Barriers to accessing and receiving antenatal care: Findings from interviews with Australian women experiencing disadvantage.

AIM: To identify the barriers associated with inadequate antenatal attendance by disadvantaged women in Australia and to further explore how these barriers are experienced by this population group. DESIGN: A qualitative descriptive study utilizing semi-structured interviews and thematic analysis. METHODS: Interviews were conducted with 11 pregnant women who self-identified as experiencing disadvantage, purposively sampled from a local government area of Victoria, Australia, characterized by socio-economic disadvantage. Data were collected from February to July 2019. RESULTS: Study participants reported a range of barriers to receiving timely and adequate antenatal care (ANC). For several women, a combination of personal (e.g., emotions, knowledge), health service provision (e.g., limited access to continuity of care provider and continuity of information, inflexible scheduling, difficulty travelling, staff attitudes), and broader social-contextual factors (e.g., financial situation, language, cultural norms) were ultimately insurmountable. Whereas some barriers were experienced as hassles or annoyances, others were unacceptable, overwhelming, or humiliating. CONCLUSION: Women experiencing disadvantage in Australia value ANC but face multiple and complex barriers that undermine timely and regular access. IMPLICATIONS FOR THE PROFESSION AND/PATIENT CARE: A wide range of strategies targeting barriers across multiple levels of the social-ecological environment are required if ANC attendance rates are to improve and ultimately redress existing health disparities. Various continuity of care models are well-placed to address many of the identified barriers and should be made more accessible to women, and particularly those women experiencing disadvantage. IMPACT: Antenatal care appointments promote the health of women and their babies during pregnancy, but for many women, particularly those experiencing disadvantage, access is delayed or inadequate. ANC providers play a critical role in facilitating timely and adequate care. Health service practitioners and management, and health services policymakers need to understand the complexity of the barriers women encounter. These stakeholders can utilize the findings reported herein to develop more effective strategies for overcoming multiple and multi-level barriers. REPORTING METHOD: The study is reported in accordance with the relevant EQUATOR guidelines: the standards for reporting qualitative research (SRQR) and consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

The contribution of visual processing to academic achievement in adolescents born extremely preterm or extremely low birth weight.

Children born extremely preterm (EP, <28 weeks) and/or extremely low birth weight (ELBW, <1000 g) have more academic deficiencies than their term-born peers, which may be due to problems with visual processing. The aim of this study is to determine (1) if visual processing is related to poor academic outcomes in EP/ELBW adolescents, and (2) how much of the variance in academic achievement in EP/ELBW adolescents is explained by visual processing ability after controlling for perinatal risk factors and other known contributors to academic performance, particularly attention and working memory. A geographically determined cohort of 228 surviving EP/ELBW adolescents (mean age 17 years) was studied. The relationships between measures of visual processing (visual acuity, binocular stereopsis, eye convergence, and visual perception) and academic achievement were explored within the EP/ELBW group. Analyses were repeated controlling for perinatal and social risk, and measures of attention and working memory. It was found that visual acuity, convergence and visual perception are related to scores for academic achievement on univariable regression analyses. After controlling for potential confounds (perinatal and social risk, working memory and attention), visual acuity, convergence and visual perception remained associated with reading and math computation, but only convergence and visual perception are related to spelling. The additional variance explained by visual processing is up to 6.6% for reading, 2.7% for spelling, and 2.2% for math computation. None of the visual processing variables or visual motor integration are associated with handwriting on multivariable analysis. Working memory is generally a stronger predictor of reading, spelling, and math computation than visual processing. It was concluded that visual processing difficulties are significantly related to academic outcomes in EP/ELBW adolescents; therefore, specific attention should be paid to academic remediation strategies incorporating the management of working memory and visual processing in EP/ELBW children.

School-Age Outcomes of Early Intervention for Preterm Infants and Their Parents: A Randomized Trial.

