A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting.

PURPOSE: Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. METHODS: The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. RESULTS: At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. CONCLUSIONS: Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Reducing Disparities in Postpartum Care Utilization: Development of a Clinical Risk Assessment Tool.

INTRODUCTION: Patients receiving care at Federally Qualified Health Centers (FQHCs) have low postpartum care attendance. Perinatal morbidity and mortality disproportionately affect patients with low-income and are potentially preventable. The purpose of this study was to develop a clinical decision support tool to identify FQHC patients less likely to return for postpartum care. To accomplish this purpose, we evaluated established predictors and novel risk factors in our patient population. METHODS: This is a retrospective, secondary data analysis of 50,022 patients who received prenatal care past 24 weeks' gestation in FQHCs between 2012 and 2017. The postpartum visit was defined using Healthcare Effectiveness Data and Information Set measures as early care (birth to 21 days) and later care (21-84 days). Anderson's Behavioral Model for Access to Healthcare guided inclusion of potentially predictive factors. We stratified data by postpartum care attendance, and a final predictive model was selected by model fit statistics and clinical relevance. RESULTS: In our sample, 64% of birthing persons attended postpartum care at FQHCs. Of those who returned for care, 38% returned within 21 days postbirth and 62% returned between 21 and 84 days, with 28% returning for both early and later care. Predictors for postpartum care attendance included maternal age, parity, gestational age at first visit, and number of prenatal care visits. A clinical decision support tool for identifying patients less likely to return for care was created. DISCUSSION: An easy to implement clinical decision support tool can help identify FQHC patients at risk for postpartum nonattendance. Future interventions to improve adequacy of prenatal care can encourage early entry into prenatal care and sufficient prenatal visits. These efforts may improve postpartum care attendance and maternal health.

Addressing racial disparities in perinatal care for African American/Black individuals in the Chicago community health setting: a qualitative study.

BACKGROUND: There are persistent disparities in maternal and infant perinatal outcomes experienced by Black birthing persons compared with non-Hispanic white (NHW) individuals in the US. The differences in outcomes arise from not only socioeconomic factors and individual health behaviors but also structural racism. Recent research is beginning to elucidate the benefits of patient navigation to support underserved minoritized individuals who experience this constellation of barriers to equitable care. Qualitative research that utilizes both the experiences of Black birthing individuals and the expert opinion of healthcare providers working with them can serve to guide a patient navigation intervention to further decrease disparities in perinatal outcomes. METHODS: We conducted 30 interviews between August and December 2020 with Black birthing individuals in the Chicago metropolitan area and healthcare providers who care for this population both in Chicago and across the nation to explore their experiences, perceptions of barriers to care and ways to decrease inequities. RESULTS: Clinical care team members acknowledged the presence of health disparities experienced by Black pregnant individuals compared with their NHW counterparts stemming from racism, discrimination, and lack of resources. Patients similarly reported personal experiences with these disparities and barriers to care. The successful methods used by clinical care teams to help decrease these differences in the past included patient education on important topics such as breastfeeding and the use of patient advocates. Effectively screening for social determinants of health by someone the patient trusts was also cited as important. Regarding perinatal care practices, clinical care team members described the importance of patient education needs and care team cultural competency. Patients' reported positive and negative experiences corroborated these findings, emphasizing the importance of trust, listening, education, access to care, support, and patient advocacy. Finally, the care team members and patients agreed that active trust-building can help the provider/patient relationship and ultimately improve outcomes. CONCLUSIONS: These qualitative research findings improve the understanding of barriers to care and will help guide development of an intervention to reduce the health disparities experienced by Black pregnant persons.

Predicting Postpartum Transition to Primary Care in Community Health Centers.

