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Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals.This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient.Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%).Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.

Objective This study aimed to describe opioid prescribing patterns for pregnant patients with a history of or active opioid use to inform postpartum pain management strategies. Study Design We conducted a retrospective cohort analysis of all patients with a history of opioid use disorder (OUD) or chronic pain seen at a single outpatient clinic specializing in opioid use and OUD in pregnancy from January 2019 to August 2021. Patient characteristics, delivery outcomes, and opioid prescribing information were collected through electronic health record fields. We used descriptive statistics to characterize differences in receipt of an opioid prescription, prescription size, and receipt of a prescription refill across three patient groups: patients with OUD on medication, patients with OUD maintaining abstinence, and patients with chronic pain using opioids. In the study period, the institutional average rate of opioid prescribing after cesarean and vaginal birth were 80.0 and 2.8%, respectively. Results Of the 69 patients included in this study, 46 (66.7%) had a history of OUD on medication, 14 (20.3%) had a history of OUD maintaining abstinence, and 9 (13.0%) had a history of chronic pain. Receipt of an opioid prescription after childbirth was more common after cesarean birth (12/23, 52.2%) than vaginal birth (3/46, 6.5%). Refills were common in patients who received an opioid proscription (cesarean: 5/12, 41.7%; vaginal: 1/3, 33.3%). Conclusion Compared with institutional averages, postpartum opioid prescribing rates for people with a history of OUD or chronic pain were 50 to 60% lower for cesarean birth and three times higher for vaginal birth. Future work is needed to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations. Key Points

Objective To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare) in pregnancy panel process and key recommendations for prenatal care delivery. Methods We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine). Results The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices. Conclusion The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals.

Objective To perform a literature review of key aspects of prenatal care delivery to inform new guidelines. Data sources A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov. Methods of study selection We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction. Tabulation, integration, and results Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth. Conclusion Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

The coronavirus disease 2019 pandemic led to some of the most drastic changes in clinical care delivery ever seen in the United States. Almost overnight, providers of prenatal care adopted virtual visits and reduced visit schedules. These changes stood in stark contrast to the 12 to 14 in-person prenatal visit schedule that had been previously recommended for almost a century. As maternity care providers consider what prenatal care delivery changes we should maintain following the acute pandemic, we may gain insight from understanding the evolution of prenatal care delivery guidelines. In this paper, we start by sketching out the relatively unstructured beginnings of prenatal care in the 19th century. Most medical care fell within the domain of laypeople, and childbirth was a central feature of female domestic culture. We explore how early discoveries about "toxemia" created the groundwork for future prenatal care interventions, including screening of urine and blood pressure-which in turn created a need for routine prenatal care visits. We then discuss the organization of the medical profession, including the field of obstetrics and gynecology. In the early 20th century, new data increasingly revealed high rates of both infant and maternal mortalities, leading to a greater emphasis on prenatal care. These discoveries culminated in the first codification of a prenatal visit schedule in 1930 by the Children's Bureau. Surprisingly, this schedule remained essentially unchanged for almost a century. Through the founding of the American College of Obstetricians and Gynecologists, significant technological advancements in laboratory testing and ultrasonography, and calls of the National Institutes of Health Task Force for changes in prenatal care delivery in 1989, prenatal care recommendations continued to be the same as they had been in 1930-monthly visits until 28 weeks' gestation, bimonthly visits until 36 weeks' gestation, and weekly visits until delivery. However, coronavirus disease 2019 forced us to change, to reconsider both the need for in-person visits and frequency of visits. Currently, as we transition from the acute pandemic, we should consider how to use what we have learned in this unprecedented time to shape future prenatal care. Lessons from a century of prenatal care provide valuable insights to inform the next generation of prenatal care delivery.

Purpose Opioid-sparing protocols have significantly reduced opioid use postcesarean birth through maximizing nonpharmacologic and nonopioid pain management tools. This study explored nurses' experiences with an opioid-sparing protocol at a single institution, where inpatient opioid prescribing was reduced by over half. Method Focus groups were used to identify key facilitators and barriers to implementation of the opioid-sparing protocol. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis. Focus groups were recorded, transcribed, thematically coded, and analyzed for barriers and facilitators using predetermined CFIR domains. Results Three focus groups of nurses who care for women during postpartum were conducted in March and April 2019. Fourteen nurses participated. They were all women, with an average of 9.3 years (SD = 5.4) of maternity nursing experience. Facilitators of implementation were: 1) high satisfaction with the intervention's efficacy; 2) awareness of opioid harms promoting readiness for opioid-sparing efforts; 3) adequate staffing and the culture of evidence-based practice; and 4) bedside skills in pain management to identify patients' needs. The most significant barrier was a lack of nurse engagement with protocol development and implementation. Clinical implications An increased partnership among the interprofessional team members through all stages of implementation is necessary for the success and sustainability of best patient care practices.

