Faculty Bibliography

OBJECTIVE: The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy. STUDY DESIGN/METHODS:) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities. RESULTS: = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00. CONCLUSION/CONCLUSIONS: Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period. KEY POINTS/CONCLUSIONS:· Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

Over a decade following the nationwide push to implement electronic health records (EHRs), the focus has shifted to addressing the cognitive burden associated with their use. Most research and discourse about the EHR's impact on clinicians' cognitive work has focused on physicians rather than on nursing-specific issues. Labor and delivery nurses may encounter unique challenges when using EHRs because they also interact with an electronic fetal monitoring system, continuously managing and synthesizing both maternal and fetal data. This grounded theory study explored labor and delivery nurses' perceptions of the EHR's impact on their cognitive work. Data were individual interviews and participant observations with twenty-one nurses from two labor and delivery units in the western U.S. and were analyzed using dimensional analysis. Nurses managed the tension between caring and charting using various strategies to integrate the EHR into their dynamic, high-acuity, specialty practice environment while using EHRs that were not designed for perinatal patients. Use of the EHR and associated technologies disrupted nurses' ability to locate and synthesize information, maintain an overview of the patient's status, and connect with patients and families. Individual-, group-, and environmental-level factors facilitated or constrained nurses' integration of the EHR. These findings represent critical safety failures requiring comprehensive changes to EHR designs and better processes for responding to end-user experiences. More research is needed to develop EHRs that support the dynamic and relationship-based nature of nurses' work and to align with specialty practice environments.

OBJECTIVE:To solicit advice from members of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) on what to include in an update of nurse staffing standards. DESIGN/METHODS:Online, single-question survey with thematic analysis of responses. SETTING/METHODS:Electronic survey link sent via e-mail. PARTICIPANTS/METHODS:AWHONN members who shared their e-mail with the association and who responded to the survey (n = 1,813). MEASURES/METHODS:Participants were asked to answer this single question: "The AWHONN (2010) Guidelines for Professional Registered Nurse Staffing for Perinatal Units are being updated. During their initial development, feedback from nearly 900 AWHONN members was extremely helpful in providing specific details for the nurse staffing guidelines. We'd really like to hear from you again. Please give the writing team your input. What should AWHONN consider when updating the AWHONN nurse staffing guidelines?" RESULTS:The e-mail was successfully delivered to 20,463 members; 8,050 opened the e-mail, and 3,050 opened the link to the survey. There were 1,892 responses. After removing duplicate and blank responses, 1,813 responses were available for analysis. They represented all hospital practice settings for maternity and newborn care and included nurses from small-volume and rural hospitals. Primary concerns of respondents centered on two aspects of patient acuity-the increasing complexity of clinical cases and the need to link nurse staffing standards to patient acuity. Other themes included maintaining current nurse-to-patient ratios, needing help with implementation in the context of economic challenges, and changing wording from "guidelines" to "standards" to promote widespread adoption. CONCLUSION/CONCLUSIONS:In a single-question survey, AWHONN members offered rich, detailed recommendations that were used in the updating of the AWHONN nurse staffing standards.

OBJECTIVE:Communication failures between clinicians lead to poor patient outcomes. Critically injured patients have multiple injured organ systems and require complex multidisciplinary care from a wide range of healthcare professionals and communication failures are abundantly common. This study sought to determine barriers and facilitators to interdisciplinary communication between the consulting trauma, intensive care unit (ICU) team and specialty consultants for critically injured patients at an urban, safety-net, level 1 trauma centre. DESIGN:An observational qualitative study of barriers and facilitators to interdisciplinary communication. SETTING:We conducted observations of daily rounds in two trauma surgical ICUs and recorded the most frequently consulted teams. PARTICIPANTS:Key informant interviews after presenting clinical vignettes as discussion prompts were conducted with a broad range of clinicians from the ICUs and physicians and nurse practitioners from the consultant teams who were identified during the observations. Interviews were recorded and transcribed verbatim. Data of these 10 interviews were combined with primary transcript data from prior study (25 interviews) and analysed together because of the same setting with same themes. Independent coding of the transcripts, with iterative reconciliation, was performed by two coders. OUTCOMES MEASURES:Facilitators and barriers of interdisciplinary communication were identified. RESULTS:A total of 35 interview transcripts were analysed. Cardiology and interventional radiology were the most frequently consulted teams. Consulting and consultant clinicians reported that perceived accessibility from the team seeking a consultation and the consultant team impacted interdisciplinary communication. Accessibility had a physical dimension as well as a psychological dimension. Accessibility was demonstrated by responsiveness between clinicians of different disciplines and in turn facilitated interdisciplinary communication. Social norms, cognitive biases, hierarchy and relationships were reported as both facilitators and barriers to accessibility, and therefore, interdisciplinary communication. CONCLUSION:Accessibility impacted interdisciplinary communication between the consulting and the consultant team. ARTICLE SUMMARY:Elucidates barriers and facilitators to interdisciplinary communication between consulting and consultant teams.

Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957-965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007-2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ < 0.41 for 13 of 21 two-way comparisons). Low concordance was particularly driven by the presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research on validity of SMM definitions, using more fine-grained data sources, is needed.

