Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 33 Records) |
Query Trace: Goodman DA[original query] |
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Pregnancy-Related Mortality Due to Cardiovascular Conditions: Maternal Mortality Review Committees in 32 U.S. States, 2017 to 2019
Briller J , Trost SL , Busacker A , Joseph NT , Davis NL , Petersen EE , Goodman DA , Hollier LM . JACC Advances 2024 3 (12) Background: Cardiomyopathy (CM) and other cardiovascular conditions (OCVs) are among the most frequent causes of pregnancy-related death in the United States. Objectives: The purpose of this paper was to report demographic and clinical characteristics, preventability, contributing factors, and Maternal Mortality Review Committee (MMRC) recommendations among pregnancy-related deaths with underlying causes of CM, OCVs, and the 2 combined (cardiovascular conditions, CV). Methods: We analyzed pregnancy-related death data from MMRCs in 32 states, occurring during 2017 to 2019, with MMRC-determined underlying causes of CVs. We describe distributions of demographic characteristics, present the most frequent contributing factor classes, and provide example MMRC prevention recommendations. Results: Among 210 pregnancy-related deaths due to CVs, 84 (40%) were due to CM and 126 (60%) to OCVs. More than half (51.2%) of CM deaths were among non-Hispanic Black persons. Two-thirds (66%) of all CV deaths occurred among people <35 years old. Approximately 53% of CM deaths and 31% of OCV deaths occurred 43 to 365 days postpartum. Over 75% of pregnancy-related deaths due to CVs were determined by MMRCs to be preventable. The 5 most frequent contributing factor classes accounted for 50% of the total MMRC-identified contributing factors. MMRC prevention recommendations occur at multiple levels. Conclusions: Most pregnancy-related deaths due to CM and OCV are preventable. Example MMRC recommendations provided in this report illustrate prevention opportunities that address contributing factors, including broader awareness of urgent warning signs, improved handoffs for care coordination and continuity, and expanded accessibility of community-based comprehensive and integrated care services. © 2024 The Authors |
Maternal risk conditions and outcomes by levels of maternal care
DeSisto CL , Ewing AC , Diop H , Easter SR , Harvey E , Kane DJ , Naiman-Sessions M , Osei-Poku G , Riley M , Shanholtzer B , Stach AM , Dronamraju R , Catalano A , Clark EA , Madni SA , Womack LS , Kuklina EV , Goodman DA , Kilpatrick SJ , Menard MK . J Womens Health (Larchmt) 2024 Objectives: To (1) determine associations between maternal risk conditions and severe adverse outcomes that may benefit from risk-appropriate care and (2) assess whether associations between risk conditions and outcomes vary by level of maternal care (LoMC). Methods: We used the 2017-2019 National Inpatient Sample (NIS) to calculate associations between maternal risk conditions and severe adverse outcomes. Risk conditions included severe preeclampsia, placenta accreta spectrum (PAS) conditions, and cardiac conditions. Outcomes included disseminated intravascular coagulation (DIC) with blood products transfusion or shock, pulmonary edema or acute respiratory distress syndrome (ARDS), stroke, acute renal failure, and a composite cardiac outcome. Then we used 2019 delivery hospitalization data from five states linked to hospital LoMC. We calculated associations between risk conditions and outcomes overall and stratified by LoMC and assessed for effect modification by LoMC. Results: We found positive measures of association between risk conditions and outcomes. Among patients with severe preeclampsia or PAS, the magnitudes of the associations with DIC with blood products transfusion or shock, pulmonary edema or ARDS, and acute renal failure were lower in Level III/IV compared with <Level III facilities. Among patients with cardiac conditions, the magnitudes of the associations with these outcomes, along with stroke, were also lower in Level III/IV compared with <Level III facilities. The proportion of patients with risk conditions that delivered in <Level III facilities was 19.8-46.8%. Conclusions: Odds of severe adverse outcomes among women with selected risk conditions were lower for births occurring at higher-level facilities, supporting the benefit of risk-appropriate care. |
Pregnancy-related deaths due to hemorrhage: Pregnancy Mortality Surveillance System, 2012-2019
Hollier LM , Busacker A , Njie F , Syverson C , Goodman DA . Obstet Gynecol 2024 Hemorrhage has been a leading cause of pregnancy-related death in the Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System since 1987 when reporting began. Pregnancy Mortality Surveillance System data from 2012 to 2019 were analyzed to describe pregnancy-related deaths from hemorrhage. Pregnancy-related mortality ratios were estimated for hemorrhage overall and by hemorrhage subclassifications. Specific subclassifications of hemorrhage-related deaths were analyzed by sociodemographic characteristics. Overall, there were 606 deaths due to hemorrhage. The pregnancy-related mortality ratio for hemorrhage overall was 1.94 per 100,000 live births. Ruptured ectopic pregnancy was the most frequent subclassification (22.9%) of pregnancy-related hemorrhage deaths, followed by postpartum hemorrhage (21.2%). There were no significant trends in the pregnancy-related mortality ratio, overall or among any subclassification of hemorrhage deaths, from 2012 to 2019. Reporting subclassifications of pregnancy-related hemorrhage deaths could improve the ability to focus interventions and assess progress over time. |
Ranked severe maternal morbidity index for population-level surveillance at delivery hospitalization based on hospital discharge data
