Objective To determine the most effective tocolytic agent at delaying delivery. Design Systematic review and network meta-analysis. Data sources Cochrane Central Register of Controlled Trials, Medline, Medline In-Process, Embase, and CINAHL up to 17 February 2012. Study selection Randomised controlled trials of tocolytic therapy in women at risk of preterm delivery. Data extraction At least two reviewers extracted data on study design, characteristics, number of participants, and outcomes reported (neonatal and maternal). A network meta-analysis was done using a random effects model with drug class effect. Two sensitivity analyses were carried out for the primary outcome; restricted to studies at low risk of bias and restricted to studies excluding women at high risk of preterm delivery (those with multiple gestation and ruptured membranes). Results Of the 3263 titles initially identified, 95 randomized controlled trials of tocolytic therapy were reviewed. Compared with placebo, the probability of delivery being delayed by 48 hours was highest with prostaglandin inhibitors (odds ratio 5.39, 95% credible interval 2.14 to 12.34) followed by magnesium sulfate (2.76, 1.58 to 4.94), calcium channel blockers (2.71, 1.17 to 5.91), beta mimetics (2.41, 1.27 to 4.55), and the oxytocin receptor blocker atosiban (2.02, 1.10 to 3.80). No class of tocolytic was significantly superior to placebo in reducing neonatal respiratory distress syndrome. Compared with placebo, side effects requiring a change of medication were significantly higher for beta mimetics (22.68, 7.51 to 73.67), magnesium sulfate (8.15, 2.47 to 27.70), and calcium channel blockers (3.80, 1.02 to 16.92). Prostaglandin inhibitors and calcium channel blockers were the tocolytics with the best probability of being ranked in the top three medication classes for the outcomes of 48 hour delay in delivery, respiratory distress syndrome, neonatal mortality, and maternal side effects (all cause). Conclusions Prostaglandin inhibitors and calcium channel blockers had the highest probability of delaying delivery and improving neonatal and maternal outcomes.

Tocolytic therapy for preterm delivery: systematic review and network meta-analysis

OBJECTIVE
We tested the hypothesis that short interpregnancy intervals (IPIs) increase the risk for preterm birth (PTB), recurrence of PTB, and delivery at early extremes of gestational age.


STUDY DESIGN
Using the Missouri Department of Health's birth certificate database, we performed a population-based cohort study of 156,330 women who had 2 births from 1989-1997. The association between IPI and subsequent pregnancy outcome was assessed.


RESULTS
The shortest IPIs (<6 months) increased the risk of extreme PTB (adjusted odds ratio, 1.41; 95% CI, 1.13-1.76). IPIs of <6 months and 6-12 months increased the overall risk of PTB (adjusted odds ratios, 1.48 [95% CI, 1.37-1.61] and 1.14 [95% CI, 1.06-1.23], respectively) and PTB recurrence (adjusted odds ratios, 1.44 [95% CI, 1.19-1.75] and 1.24 [95% CI, 1.02-1.50], respectively).


CONCLUSION
The risk of PTB and its recurrence increases with short IPIs, even after adjustment for coexisting risk factors. This highlights the importance of counseling women with either an initial term or preterm birth to wait at least 12 months between delivery and subsequent conception.

Iconographies supplémentaires de l'article : A short interpregnancy interval is a risk factor for preterm birth and its recurrence

https://escholarship.org/content/qt4887h2x5/qt4887h2x5.pdf?t=qantfz

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

A comprehensive review of immigrant access to health and human services

Importance An increasing diversity of children’s health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children’s Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. Objective To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. Design, Setting, and Participants A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children’s Health, comprising 80 655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. Exposures Insurance type was ascertained using a caregiver-reported measure of insurance status and each household’s poverty status (percentage of the federal poverty level). Main Outcomes and Measures Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. Results Among the 80 655 children, 51 123 (57.3%) had private insurance, 11 853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P P P P P P Conclusions and Relevance This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/2470859/poi150069.pdf

Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families

Objective
To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care.

/pdf/midwifery-care-at-a-freestanding-birth-center-a-safe-and-3eeofsrefn.pdf

Midwifery care at a freestanding birth center: a safe and effective alternative to conventional maternity care.

