Treating perinatal opioid use disorder in rural settings: Challenges and opportunities.

Perinatal opioid use disorder (OUD) is a life-threatening condition that significantly impacts women in rural areas. Medication assisted treatment (MAT) is the recommended treatment but can be difficult to access. Pregnant women may initially present for treatment of OUD in the emergency department, on labor and delivery units, or in an office setting, each of which presents unique challenges. Initiation of MAT in the appropriate setting, based on accurate assessment of gestational age, is a centrally important component of care for perinatal OUD. However, initiating treatment may present challenges to providers who lack experience treating this disorder. Vermont and New Hampshire are predominantly rural states which have focused on expanding MAT access for pregnant women using two different approaches to integrating treatment with maternity care.

Comparing long-acting reversible contraception insertion rates in women with Medicaid vs. private insurance in a clinic with a two-visit protocol.

OBJECTIVE: This study examined whether women with Medicaid are less likely to receive long-acting reversible contraception (LARC) in a clinic requiring two visits for insertion. STUDY DESIGN: LARC insertion and pregnancy rates were compared among women with Medicaid vs. private insurance, along with other predictors, in a retrospective chart review (N=447). RESULTS: Univariately, fewer women with Medicaid vs. private insurance received LARC (66% vs. 79%, p<.01) and more become pregnant (18% vs. 6%, p<.001). Significant multivariate predictors of not receiving LARC were being unmarried and postpartum, both of which were associated with having Medicaid. CONCLUSION: Women with Medicaid are less likely than women with private insurance to have a requested LARC device inserted when a clinic requires two visits for insertion.

Examining two different schedules of financial incentives for smoking cessation among pregnant women.

OBJECTIVE: To examine whether an efficacious voucher-based incentives intervention for decreasing smoking during pregnancy and increasing fetal growth could be improved without increasing costs. The strategy was to redistribute the usual incentives so that higher values were available early in the quit attempt. METHOD: 118 pregnant smokers in greater Burlington, Vermont (studied December, 2006-June, 2012) were randomly assigned to the revised contingent voucher (RCV) or usual contingent voucher (CV) schedule of abstinence-contingent vouchers, or to a non-contingent voucher (NCV) control condition wherein vouchers were provided independent of smoking status. Smoking status was biochemically verified; serial sonographic estimates of fetal growth were obtained at gestational weeks 30-34. RESULTS: RCV and CV conditions increased point-prevalence abstinence above NCV levels at early (RCV: 40%, CV: 46%, NCV: 13%, p=.007) and late-pregnancy (RCV: 45%; CV: 36%; NCV, 18%; p=.04) assessments, but abstinence levels did not differ between the RCV and CV conditions. The RCV intervention did not increase fetal growth above control levels while the CV condition did so (p<.05). CONCLUSION: This trial further supports the efficacy of CV for increasing antepartum abstinence and fetal growth, but other strategies (e.g., increasing overall incentive values) will be necessary to improve outcomes further.

Financial incentives for smoking cessation among pregnant and newly postpartum women.

OBJECTIVE: Smoking during pregnancy is the leading preventable cause of poor pregnancy outcomes in the U.S., causing serious immediate and longer-term adverse effects for mothers and offspring. In this report we provide a narrative review of research on the use of financial incentives to promote abstinence from cigarette smoking during pregnancy, an intervention wherein women earn vouchers exchangeable for retail items contingent on biochemically-verified abstinence from recent smoking. METHODS: Published reports based on controlled trials are reviewed. All of the reviewed research was conducted by one of two research groups who have investigated this treatment approach. RESULTS: Results from six controlled trials with economically disadvantaged pregnant smokers support the efficacy of financial incentives for increasing smoking abstinence rates antepartum and early postpartum. Results from three trials provide evidence that the intervention improves sonographically estimated fetal growth, mean birth weight, percent of low-birth-weight deliveries, and breastfeeding duration. CONCLUSIONS: The systematic use of financial incentives has promise as an efficacious intervention for promoting smoking cessation among economically disadvantaged pregnant and recently postpartum women and improving birth outcomes. Additional trials in larger and more diverse samples are warranted to further evaluate the merits of this treatment approach.

Understanding reasons for delay in seeking acute stroke care in an underserved urban population.

BACKGROUND AND PURPOSE: Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. METHODS: A survey of respondents' likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with patients with acute stroke or a proxy. RESULTS: In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of patients with stroke interviewed actually called 911 first (OR, 63.9; 95% CI, 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of patients with stroke reported significant delay in seeking medical attention, and almost half said the reason for the delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, whereas 35% cited having no other transportation options. CONCLUSIONS: In this predominantly black urban population, although 89% of community volunteers report the intent of calling 911 during a stroke, only 12% of actual patients with stroke did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke.