Prenatal care is one of the most widely used preventive care services in the United States, yet prenatal care delivery recommendations have remained largely unchanged since just before World War II. The current prenatal care model can be improved to better serve modern patients and the health care providers who care for them in three key ways: 1) focusing more on promotion of health and wellness as opposed to primarily focusing on medical complications, 2) flexibly incorporating patient preferences, and 3) individualizing care. As key policymakers and stakeholders grapple with higher maternity care costs and poorer outcomes, including lagging access, equity, and maternal and infant morbidity and mortality in the United States compared with other high-income countries, the opportunity to improve prenatal care has been given insufficient attention. In this manuscript, we present a new conceptual model for prenatal care that incorporates both patients' medical and social needs into four phenotypes, and use human-centered design methods to describe how better matching patient needs with prenatal services can increase the use of high-value services and decrease the use of low-value services. Finally, we address some of the key challenges to implementing right-sized prenatal care, including capturing outcomes through research and payment.

Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today.Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities.From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes.In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.

Background National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits—packages of resources and strategies to facilitate the implementation of new services—are a promising approach for guiding clinical practice change. Objective This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing. Study Design We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]). Results In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were “extremely” or “somewhat” satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%–79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%–29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%–63%; hospitalization, 45%–58%; outpatient after delivery, 69%–65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care. Conclusion A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

The Four Components of Instructional Design (4C-ID) Model has been used to teach Medical Decision Making (MDM), a core competency recognized by the Liaison Committee for Medical Education. 4 Components of Instructional Design (4C-ID) has been applied in general medical education, but not the inpatient clerkship setting. A 4C-ID video for inpatient rounding, like postpartum rounding in Ob/Gyn, could help improve MDM on busy services.Students in the third year Ob/Gyn clerkship were randomized by clerkship group to receive a 20-minute postpartum rounding video, based on 4C-ID principles, or usual teaching. MDM and knowledge were assessed pre-/postintervention with the Diagnostic Thinking Inventory and a case-based evaluation. Satisfaction was assessed with Likert style questions.Seventy-eight students were randomized (36 control, 42 intervention). Both groups had equal baseline measures of MDM and knowledge, and similar postclerkship MDM. The intervention group demonstrated higher knowledge postclerkship (17.1, 22.6 p0.001). Students in the intervention felt prepared by the video, and would recommend it. Students in the control group reported higher satisfaction with their postpartum rounding experience (3.9, 3.5 p = 0.04).Videos are easy to incorporate teaching platforms for medical students, however, the 4C-ID based video in this study did not increase student MDM. In addition, educators should use caution when integrating video into coursework as use of video may lead to decreased student satisfaction as it did in this study.

Background Immediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions. Methods We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017–2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success. Results We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders’ professional values, perception of meeting patients’ needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused. Conclusions Implementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings.

To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery.This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates.Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99).Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.

Each year, nearly 4 million pregnant patients in the United States receive prenatal care-a crucial preventive service that improves pregnancy outcomes for mothers and their children. National guidelines currently recommend 12-14 in-person prenatal visits, a schedule that has remained unchanged since 1930. When scrutinizing the standard prenatal visit schedule, it becomes clear that prenatal care is overdue for a redesign. We have strong evidence of the benefits of prenatal services, such as screening for gestational diabetes and maternal vaccination. However, how to deliver these services is not clear. Studies of prenatal services consistently demonstrate that such care can be delivered in fewer than 14 visits and that patients do not need to visit clinics in person to receive all maternity services. Telemedicine has emerged as a promising care delivery option for patients seeking greater flexibility, and early trials leveraging virtual care and remote monitoring have shown positive maternal and fetal outcomes with high patient satisfaction. Our institution has worked for the past year on a new prenatal care pathway. Our initial work assessed the literature, elicited patient perspectives, and captured the insights of experts in patient-centered care delivery. There are 2 key principles that guide prenatal care redesign: (1) design care delivery around essential services, using in-person care for services that cannot be delivered remotely and offering video visits for other essential services, and (2) creation of flexible services for anticipatory guidance and psychosocial support that allow patients to tailor support to meet their needs through opt-in programs. The rise of coronavirus disease 2019 prompted us to extend this early work and rapidly implement a redesigned prenatal care pathway. In this study, we outline our experience in transitioning to a new prenatal care model with 4 in-person visits, 1 ultrasound visit, and 4 virtual visits (the 4-1-4 prenatal plan). We then explore how insights from this implementation can inform patient-centered prenatal care redesign during and beyond the coronavirus disease 2019 pandemic.

