Comparing the effect of two systems-level interventions on perinatal generalized anxiety disorder and post-traumatic stress disorder symptoms.

BACKGROUND: The Massachusetts Child Psychiatry Access Program (MCPAP for Moms) and PRogram In Support of Moms (PRISM) are designed to help obstetric practices address perinatal depression. PRISM includes the statewide MCPAP for Moms program plus proactive implementation support. OBJECTIVE: The goal of this study was to understand the impact of these programs on perinatal Generalized Anxiety Disorder (GAD) and Post-traumatic Stress Disorder (PTSD) symptoms among individuals screening positive for depression. STUDY DESIGN: We conducted a secondary analysis of 2017-2022 data from a cluster randomized controlled trial of MCPAP for Moms vs. PRISM. We included participants completing a GAD or PTSD screen at baseline (n=254) with antenatal Edinburgh Postnatal Depression Scale (EPDS) scores ≥ 10. We assessed change in GAD and PTSD symptoms at from pregnancy (4 to <25 weeks Gestational Age (GA) or 32-40 weeks GA), to 4-12 weeks postpartum and 11-13 months postpartum. We conducted a difference-in-difference analysis to compare symptom change from pregnancy to postpartum. We used adjusted linear mixed models with repeated measures to examine the impact of MCPAP for Moms and PRISM on changes in the Generalized Anxiety Disorder 7 (GAD-7) and the PTSD CheckList (PCL-C). RESULTS: Mean GAD-7 scores decreased by 3.6 (MCPAP for Moms) and 6.3 (PRISM) points at from pregnancy to 4-12 weeks postpartum. Mean PCL-C scores decreased by 6.2 and 10.0 points, respectively, at 4-12 weeks postpartum among individuals screening positive on the GAD-7 (n=83) or PCL-C (n=58) in pregnancy. GAD-7 and PCL-C scores decreased among both groups at 11-13 months postpartum. These changes were clinically meaningful. PRISM conferred a statistically significant greater decrease (2.7 points) on the GAD-7 than MCPAP for Moms at 4-12 weeks postpartum. No differences were found between MCPAP for Moms and PRISM in PCL-C or GAD-7 change at 11-13 months, although both were associated with a reduction in GAD and PTSD symptoms at 4-12 weeks and 11-13 months postpartum. CONCLUSION: Both MCPAP for Moms and PRISM could help to improve symptoms for individuals experiencing co-occurring symptoms of depression, GAD, or PTSD. PRISM may confer additional benefit in the early postpartum period, although this difference was not clinically significant.

Effectiveness of two systems-level interventions to address perinatal depression in obstetric settings (PRISM): an active-controlled cluster-randomised trial.

BACKGROUND: Perinatal depression is a common and undertreated condition, with potential deleterious effects on maternal, obstetric, infant, and child outcomes. We aimed to compare the effectiveness of two systems-level interventions in the obstetric setting-the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms and the PRogram In Support of Moms (PRISM)-in improving depression symptoms and participation in mental health treatment among women with perinatal depression. METHODS: In this cluster-randomised, active-controlled trial, obstetric practices across Massachusetts (USA) were allocated (1:1) via covariate adaptive randomisation to either continue participating in the MCPAP for Moms intervention, a state-wide, population-based programme, or to participate in the PRISM intervention, which involved MCPAP for Moms plus a proactive, multifaceted, obstetric practice-level intervention with intensive implementation support. English-speaking women (aged ≥18 years) who screened positive for depression (Edinburgh Postnatal Depression Scale [EPDS] score ≥10) were recruited from the practices. Patients were followed up at 4-25 weeks of gestation, 32-40 weeks of gestation, 0-3 months postpartum, 5-7 months postpartum, and 11-13 months postpartum via telephone interview. Participants were masked to the intervention; investigators were not masked. The primary outcome was change in depression symptoms (EPDS score) between baseline assessment and 11-13 months postpartum. Analysis was done by intention to treat, fitting generalised linear mixed models adjusting for age, insurance status, education, and race, and accounting for clustering of patients within practices. This trial is registered with ClinicalTrials.gov, NCT02760004. FINDINGS: Between July 29, 2015, and Sept 20, 2021, ten obstetric practices were recruited and retained; five (50%) practices were randomly allocated to MCPAP for Moms and five (50%) to PRISM. 1265 participants were assessed for eligibility and 312 (24·7%) were recruited, of whom 162 (51·9%) were enrolled in MCPAP for Moms practices and 150 (48·1%) in PRISM practices. Comparing baseline to 11-13 months postpartum, EPDS scores decreased by 4·2 (SD 5·2; p<0·0001) among participants in MCPAP for Moms practices and by 4·3 (SD 4.5; p<0·0001) among those in PRISM practices (estimated difference between groups 0·1 [95% CI -1·2 to 1·4]; p=0·87). INTERPRETATION: Both the MCPAP for Moms and PRISM interventions were equally effective in improving depression symptoms. This finding is important because the 4-point decrease in EPDS score is clinically significant, and MCPAP for Moms has a lower intensity and greater population-based reach than does PRISM. FUNDING: US Centers for Disease Control and Prevention.