INTRODUCTION: Although the transition to primary care after routine postpartum care has been recommended to mitigate adverse maternal outcomes, little is known about real-world transition patterns. The objective of this study was to describe the patterns and predictors of transition in a postpartum cohort receiving care at federally qualified health centers and a subcohort of clinically high-risk patients. METHODS: Electronic health record data collected between 2017 and 2019 were analyzed in 2021 for unadjusted analyses and multivariable regression models for both the full and high-risk cohorts. The primary outcome was completion of a primary care visit within 6 months of delivery. Primary predictors in both cohorts were insurance loss, postpartum visit, first-trimester visit, and medical visit within the year prepregnancy; for the full cohort, high-risk status was also studied. RESULTS: The full cohort (N=7,926) analysis showed that 17.3% completed a primary care visit. In unadjusted and adjusted analysis, all 5 predictors were significantly associated with primary care visit completion; 25.0% of high-risk patients completed a primary care visit, and patients who lost insurance had 66% lower odds of primary care visit completion (95% CI=0.24, 0.48). In unadjusted and adjusted analysis for the high-risk cohort (n=1,956, 24.7% of full cohort), all predictors except postpartum visit were significantly associated with primary care visit completion. CONCLUSIONS: Postpartum patients at federally qualified health centers transitioned to primary care at low rates; insurance loss was one significant barrier to care. Strategies to increase continuity, including improving insurance access, should be studied. Future research is needed to study structural inequity, the impact of primary care on maternal outcomes, and patient experience.

Provider Perspectives on Factors Affecting the PrEP Care Continuum Among Black Cisgender Women in the Midwest United States: Applying the Consolidated Framework for Implementation Research.

BACKGROUND: To End the HIV Epidemic and reduce the number of incident HIV infections in the United States by 90%, pre-exposure prophylaxis (PrEP) uptake and persistence among cisgender women, particularly racial and ethnic minority women, must be increased. Medical providers play a pivotal role across the PrEP care continuum. METHODS: In this qualitative study, guided by the Consolidated Framework for Implementation Research, we explored health care provider perspectives on facilitators and barriers to PrEP implementation strategies for Black cisgender women in the Midwest United States. Data were analyzed using a deductive thematic content analysis approach. RESULTS: A total of 10 medical providers completed individual qualitative interviews. Using the Consolidated Framework for Implementation Research framework, we identified intervention characteristics (cost, dosing, and adherence), individual patient and provider level factors (self-efficacy, knowledge, and attitudes), and systematic barriers (inner setting and outer setting) that ultimately lead to PrEP inequalities. Implementation strategies to improve the PrEP care continuum identified include provider training, electronic medical record optimization, routine patient education, and PrEP navigation. CONCLUSION: This study provides (1) medical provider insight into implementation factors that can be modified to improve the PrEP care continuum for Black cisgender women and (2) an implementation research logic model to guide future studies.

COVID-19: Exploring the Repercussions on Federally Qualified Health Center Service Delivery and Quality.

The COVID-19 pandemic has brought about a precipitous transformation in health care delivery in the nation's safety-net, primary care system of federally qualified health centers (FQHCs). This study uses electronic health record data to quantify the extent of changes to visit volume in 36 FQHCs across 19 states as well as changes in quality metrics. We found a steep decline in in-person visits in March 2020 accompanied by a sharp increase in telehealth visits; however, combined volume remained 23% below pre-pandemic levels. The implications for public health are significant, as preventive and chronic care deferral could lead to exacerbations of health disparities. Our examination of the impact on quality measures suggests that gaps in care are already emerging. Services that cannot be readily performed virtually are most affected. As FQHC visit numbers recover, concerted efforts are needed to encourage access and re-engage at-risk groups that fell out of care.

The Complex Interplay of Communication and Trust in Healthcare Delivery.

Effective communication in clinician-patient relationships is an essential part of improving health outcomes. Ineffective communication in clinical settings leaves patients feeling undervalued and unheard. Breakdowns in communication can have particularly profound effects on minority or underserved populations, where health disparities already exist. Effective communication is critical for establishing trust, which allows individuals to feel they can share their concerns and questions. Distrust is a particularly important issue in maternal health, where current US rates of maternal mortality and morbidity are 3.1 times higher in Black and African American (AA) pregnant and birthing persons than their non-Hispanic white counterparts. To address the widespread issue of medical distrust and its connection with maternal health outcomes, the OPTIMIZE study is currently implementing an innovative intervention aimed at improving perinatal care for Black/AA pregnant persons. This intervention prompts clinician-patient conversations to enhance communication and repair trust, including a focus on patients' goals, concerns, social determinants of health, and safety. The implications of this intervention are broad, including the potential to improve trust and communication in other clinical specialties.