The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption.This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation.A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2,A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective.· Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.. · Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.. · Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use)..

Prenatal care is one of the most widely used preventive care services in the United States, yet prenatal care delivery recommendations have remained largely unchanged since just before World War II. The current prenatal care model can be improved to better serve modern patients and the health care providers who care for them in three key ways: 1) focusing more on promotion of health and wellness as opposed to primarily focusing on medical complications, 2) flexibly incorporating patient preferences, and 3) individualizing care. As key policymakers and stakeholders grapple with higher maternity care costs and poorer outcomes, including lagging access, equity, and maternal and infant morbidity and mortality in the United States compared with other high-income countries, the opportunity to improve prenatal care has been given insufficient attention. In this manuscript, we present a new conceptual model for prenatal care that incorporates both patients' medical and social needs into four phenotypes, and use human-centered design methods to describe how better matching patient needs with prenatal services can increase the use of high-value services and decrease the use of low-value services. Finally, we address some of the key challenges to implementing right-sized prenatal care, including capturing outcomes through research and payment.

Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for the millions of women who will experience a cesarean delivery each year. Enhanced recovery after surgery, a standardized, evidence-based, interdisciplinary protocol, has been successfully used in other surgical specialties including gynecology to improve quality of care and patient satisfaction while reducing overall health care costs through reduced length of stay. Enhanced recovery after surgery society guidelines for cesarean delivery were just released in August 2018. Obstetric patients, who face the dual challenge of being postpartum and postoperative, could benefit greatly from protocols that optimize their return to physiological function and reduce surgical morbidity. Although enhanced recovery after surgery has been widespread in other surgical specialties, uptake of this protocol in obstetrics has lagged behind. We believe enhanced recovery after surgery for cesarean delivery can effectively address 3 challenges faced by obstetrician/gynecologists. These are: (1) improving care for the high number of women undergoing cesarean deliveries; (2) using evidence-based care bundles to prevent maternal morbidity and mortality, address disparities, and reduce costs; and (3) limiting postoperative opioid prescribing in response to the opioid crisis. Enhanced recovery after surgery for cesarean delivery and other standardized care protocols have the potential to reduce the disproportionately high rates of maternal morbidity and mortality in the United States, and ensure all patients, regardless of demographics or location, receive the same level of high-quality peripartum care.

Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period.This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery.We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing,$0-$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type.Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point.Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.

Importance Research has shown an association between opioid prescribing after major or minor procedures and new persistent opioid use. However, the association of opioid prescribing with persistent use among women after vaginal delivery or cesarean delivery is less clear. Objective To assess the association between opioid prescribing administered for vaginal or cesarean delivery and rates of new persistent opioid use among women. Design, Setting, and Participants This retrospective cohort study used national insurance claims data for 988 036 women from a single private payer from January 1, 2008, to December 31, 2016. Participants included reproductive age, opioid-naive women with 1 year of continuous enrollment before and after delivery. For participants with multiple births, only the first birth was included. Exposures Peripartum opioid prescription (1 week before delivery to 3 days after discharge) captured by pharmacy claims, including prescription timing and size in oral morphine equivalents. Multivariable adjusted odds ratios were estimated using regression models. Main Outcomes and Measures Rates of new persistent opioid use, defined as pharmacy claims for 1 or more opioid prescription 4 to 90 days after discharge and 1 or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions. Results In total, 308 226 deliveries were included: 195 013 (63.3%) vaginal deliveries and 113 213 (36.7%) cesarean deliveries. Participant mean (SD) age was 31.3 (5.3) years, and 70 567 (51.0%) were white patients. Peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries had new persistent opioid use. By contrast, among women not receiving a peripartum opioid prescription, 0.5% with vaginal delivery and 1.0% with cesarean delivery had new persistent opioid use. From 2008 to 2016, opioid prescription fills decreased for vaginal deliveries from 26.9% to 23.8% (P Conclusions and Relevance The results of the present study suggested that opioid prescribing and new persistent use after vaginal delivery or cesarean delivery have decreased since 2008. However, modifiable prescribing patterns were associated with persistent opioid use for patients who underwent vaginal delivery, and risk factors following cesarean delivery mirrored those of other surgical conditions. Judicious opioid prescribing and preoperative risk screening may be opportunities to decrease new persistent opioid use after childbirth.