Rural/urban differences in health care utilization and costs by perinatal depression status among commercial enrollees.

PURPOSE: To understand differences in health care utilization and medical expenditures by perinatal depression (PND) status during pregnancy and 1-year postpartum overall and by rural/urban status. METHODS: We estimated differences in health care utilization and medical expenditures by PND status for individuals with an inpatient live-birth delivery in 2017, continuously enrolled in commercial insurance from 3 months before pregnancy through 1-year postpartum (study period), using MarketScan Commercial Claims data. Multivariable regression was used to examine differences by rurality. FINDINGS: Ten percent of commercially insured individuals had claims with PND. A smaller proportion of rural (8.7%) versus urban residents (10.0%) had a depression diagnosis (p < 0.0001). Of those with PND, a smaller proportion of rural (5.5%) versus urban residents (9.6%) had a depression claim 3 months before pregnancy (p < 0.0001). Compared with urban residents, rural residents had greater differences by PND status in total inpatient days (rural: 0.7, 95% confidence interval [CI]: 0.6-0.9 vs. urban: 0.5, 95% CI: 0.5-0.6) and emergency department (ED) visits (rural: 0.7, 95% CI: 0.6-0.9 vs. urban: 0.5, 95% CI: 0.4-0.5), but a smaller difference by PND status in the number of outpatient visits (rural: 9.2, 95% CI: 8.2-10.2 vs. urban: 13.1, 95% CI: 12.7-13.5). Differences in expenditures for inpatient services by PND status differed by rural/urban status (rural: $2654; 95% CI: $1823-$3485 vs. urban: $1786; 95% CI: $1445-$2127). CONCLUSIONS: Commercially insured rural residents had more utilization for inpatient and ED services and less utilization for outpatient services. Rural locations can present barriers to evidence-based care to address PND.

Timing of Postpartum Depressive Symptoms.

Introduction: Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period. Methods: We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods. Results: Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression. Conclusion: Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Mental health and substance use disorders at delivery hospitalization and readmissions after delivery discharge.

