Julia C. Phillippi’s research while affiliated with Vanderbilt University and other places

(Abstracted from Birth 2024;51:659–666) Professional organizations, including the American College of Obstetrics and Gynecologists, American College of Nurse-Midwives, and American Academy of Pediatrics, support informed decision-making when choosing a birth setting—whether it is at home, in a birth center, or in a hospital. Freestanding birth centers accredited by the Commission for the Accreditation of Birth Centers (CABC) only provide intrapartum care to those with low risk factors for a physiologic birth, excluding at-risk pregnancies.

Member checking enhances the trustworthiness and transformative potential of qualitative research. There are a variety of aims and approaches to reengaging with participants in sharing data or preliminary analysis and soliciting feedback through member checking. Published studies often lack descriptions of member-checking methods or outcomes, and there is a lack of research on the use of technologies for this purpose. Asynchronous video and internet-based technologies can be valuable tools to improve the accessibility, equity, effectiveness, and acceptability of member checking and foster increased engagement. This publication presents a detailed description of member checking in an exemplar study that used readily available technologies to create a video synopsis of preliminary findings and embed that video in a multimedia, mixed methods web-based survey which was emailed to participants. This member-checking method was purposefully selected to advance the specific research aims of the study, reflect the epistemological stance of the researchers and unique considerations of the study population, and address relevant situational factors to optimize participant engagement. This strategy facilitated wide, cost-effective, and timely distribution and resulted in a good response rate with rich feedback. Asynchronous technologies were a useful alternative to in-person or synchronous meetings to facilitate voluntary participation, foster reflection that deepened analysis, and capture multiple voices and perspectives. Findings from this research support the use of video and electronic survey technologies to enhance study credibility, address ethical and methodological challenges related to member checking, and increase equity and engagement. Future studies are needed to expand and refine integration of technologies into member checking to address diverse research aims, contexts, and study populations.

Objective The aim of the study was to examine the relationship between opioid use disorder (OUD)-related service trajectories during pregnancy and postpartum emergency department (ED) and hospitalizations. Methods We used the Merative MarketScan Commercial Claims and Encounters Database (2013–2021) to identify a cohort of pregnant individuals with OUD. We used group-based multitrajectory modeling to identify opioid-related treatment and service trajectories during pregnancy and examined their association with postpartum ED and hospital utilization. Results Seven opioid-related treatment and service trajectories were identified in our cohort of 2,531 pregnant individuals with OUD. Compared to individuals initiating medications for OUD (MOUD) halfway through pregnancy but maintaining high adherence without ancillary services, those receiving only services throughout pregnancy had a higher risk of postpartum ED visits ( HRED = 1.34). This latter group also faced significantly higher risks of postpartum hospitalizations, compared to adherent MOUD use (proportion of days covered ≥80%) alone, both throughout or in the latter half of pregnancy ( HRHOS = 1.93; HRHOS = 1.60), and patients without MOUD or services ( HRHOS = 1.43). Individuals initiating MOUD late in pregnancy with poor adherence and infrequent service use faced significantly higher risks of postdelivery hospitalization compared to consistent MOUD users throughout pregnancy ( HRHOS = 2.33), or in the latter half, with or without services ( HRHOS = 2.02; HRHOS = 1.93), and those not receiving MOUD or services ( HRHOS = 1.73). Conclusions Adherent MOUD use either throughout pregnancy or the latter half of pregnancy, irrespective of other service use, was associated with better postpartum outcomes defined by fewer ED visits and hospitalizations.

National health policy initiatives recommend increased integration of midwifery care in the United States to improve care quality and reduce maternal health disparities. However, the service models through which midwives provide midwifery care and produce quality outcomes are poorly understood. Midwifery‐led care is a service model frequently associated with improved outcomes compared with other models. The service model has been infrequently or inconsistently studied in the Unites States and has been narrowly defined and applied to perinatal care. The purpose of this concept analysis was to evaluate the concept of midwifery‐led care and expand the definition to guide midwifery practice, research, and health policy. The analysis followed Walker and Avant's methodology. Three attributes of midwifery‐led care were identified: (1) midwife as the lead clinician; (2) person‐midwife partnership; and (3) care embodies midwifery philosophy. Antecedents were (1) license to practice as a midwife; (2) a person needing or desiring sexual, reproductive, perinatal, or newborn care; (3) a person with low‐ or moderate‐risk health status; (4) regulations and guidelines that support provision of midwifery care; and (5) reimbursement for services. Consequences of midwifery‐led care included (1) improved maternal and neonatal outcomes, (2) patient satisfaction, and (3) reduced health care costs. The presented expanded definition of midwifery‐led care is the first to use a systems level approach and explicitly center the person receiving care and the philosophical approach of midwifery care. Application of this definition is needed in theoretical and pragmatic research to classify midwifery‐led care and other service models and compare patient‐ and organization‐level outcomes.