Kuklina EV , Ewing AC , Satten GA , Callaghan WM , Goodman DA , Ferre CD , Ko JY , Womack LS , Galang RR , Kroelinger CD . PLoS One 2023 18 (11) e0294140 BACKGROUND: Severe maternal morbidity (SMM) is broadly defined as an unexpected and potentially life-threatening event associated with labor and delivery. The Centers for Disease Control and Prevention (CDC) produced 21 different indicators based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) hospital diagnostic and procedure codes to identify cases of SMM. OBJECTIVES: To examine existing SMM indicators and determine which indicators identified the most in-hospital mortality at delivery hospitalization. METHODS: Data from the 1993-2015 and 2017-2019 Healthcare Cost and Utilization Project's National Inpatient Sample were used to report SMM indicator-specific prevalences, in-hospital mortality rates, and population attributable fractions (PAF) of mortality. We hierarchically ranked indicators by their overall PAF of in-hospital mortality. Predictive modeling determined if SMM prevalence remained comparable after transition to ICD-10-CM coding. RESULTS: The study population consisted of 18,198,934 hospitalizations representing 87,864,173 US delivery hospitalizations. The 15 top ranked indicators identified 80% of in-hospital mortality; the proportion identified by the remaining indicators was negligible (2%). The top 15 indicators were: restoration of cardiac rhythm; cardiac arrest; mechanical ventilation; tracheostomy; amniotic fluid embolism; aneurysm; acute respiratory distress syndrome; acute myocardial infarction; shock; thromboembolism, pulmonary embolism; cerebrovascular disorders; sepsis; both DIC and blood transfusion; acute renal failure; and hysterectomy. The overall prevalence of the top 15 ranked SMM indicators (~22,000 SMM cases per year) was comparable after transition to ICD-10-CM coding. CONCLUSIONS: We determined the 15 indicators that identified the most in-hospital mortality at delivery hospitalization in the US. Continued testing of SMM indicators can improve measurement and surveillance of the most severe maternal complications at the population level. |
Association of Medicaid expansion under the Affordable Care Act with Medicaid coverage in the prepregnancy, prenatal, and postpartum periods
Chen J , Ouyang L , Goodman DA , Okoroh EM , Romero L , Ko JY , Cox S . Womens Health Issues 2023 33 (6) 582-591 Introduction: We evaluated how the Affordable Care Act (ACA) Medicaid eligibility expansion affected perinatal insurance coverage patterns for Medicaid-enrolled beneficiaries who gave birth overall and by race/ethnicity. We also examined state-level heterogeneous impacts. Methods: Using the 2011–2013 Medicaid Analytic eXtract and the 2016–2018 Transformed Medicaid Statistical Information System Analytic File databases, we identified 1.4 million beneficiaries giving birth in 2012 (pre-ACA expansion cohort) and 1.5 million in 2017 (post-ACA expansion cohort). We constructed monthly coverage rates for the two cohorts by state Medicaid expansion status and obtained difference-in-differences estimates of the association of Medicaid expansion with coverage overall and by race/ethnicity group (non-Hispanic White, non-Hispanic Black, and Hispanic). To explore state-level heterogeneous impacts, we divided the expansion and non-expansion states into groups based on the differences in the income eligibility limits for low-income parents in each state between 2012 and 2017. Results: Medicaid expansion was associated with 13 percentage points higher coverage in the 9 to 12 months before giving birth, and 11 percentage points higher coverage at 6 to 12 months postpartum. Hispanic birthing individuals had the greatest relative increases in coverage, followed by non-Hispanic White and non-Hispanic Black individuals. In Medicaid expansion states, those who experienced the greatest increases in income eligibility limits for low-income parents generally saw the greatest increases in coverage. In non-expansion states, there was less heterogeneity between state groupings. Conclusions: Pregnancy-related Medicaid eligibility did not have major changes in the 2010s. However, states’ adoption of ACA Medicaid expansion after 2012 was associated with increased Medicaid coverage before, during, and after pregnancy. The increases varied by race/ethnicity and across states. © 2023 |
Consensus pregnancy-related criteria for suicide and unintentional overdoses using a Delphi process
Smid MC , Vaughn P , Nowicki CC , Goodman DA , Zaharatos J , Campbell KA . Arch Womens Ment Health 2023 Suicide and unintentional overdose are leading manners of preventable death during and within a year of pregnancy. Recently, the Utah Maternal Mortality Review Committee (MMRC) developed 10 criteria to guide pregnancy-related classification of these deaths. Our objective was to (1) evaluate if consensus could be reached across experts in maternal mortality review when applying criteria to the determination of pregnancy-relatedness in mock MMRC case evaluation and (2) assess how additional case information shifted participants' determination of pregnancy-relatedness in these mock cases. We used a modified Delphi process to evaluate criteria for pregnancy-related suicides and unintentional overdose. The study team developed base case scenarios to reflect the 10 proposed criteria. Base scenarios varied in timing of death (prenatal or delivery, early postpartum (<6 months), late postpartum (6-12 months)) and level of additional information available (e.g., informant interviews, social media posts). Consensus in favor of a criterion was met when ≥75% of participants identified a case as pregnancy-related in at least 1 scenario. Fifty-eight participants, representing 48 MMRCs, reviewed scenarios. Of 10 proposed criteria, 8 reached consensus. Overall, participants classified 19.4% of base case scenarios as pregnancy-related, which increased to 56.8% with additional information. Pregnancy-related classification changed across timing of death and with availability of additional information (prenatal or delivery 27.7% versus 84.6%; early postpartum 30.0% versus 58.3%; late postpartum 0.0% versus 25.0%, respectively). We identified consensus supporting the application of 8 standardized criteria in MMRC determinations of pregnancy-relatedness among suicide and unintentional overdose deaths. |
Pregnancy-related deaths by Hispanic origin, United States, 2009-2018