BACKGROUND: The objective was to assess mental health and substance use disorders (MSUD) at delivery hospitalization and readmissions after delivery discharge. METHODS: This is a population-based retrospective cohort study of persons who had a delivery hospitalization during January to September in the 2019 Nationwide Readmissions Database. We calculated 90-day readmission rates for MSUD and non-MSUD, overall and stratified by MSUD status at delivery. We used multivariable logistic regressions to assess the associations of MSUD type, patient, clinical, and hospital factors at delivery with 90-day MSUD readmissions. RESULTS: An estimated 11.8% of the 2,697,605 weighted delivery hospitalizations recorded MSUD diagnoses. The 90-day MSUD and non-MSUD readmission rates were 0.41% and 2.9% among delivery discharges with MSUD diagnoses, compared to 0.047% and 1.9% among delivery discharges without MSUD diagnoses. In multivariable analysis, schizophrenia, bipolar disorder, stimulant-related disorders, depressive disorders, trauma- and stressor-related disorders, alcohol-related disorders, miscellaneous mental and behavioral disorders, and other specified substance-related disorders were significantly associated with increased odds of MSUD readmissions. Three or more co-occurring MSUDs (vs one MSUD), Medicare or Medicaid (vs private) as the primary expected payer, lowest (vs highest) quartile of median household income at residence zip code level, decreasing age, and longer length of stay at delivery were significantly associated with increased odds of MSUD readmissions. CONCLUSION: Compared to persons without MSUD at delivery, those with MSUD had higher MSUD and non-MSUD 90-day readmission rates. Strategies to address MSUD readmissions can include improved postpartum MSUD follow-up management, expanded Medicaid postpartum coverage, and addressing social determinants of health.

COVID-19 Outbreaks Linked to Workplaces, 23 US Jurisdictions, August-October 2021.

OBJECTIVES: Early in the COVID-19 pandemic, several outbreaks were linked with facilities employing essential workers, such as long-term care facilities and meat and poultry processing facilities. However, timely national data on which workplace settings were experiencing COVID-19 outbreaks were unavailable through routine surveillance systems. We estimated the number of US workplace outbreaks of COVID-19 and identified the types of workplace settings in which they occurred during August-October 2021. METHODS: The Centers for Disease Control and Prevention collected data from health departments on workplace COVID-19 outbreaks from August through October 2021: the number of workplace outbreaks, by workplace setting, and the total number of cases among workers linked to these outbreaks. Health departments also reported the number of workplaces they assisted for outbreak response, COVID-19 testing, vaccine distribution, or consultation on mitigation strategies. RESULTS: Twenty-three health departments reported a total of 12 660 workplace COVID-19 outbreaks. Among the 12 470 workplace types that were documented, 35.9% (n = 4474) of outbreaks occurred in health care settings, 33.4% (n = 4170) in educational settings, and 30.7% (n = 3826) in other work settings, including non-food manufacturing, correctional facilities, social services, retail trade, and food and beverage stores. Eleven health departments that reported 3859 workplace outbreaks provided information about workplace assistance: 3090 (80.1%) instances of assistance involved consultation on COVID-19 mitigation strategies, 1912 (49.5%) involved outbreak response, 436 (11.3%) involved COVID-19 testing, and 185 (4.8%) involved COVID-19 vaccine distribution. CONCLUSIONS: These findings underscore the continued impact of COVID-19 among workers, the potential for work-related transmission, and the need to apply layered prevention strategies recommended by public health officials.

Clinician Knowledge and Practices Related to a Patient History of Hypertensive Disorders of Pregnancy.

OBJECTIVE: To describe clinician screening practices for prior hypertensive disorders of pregnancy, knowledge of future risks associated with hypertensive disorders of pregnancy, barriers and facilitators to referrals for cardiovascular disease risk evaluation in women with prior hypertensive disorders of pregnancy, and variation by clinician- and practice-level characteristics. METHODS: We used data from Fall DocStyles 2020, a cross-sectional, web-based panel survey of currently practicing U.S. clinicians. Of 2,231 primary care physicians, obstetrician-gynecologists (ob-gyns), nurse practitioners, and physician assistants invited to participate, 67.3% (n=1,502) completed the survey. We calculated the prevalence of screening, knowledge of future risks, and barriers and facilitators to referrals, and assessed differences by clinician type using χ2 tests. We evaluated associations between clinician- and practice-level characteristics and not screening using a multivariable log-binomial model. RESULTS: Overall, 73.6% of clinicians screened patients for a history of hypertensive disorders of pregnancy; ob-gyns reported the highest rate of screening (94.8%). Overall, 24.8% of clinicians correctly identified all cardiovascular risks associated with hypertensive disorders of pregnancy listed in the survey. Lack of patient follow-through (51.5%) and patient refusal (33.6%) were the most frequently cited barriers to referral. More referral options (42.9%), patient education materials (36.2%), and professional guidelines (34.1%) were the most frequently cited resources needed to facilitate referrals. In the multivariable model, primary care physicians and nurse practitioners, as well as physician assistants, were more likely than ob-gyns to report not screening (adjusted prevalence ratio 5.54, 95% CI 3.24-9.50, and adjusted prevalence ratio 7.42, 95% CI 4.27-12.88, respectively). Clinicians seeing fewer than 80 patients per week (adjusted prevalence ratio 1.81, 95% CI 1.43-2.28) were more likely to not screen relative to those seeing 110 or more patients per week. CONCLUSION: Three quarters of clinicians reported screening for a history of hypertensive disorders of pregnancy; however, only one out of four clinicians correctly identified all of the cardiovascular risks associated with hypertensive disorders of pregnancy listed in the survey.

Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin.

BACKGROUND: To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care. METHODS: We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests. RESULTS: Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women. CONCLUSIONS: These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.

Clinical Practice Changes in Monitoring Hypertension Early in the COVID-19 Pandemic.

BACKGROUND: Clinical practices can use telemedicine and other strategies (e.g., self-measured blood pressure [SMBP]) for remote monitoring of hypertension to promote control while decreasing risk of exposure to SARS-CoV-2, the virus that causes COVID-19. METHODS: The DocStyles survey collected data from primary care providers (PCPs), obstetricians-gynecologists (OB/GYNs), and nurse practitioners/physician assistants (NP/PAs) in fall 2020 (n = 1,502). We investigated clinical practice changes for monitoring hypertension that were implemented early in the COVID-19 pandemic and examined differences by clinician and practice characteristics (P < 0.05). RESULTS: Overall, 369 (24.6%) of clinicians reported their clinical practices made no changes in monitoring hypertension early in the pandemic, 884 (58.9%) advised patients to monitor blood pressure at home or a pharmacy, 699 (46.5%) implemented or increased use of telemedicine for blood pressure monitoring visits, and 545 (36.3%) reduced the frequency of office visits for blood pressure monitoring. Compared with NP/PAs, PCPs were more likely to advise SMBP monitoring (adjusted prevalence ratios [aPR] 1.28, 95% confidence intervals [CI] 1.11-1.47), implement or increase use of telemedicine (aPR 1.23, 95% CI 1.04-1.46), and reduce the frequency of office visits (aPR 1.37, 95% CI 1.11-1.70) for blood pressure monitoring, and less likely to report making no practice changes (aPR 0.63, 95% CI 0.51-0.77). CONCLUSIONS: We noted variation in clinical practice changes by clinician type and practice characteristics. Clinical practices may need additional support and resources to fully maximize telemedicine and other strategies for remote monitoring of hypertension during pandemics and other emergencies that can disrupt routine health care.

Healthcare Utilization and Costs Associated With Perinatal Depression Among Medicaid Enrollees.

INTRODUCTION: Differences in healthcare utilization and medical expenditures associated with perinatal depression are estimated. METHODS: Using the MarketScan Multi-State Medicaid Database, the analytic cohort included individuals aged 15-44 years who had an inpatient live birth delivery hospitalization between January 1, 2017 and December 31, 2018. Multivariable negative binomial regression models were used to estimate the differences in utilization associated with perinatal depression, and multivariable generalized linear models were used to estimate the differences in expenditures associated with perinatal depression. Analyses were conducted in 2021. RESULTS: The cohort included 330,593 individuals. Nearly 17% had perinatal depression. Compared with individuals without perinatal depression individuals with perinatal depression had a larger number of inpatient admissions (0.19, 95% CI=0.18, 0.20), total inpatient days (0.95, 95% CI=0.92, 0.97), outpatient visits (14.02, 95% CI=13.81, 14.22), emergency department visits (1.70, 95% CI=1.66, 1.74), and weeks of drug therapy covered by a prescription (28.70, 95% CI=28.12, 29.28) and larger total expenditures ($5,078, 95% CI=$4,816, $5,340). Non-Hispanic Black individuals had larger differences in utilization and expenditures for inpatient services and outpatient visits but smaller differences in utilization for pharmaceutical services associated with perinatal depression than non-Hispanic White individuals. Hispanic individuals had larger differences in utilization for outpatient visits but smaller differences in utilization for pharmaceutical services associated with perinatal depression than non-Hispanic White individuals. CONCLUSIONS: Individuals with perinatal depression had more healthcare utilization and medical expenditures than individuals without perinatal depression, and differences varied by race/ethnicity. The findings highlight the need to ensure comprehensive and equitable mental health care to address perinatal depression.