Background The growing emphasis on patient experience in medical research has increased the focus on patient-reported outcomes and symptom measures. However, patient-reported outcomes data are subject to recall bias, limiting reliability. Patient-reported data are most valid when reported by patients in real time; however, this type of data is difficult to collect from patients experiencing acute health events such as labor. Mobile technologies such as the MyCap app, integrated with the REDCap (Research Electronic Data Capture) platform, have emerged as tools for collecting patient-generated health data in real time offering potential improvements in data quality and relevance. Objective This study aimed to evaluate the feasibility of using MyCap for real-time, patient-reported data collection during latent labor. The objective was to assess the usability of MyCap in characterizing patient experiences during this acute health event and to identify any challenges in data collection that could inform future research. Methods In this descriptive cohort study, we quantified and characterized data collected prospectively through MyCap and the extent to which participants engaged with the app as a research tool for collecting patient-reported data in real time. Longitudinal quantitative and qualitative surveys were sent to (N=18) enrolled patients with term pregnancies planning vaginal birth at Oregon Health Sciences University. Participants were trained in app use prenatally. Then participants were invited to initiate the research survey on their personal smartphone via MyCap when they experienced labor symptoms and were asked to return to MyCap every 3 hours to provide additional longitudinal symptom data. Results Out of 18 enrolled participants, 17 completed the study. During latent labor, 13 (76.5%) participants (all those who labored at home and two-thirds of those who were induced) recorded at least 1 symptom report during latent labor. A total of 191 quantitative symptom reports (mean of 10 per participant) were recorded. The most commonly reported symptoms were fatigue, contractions, and pain, with nausea and diarrhea being less frequent but more intense. Four participants recorded qualitative data during labor and 14 responded to qualitative prompts in the postpartum period. The study demonstrated that MyCap could effectively capture real-time patient-reported data during latent labor, although qualitative data collection during active symptoms was less robust. Conclusions MyCap is a feasible tool for collecting prospective data on patient-reported symptoms during latent labor. Participants engaged actively with quantitative symptom reporting, though qualitative data collection was more challenging. The use of MyCap appears to reduce recall bias and facilitate more accurate data collection for patient-reported symptoms during acute health events outside of health care settings. Future research should explore strategies to enhance qualitative data collection and assess the tool’s usability across more diverse populations and disease states.

Importance In response to the growing opioid crisis, states implemented opioid prescribing limits to reduce exposure to opioid analgesics. Research in other clinical contexts has found that these limits are relatively ineffective at changing opioid analgesic prescribing. Objective To examine the association of state-level opioid prescribing limits with opioid prescribing within the 30-day postpartum period, as disaggregated by type of delivery (vaginal vs cesarean) and opioid naivete. Design, Setting, and Participants This retrospective, observational cohort study used commercial claims data from January 1, 2014, to December 31, 2021, from 49 US states and a difference-in-differences staggered adoption estimator to examine changes in postpartum opioid prescribing among all deliveries to enrollees between the ages of 18 and 44 years in the US. Exposures The implementation of a state opioid prescribing limit between 2017 and 2019. Main Outcomes and Measurements The primary outcomes for this analysis were the number of prescriptions for opioid analgesics, proportion of prescriptions with a supply greater than 7 days, and milligrams of morphine equivalent (MMEs) per delivery between 3 days before and 30 days after delivery. Results A total of 1 572 338 deliveries (enrollee mean [SD] age, 30.20 [1.59] years) were identified between 2014 and 2021, with 32.3% coded as cesarean deliveries. A total of 98.4% of these were to opioid-naive patients. The mean MMEs per delivery was 310.79, with higher rates in earlier years, states that had an opioid prescribing limit, and cesarean deliveries. In a covariate-adjusted difference-in-differences regression analysis, opioid prescribing limits were associated with a decrease of 148.70 MMEs per delivery (95% CI, −657.97 to 360.57) compared with states without such limits. However, these changes were not statistically significant. The pattern of results was similar among other opioid-prescribing outcomes and types of deliveries. Conclusions and Relevance The results of this cohort study suggest that opioid prescribing limits are not associated with changes in postpartum opioid prescribing regardless of delivery type or opioid naivete, which is consistent with research findings on these limits in other conditions or settings. Future research could explore what kinds of prevention mechanisms reduce the risk of opioid prescribing during pregnancy and postpartum.

