https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30569-X.pdf

Structural racism and health inequities in the USA: evidence and interventions

www.mobilehealthmap.org 617‐442‐3200 New research shows that mobile health clinics improve health outcomes for hard to reach populations in cost‐effective and culturally competent ways . A Harvard Medical School study determined that for every dollar invested in a mobile health clinic, the US healthcare system saves $30 on average. Mobile health clinics, which offer a range of services from preventive screenings to asthma treatment, leverage their mobility to treat people in the convenience of their own communities. For example, a mobile health clinic in Baltimore, MD, has documented savings of $3,500 per child seen due to reduced asthma‐related hospitalizations. The estimated 2,000 mobile health clinics across the country are providing similarly cost‐effective access to healthcare for a wide range of populations. Many successful mobile health clinics cite their ability to foster trusting relationships. Qualitative research in such mobile health clinics has found that patients value the informal, familiar environment in a convenient location, with staff who “are easy to talk to,” and that the staff’s “marriage of professional and personal discourses” provides patients the space to disclose information themselves. A communications academic argued that mobile health clinics’ unique use of space is important in facilitating these relationships. Mobile health clinics park in the heart of the community in familiar spaces, like shopping centers or bus stations, which lend themselves to the local community atmosphere.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

Context Maternal depressive symptoms during pregnancy have been reported in some, but not all, studies to be associated with an increased risk of preterm birth (PTB), low birth weight (LBW), and intrauterine growth restriction (IUGR). Objective To estimate the risk of PTB, LBW, and IUGR associated with antenatal depression. Data Sources and Study Selection We searched for English-language and non–English-language articles via the MEDLINE, PsycINFO, CINAHL, Social Work Abstracts, Social Services Abstracts, and Dissertation Abstracts International databases (January 1980 through December 2009). We aimed to include prospective studies reporting data on antenatal depression and at least 1 adverse birth outcome: PTB ( Data Extraction Information was extracted on study characteristics, antenatal depression measurement, and other biopsychosocial risk factors and was reviewed twice to minimize error. Data Synthesis Pooled relative risks (RRs) for the effect of antenatal depression on each birth outcome were calculated using random-effects methods. In studies of PTB, LBW, and IUGR that used a categorical depression measure, pooled effect sizes were significantly larger (pooled RR [95% confidence interval] = 1.39 [1.19-1.61], 1.49 [1.25-1.77], and 1.45 [1.05-2.02], respectively) compared with studies that used a continuous depression measure (1.03 [1.00-1.06], 1.04 [0.99-1.09], and 1.02 [1.00-1.04], respectively). The estimates of risk for categorically defined antenatal depression and PTB and LBW remained significant when the trim-and-fill procedure was used to correct for publication bias. The risk of LBW associated with antenatal depression was significantly larger in developing countries (RR = 2.05; 95% confidence interval, 1.43-2.93) compared with the United States (RR = 1.10; 95% confidence interval, 1.01-1.21) or European social democracies (RR = 1.16; 95% confidence interval, 0.92-1.47). Categorically defined antenatal depression tended to be associated with an increased risk of PTB among women of lower socioeconomic status in the United States. Conclusions Women with depression during pregnancy are at increased risk for PTB and LBW, although the magnitude of the effect varies as a function of depression measurement, country location, and US socioeconomic status. An important implication of these findings is that antenatal depression should be identified through universal screening and treated.

/pdf/a-meta-analysis-of-depression-during-pregnancy-and-the-risk-qay1p84bn6.pdf

A Meta-analysis of Depression During Pregnancy and the Risk of Preterm Birth, Low Birth Weight, and Intrauterine Growth Restriction

https://thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)01044-2.pdf

Why invest, and what it will take to improve breastfeeding practices?

Safe prevention of the primary cesarean delivery

Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.

Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues

Structural racism leads to increased rates of premature death and reduced levels of overall health and well-being — an epidemic affecting our whole society. As clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism.