Parker-Collins W , Njie F , Goodman DA , Cox S , Chang J , Petersen EE , Beauregard JL . J Womens Health (Larchmt) 2023 32 (12) 1320-1327 Objective: To describe pregnancy-related mortality among Hispanic people by place of origin (country or region of Hispanic ancestry), 2009-2018. Materials and Methods: We conducted a cross-sectional descriptive study of pregnancy-related deaths among Hispanic people, stratified by place of origin (Central or South America, Cuba, Dominican Republic, Mexico, Puerto Rico, Other and Unknown Hispanic), using Pregnancy Mortality Surveillance System data, 2009-2018. We describe distributions of pregnancy-related deaths and pregnancy-related mortality ratios (number of pregnancy-related deaths per 100,000 live births) overall and by place of origin for select demographic and clinical characteristics. Results: For 2009-2018, the overall pregnancy-related mortality ratio among Hispanic people was 11.5 pregnancy-related deaths per 100,000 live births (95% confidence intervals [CI]: 10.8-12.2). In general, pregnancy-related mortality ratios were higher among older age groups (i.e., 35 years and older) and lower among those with higher educational attainment (i.e., college degree or higher). Approximately two in five pregnancy-related deaths among Hispanic people occurred on the day of delivery through 6 days postpartum. Place of origin-specific pregnancy-related mortality ratios ranged from 9.6 (95% CI: 5.8-15.0) among people of Cuban origin to 15.3 (95% CI: 12.4-18.3) among people of Puerto Rican origin. Hemorrhage and infection were the most frequent causes of pregnancy-related deaths overall among Hispanic people. People of Puerto Rican origin had a higher proportion of deaths because of cardiomyopathy. Conclusions: We identified differences in pregnancy-related mortality by place of origin among Hispanic people that can help inform prevention of pregnancy-related deaths. |
Levels of neonatal care among birth facilities in 20 states and other jurisdictions: CDC levels of care assessment tool(SM) (CDC LOCATe(SM))
Wilkers JL , DeSisto CL , Ewing AC , Madni SA , Beauregard JL , Brantley MD , Goodman DA . J Perinatol 2022 43 (4) 484-489 OBJECTIVE: Describe discrepancies between facilities' self-reported level of neonatal care and Centers for Disease Control and Prevention Levels of Care Assessment Tool(SM) (CDC LOCATe(SM))-assessed level. STUDY DESIGN: CDC LOCATe(SM) data from 765 health facilities in the United States, including 17 states, one territory, one large multi-state hospital system, and one perinatal region within a state, was collected between 2016 and 2021 for this cross-sectional analysis. RESULT: Among 721 facilities that self-reported level of neonatal care, 33.1% had discrepancies between their self-reported level and their LOCATe(SM)-assessed level. Among facilities with discrepancies, 75.3% self-reported a higher level of neonatal care than their LOCATe(SM)-assessed level. The most common elements contributing to discrepancies were limited specialty and subspecialty staffing, such as neonatology or neonatal surgery. CONCLUSION: Results highlight opportunities for jurisdictions to engage with facilities, health systems, and partners about levels of neonatal care, and to collaborate to promote standardized systems of risk-appropriate care. |
Examining the ratio of obstetric beds to births, 2000-2019
DeSisto CL , Goodman DA , Brantley MD , Menard MK , Declercq E . J Community Health 2022 47 (5) 828-834 The number of U.S. births has been declining. There is also concern about rural obstetric units closing. To better understand the relationship between births and obstetric beds during 2000-2019, we examined changes over time in births, birth hospital distributions (i.e., hospital birth volume, ownership, and urban-rural designation), and the ratio of births to obstetric beds. We analyzed American Hospital Association Annual Survey data from 2000 to 2019. We included U.S. hospitals with at least 25 reported births during the year and at least 1 reported obstetric bed. We categorized birth volume to identify and describe hospitals with maternity services using seven categories. We calculated ratios of number of births to number of obstetric beds overall, by annual birth volume category, by three categories of hospital ownership, and by six urban-rural categories. The ratio of births to obstetric beds, which may represent need for maternity services, has stayed relatively consistent at 65 over the past two decades, despite the decline in births and changes in birth hospital distributions. The ratios were smallest in hospitals with < 250 annual births and largest in hospitals with ≥ 7000 annual births. The largest ratios of births to obstetric beds were in large metro areas and the smallest ratios were in noncore areas. At a societal level, the reduction in obstetric beds corresponds with the drop in the U.S. birth rate. However, consistency in the overall ratio can mask important differences that we could not discern, such as the impact of closures on distances to closest maternity care. |
Homicide during pregnancy and the postpartum period in the United States, 2018-2019
Goodman DA , Beauregard JL , Trost SL , Declercq E . Obstet Gynecol 2022 139 (4) 692 In the November 2021 issue, Wallaceet al1report,“Homicide mortality dur-ing pregnancy and within thefirst 42days from the end of pregnancy-.exceeded all the leading causes ofmaternal mortality.”using mortalitydata for females aged 10–44 years fromthe Centers for Disease Control andPrevention’s National Vital StatisticsSystem. There are two ways in whichthis statement may be inaccurate.Thefirst is that comparing all casesof homicide with the leading threedisaggregated direct obstetric causes ofdeath (ie, hemorrhage, hypertensivedisorders, sepsis) is not an equivalentcomparison. As reported, homicidemortality rates appear similar to thethree leading specific causes of directobstetric death when combined. Fur-ther, this comparison leaves out the restof the direct obstetric deaths from othercauses. In 2018, there were six times asmany total direct obstetric deaths2ashomicides, as reported |
County-level associations between pregnancy-related mortality ratios and contextual sociospatial indicators