Mathematical modeling study of school-based chlamydia screening: potential impact on chlamydia prevalence in intervention schools and surrounding communities.

BACKGROUND: Chlamydia screening in high schools offers a way to reach adolescents outside of a traditional clinic setting. Using transmission dynamic modeling, we examined the potential impact of high-school-based chlamydia screening programs on the burden of infection within intervention schools and surrounding communities, under varying epidemiological and programmatic conditions. METHODS: A chlamydia transmission model was calibrated to epidemiological data from three different settings. Philadelphia and Chicago are two high-burden cities with existing school-based screening programs. Rural Iowa does not have an existing program but represents a low-burden setting. We modeled the effects of the two existing programs to analyze the potential influence of program coverage and student participation. All three settings were used to examine a broader set of hypothetical programs with varying coverage levels and time trends in participation. RESULTS: In the modeled Philadelphia program, prevalence among the intervention schools' sexually active 15-18 years old population was 4.34% (95% credible interval 3.75-4.71%)after 12 program years compared to 5.03% (4.39-5.43%) in absence of the program. In the modeled Chicago program, prevalence was estimated as 5.97% (2.60-7.88%) after 4 program years compared to 7.00% (3.08-9.29%) without the program. In the broader hypothetical scenarios including both high-burden and low-burden settings, impact of school-based screening programs was greater in absolute terms in the higher-prevalence settings, and benefits in the community were approximately proportional to population coverage of intervention schools. Most benefits were garnered if the student participation did not decline over time. CONCLUSIONS: Sustained high student participation in school-based screening programs and broad coverage of schools within a target community are likely needed to maximize program benefits in terms of reduced burden of chlamydia in the adolescent population.

Local Disparities in Breastfeeding Initiation and Duration: A Cross-Sectional Population-Based Survey in Ten Chicago Community Areas.

Breastfeeding confers substantial health benefits to women and infants. While disparities in breastfeeding persist in the United States, the extent of these disparities at the local level is unclear. This study aimed to identify local level and racial/ethnic breastfeeding disparities within Chicago. A community-based representative survey including questions on breastfeeding was conducted in Chicago. We estimated the proportion of women who breastfed their last child for any length of time and who breastfed at 6 months by neighborhood and maternal characteristics. We performed Rao-Scott corrected chi-squared tests to analyze factors hypothesized to be associated with breastfeeding. Between March 2015 and September 2016, 641 women with at least one live birth completed the survey. We found no differences by community area in the breastfeeding initiation or breastfeeding for at least 6 months. Puerto Rican women had the lowest prevalence of breastfeeding initiation and continuation at 6 months in contrast to Mexican women who reported the highest prevalence of these practices. We found breastfeeding disparities between Puerto Rican and Mexican Hispanic subgroups. Policies and programs aimed at increasing breastfeeding should prioritize groups that are least likely to initiate breastfeeding or most likely to breastfeed for a limited duration.

Examining Time to Treatment and the Role of School-Based Health Centers in a School-Based Sexually Transmitted Infection Program.

BACKGROUND: Barriers to health care service utilization contribute to the spread of sexually transmitted infections (STIs) among teens. School-based STI screening programs reach adolescents outside of the clinic-based health care model and schools with school-based health centers (SBHCs) may expedite treatment because of their proximity to the population. This study examined whether students who tested positive for STIs in a school-based screening program had differing times to treatment based on treatment location. METHODS: All positive cases of chlamydia and gonorrhea from the 2012-2013 school year in a Chicago Department of Public Health (CDPH) and Chicago Public Schools school-based STI screening program were reviewed. Median time to treatment was compared for those treated at an SBHC versus those treated elsewhere (CDPH STI clinic, community health center, private physician). RESULTS: Overall, 540 students had positive results. The median age was 17 years, 427 had chlamydia (79.1%), 59 had gonorrhea (10.9%), and 54 had dual infections (10.0%); 144 were tested in a school with a SBHC on site (26.7%). Of the 483 students who received treatment (89.4%), those treated at a SBHC had a faster time to treatment compared to CDPH STI clinics (median 17 days versus 28 days, respectively, p < .001). CONCLUSIONS: For students testing positive in the Chicago school-based STI program, time to treatment is accelerated in locations with SBHCs.