Examining maternal weight gain during contingency-management treatment for smoking cessation among pregnant women.

Excessive maternal weight gain during pregnancy can result in serious adverse maternal and neonatal health consequences making it an important outcome to monitor in developing smoking-cessation interventions for pregnant women. Maternal weight gain was investigated in the present study with 154 pregnant participants in controlled trials investigating the efficacy of contingency management (CM) for smoking cessation. Women were assigned to either an abstinence-contingent condition wherein they earned vouchers exchangeable for retail items by abstaining from smoking or to a control condition where they received comparable vouchers independent of smoking status. Mean percent of negative smoking-status tests throughout antepartum was greater in the incentive than control condition (45.2±4.6 vs. 15.5±2.4, p<.001) as was late-pregnancy point-prevalence abstinence (36% vs. 8%, p<.001) but maternal weight gain did not differ significantly between treatment conditions (15.0±0.8kg vs. 15.0±0.9 kg, p=.97). In a comparison of women classified by smoking status rather than treatment condition, a greater percent of negative smoking-status tests predicted significantly more weight gain (0.34 kg per 10% increase in negative tests), an effect that appeared to be attributable to women with greater abstinence having larger infants. This study shows no evidence of excessive maternal weight gain among pregnant women receiving a CM intervention for smoking cessation.

Effects of smoking cessation with voucher-based contingency management on birth outcomes.

AIMS: This study examined whether smoking cessation using voucher-based contingency management (CM) improves birth outcomes. DESIGN: Data were combined from three controlled trials. SETTING: Each of the trials was conducted in the same research clinic devoted to smoking and pregnancy. PARTICIPANTS: Participants (n=166) were pregnant women who participated in trials examining the efficacy of voucher-based CM for smoking cessation. Women were assigned to either a contingent condition, wherein they earned vouchers exchangeable for retail items by abstaining from smoking, or to a non-contingent condition where they received vouchers independent of smoking status. MEASUREMENT: Birth outcomes were determined by review of hospital delivery records. FINDINGS: Antepartum abstinence was greater in the contingent than non-contingent condition, with late-pregnancy abstinence being 34.1% versus 7.4% (P<0.001). Mean birth weight of infants born to mothers treated in the contingent condition was greater than infants born to mothers treated in the non-contingent condition (3295.6 ± 63.8 g versus 3093.6 ± 67.0 g, P = 0.03) and the percentage of low birth weight (<2500 g) deliveries was less (5.9% versus 18.5%, P = 0.02). No significant treatment effects were observed across three other outcomes investigated, although each was in the direction of improved outcomes in the contingent versus the non-contingent condition: mean gestational age (39.1 ± 0.2 weeks versus 38.5 ± 0.3 weeks, P = 0.06), percentage of preterm deliveries (5.9 versus 13.6, P = 0.09), and percentage of admissions to the neonatal intensive care unit (4.7% versus 13.8%, P = 0.06). CONCLUSIONS: These results provide evidence that smoking-cessation treatment with voucher-based CM may improve important birth outcomes.

Effects of cigarette smoking cessation on breastfeeding duration.

INTRODUCTION: The purpose of this study was to use data from controlled trials to examine whether smoking cessation increases breastfeeding duration. Correlational studies have confirmed associations between smoking status and breastfeeding duration, but whether smoking cessation increases breastfeeding duration has not been established. METHODS: Participants (N = 158) were smokers at the start of prenatal care who participated in controlled trials on smoking cessation. Women were assigned to either an incentive-based intervention wherein they earned vouchers exchangeable for retail items by abstaining from smoking or a control condition where they received comparable vouchers independent of smoking status. Treatments were provided antepartum through 12-week postpartum. Maternal reports of breastfeeding collected at 2-, 4-, 8-, 12-, and 24-week postpartum were compared between treatment conditions. Whether women were exclusively breastfeeding was not investigated. RESULTS: The incentive-based treatment significantly increased breastfeeding duration compared with rates observed among women receiving the control treatment, with significant differences between treatment conditions observed at 8-week (41% vs. 26%; odds ratio [OR] = 2.7, 95% CI = 1.3-5.6, p = .01) and 12-week (35% vs. 17%; OR = 3.4, 95% CI = 1.5-7.6, p = .002) postpartum. No significant treatment effects on breastfeeding were observed at other assessments. Changes in smoking status mediated the effects of treatment condition on breastfeeding duration. CONCLUSIONS: These results provide evidence from controlled studies that smoking cessation increases breastfeeding duration, which, to our knowledge, has not been previously reported.