OBJECTIVE: To examine the child and parental outcomes at school age of a randomized controlled trial of a home-based early preventative care program for infants born very preterm and their caregivers. METHODS: At term-equivalent age, 120 infants born at a gestational age of <30 weeks were randomly allocated to intervention (n = 61) or standard care (n = 59) groups. The intervention included 9 home visits over the first year of life focusing on infant development, parental mental health, and the parent-infant relationship. At 8 years' corrected age, children's cognitive, behavioral, and motor functioning and parental mental health were assessed. Analysis was by intention to treat. RESULTS: One hundred children, including 13 sets of twins, attended follow-up (85% follow-up of survivors). Children in the intervention group were less likely to have mathematics difficulties (odds ratio, 0.42; 95% confidence interval [CI], 0.18 to 0.98; P = .045) than children in the standard care group, but there was no evidence of an effect on other developmental outcomes. Parents in the intervention group reported fewer symptoms of depression (mean difference, -2.7; 95% CI, -4.0 to -1.4; P < .001) and had reduced odds for mild to severe depression (odds ratio, 0.14; 95% CI, 0.03 to 0.68; P = .0152) than parents in the standard care group. CONCLUSIONS: An early preventive care program for very preterm infants and their parents had minimal long-term effects on child neurodevelopmental outcomes at the 8-year follow-up, whereas primary caregivers in the intervention group reported less depression.

The long-term outcome of extremely preterm (<28 weeks' gestational age) infants with and without severe retinopathy of prematurity.

BACKGROUND: Severe retinopathy of prematurity (ROP) is associated with an increased risk for ophthalmologic morbidity, but the long-term impact in other domains is less clear. The aim of the current study was to determine whether severe ROP was related to poorer visual, cognitive, and educational outcomes in a representative sample of EP adolescents, and whether this persisted after adjusting for confounding neonatal risk factors. METHOD: One hundred and eighty extremely preterm (EP; <28 weeks) adolescents (17-18 years) were assessed on a range of neurodevelopmental measures, including visual processing, IQ, visual learning, visual-motor integration, and academic achievement. EP adolescents were grouped according to ROP status, (1) severe ROP (stage 3 or greater) in the worse eye; or (2) no or mild ROP and were compared on each outcome. Longitudinal data were compared at 2, 5, 8, and 17-18 years for general cognitive outcome. RESULTS: The severe ROP group performed more poorly and had more impairments than the non-severe ROP group on measures of visual processing, visual-motor integration, visual learning, IQ, and some academic achievement tests at 17-18 years of age. Group differences diminished after controlling for perinatal risk factors (severe white matter injury, post-natal corticosteroid, and surgery in the neonatal period), and only visual acuity scores remained significantly different between the groups. IQ scores remained consistently lower in the severe ROP group over time, but the magnitude reduced after adjusting for perinatal risk factors. CONCLUSIONS: Extremely preterm children with severe ROP are at increased risk for ongoing visual processing difficulties and lower IQ compared with EP peers without severe ROP. While severe ROP is a predictor of long-term impairments, this association is largely mediated by other neonatal risk factors.

Long-term effect of high-dose supplementation with DHA on visual function at school age in children born at <33 wk gestational age: results from a follow-up of a randomized controlled trial.

BACKGROUND: Children born preterm are at risk of visual-processing impairments. Several lines of evidence have contributed to the rationale that docosahexaenoic acid (DHA) supplementation of preterm infants may improve outcomes in visual processing. OBJECTIVE: The aim was to determine whether at 7 y of age children who were born very preterm and who received a high-DHA diet have better visual-processing outcomes than do infants fed a standard-DHA diet. DESIGN: This was a follow-up study in a subgroup of children from a randomized controlled trial. Infants were randomly assigned to milk containing a higher concentration of DHA (1% of total fatty acids; high-DHA group) or a standard amount of DHA (0.2-0.3% of total fatty acids as DHA; control group). The randomization schedule was stratified by sex and birth weights of <1250 or ≥1250 g. A total of 104 (49 in the high-DHA group and 55 in the standard-DHA group) children aged 7 y were assessed on a range of visual-processing measures, including visual acuity, contrast sensitivity, vernier acuity, binocular stereopsis, and visual perception. RESULTS: There was no evidence of differences between the high-DHA and standard-DHA groups in any of the visual-processing measures. In the majority (12 of 13) of variables assessed, the direction of effect favored the control group. The study was large enough to detect a moderate treatment effect, if one truly existed. CONCLUSION: Supplementing human milk with DHA at a dose of ∼1% of total fatty acids given in the first months of life to very preterm infants does not appear to confer any long-term benefit for visual processing at school age. This trial was registered at anzctr.org/au as ACTRN12606000327583.