Barrera CM , Kramer MR , Merkt PT , Petersen EE , Brantley MD , Eckhaus L , Beauregard JL , Goodman DA . Obstet Gynecol 2022 139 (5) 855-865 OBJECTIVE: To characterize county-level differences in pregnancy-related mortality as a function of sociospatial indicators. METHODS: We conducted a cross-sectional multilevel analysis of all pregnancy-related deaths and all live births with available ZIP code or county data in the Pregnancy Mortality Surveillance System during 2011-2016 for non-Hispanic Black, Hispanic (all races), and non-Hispanic White women aged 15-44 years. The exposures included 31 conceptually-grounded, county-specific sociospatial indicators that were collected from publicly available data sources and categorized into domains of demographic; general, reproductive, and behavioral health; social capital and support; and socioeconomic contexts. We calculated the absolute difference of county-level pregnancy-related mortality ratios (deaths per 100,000 live births) per 1-unit increase in the median absolute difference between women living in counties with higher compared with lower levels of each sociospatial indicator overall and stratified by race and ethnicity. RESULTS: Pregnancy-related mortality varied across counties and by race and ethnicity. Many sociospatial indicators were associated with county-specific pregnancy-related mortality ratios independent of maternal age, population size, and Census region. Across domains, the most harmful indicators were percentage of low-birth-weight births (absolute ratio difference [RD] 6.44; 95% CI 5.36-7.51), percentage of unemployed adults (RD 4.98; 95% CI 3.91-6.05), and food insecurity (RD 4.92; 95% CI 4.14-5.70). The most protective indicators were higher median household income (RD -2.76; 95% CI -3.28 to -2.24), percentage of college-educated adults (RD -2.28; 95% CI -2.81 to -1.75), and percentage of owner-occupied households (RD -1.66; 95% CI -2.29 to -1.03). The magnitude of these associations varied by race and ethnicity. CONCLUSION: This analysis identified sociospatial indicators of pregnancy-related mortality and showed an association between pregnancy-related deaths and place of residence overall and stratified by race and ethnicity. Understanding county-level context associated with pregnancy-related mortality may be an important step towards building public health evidence to inform action to reduce pregnancy-related mortality at local levels. |
CDC LOCATe: discrepancies between self-reported level of maternal care and LOCATe-assessed level of maternal care among 463 birth facilities
Madni SA , Ewing AC , Beauregard JL , Brantley MD , Menard MK , Goodman DA . J Perinatol 2021 42 (5) 589-594 OBJECTIVE: Describe sources of discrepancy between self-assessed LoMC (level of maternal care) and CDC LOCATe(®)-assessed (Levels of Care Assessment Tool) LoMC. STUDY DESIGN: CDC LOCATe(®) was implemented at 480 facilities in 13 jurisdictions, including states, territories, perinatal regions, and hospital systems, in the U.S. Cross-sectional analyses were conducted to compare facilities' self-reported LoMC and LOCATe(®)-assessed LoMC. RESULT: Among 418 facilities that self-reported an LoMC, 41.4% self-reported a higher LoMC than their LOCATe(®)-assessed LoMC. Among facilities with discrepancies, the most common elements lacking to meet self-reported LoMC included availability of maternal-fetal medicine (27.7%), obstetric-specializing anesthesiologist (16.2%), and obstetric ultrasound services (12.1%). CONCLUSION: Two in five facilities self-report a LoMC higher than their LOCATe(®)-assessed LoMC, indicating discrepancies between perceived maternal care capabilities and those recommended in current LoMC guidelines. Results highlight an opportunity for states to engage with facilities, health systems, and other stakeholders about LoMC and collaborate to strengthen systems for improving maternal care delivery. |
Urban-Rural Differences in Pregnancy-Related Deaths, United States, 2011-2016
Merkt PT , Kramer MR , Goodman DA , Brantley MD , Barrera CM , Eckhaus L , Petersen EE . Am J Obstet Gynecol 2021 225 (2) 183 e1-183 e16 BACKGROUND: The U.S. pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race/ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths. OBJECTIVE: We sought to compare pregnancy-related mortality across and within urban and rural counties by race/ethnicity and age. STUDY DESIGN: We conducted a descriptive analysis of 3,747 pregnancy-related deaths during 2011-2016 (the most recent available) with available ZIP code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian/Alaska Native, and Asian/Pacific Islander women ages 15-44 years. We aggregated data by U.S. county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution. RESULTS: Of the total 3,747 pregnancy-related deaths analyzed, 52% occurred in large metro counties and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8, 95% CI: 14.2-15.5) while noncore counties had the highest (24.1, 95% CI: 21.4-27.1), including for most race/ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women ages 25-34 years and ages 35-44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women compared to non-Hispanic White women. Non-Hispanic American Indian/Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2-3 times that of non-Hispanic White women in the same areas. CONCLUSION: Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed among urban-rural categories, including by age group and by race/ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths. |
Levels of risk-appropriate care: Ensuring women deliver at the right place at the right time
Kroelinger CD , Goodman DA . J Womens Health (Larchmt) 2019 29 (3) 281-282 Risk-appropriate care, or care in a facility with the capabilities and staffing to adequately meet the needs of patients, is not a new concept in medicine.1–3 For decades, clinical organizations, including the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG/SMFM), have partnered to publish risk-appropriate care guidelines, particularly for neonates.4 In 2012, AAP published a revised neonatal levels of care designation policy statement to provide uniform definitions and standards of service for provision of neonatal care,5 with reaffirmation in 2015.6 |
Designation of neonatal levels of care: a review of state regulatory and monitoring policies
Kroelinger CD , Okoroh EM , Goodman DA , Lasswell SM , Barfield WD . J Perinatol 2019 40 (3) 369-376 OBJECTIVE: Summarize policies on levels of neonatal care designation among 50 states and District of Columbia (DC). STUDY DESIGN: Systematic review of publicly available, web-based information on levels of neonatal care designation policies for each state/DC. Information on designating authorities, designation oversight, licensure requirement, and ongoing monitoring for designated levels of care abstracted from 2019 published rules, statutes, and regulations. RESULT: Thirty-one (61%) of 50 states/DC had designated authority policies for neonatal levels of care. Fourteen (27%) incorporated oversight of neonatal levels of care into the licensure process. Among jurisdictions with designated authority, 25 (81%) used a state agency and 15 (48%) had direct oversight. Twenty-two (71%) of 31 states with a designating authority required ongoing monitoring, 14 (64%) used both hospital reporting and site visits for monitoring with only ten requiring site visits. CONCLUSIONS: Limited direct oversight influences regulation of regionalized systems, potentially impacting facility service monitoring and consequent management of vulnerable infants. |