IMPORTANCE/OBJECTIVE:Complications during pregnancy and birth can impact whether an individual has more children. Individuals experiencing SMM are at a higher risk of general and reproductive health issues after pregnancy, which could reduce the probability of a subsequent birth. OBJECTIVE:To examine whether experiencing SMM during an individual's first birth affects their probability of having an additional birth, and whether this effect varies by maternal factors. METHODS:This retrospective cohort study US linked vital records and maternal discharges from 1997 to 2017 to identify all California births. The exposure, Severe Maternal Morbidity (SMM) was identified using a Centers for Disease Control and Prevention index. Individuals whose first birth was a singleton live birth were followed until their second birth or December 31, 2017, whichever came first. Hazard ratios for having a subsequent birth were estimated using Cox proportional hazard regression models. This association was assessed overall and stratified by maternal factors of a priori interest: age, race/ethnicity, and payer. RESULTS:Of the 3,916,413 individuals in our study, 51,872 (1.3%) experienced SMM at first birth. Compared to those who do not experience SMM, individuals who had SMM had a lower hazard, or instantaneous rate, of subsequent birth (adjusted HR 0.83, 95% CI: 0.82, 0.84); this association was observed in all levels of stratification (for example, adjusted HR range for known race/ethnicity: 0.78, 95% CI: 0.76, 0.80 for non-Hispanic White to 0.90, 95% CI: 0.88, 0.92 for Hispanic) and all indicators of SMM (0.24, 95% CI: 0.17, 0.35 for cardiac arrest/ventricular fibrillation to 0.84, 95% CI: 0.80, 0.87 for eclampsia). CONCLUSION AND RELEVANCE/UNASSIGNED:Our findings suggest that individuals who experience SMM at the time of their first birth are less likely to have a subsequent birth as compared to those who do not experience SMM at the time of their first birth. While the reasons for these findings are unclear, they could inform reproductive life planning discussions for individuals experiencing SMM. Future directions include studies exploring the reasons for not having a subsequent birth.

Interpregnancy interval (IPI) associates with adverse perinatal outcomes, but its contribution to severe maternal morbidity (SMM) remains unclear. We examined the association between IPI and SMM, using data linked across sequential pregnancies to women in California 1997-2012. Adjusting for confounders measured at the index pregnancy (i.e. the first in a pair of consecutive pregnancies), we estimated adjusted risk ratios (aRRs) of SMM related to the subsequent pregnancy. We further conducted within-mother comparisons and analyses stratified by parity and maternal age at the index pregnancy. Compared to 18-23 months, IPI<6 months had same risk for SMM in between-mother comparison (aRR=0.96, 95%CI 0.91, 1.02) but lower risk in within-mother comparison (aRR=0.76, 95% confidence interval (CI) 0.67, 0.86). IPI 24-59 months and IPI≥60 months associated with increased risk of SMM in both between-mother (aRR=1.18, 95%CI 1.13, 1.23 and aRR=1.76, 95% CI 1.68, 1.85 respectively) and within-mother comparisons (aRR=1.22, 95%CI 1.11, 1.34 and aRR=1.88, 95% CI 1.66, 2.13 respectively). The association between IPI and SMM did not substantially differ by maternal age and parity. Longer IPI was associated with increased risk of SMM, which may be partly attributed to interpregnancy health.

Studies in low-resource settings have highlighted disparities in person-centred maternity care (PCMC)-respectful and responsive care during childbirth-based on women's socioeconomic status (SES) and other characteristics. Yet few studies have explored factors that may underlie these disparities. In this study, we examined implicit and explicit SES bias in providers' perceptions of women's expectations and behaviours, as well as providers' general views regarding factors influencing differential treatment of women. We conducted a convergent mixed-methods study with 101 maternity providers in western Kenya. Implicit SES bias was measured using an adaptation of the Implicit Association Test (IAT) and explicit SES bias assessed using situationally specific vignettes. Qualitative data provided additional details on the factors contributing to disparities. Results provide evidence for the presence of both implicit and explicit bias related to SES that might influence PCMC. Differential treatment was linked to women's appearance, providers' perceptions of women's attitudes, assumptions about who is more likely to understand or be cooperative, women's ability to advocate for themselves or hold providers accountable, ability to pay for services in a timely manner, as well as situational factors related to stress and burnout. These factors interact in complex ways to produce PCMC disparities, and providing better care to certain groups does not necessarily indicate preference for those groups or a desire to provide better care to them. The findings imply the need for multilevel approaches to addressing disparities in maternity care. This should include provider training on PCMC and their biases, advocacy for women of low SES, accountability mechanisms, and structural and policy changes within health care settings.

BACKGROUND:Severe maternal morbidity (SMM) has increased in the United States by 45% in the last decade. While the recurrence of several adverse pregnancy outcomes from one pregnancy to the next has been established, the recurrence risk of SMM is unknown. OBJECTIVE:To determine whether women who have SMM in a first pregnancy are at increased risk of SMM in their second pregnancy, compared to women who did not have SMM in their first pregnancy. METHODS:This is a population-based study using linked vital statistics and hospital discharge records from the Office of Statewide Health Planning and Development in California from 1997 to 2012. The study population had their first two singleton births (live births or stillbirths) in California between 1997 and 2012 (n = 1 180 357). The primary exposure was SMM during the hospitalisation at first birth, and the primary outcome was SMM during the hospitalisation at second birth. Prevalence and risk ratios of SMM at second birth were computed for women who did and did not have SMM at first birth, as well as for certain specific indicators of SMM. RESULTS:Of the 1 180 357 women included in this analysis, 9088 (77 per 10 000 births) experienced SMM at first birth. Among these women, the prevalence of SMM at second birth was 470 per 10 000 births, compared to 68 per 10 000 births among women without SMM at first birth. This corresponded to an unadjusted risk ratio of 6.87 (95% CI 6.23, 7.57), which did not differ substantially when adjusted for factors known to be associated with SMM (6.42, 95% CI 5.86, 7.13). CONCLUSION/CONCLUSIONS:Women experiencing SMM in their first pregnancy were at an approximately sixfold increased risk of experiencing SMM in their second pregnancy.