Home Visits With A Registered Nurse Did Not Affect Prenatal Care In A Low-Income Pregnant Population.

There is an urgent need to improve maternal and neonatal health outcomes and decrease their racial disparities in the US. Prenatal nurse home visiting programs could help achieve this by increasing the use and quality of prenatal care and facilitating healthy behaviors during pregnancy. We conducted a randomized controlled trial of 5,670 Medicaid-eligible pregnant people in South Carolina to evaluate how a nurse home visiting program affected prenatal health care and health outcomes. We compared outcomes between the treatment and control groups and found little evidence of statistically significant differences in the intensity of prenatal care use, receipt of guideline-based prenatal care services, other health care use, or gestational weight gain. Nor did we find treatment effects in subgroup analyses of socially vulnerable participants (46.9 percent of the sample) or non-Hispanic Black participants (52.0 percent of the sample). Compared with the broader Medicaid population, our trial participants had more health and social risk factors, more engagement with prenatal care, and similar pregnancy outcomes. Delivering intensive nurse home visiting programs to the general Medicaid population might not be an efficient method to improve prenatal care for those who need the most support during pregnancy.

Trends in postpartum mental health care before and during COVID-19.

OBJECTIVE: To assess the impact of COVID-19 on trends in postpartum mental health diagnoses and utilization of psychotherapy and prescription drug treatment. DATA SOURCES: Data were obtained from a large, national health insurance claims database that tracks individuals longitudinally. STUDY DESIGN: We used interrupted time series models to examine changes in trends of postpartum mental health diagnoses before and during the COVID-19 pandemic and t-tests to examine differences in treatment. DATA EXTRACTION METHODS: We used billing codes to identify individuals who received mental health-related diagnoses and treatment in the first 90 days after a birth hospitalization. We excluded individuals diagnosed with schizophrenia or bipolar disorder and those with an unknown payer at delivery. PRINCIPAL FINDINGS: Compared to the pre-pandemic period, the trend in new postpartum mental health diagnoses increased significantly in the post-COVID-19 period (0.06 percentage points [95%CI 0.01, 0.11]). Over 12 months, the percentage of new diagnoses was 5.0% greater relative to what would be expected in absence of COVID-19. The percentage of diagnosed individuals who did not receive treatment increased from 50.4% to 52.7% (p = 0.003). CONCLUSIONS: Findings point to an urgent need to improve screening and treatment pathways for perinatal individuals in the wake of COVID-19.

Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial.

Importance: Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. Objective: To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. Design, Setting, and Participants: This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. Interventions: Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. Main Outcomes and Measures: There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. Results: Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. Conclusions and Relevance: In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03360539.

Protocol for a randomized controlled trial evaluating the impact of the Nurse-Family Partnership's home visiting program in South Carolina on maternal and child health outcomes.

BACKGROUND: Policy-makers are increasingly seeking rigorous evidence on the impact of programs that go beyond typical health care settings to improve outcomes for low-income families during the critical period around the transition to parenthood and through early childhood. METHODS: This study is a randomized controlled trial evaluating the impact of the Nurse-Family Partnership's expansion in South Carolina. The scientific trial was made possible by a "Pay for Success" program embedded within a 1915(b) Waiver from Medicaid secured by the South Carolina Department of Health and Human Services. This protocol describes study procedures and defines primary and secondary health-related outcomes that can be observed during the intervention period (including pregnancy through the child's first 2 years of life). Primary study outcomes include (1) a composite indicator for adverse birth outcomes including being born small for gestational age, low birth weight (less than 2500 g), preterm birth (less than 37 weeks' gestation), or perinatal mortality (fetal death at or after 20 weeks of gestation or mortality in the first 7 days of life), (2) a composite outcome indicating health care utilization or mortality associated with major injury or concern for abuse or neglect occurring during the child's first 24 months of life, and (3) an indicator for an inter-birth interval of < 21 months. Secondary outcomes are defined similarly in three domains: (1) improving pregnancy and birth outcomes, (2) improving child health and development, and (3) altering the maternal life course through changes in family planning. DISCUSSION: Evidence from this trial on the impact of home visiting services delivered at scale as part of a Medicaid benefit can provide policy-makers and stakeholders with crucial information about the effectiveness of home visiting programs in improving health and well-being for low-income mothers and children and about novel financing mechanisms for cross-silo interventions. TRIAL REGISTRATION: The trial was registered prospectively on the American Economic Association Trial Registry (the primary registry for academic economists doing policy trials) on 16 February 2016 ( AEARCTR-0001039 ). ClinicalTrials.gov NCT03360539 . Registered on 28 November 2017.

Financial Support to Medicaid-Eligible Mothers Increases Caregiving for Preterm Infants.