Hypertension at delivery hospitalization - United States, 2016-2017.

In this study, hospital discharge data from the 2016-2017 Healthcare Cost and Utilization Project were analyzed to describe national and, where data were available, state-specific prevalences of chronic hypertension and pregnancy-associated hypertension at delivery hospitalization. In 2016-2017, the prevalence of chronic hypertension was 216 per 10,000 delivery hospitalizations nationwide, ranging from 125 to 400 per 10,000 delivery hospitalizations in individual states. The prevalence of pregnancy-associated hypertension was 1021 per 10,000 delivery hospitalizations nationwide, ranging from 693 to 1382 per 10,000 delivery hospitalizations in individual states. The burden of hypertensive disorders in pregnancy remains high and varies considerably by jurisdiction.

Pregnancy Intention: Associations with Maternal Behaviors and Experiences During and After Pregnancy.

Background: The associations between levels of pregnancy intention and adverse behaviors or experiences during pregnancy and postpartum have not been well described. Materials and Methods: We used 2018 Pregnancy Risk Assessment Monitoring System data from 31 jurisdictions in the United States (n = 32,777) to estimate prevalence of inadequate prenatal care (PNC), inappropriate gestational weight gain, depression during pregnancy, intimate partner violence (IPV) during pregnancy, third trimester smoking, no breastfeeding, no postpartum visit, postpartum depressive symptoms, and postpartum smoking by categories of pregnancy intention: unwanted, ambivalent (i.e., unsure), mistimed (i.e., wanted later), or wanted (i.e., wanted then/sooner). Regression models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) of associations between pregnancy intention and maternal behaviors or experiences. Results: Approximately 16% of women reported pregnancy ambivalence. Women with pregnancy ambivalence (versus wanted pregnancies) had higher prevalence of all adverse maternal behaviors and experiences. Separate models found women with unwanted pregnancy (vs. ambivalent) had higher prevalence for depression during pregnancy (aPR: 1.40, 95% CI: 1.21-1.63), IPV (aPR: 1.75, 95% CI: 1.11-2.77), no breastfeeding (aPR: 1.22, 95% CI: 1.04-1.44), no postpartum visit (aPR: 1.28, 95% CI: 1.06-1.55), and postpartum depressive symptoms (aPR: 1.19, 95% CI: 1.00-1.42); Women with mistimed pregnancy (vs. ambivalent) had lower prevalence for inadequate PNC (aPR: 0.89, 95% CI: 0.81-0.98), third trimester smoking (aPR: 0.68, 95% CI: 0.57-0.80), no breastfeeding (aPR: 0.85, 95% CI: 0.74-0.98), and postpartum smoking (aPR: 0.83, 95% CI: 0.73-0.95). Discussion: The results emphasize the importance of recommended screening and care during the preconception, prenatal, and postpartum periods.

Postpartum Care Utilization Among Women with Medicaid-Funded Live Births in Oregon.