Application of an implementation science framework to policies on immediate postpartum long-acting reversible contraception
DeSisto CL , Kroelinger CD , Estrich C , Velonis A , Uesugi K , Goodman DA , Pliska E , Akbarali S , Rankin KM . Public Health Rep 2019 134 (2) 33354918824329 OBJECTIVES:: Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework-the Consolidated Framework for Implementation Research (CFIR)-to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies. METHODS:: We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR. RESULTS:: Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies. CONCLUSIONS:: State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives. |
State-identified implementation strategies to increase uptake of immediate postpartum long-acting reversible contraception policies
Kroelinger CD , Morgan IA , DeSisto CL , Estrich C , Waddell LF , Mackie C , Pliska E , Goodman DA , Cox S , Velonis A , Rankin KM . J Womens Health (Larchmt) 2018 28 (3) 346-356 BACKGROUND: In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation. MATERIALS AND METHODS: Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified. RESULTS: The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities. CONCLUSIONS: Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women. |
Severe maternal or near miss morbidity: Implications for public health surveillance and clinical audit
Kuklina EV , Goodman DA . Clin Obstet Gynecol 2018 61 (2) 307-318 This chapter reviews the historical development of indicators to identify severe maternal morbidity/maternal near miss (SMM/MNM), and their use for public health surveillance, research, and clinical audit. While there has been progress toward identifying standard definitions for SMM/MNM within countries, there remain inconsistencies in the definition of SMM/MNM indicators and their application between countries. Using these indicators to screen for events that then trigger a clinical audit may both under identify select SMM/MNM (false negative)and over identify select SMM/MNM (false positive). Thus, indicators which support the efficient identification of SMM/MNM for the purpose of facility-based clinical audits are still needed. |
Policy change is not enough: Engaging provider champions on immediate postpartum contraception
Okoroh EM , Kane DJ , Gee RE , Kieltyka L , Frederiksen BN , Baca KM , Rankin KM , Goodman DA , Kroelinger CD , Barfield WD . Am J Obstet Gynecol 2018 218 (6) 590 e1-590 e7 Rates of short interval pregnancies resulting in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception (LARC) methods have annual failure rates of less than 1% compared with 9% for oral contraceptive pills, and are an effective strategy to reduce unintended pregnancies. To increase access to LARCs in the immediate postpartum period, several State Medicaid programs, including those in Iowa (IA) and Louisiana (LA), recently established reimbursement policies to remove the barriers to reimbursement of immediate postpartum LARC insertion. We used a mixed-methods approach, to analyze 2013-2015 linked Medicaid and vital records data from both IA and LA, to describe trends in immediate postpartum LARC provision one year prior to and following the Medicaid reimbursement policy change. We also used data from key informant interviews with State program staff to understand how provider champions affected policy uptake. We found that the monthly average for the number of insertions in IA increased from 4.6 per month prior to the policy to 6.6 per month post policy, and in LA, the average increased from 2.6 per month prior to the policy to 45.2 per month. In both states, the majority of insertions occurred at one academic/teaching hospital. In LA, the additional increase may be due to the engagement of a provider champion who worked at both the state and facility level. Recruiting, training, engaging, and supporting provider champions, as facilitators, with influence at state and facility levels, is an important component of a multipart strategy for increasing successful implementation of State-level Medicaid payment reform policies that allow reimbursement for immediate postpartum LARC insertions. |
Comparison of state risk-appropriate neonatal care policies with the 2012 AAP policy statement
Kroelinger CD , Okoroh EM , Goodman DA , Lasswell SM , Barfield WD . J Perinatol 2017 38 (4) 411-420 OBJECTIVE: Compare state policies with standards outlined in the 2012 AAP Policy Statement on Levels of Neonatal Care. STUDY DESIGN: Systematic, web-based review of publicly available policies on levels of care in all states in 2014. Infant risk information, equipment capabilities, and specialty staffing were abstracted from published rules, statutes, and regulations. RESULT: Twenty-two states had a policy on regionalized perinatal care. State policies vary in consistency with the AAP Policy, with 60% of states including standards consistent with Level I criteria, 48% Level II, 14% Level III, and one state with Level IV. Ventilation capability standards are highly consistent (66-100%), followed by imaging capability standards (50-90%). Policy language on specialty staffing (44-68%), and subspecialty staffing (39-50%) are moderately consistent. CONCLUSION: State policies vary in consistency, a potentially significant barrier to monitoring, regulation, uniform care provision and measurement, and reporting of national-level measures on risk-appropriate care. |
Using a multi-state Learning Community as an implementation strategy for immediate postpartum long-acting reversible contraception