Management of acute cystitis in a transfeminine patient is discussed as an example of treatment of urinary tract infections (UTIs). The case is an introduction for clinicians who typically care for cisgender women and wish to expand the populations they serve to include care of gender‐diverse individuals. This is supportive of the 2021 American College of Nurse‐Midwives Position Statement on Health Care for Transgender and Gender Non‐Binary People. Possible differential diagnoses for urinary symptoms in transfeminine patients are discussed, as well as relevant history taking, examination skills, and treatment guidelines for acute cystitis of patients with penises along with discussion of basic care for transgender individuals seeking midwifery or primary care services.

Introduction Existing data is often used for reproductive research and quality improvement. Electronic health records (EHRs) with a single data field for sex and gender conflate sex assigned at birth, genotype, gender identity, and the presence of anatomic tissue and organs. This is problematic for inclusion of transgender and gender‐diverse populations in research. This article discusses considerations with a single‐item sex and gender variable drawn from EHR records and describes an audit to determine variable validity as a criterion for inclusion or exclusion in perinatal research. Methods Individuals with a live birth at a large academic medical center from 2010 to 2022 were identified via electronic query, and records with male demographic information were reviewed to validate (1) the patient's date of birth and delivery date in the EHR matched the medical record number, (2) male sex and gender demographic information, and (3) male gender terms in EHR notes. Results All health records of male birthing individuals (n = 8) had EHR evidence of giving birth within the health system during the timeframe, and the date of birth matched the medical record number of the EHR. All had male gender in the EHR demographic information. Six patients did not have any male gender terms in available EHR notes, only female gender terms. Two records had recent notes using male gender terms. Discussion Current EHRs may not have reliable data on the gender and sex of gender‐diverse individuals. A single sex and gender variable drawn from EHRs should not be used as inclusion or exclusion criteria for health research or quality improvement without additional record review. EHRs can be updated to collect more data on sex, gender identity, and other relevant variables to improve research and quality improvement.

Background Weight bias toward individuals with higher body weights in healthcare settings is associated with adverse health behaviors, reduced healthcare utilization, and poor health outcomes. The purpose of this integrative review was to explore: (1) What has been measured and described regarding perinatal care providers' and students' weight bias toward pregnant, birthing, and postpartum individuals with higher body weights? (2) What has been measured and described regarding pregnant, birthing, and postpartum individuals' experiences of weight bias? (3) What is the association of experiences of weight bias with perinatal and mental health outcomes among pregnant, birthing, and postpartum individuals? Methods We conducted a systematic search in CINAHL, PubMed, and PsycINFO databases to identify relevant research publications related to the Medical Subject Headings (MeSH) terms weight prejudice (and related terms) and pregnancy (and related terms). The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA), Johns Hopkins Nursing Evidence‐Based Practice model for study quality determination, and the Whittemore and Knafl integrative review framework for data extraction and analyses. Results Twenty‐two publications met inclusion criteria, representing six countries and varying study designs. This review found pervasive sources of explicit weight bias in the perinatal period, including care providers and close relationships. Experiences of weight bias among pregnant and postpartum individuals are associated with adverse perinatal and mental health outcomes. Discussion The findings address a knowledge gap regarding a summary of literature on weight bias in the perinatal period and elucidate its prevalence as well as its negative influence on perinatal and mental health outcomes. Future research efforts on this topic must examine the nature and extent of perinatal care providers' weight bias by demographic factors and explore its association with clinical decision‐making and perinatal and mental health outcomes.

Objective Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling) Design Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats) Setting Planned community birth (homes and birth centers), United States Sample Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset Methods Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes Main outcome measures Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death Results One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7–10.4 and OR 18.6, 95% CI 15.9–21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4–16.3), even after congenital anomalies were excluded. Conclusions All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.