The federal Strong Start for Mothers and Newborns initiative supported alternative approaches to prenatal care, enhancing service delivery through the use of birth centers, group prenatal care, and maternity care homes. Using propensity score reweighting to control for medical and social risks, we evaluated the impacts of Strong Start's models on birth outcomes and costs by comparing the experiences of Strong Start enrollees to those of Medicaid-covered women who received typical prenatal care. We found that women who received prenatal care in birth centers had lower rates of preterm and low-birthweight infants, lower rates of cesarean section, and higher rates of vaginal birth after cesarean than did the women in the comparison groups. Improved outcomes were achieved at lower costs. There were few improvements in outcomes for participants who received group prenatal care, although their costs were lower in the prenatal period, and no improvements in outcomes for participants in maternity care homes.

/pdf/improving-birth-outcomes-and-lowering-costs-for-women-on-qqbuguz0wf.pdf

Improving Birth Outcomes And Lowering Costs For Women On Medicaid: Impacts Of 'Strong Start For Mothers And Newborns'.

Objectives: Medicaid pays for about half the births in the United States, at very high cost. Compared to usual obstetrical care, care by midwives at a birth center could reduce costs to the Medicaid program. This study draws on information from a previous study of the outcomes of birth center care to determine whether such care reduces Medicaid costs for low income women. Methods: The study uses results from a study of maternal and infant outcomes at the Family Health and Birth Center in Washington, D.C. Costs to Medicaid are derived from birth center data and from other national sources of the cost of obstetrical care. Results: We estimate that birth center care could save an average of $1,163 per birth (2008 constant dollars), or $11.6 million per 10,000 births per year. Conclusions: Medicaid is the leading payer for maternity services. As Medicaid faces continuing cost increases and budget constraints, policy makers should consider a larger role for midwives and birth centers in maternity care for low-risk Medicaid pregnant women.

/pdf/potential-medicaid-cost-savings-from-maternity-care-based-at-pdvbc8xi0a.pdf

Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center

This is the final report on findings from an evaluation of the Childrenâ€™s Health Insurance Program (CHIP) that was mandated in the CHIP Reauthorization Act. The evaluation was conducted by Mathematica Policy Research and its partner The Urban Institute, and was overseen by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings

Background Medicaid pays for approximately half of United States births, yet little research has explored Medicaid beneficiaries' perspectives on their maternity care. Typical maternity care in the United States has been criticized as too medically focused while insufficiently addressing psychosocial risks and patient education. Enhanced care strives for a more holistic approach. Methods The perspectives of participants in the Strong Start for Mothers and Newborns II initiative, which provided enhanced prenatal care to women covered by Medicaid or the Children's Health Insurance Program (CHIP) during pregnancy through Birth Centers, Group Prenatal Care, and Maternity Care Homes, are evaluated. Strong Start intended to improve care quality and birth outcomes while lowering costs. We analyzed data from 133 focus groups with 951 pregnant or postpartum women who participated in Strong Start from 2013 to 2017. Results The majority of focus group participants said that Strong Start's enhanced care offered numerous important benefits over typical maternity care, including considerably more focus on women's psychosocial risk factors and need for education. They praised increased support; nutrition, breastfeeding, and family planning education; community referrals; longer time with practitioners; and involvement of partners in their care. Maternity Care Home participants, however, occasionally voiced concerns over lack of practitioner continuity and short clinical appointments, whereas Group Prenatal Care participants sometimes said they could not attend visits because of lack of childcare. Conclusions Medicaid and CHIP beneficiaries reported positive experiences with Strong Start care. If more Medicaid practitioners could adopt aspects of the prenatal care approaches that women praised most, it is likely that women's risk factors could be more effectively addressed and their overall care experiences could be improved.

Sarah Benatar

Papers

Midwifery care at a freestanding birth center: a safe and effective alternative to conventional maternity care.

Improving Birth Outcomes And Lowering Costs For Women On Medicaid: Impacts Of 'Strong Start For Mothers And Newborns'.

Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center

CHIPRA Mandated Evaluation of the Children's Health Insurance Program: Final Findings

What do women in Medicaid say about enhanced prenatal care? Findings from the national Strong Start evaluation.