohort, 43% in the peak-COVID cohort, and 56% in the ongoing-COVID cohort (p > 0.05). There was a nonsignificant increase in postpartum visit show rate for telemedicine visits compared to in-person visits in the peak-COVID cohort (76% vs. 65%; relative risk [RR] 1.17 [0.87-1.57]) and ongoing-COVID cohort (85% vs. 74%; RR 1.16 [0.90-1.50]). Patients were significantly less likely to have a Patient Health Questionnaire-2 Depression screen in the peak-COVID and ongoing-COVID cohorts (22% and 33%) than in the pre-COVID cohort (74%) (p < 0.01). There were no significant differences in hospital readmissions, contraceptive use or breastfeeding rates across cohorts (p > 0.05). Conclusions: At our urban FQHC, telemedicine was comparable to in-person postpartum care in terms of attendance rates during the COVID-19 pandemic, without an increase in rates of hospital visits or readmissions. However, postpartum depression screening needs to be better integrated into the telemedicine visit type.

Systematic review of the evidence for resolution of common breastfeeding problems-Ankyloglossia (Tongue Tie).

AIM: Tongue tie is a common problem affecting breastfeeding due to poor infant latch and/or maternal pain. Evidence of whether treatment improves breastfeeding outcomes is conflicting. We conducted a systematic review and meta-analysis to examine the effectiveness of tongue-tie treatment on breastfeeding difficulties. METHODS: We searched peer-reviewed and grey literature in MEDLINE (OVID), PubMed, CINAHL Plus, EMBASE and PsycINFO, from 01/1970 to 09/2019. INCLUSION: randomised and non-randomised clinical trials, and quasi-experimental study designs, involving breastfeeding interventions for full-term singleton infants, using standardised measure of breastfeeding difficulty. EXCLUSION: qualitative and purely observational studies, lacked operational definition of breastfeeding difficulty, lacked control/comparison group. We assessed risk of bias, summarised study quality and results and conducted meta-analysis using random effects modelling. RESULTS: Six studies on tongue-tie division were included (4 randomised and 2 non-randomised). Meta-analysis of standardised mean differences in breastfeeding difficulty scores in four studies showed statistically significant differences in favour of frenotomy (Pooled SMD +2.12, CI:(0.17-4.08)p = 0.03). Similarly, a statistically significant difference in favour of frenotomy was observed for pain (Pooled SMD -1.68, 95% CI: (-2.87- -0.48). CONCLUSION: Results support that infant frenotomy is effective for improving standardised scores on breastfeeding difficulty and maternal pain scales and could improve breastfeeding outcomes.

Improving perinatal depression screening and management: results from a federally qualified health center.

INTRODUCTION: Perinatal depression affects 8.5-20% of women. In a systematic review 22% of women with a positive depression screen use mental health services. The objective of this study was to examine the effectiveness of on-site management in the perinatal setting and barriers to care. METHODS: This is a retrospective chart review of 1042 women who received perinatal care between 1 January to 31 December 2019. Primary outcome was percentage of patients who were assessed after a positive depression screen. The secondary outcome was to determine factors affecting patients' receptiveness to assessment/treatment. RESULTS: 9.52% of women screened positive. Sixty-two (63.9%) met with an on-site social worker for assessment, 6 (6.2%) misunderstood the screening questions, and 33 (34.0%) met criteria for depression. Of those, 9 (27.3%) attended at least one follow-up, 8 (24.2%) were referred to or already in care, 7 (21.2%) no-showed, and 9 (27.3%) declined further care. English speaking patients were more likely to meet with a social worker for diagnostic assessment (69.9% versus 45.8%, P = 0.033). CONCLUSION: On-site management of a positive depression screen yielded a follow-up rate of 64% versus 49% in other studies. Non-English language may be a barrier to accessing mental health car.

Achieving Baby-Friendly Designation at a Large Metropolitan Center.

OBJECTIVE: This study aimed to describe the journey of obtaining Baby-Friendly designation as a large metropolitan center in an urban city and review the initial patient-related outcomes. STUDY DESIGN: Our medical center participated in the New York City Department of Health and Mental Hygiene Breastfeeding Hospital Collaborative from 2012 to 2017. Monthly meetings were held to monitor data, and audits conducted among prenatal sites and maternity units. This hospital collaborative was established to help facilities through the designation process. RESULTS: Breastfeeding education in the prenatal setting was provided consistently at all outpatient sites. By 2017, 89.8% of patients had received appropriate education and support during their prenatal visits. There was a shift in feeding pattern from mostly formula feeding with some breastfeeding to primarily breastfeeding with fewer formula feeds. Baby-Friendly designation was achieved in June 2017 after a formal Baby-Friendly USA assessment. CONCLUSION: Since embarking on this journey, there has been a consistent increase in antenatal patient education and a paradigm shift from some breastfeeding to mostly breastfeeding among the mother-baby dyads which combination feed. Our hospital center has continued to successfully maintain the workflow changes implemented during the Baby-Friendly process.