/pdf/structural-racism-and-supporting-black-lives-the-role-of-2hwn87d69u.pdf

Structural Racism and Supporting Black Lives — The Role of Health Professionals

OBJECTIVES: To describe incidence, health care use, and cost trends for infants with neonatal abstinence syndrome (NAS) who are covered by Medicaid compared with other infants. METHODS: We used 2004–2014 hospital birth data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States ( N = 13 102 793). Characteristics and trends among births impacted by NAS were examined by using univariate statistics and logistic regression. RESULTS: Medicaid covered 73.7% of NAS-related births in 2004 (95% confidence interval [CI], 68.9%–77.9%) and 82.0% of NAS-related births in 2014 (95% CI, 80.5%–83.5%). Among infants covered by Medicaid, NAS incidence increased more than fivefold during our study period, from 2.8 per 1000 births (95% CI, 2.1–3.6) in 2004 to 14.4 per 1000 births (95% CI, 12.9–15.8) in 2014. Infants with NAS who were covered by Medicaid were significantly more likely to be transferred to another hospital and have a longer length of stay than infants without NAS who were enrolled in Medicaid or infants with NAS who were covered by private insurance. Adjusting for inflation, total hospital costs for NAS births that were covered by Medicaid increased from $65.4 million in 2004 to $462 million in 2014. The proportion of neonatal hospital costs due to NAS increased from 1.6% in 2004 to 6.7% in 2014 among births that were covered by Medicaid. CONCLUSIONS: The number of Medicaid-financed births that are impacted by NAS has risen substantially and totaled $462 million in hospital costs in 2014. Improving affordable health insurance coverage for low-income women before pregnancy would expand access to substance use disorder treatment and could reduce NAS-related morbidity and costs.

Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014

Context Perinatal depression affects at least 10% to 12% of new mothers, and diabetes complicates up to 9% of pregnancies. Prior research shows a higher rate of major depression among individuals with diabetes. Objective To examine the association between diabetes and depression during pregnancy and the postpartum period among a sample of low-income women. Design, Setting, and Patients Retrospective cohort study using data from New Jersey's Medicaid administrative claims database of 11 024 women who gave birth between July 1, 2004, and September 30, 2006, and who were continuously enrolled in Medicaid for 6 months prior to delivery and 1 year after giving birth. Main Outcome Measures Multivariate logistic regression was used to assess the association between prepregnancy diabetes or gestational diabetes and perinatal depression. Depression was defined as an International Classification of Diseases, Ninth Revision, diagnosis for depression or a prescription drug claim for an antidepressant medication, and diabetes was defined as having a diabetes diagnosis or filling a prescription for a diabetes medication. Both measures were assessed during the 6 months prior to and up to 1 year following delivery. Results In the sample of women who gave birth, 15.2% (n = 100) with prepregnancy or gestational diabetes and 8.5% (n = 886) without diabetes were depressed during pregnancy or postpartum. After adjusting for age, race, year of delivery, and gestational age at birth, women with diabetes compared with those without diabetes had nearly double the odds of experiencing depression during the perinatal period (odds ratio, 1.85; 95% confidence interval, 1.45-2.36). Women with diabetes and no prenatal indication of depression (n = 62, 9.6%) had higher odds than their counterparts without diabetes (n = 604, 5.9%) of receiving a postpartum depression diagnosis or taking an antidepressant medication in the year following delivery (odds ratio, 1.69; 95% confidence interval, 1.27-2.23). Conclusion Prepregnancy or gestational diabetes was independently associated with perinatal depression, including new onset of postpartum depression, in our sample of low-income new mothers.

https://jamanetwork.com/journals/jama/articlepdf/183451/joc90007_842_847.pdf

Association between diabetes and perinatal depression among low-income mothers.

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than eighteen million women of reproductive age living in rural America. Yet th...

Katy B. Kozhimannil

Papers

Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues

Structural Racism and Supporting Black Lives — The Role of Health Professionals

Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014

Association between diabetes and perinatal depression among low-income mothers.

Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004–14