OBJECTIVES: To assess the impact of financial support on maternal caregiving activities for preterm infants. METHODS: We conducted a small randomized controlled trial (RCT) in two Massachusetts Neonatal Intensive Care Units (NICUs). We enrolled 46 Medicaid-eligible mothers of preterm infants between January 2017 and June 2018 and randomly assigned them to a treatment group (up to 3 weekly financial transfers of $200 each while their infant was in the hospital) or a control group. We collected hospital-record data while the infant was admitted. The primary outcome was a binary variable indicating skin-to-skin care (STSC) was provided during a hospital day. Secondary outcomes included daily maternal visitation, daily provision of breastmilk, neonatal growth and length of stay (LOS). Multilevel generalized linear models with random effects were used to estimate treatment effects on daily maternal behaviors and ordinary least squares models were used to estimate impacts on neonatal growth and LOS. RESULTS: We assigned 25 women to the intervention and 21 to the control and observed them over 703 days of their infants' hospitalization. Mothers who received financial support were more likely to provide STSC (adjusted risk ratio: 1.85; 95% confidence interval [CI] 1.31-2.62) and breastmilk (adjusted risk ratio: 1.36; 95% CI 1.06-1.75) while their infant was in the NICU. We see no statistically significant impact on neonatal growth outcomes or LOS, though estimated confidence intervals are imprecise. CONCLUSIONS: Our evidence demonstrates the potential for financial support to increase mothers' engagement with caregiving behaviors for preterm infants during the NICU stay.

Evaluation of different temporal periods between hormone-induced ovulation attempts in the female Fowler's toad Anaxyrus fowleri.

Many amphibian species reinitiate the processes of preparing for reproduction (e.g. oogenesis) soon after breeding indicating hormone-induced ovulation could potentially be achieved out-of-season, which would lead to higher annual fecundity compared to mono-seasonal breeding. Such strategies would be beneficial to captive breeding programs for threatened species that are short-lived, have aging populations or need large numbers of offspring to meet reintroduction goals for species recovery. Unfortunately, little is known regarding how female anurans respond to multiple ovulation events within a year, which could lead to higher annual fecundity compared to mono-seasonal breeding. Thus, we evaluated the effect of temporal period between exogenous hormone stimulation events on egg production using the Fowler's toad Anaxyrus fowleri as a model species. Female toads (n = 21) were administered hormone therapy twice in 1 year with toads randomly assigned to a treatment of either a 4-, 8- or 12-month recovery period between hormone stimulations. Ovulation was induced using two priming doses of human chorionic gonadotropin (100 IU; hCG) 72 h apart, followed by a resolving dose of hCG (500 IU) plus gonadotropin releasing hormone analogue (GnRHa; 15 µg) given 24 h after the second priming injection. Measured response variables include the number of females ovulating after treatment, total number of eggs produced and percent fertilization, neurula and tadpole development. No significant treatment effects were observed for any response variable (P > 0.05). Findings from this study suggest that hormone therapy can be administered in a bufonid species every 4 or 8 months without significantly affecting the number of ovulating females, egg production, fertilization, neurulation or tadpole development. By collecting gametes out-of-season or multiple times throughout the year, captive breeding programs could potentially increase tadpole production for reintroductions as well as extend the breeding window in captivity.

Frequency of exogenous hormone therapy impacts spermiation in male Fowler's toad (Bufo fowleri).

Amphibians are experiencing a global extinction crisis and captive assurance colonies, along with reintroduction programs, are necessary to prevent further losses. Assisted reproductive technologies (ART), such as hormone-stimulated gamete collection and in vitro fertlisation (IVF), are conservation methods that can be used to increase reproductive output for breeding and reintroduction programs when animals fail to breed naturally. In order to maximise the production of offspring using ART, it is important to establish the physiological limitations on the frequency that hormone therapy can be used to collect gametes for IVF or assisted breeding. The present study examined the effects of the frequency of hormone-induced spermiation on sperm quantity and quality in Fowler's toad (Bufo fowleri) by comparing four levels of hormone injection frequencies: twice a week, once a week, every other week, and every 3 weeks. Sperm release was induced with an intraperitoneal injection of 300IU human chorionic gonadotropin (hCG). Spermatozoa were collected at three time points after injection (5, 7 and 9h) and sperm concentration, motility and quality of forward progressive movement were measured. A significant decrease in sperm concentration (P<0.01) was observed with the most frequent treatment (twice a week hormone injections). However, there was no negative effect of the treatments on sperm motility (P=0.06) or forward movement (P=0.06). We also observed a significant decrease in the concentration (P<0.01), motility (P=0.02) and quality of forward progressive movement (P=0.01) of spermatozoa at the 9h collection compared with earlier collection times. These results have clear implications for amphibian captive breeding programs, where more frequent hormone-induced spermiation could have a negative effect on male performance. We recommend that hormone injections be spaced a minimum of 2 weeks apart to optimise the health of the animals, assisted breeding, IVF or collection of gametes for genome resource banking.