DeSisto CL , Estrich C , Kroelinger CD , Goodman DA , Pliska E , Mackie CN , Waddell LF , Rankin KM . Implement Sci 2017 12 (1) 138 BACKGROUND: Implementation strategies are imperative for the successful adoption and sustainability of complex evidence-based public health practices. Creating a learning collaborative is one strategy that was part of a recently published compilation of implementation strategy terms and definitions. In partnership with the Centers for Disease Control and Prevention and other partner agencies, the Association of State and Territorial Health Officials recently convened a multi-state Learning Community to support cross-state collaboration and provide technical assistance for improving state capacity to increase access to long-acting reversible contraception (LARC) in the immediate postpartum period, an evidence-based practice with the potential for reducing unintended pregnancy and improving maternal and child health outcomes. During 2015-2016, the Learning Community included multi-disciplinary, multi-agency teams of state health officials, payers, clinicians, and health department staff from 13 states. This qualitative study was conducted to better understand the successes, challenges, and strategies that the 13 US states in the Learning Community used for increasing access to immediate postpartum LARC. METHODS: We conducted telephone interviews with each team in the Learning Community. Interviews were semi-structured and organized by the eight domains of the Learning Community. We coded transcribed interviews for facilitators, barriers, and implementation strategies, using a recent compilation of expert-defined implementation strategies as a foundation for coding the latter. RESULTS: Data analysis showed three ways that the activities of the Learning Community helped in policy implementation work: structure and accountability, validity, and preparing for potential challenges and opportunities. Further, the qualitative data demonstrated that the Learning Community integrated six other implementation strategies from the literature: organize clinician implementation team meetings, conduct educational meetings, facilitation, promote network weaving, provide ongoing consultation, and distribute educational materials. CONCLUSIONS: Convening a multi-state learning collaborative is a promising approach for facilitating the implementation of new reimbursement policies for evidence-based practices complicated by systems challenges. By integrating several implementation strategies, the Learning Community serves as a meta-strategy for supporting implementation. |
Contribution of maternal age and pregnancy checkbox on maternal mortality ratios in the United States, 1978-2012
Davis NL , Hoyert DL , Goodman DA , Hirai AH , Callaghan WM . Am J Obstet Gynecol 2017 217 (3) 352 e1-352 e7 BACKGROUND: Maternal mortality ratios (MMR) appear to have increased in the United States over the last decade. Three potential contributing factors are: 1) a shifting maternal age distribution, 2) changes in age-specific MMR, and 3) the addition of a checkbox indicating recent pregnancy on the death certificate. OBJECTIVE: Determine the contribution of rising maternal age on changes in MMR from 1978-2012, and estimate the contribution of the pregnancy checkbox on increases in MMR over the last decade. STUDY DESIGN: Kitagawa decomposition analyses were conducted to partition the maternal age contribution to the MMR increase into two components: changes due to a shifting maternal age distribution, and changes due to higher age-specific mortality ratios. We used National Vital Statistics System (NVSS) natality and mortality data. The following five-year groupings were used: 1978-1982, 1988-1992, 1998-2002, and 2008-2012. Changes in age-specific MMRs among states that adopted the standard pregnancy checkbox onto their death certificate before 2008 (n=23) were compared with states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (n=11) to estimate the percentage increase in the MMR due to the pregnancy checkbox. RESULTS: Overall U.S. MMRs for 1978-1982, 1988-1992, and 1998-2002 were 9.0, 8.1, and 9.1 deaths per 100,000 live births, respectively. There was a modest increase in the MMR between 1998-2002 and 2008-2012 in the 11 states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (8.6 and 9.9 deaths per 100,000 respectively). However, the MMR more than doubled between 1998-2002 and 2008-2012 in the 23 states that adopted the standard pregnancy checkbox (9.0 to 22.4); this dramatic rise was almost entirely attributable to increases in age-specific MMRs (94.9%) as opposed to increases in maternal age (5.1%), with an estimated 90% of the observed change reflecting the change in maternal death identification rather than a real change in age-specific rates alone. Of all age categories, women ages 40 and older in states that adopted the standard pregnancy checkbox had the largest increase in MMR-from 31.9 to 200.5-a relative increase of 528%, which accounted for nearly one-third of the overall increase. An estimated 28.8% of the observed change was potentially due to maternal death misclassification among women ≥40. CONCLUSION: Increasing age-specific maternal mortality seems to be contributing more heavily than a changing maternal age distribution to recent increases in MMR. In states with the standard pregnancy checkbox, the vast majority of the observed change in MMR over the last decade was estimated to be due to the pregnancy checkbox, with the greatest change in MMR occurring in women ages ≥40 years. The addition of a pregnancy checkbox on state death certificates appears to be increasing case identification, but may also be leading to maternal death misclassification, particularly for women ages ≥40 years. |
Perinatal regionalization: A geospatial view of perinatal critical care, United States, 2010-2013