MOBILE-izing Adolescent Sexual and Reproductive Health Care: A Pilot Study Using a Mobile Health Unit in Chicago.

BACKGROUND: Adolescents experience numerous barriers to obtaining sexual and reproductive health care (SRHC). Mobile Health Units (MHUs) can remove some barriers by traveling to the community. This pilot study developed Mobile SRHC through an iterative process on an existing MHU and evaluated it among adolescents and providers. METHODS: Mobile SRHC was developed through a mixed-method, multiphase study. Three key informant interviews with MHU providers, an adolescent needs assessment survey, and a Youth Model Development Session informed model development. Emergency contraception (EC), oral contraceptive pills (OCPs), and depot-medroxyprogesterone acetate (DMPA) were sequentially incorporated into MHU services. Administrative data assessed method distribution and surveys assessed patient satisfaction. RESULTS: Key informants held positive attitudes toward implementing Mobile SRHC into their practice. Needs assessment surveys (N = 103) indicated a majority was interested in learning about sexual health (66.0%) and obtaining birth control (54.4%) on an MHU. Over 3 months, 123 adolescents participated in Mobile SRHC. Seven packs and 9 prescriptions of EC, 8 3-month packs and 10 prescriptions of OCPs, and 5 injections and 5 prescriptions of DMPA were distributed. Ninety-two percent of adolescent participants reported they would recommend Mobile SRHC to friends. CONCLUSIONS: Mobile SRHC is a feasible approach for reproductive health care among adolescents.

Short Interpregnancy Intervals: Results from the First Baby Study.

BACKGROUND: Short interpregnancy interval (SIPI), defined as 18 months or fewer between delivery and subsequent conception, has become an independent marker of maternal and child health. METHODS: We performed a secondary analysis of 18 months of data from The First Baby Study, a prospective cohort of women followed from pregnancy through 3 years after their first birth. Women with SIPIs by 6, 6 to 12, and 12 to 18 months were compared with those without conceptions at those times. We then analyzed pregnancy intention of the subpopulation of women with a SIPI of 18 months or fewer. Logistic regression analyses determined associations between maternal characteristics, including sociodemographic and reproductive indicators, and SIPI incidence and intention. FINDINGS: Of 3,006 participants, 795 (26.5%) had a repeat pregnancy within 18 months: 58 (1.9%) occurred within 6 months, 242 (8.1%) between 6 and 12 months, and 495 (16.5%) between 12 and 18 months. Incidence of SIPI at each interval differed by maternal characteristics, including income, marital status, and intention. Most women (84%) with a SIPI of 6 months or less classified them as unintended. Less than 2% of women with SIPIs of 18 months or fewer reported any contraceptive use in the postpartum period and no pregnancies occurred with the use of very effective methods, including long-acting reversible contraception. CONCLUSIONS: The population of women at risk for SIPI is not homogenous. Among those with SIPIs, there is a stark contrast in intention between those who conceive early (≤6 months) versus later (≥12 months). Given that almost no pregnancies occurred when women used postpartum contraception, contraceptive counseling and unfettered access should be available for those at greatest risk for an early, repeat, unintended pregnancy.

Change in Population Characteristics and Teen Birth Rates in 77 Community Areas: Chicago, Illinois, 1999-2009.