INTRODUCTION: Postpartum care is an important strategy for preventing and managing chronic disease in women with pregnancy complications (i.e., gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP)). METHODS: Using a population-based, cohort study among Oregon women with Medicaid-financed deliveries (2009-2012), we examined Medicaid-financed postpartum care (postpartum visits, contraceptive services, and routine preventive health services) among women who retained Medicaid coverage for at least 90 days after delivery (n = 74,933). We estimated postpartum care overall and among women with and without GDM and/or HDP using two different definitions: 1) excluding care provided on the day of delivery, and 2) including care on the day of delivery. Pearson chi-square tests were used to assess differential distributions in postpartum care by pregnancy complications (p < .05), and generalized estimating equations were used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: Of Oregon women who retained coverage through 90 days after delivery, 56.6-78.1% (based on the two definitions) received any postpartum care, including postpartum visits (26.5%-71.8%), contraceptive services (30.7-35.6%), or other routine preventive health services (38.5-39.1%). Excluding day of delivery services, the odds of receiving any postpartum care (aOR 1.26, 95% CI 1.08-1.47) or routine preventive services (aOR 1.32, 95% CI 1.14-1.53) were meaningfully higher among women with GDM and HDP (reference = neither). DISCUSSION: Medicaid-financed postpartum care in Oregon was underutilized, it varied by pregnancy complications, and needs improvement. Postpartum care is important for all women and especially those with GDM or HDP, who may require chronic disease risk assessment, management, and referrals.

Impact of the COVID-19 pandemic on mental health, access to care, and health disparities in the perinatal period.

BACKGROUND: The COVID-19 pandemic has affected mental health and created barriers to healthcare. In this study, we sought to elucidate the pandemic's effects on mental health and access to care for perinatal individuals. METHODS: This cross-sectional study of individuals in Massachusetts who were pregnant or up to three months postpartum with a history of depressive symptoms examined associations between demographics and psychiatric symptoms (via validated mental health screening instruments) and the COVID-19 pandemic's effects on mental health and access to care. Chi-square associations and multivariate regression models were used. RESULTS: Of 163 participants, 80.8% perceived increased symptoms of depression and 88.8% of anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD at time of interview, higher education, and income were associated with increased symptoms of depression and anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD were also associated with perceived changes in access to mental healthcare. Compared to non-Hispanic White participants, participants of color (Black, Asian, Multiracial, and/or Hispanic/Latinx) were more likely to report that the pandemic changed their mental healthcare access (aOR:3.25, 95%CI:1.23, 8.59). LIMITATIONS: Limitations included study generalizability, given that participants have a history of depressive symptoms, and cross-sectional design. CONCLUSIONS: The pandemic has increased symptoms of perinatal depression and anxiety and impacted perceived access to care. Self-reported increases in depression and anxiety and changes to healthcare access varied by education, race/ethnicity, income, and positive screens. Understanding these differences is important to address perinatal mental health and provide equitable care.

Surveillance of Hypertension Among Women of Reproductive Age: A Review of Existing Data Sources and Opportunities for Surveillance Before, During, and After Pregnancy.

Hypertension is one of the largest modifiable risk factors for cardiovascular disease in the United States, and when it occurs during pregnancy, it can lead to serious risks for both the mother and child. There is currently no nationwide or state surveillance system that specifically monitors hypertension among women of reproductive age (WRA). We reviewed hypertension information available in the Behavioral Risk Factor Surveillance System (BRFSS), National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), and Pregnancy Risk Assessment and Monitoring System (PRAMS) health surveys, the Health care Cost and Utilization Project administrative data sets (National Inpatient Sample, State Inpatient Databases, Nationwide Emergency Department Sample, and State Emergency Department Database and the Nationwide Readmissions Database), and the National Vital Statistics System. BRFSS, NHIS, and NHANES and administrative data sets have the capacity to segment nonpregnant WRA from pregnant women. PRAMS collects information on hypertension before and during pregnancy only among women with a live birth. Detailed information on hypertension in the postpartum period is lacking in the data sources that we reviewed. Enhanced data collection may improve opportunities to conduct surveillance of hypertension among WRA.

Trends in Selected Chronic Conditions and Related Risk Factors Among Women of Reproductive Age: Behavioral Risk Factor Surveillance System, 2011-2017.