Brantley MD , Davis NL , Goodman DA , Callaghan WM , Barfield WD . Am J Obstet Gynecol 2016 216 (2) 185 e1-185 e10 BACKGROUND: Perinatal services exist today as a dyad of maternal and neonatal care. When perinatal care is fragmented or unavailable, excess morbidity and mortality may occur in pregnant women and newborns. OBJECTIVE: Describe spatial relationships between women of reproductive age, individual perinatal subspecialists (Maternal Fetal Medicine and Neonatology), and obstetric and neonatal critical care facilities in the United States to identify gaps in health care access. STUDY DESIGN: We used geographic visualization and conducted surface interpolation, nearest neighbor, and proximity analyses. Source data included 2010 United States Census, October 2013 National Provider Index, 2012 American Hospital Association, 2012 National Center for Health Statistics Natality File, and the 2011 American Academy of Pediatrics Directory. RESULTS: In October 2013, there were 2.5 neonatologists for every Maternal Fetal Medicine specialist in the United States. In 2012 there were 1.4 Level III or higher neonatal intensive care units (NICU) for every Level III obstetric unit (hereafter, obstetric critical care unit). Nationally, 87% of women of reproductive age live within 50 miles of both an obstetric critical care unit and NICU. However, 18% of obstetric critical care units had no NICU and 20% of NICUs had no obstetric critical care unit within a 10 mile radius. Additionally, 26% of obstetric critical care units had no Maternal Fetal Medicine specialist practicing within 10 miles of the facility and 4% of NICUs had no neonatologist practicing within 10 miles. CONCLUSION: Gaps in access and discordance between the availability of Level III or higher obstetric and neonatal care may affect delivery of risk appropriate care for high risk maternal fetal dyads. Further study is needed to understand the importance of these gaps and discordance on maternal and neonatal outcomes. |
United States and territory telemedicine policies: Identifying gaps in perinatal care
Okoroh EM , Kroelinger CD , Smith AM , Goodman DA , Barfield WD . Am J Obstet Gynecol 2016 215 (6) 772 e1-772 e6 BACKGROUND: Perinatal regionalization is a system of maternal and neonatal risk-appropriate health care delivery in which resources are ideally allocated for mothers and newborns during pregnancy, labor and delivery, and postpartum, in order to deliver appropriate care. Typically, perinatal risk-appropriate care is provided in-person, but with the advancement of technologies, the opportunity to provide care remotely has emerged. Telemedicine provides distance-based care to patients by consultation, diagnosis, and treatment in rural or remote US jurisdictions (states and territories). OBJECTIVES: Summarize states and territories telemedicine policies and assess if maternal and neonatal risk-appropriate care is specified. STUDY DESIGN: A 2014 systematic web-based review of publicly available rules, statutes, regulations, laws, planning documents, and program descriptions among US jurisdictions (N = 59) on telemedicine care. Policies including language on the topics of consultation, diagnosis, or treatment, and those specific to maternal and neonatal risk-appropriate care were categorized for analysis. RESULTS: Overall, 36 jurisdictions (32 states, 3 territories, and Washington DC) (61%) had telemedicine policies with language referencing consultation, diagnosis, or treatment; 29 (49%) referenced consultation, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment. Twenty-six jurisdictions (22 states, 3 territories, and Washington DC) (44%), referenced all topics. Only three jurisdictions (5%), all states, had policy language specifically addressing perinatal care. CONCLUSIONS: The majority of states have published telemedicine policies, but few specify policy language for perinatal risk-appropriate care. By ensuring that language specific to the perinatal population is included in telemedicine policies, access to maternal and neonatal care can be increased in rural, remote, and resource challenged jurisdictions. |
Importance of performance measurement and MCH epidemiology leadership to quality improvement initiatives at the national, state and local levels
Rankin KM , Gavin L , Moran JW Jr , Kroelinger CD , Vladutiu CJ , Goodman DA , Sappenfield WM . Matern Child Health J 2016 20 (11) 2239-2246 Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists' contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes. |
Application of implementation science methodology to immediate postpartum long-acting reversible contraception policy roll-out across states
Rankin KM , Kroelinger CD , DeSisto CL , Pliska E , Akbarali S , Mackie CN , Goodman DA . Matern Child Health J 2016 20 173-179 Purpose Providing long-acting reversible contraception (LARC) in the immediate postpartum period is an evidence-based strategy for expanding women's access to highly effective contraception and for reducing unintended and rapid repeat pregnancy. The purpose of this article is to demonstrate the application of implementation science methodology to study the complexities of rolling-out policies that promote immediate postpartum LARC use across states. Description The Immediate Postpartum LARC Learning Community, sponsored by the Association of State and Territorial Health Officials (ASTHO), is made up of multi-disciplinary, multi-agency teams from 13 early-adopting states with Medicaid reimbursement policies promoting immediate postpartum LARC. Partners include federal agencies and maternal and child health organizations. The Learning Community discussed barriers, opportunities, strategies, and promising practices at an in-person meeting. Implementation science theory and methods, including the Consolidated Framework for Implementation Research (CFIR), and a recent compilation of implementation strategies, provide useful tools for studying the complexities of implementing immediate postpartum LARC policies in birthing facilities across early adopting states. Assessment To demonstrate the utility of this framework for guiding the expansion of immediate postpartum LARC policies, illustrative examples of barriers and strategies discussed during the in-person ASTHO Learning Community meeting are organized by the five CFIR domains-intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and process. Conclusion States considering adopting policies can learn from ASTHO's Immediate Postpartum LARC Learning Community. Applying implementation science principles may lead to more effective statewide scale-up of immediate postpartum LARC and other evidence-based strategies to improve women and children's health. |
Working with state health departments on emerging issues in maternal and child health: immediate postpartum long-acting reversible contraceptives