OBJECTIVE: We analyzed community area differences in teen births in Chicago, Illinois, from 1999 to 2009. We analyzed the association between changes in teen birth rates and concurrent measures of community area socioeconomic and demographic change. METHODS: Mean annual changes in teen birth rates in 77 Chicago community areas were correlated with concurrent census-based population changes during the decade. Census measures included changes in race/ethnicity, adult high school dropouts, poverty or higher-income households, crowded housing, unemployment, English proficiency, foreign-born residents, or residents who moved in the last five years. We included non-collinear census measures with a p<0.1 bivariate association with change in teen births in a stepwise multiple linear regression model. RESULTS: Teen birth rates in Chicago fell faster than the overall birth rates, from 85 births per 1,000 teens in 1999 to 57 births per 1,000 teens in 2009. There were strong positive associations between increases in the percentage of residents who were black and Hispanic, poor, without a high school diploma, and living in crowded housing, and a negative association with an increase in higher-income households. Population changes in poverty, Hispanic population, and high school dropouts were the only significant measures in the final model, explaining almost half of the variance in teen birth rate changes. CONCLUSION: The study provides a model of census-based measures that can be used to evaluate predicted vs. observed rates of change in teen births across communities, offering the potential to more appropriately prioritize public health resources for preventing unintended teen pregnancy.

Likelihood of continued childbearing after cesarean delivery in the United States.

OBJECTIVE: To estimate the likelihood of continued childbearing as a function of mode of delivery and number of cesarean deliveries and to explore whether it varies by sociodemographic characteristics. METHODS: Cross-sectional data from the 2006-2010 National Survey of Family Growth were used to conduct an analysis of U.S. childbearing women. The birth trajectory for respondents who identified a live, singleton, first birth was assessed through four births. Population-weighted analyses were performed to test the association between route of delivery and sociodemographic characteristics with the likelihood of subsequent birth. RESULTS: Among 6,526 respondents, cesarean delivery, regardless of birth order, was associated with a lower likelihood of future birth, which decreased in a dose-response fashion as the number of cesarean deliveries increased. Among women with three births, those with two or three cesarean deliveries were 37% and 59% less likely (P<.05), respectively, to have a fourth birth when compared with women with three vaginal deliveries, adjusting for confounders. When interaction terms were added to the model, lower income women were significantly more likely to have a fourth birth after undergoing two or three cesarean deliveries than women with higher incomes (adjusted incidence rate ratio 2.50, 95% confidence interval [CI] 1.23-5.05 and adjusted incidence rate ratio 2.39, 95% CI 1.01-5.65, respectively). CONCLUSIONS: U.S. women who have cesarean deliveries are less likely to continue childbearing, especially because they undergo higher numbers of cesarean deliveries; however, this relationship is attenuated among low-income women. Given the risks associated with multiple cesarean deliveries, these findings underscore the need to further examine this relationship and what factors may be driving the income-based difference in childbearing after cesarean deliveries. LEVEL OF EVIDENCE: II.

Pregnancy intention and use of contraception among Hispanic women in the United States: data from the National Survey of Family Growth, 2006-2010.

BACKGROUND: Both unintended and adolescent childbearing disproportionately impact the Hispanic population of the United States. METHODS: We used the 2006-2010 National Survey of Family Growth (NSFG) to provide the most recent, nationally representative description of pregnancy, childbearing, and contraception for Hispanic females aged 15-44. We determined baseline fertility data for self-identified Hispanic female respondents. Among those reporting a pregnancy history, we calculated the proportion of pregnancies identified as unintended and their association with sociodemographic variables. We also assessed outcomes and estimates of relative risk for unintended pregnancy. Finally, we examined contraceptive use prior to self-reported unintended pregnancies. RESULTS: Approximately 70% of Hispanic women reported ever being pregnant, including 18% of teenagers. Over half (51%) of those pregnancies were unintended, including 81% among teenagers. The adjusted risk of unintended pregnancy was highest in women 15 to 19 years old and those with three or more pregnancies (incidence rate ratio [IRR] 1.64, 95% confidence interval [CI]: 1.44-1.88 and IRR 1.77, 95% CI: 1.53-2.06, respectively). Half of unintended pregnancies were preceded by no contraception. The most common reason for unintended pregnancy preceded by contraception was "improper use" (45%) and among pregnancies without use, the most common response (37%) was "I did not think I could get pregnant." CONCLUSIONS: There is a high frequency of unintended pregnancy and lack of contraceptive use among Hispanic women. These findings highlight the need for improved reproductive education and contraceptive counseling in this population.