Introduction: Chronic diseases in the United States are the leading drivers of disability, death, and health care costs. In women of reproductive age (WRA), chronic disease and related risk factors can also affect fertility and reproductive health outcomes. This analysis of trends from 2011 to 2017 adds additional indicators and updates an analysis covering 2001-2009. Methods: Data from the 2011-2017 Behavioral Risk Factor Surveillance System were analyzed for 265,544 WRA (18-44 years). To assess trends in 12 chronic conditions and related risk factors, we calculated annual prevalence estimates and adjusted prevalence ratios (APRs) with predicted marginals accounting for age, race, Hispanic ethnicity, education, and health care coverage. Results: From 2011 to 2017, prevalence decreased for current smoking (20.7%-15.9%; p < 0.001), gestational diabetes (3.1%-2.7%; p = 0.003), and high cholesterol (19.0%-16.7%; p < 0.001); prevalence increased for depression (20.4%-24.9%; p < 0.001) and obesity (24.6%-27.6%; p < 0.001). After adjustment, in 2017 WRA were more likely to report asthma (APR = 1.06; 95% confidence interval [CI] = 1.01-1.11), physical inactivity (APR = 1.08; 95% CI = 1.04-1.12), obesity (APR = 1.15; 95% CI = 1.11-1.19), and depression (APR = 1.29; 95% CI = 1.25-1.34) compared with 2011. They were less likely to report high cholesterol (APR = 0.89; 95% CI = 0.85-0.94) in 2015 compared with 2011, and current smoking (APR = 0.86; 95% CI = 0.82-0.89) and gestational diabetes (APR = 0.84; 95% CI = 0.75-0.94) in 2017 compared with 2011. Conclusions: Some chronic conditions and related risk factors improved, whereas others worsened over time. Research clarifying reasons for these trends may support the development of targeted interventions to promote improvements, potentially preventing adverse reproductive outcomes and promoting long-term health.

Positive screening rates for bipolar disorder in pregnant and postpartum women and associated risk factors.

OBJECTIVE: Bipolar disorder affects 2-8% of pregnant and postpartum women; untreated illness is associated with poor outcomes. This study aimed to describe bipolar disorder screening rates in obstetric settings and associated characteristics. METHOD: Women were recruited during pregnancy through three months postpartum from 14 obstetric clinics in Massachusetts. The Mood Disorder Questionnaire (MDQ) was used to screen for bipolar disorder; a subset previously diagnosed with bipolar was also examined. Differences in characteristics by screening outcome were tested using chi-square and t-tests. RESULTS: Of 574 participating women, 18.8% screened positive for bipolar disorder. Compared to those with negative, those with positive bipolar screens had 18.5-times the prevalence of positive substance use screens (11.1% vs. 0.6%, p < 0.001) and 3.4-times reported feeling they were not receiving adequate psychiatric help (24.0 vs. 7.0%, p < 0.001). Less than half of those with positive bipolar screens (42.0%) and 61.3% with pre-existing bipolar reported receiving current psychiatric care. CONCLUSIONS: Almost one in five perinatal women screened positive for bipolar disorder. Positive screenings were associated with comorbid substance use and low treatment rates. This study highlights the importance of screening for bipolar disorder during the perinatal period and the need for systematic approaches to ensure adequate assessment and follow-up. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier: NCT02760004.

The PRogram In Support of Moms (PRISM): study protocol for a cluster randomized controlled trial of two active interventions addressing perinatal depression in obstetric settings.