Visual memory and learning in extremely low-birth-weight/extremely preterm adolescents compared with controls: a geographic study.

BACKGROUND: Contemporary data on visual memory and learning in survivors born extremely preterm (EP; <28 weeks gestation) or with extremely low birth weight (ELBW; <1,000 g) are lacking. METHODS: Geographically determined cohort study of 298 consecutive EP/ELBW survivors born in 1991 and 1992, and 262 randomly selected normal-birth-weight controls. RESULTS: Visual learning and memory data were available for 221 (74.2%) EP/ELBW subjects and 159 (60.7%) controls. EP/ELBW adolescents exhibited significantly poorer performance across visual memory and learning variables compared with controls. Visual learning and delayed visual memory were particularly problematic and remained so after controlling for visual-motor integration and visual perception and excluding adolescents with neurosensory disability, and/or IQ <70. Male EP/ELBW adolescents or those treated with corticosteroids had poorer outcomes. CONCLUSION: EP/ELBW adolescents have poorer visual memory and learning outcomes compared with controls, which cannot be entirely explained by poor visual perceptual or visual constructional skills or intellectual impairment.

Attention difficulties in a contemporary geographic cohort of adolescents born extremely preterm/extremely low birth weight.

The aim of this study was to evaluate attention difficulties in a contemporary geographic cohort of adolescents born extremely preterm (EP, <28 weeks' gestation) or extremely low birth weight (ELBW, birth weight <1000 g). The EP/ELBW group included 228 adolescents (mean age = 17.0 years) born in Victoria, Australia in 1991 and 1992. The control group were 166 adolescents (mean age = 17.4 years) born of normal birth weight (birth weight >2499 g) who were recruited in the newborn period and matched to the EP/ELBW group on date of birth, gender, language spoken and health insurance status. Participants were assessed on measures of selective, sustained, and executive (shift and divided) attention, and parents and participants completed behavioral reports. The EP/ELBW group performed more poorly across tests of selective and executive attention, had greater rates of clinically significant difficulties compared with the control group, and also had greater behavioral attention problems as reported by parents. Neonatal risk factors were weakly associated with attention outcomes. In conclusion, higher rates of attention impairments are observed in individuals born EP/ELBW well into adolescence and may have consequences for their transition to adulthood.

Visual processing in adolescents born extremely low birth weight and/or extremely preterm.

BACKGROUND AND OBJECTIVES: Ocular growth and development differs between preterm and term-born infants and may cause long-term negative consequences for visual function, but contemporary data on long-term visual outcomes in representative samples of the highest risk extremely low birth weight (ELBW, <1000 g birth weight) or extremely preterm (EP, <28 weeks' gestation) survivors are lacking. Our objective was to compare visual functioning between ELBW/EP and normal birth weight (NBW, >2499 g birth weight) control adolescents. METHODS: Geographically determined cohort study of 228 consecutive ELBW/EP survivors born in the state of Victoria in 1991 and 1992, and 166 randomly selected NBW controls assessed between 14 and 20 years of age. Visual acuity, stereopsis, convergence, color perception, and visual perception were assessed and contrasted between groups. RESULTS: ELBW/EP subjects had significantly worse visual acuity with habitual correction in both the left and right eyes, and for the best eye (P < .001). The ELBW/EP adolescents also exhibited poorer stereopsis, odds ratio (OR) 3.22 (95% confidence interval [CI] 1.78 to 5.84), and convergence, OR 2.76 (CI 1.32 to 5.75) than controls, and more problems with visual perception, OR 3.09 (CI 1.67 to 5.71) after habitual correction. CONCLUSIONS: Despite advances in medical care improving the survival rate of high-risk ELBW/EP infants, visual morbidity is still relatively high compared with controls in late adolescence.