Kroelinger CD , Waddell LF , Goodman DA , Pliska E , Rudolph C , Ahmed E , Addison D . J Womens Health (Larchmt) 2015 24 (9) 693-701 BACKGROUND: Immediate postpartum long-acting reversible contraceptives (LARC) are highly effective in preventing unintended pregnancy. State health departments are in the process of implementing a systems change approach to better apply policies supporting the use of immediate postpartum LARC. METHODS: Beginning in 2014, a group of national organizations, federal agencies, and six states have convened a LARC Learning Community to share strategies and best practices in immediate postpartum LARC policy development and implementation. Community activities consist of in-person meetings and a webinar series as forums to discuss systems change. RESULTS: The Learning Community identified eight domains for discussion and development of resources: training, pay streams, stocking and supply, consent, outreach, stakeholder partnerships, service location, and data and surveillance. The community is currently developing resource materials and guidance for use by other state health departments. CONCLUSIONS: To effectively implement policies on immediate postpartum LARC, states must engage a number of stakeholders in the process, raise awareness of the challenges to implementation, and communicate strategies across agencies during policy development. |
United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement
Okoroh EM , Kroelinger CD , Lasswell SM , Goodman DA , Williams AM , Barfield WD . J Perinatol 2015 36 (1) 30-4 OBJECTIVE: Summarize policies that support maternal and neonatal transport among states and territories. STUDY DESIGN: Systematic review of publicly available, web-based information on maternal and neonatal transport for each state and territory in 2014. Information was abstracted from published rules, statutes, regulations, planning documents and program descriptions. Abstracted information was summarized within two categories: transport and reimbursement. RESULTS: Sixty-eight percent of states and 25% of territories had a policy for neonatal transport; 60% of states and one territory had a policy for maternal transport. Sixty-two percent of states had a reimbursement policy for neonatal transport, whereas 20% reimbursed for maternal transport. Thirty-two percent of states had an infant back-transport policy while 16% included back-transport for both. No territories had reimbursement or back-transport policies. CONCLUSION: The lack of development of maternal transport reimbursement and neonatal back-transport policies negatively impacts the achievements of risk-appropriate care, a strategy focused on improving perinatal outcomes. |
Evaluation of the 2012 18th Maternal and Child Health (MCH) Epidemiology and 22nd CityMatCH MCH Urban Leadership Conference: six month impact on science, program, and policy
Arellano DE , Goodman DA , Howlette T , Kroelinger CD , Law M , Phillips D , Jones J , Brantley MD , Fitzgerald M . Matern Child Health J 2014 18 (7) 1565-71 The 18th Maternal and Child Health (MCH) Epidemiology and 22nd CityMatCH MCH Urban Leadership Conference took place in December 2012, covering MCH science, program, and policy issues. Assessing the impact of the Conference on attendees' work 6 months post-Conference provides information critical to understanding the impact and the use of new partnerships, knowledge, and skills gained during the Conference. Evaluation assessments, which included collection of quantitative and qualitative data, were administered at two time points: at Conference registration and 6 months post-Conference. The evaluation files were merged using computer IP address, linking responses from each assessment. Percentages of attendees reporting Conference impacts were calculated from quantitative data, and common themes and supporting examples were identified from qualitative data. Online registration was completed by 650 individuals. Of registrants, 30 % responded to the 6 month post-Conference assessment. Between registration and 6 month post-Conference evaluation, the distribution of respondents did not significantly differ by organizational affiliation. In the 6 months following the Conference, 65 % of respondents reported pursuing a networking interaction; 96 % shared knowledge from the Conference with co-workers and others in their agency; and 74 % utilized knowledge from the Conference to translate data into public health action. The Conference produced far-reaching impacts among Conference attendees. The Conference served as a platform for networking, knowledge sharing, and attaining skills that advance the work of attendees, with the potential of impacting organizational and workforce capacity. Increasing capacity could improve MCH programs, policies, and services, ultimately impacting the health of women, infants, and children. |
Contributors to excess infant mortality in the U.S. South
Hirai AH , Sappenfield WM , Kogan MD , Barfield WD , Goodman DA , Ghandour RM , Lu MC . Am J Prev Med 2014 46 (3) 219-27 BACKGROUND: Infant mortality rates (IMRs) are disproportionally high in the U.S. South; however, the proximate contributors that could inform regional action remain unclear. PURPOSE: To quantify the components of excess infant mortality in the U.S. South by maternal race/ethnicity, underlying cause of death, and gestational age. METHODS: U.S. Period Linked Birth/Infant Death Data Files 2007-2009 (analyzed in 2013) were used to compare IMRs between the South (U.S. Public Health Regions IV and VI) and all other regions combined. RESULTS: Compared to other regions, there were 1.18 excess infant deaths per 1000 live births in the South, representing about 1600 excess infant deaths annually. New Mexico and Texas did not have elevated IMRs relative to other regions; excess death rates among other states ranged from 0.62 per 1000 in Kentucky to 3.82 per 1000 in Mississippi. Racial/ethnic compositional differences, generally the greater proportion of non-Hispanic black births in the South, explained 59% of the overall regional difference; the remainder was mostly explained by higher IMRs among non-Hispanic whites. The leading causes of excess Southern infant mortality were sudden unexpected infant death (SUID; 36%, range=12% in Florida to 90% in Kentucky) and preterm-related death (22%, range= -71% in Kentucky to 51% in North Carolina). Higher rates of preterm birth, predominantly <34 weeks, accounted for most of the preterm contribution. CONCLUSIONS: To reduce excess Southern infant mortality, comprehensive strategies addressing SUID and preterm birth prevention for both non-Hispanic black and white births are needed, with state-level findings used to tailor state-specific efforts. |
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