BACKGROUND: Perinatal depression, the most common pregnancy complication, is associated with negative maternal-offspring outcomes. Despite existence of effective treatments, it is under-recognized and under-treated. Professional organizations recommend universal screening, yet multi-level barriers exist to ensuring effective diagnosis, treatment, and follow-up. Integrating mental health and obstetric care holds significant promise for addressing perinatal depression. The overall study goal is to compare the effectiveness of two active interventions: (1) the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, a state-wide, population-based program, and (2) the PRogram In Support of Moms (PRISM) which includes MCPAP for Moms plus a proactive, multifaceted, practice-level intervention with intensive implementation support. METHODS: This study is conducted in two phases: (1) a run-in phase which has been completed and involved practice and patient participant recruitment to demonstrate feasibility for the second phase, and (2) a cluster randomized controlled trial (RCT), which is ongoing, and will compare two active interventions 1:1 with ten Ob/Gyn practices as the unit of randomization. In phase 1, rates of depressive symptoms and other demographic and clinical features among patients were examined to inform practice randomization. Patient participants to be recruited in phase 2 will be followed longitudinally until 13 months postpartum; they will have 3-5 total study visits depending on whether their initial recruitment and interview was at 4-24 or 32-40 weeks gestation, or 1-3 months postpartum. Sampling throughout pregnancy and postpartum will ensure participants with different depressive symptom onset times. Differences in depression symptomatology and treatment participation will be compared between patient participants by intervention arm. DISCUSSION: This manuscript describes the full two-phase study protocol. The study design is innovative because it combines effectiveness with implementation research designs and integrates critical components of participatory action research. Our approach assesses the feasibility, acceptance, efficacy, and sustainability of integrating a stepped-care approach to perinatal depression care into ambulatory obstetric settings; an approach that is flexible and can be tailored and adapted to fit unique workflows of real-world practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02760004, registered prospectively on May 3, 2016.

Recorded Diagnoses of Depression During Delivery Hospitalizations in the United States, 2000-2015.

OBJECTIVE: To describe national, state-specific, and sociodemographic trends in diagnoses of depressive disorders recorded during delivery hospitalizations. METHODS: Data were analyzed from the National Inpatient Sample (2000-2015) and 31 publicly available State Inpatient Databases (2000-2015) of the Healthcare Cost and Utilization Project. Delivery hospitalizations were identified by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes for obstetric delivery. Depressive disorders were identified from ICD-9-CM diagnoses codes classified as depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (291.89, 292.84, 293.83, 296.2-296.26, 296.3-296.36, 300.4, and 311). Prevalence rates and average annual rate change were calculated nationally and across 28 states with at least 3 years of data and age, payer source, and race or ethnicity. RESULTS: The U.S. rate of depressive disorders recorded during delivery hospitalizations increased from 4.1 diagnoses per 1,000 hospitalizations in 2000 to 28.7 in 2015. Rates significantly increased in 27 of the 28 states. Recent (2014-2015) rates were lowest in Hawaii and Nevada (less than 14/1,000) and highest in Vermont, Minnesota, Oregon, and Wisconsin (greater than 49/1,000). Rates in 2015 were highest among those aged 35 years or older, public insurance recipients, and non-Hispanic white women (greater than 31/1,000). The highest annual rate increases were in Vermont and Maine (3.8/1,000 or greater). Non-Hispanic white women, those 35 years of age or older, and public insurance recipients showed the highest annual rate increases during 2000-2015 (1.7/1,000 or greater). CONCLUSION: During 2000-2015, rates of depressive disorders recorded during delivery hospitalizations increased nationally, in 27 states with available data, and across all sociodemographic categories.

Addressing Intimate Partner Violence to Improve Women's Preconception Health.

Exposure to violence can harm women's overall health and well-being. Data suggest that one in three women in the United States experience some form of violence by an intimate partner in their lifetime. In this commentary, we describe the implications of intimate partner violence (IPV) on women's health, specifically for women of reproductive age. We use a life-course perspective to describe the compounded impact of IPV on preconception health. Preconception health generally refers to the overall health and well-being of women (and men) before pregnancy. This report also discusses primary prevention of IPV and healthcare recommendations, and highlights surveillance systems that capture IPV indicators among women of reproductive age. Ongoing collection of state-level surveillance data may inform the implementation of intervention programs tailored to reproductive age women at risk for IPV.