Objectives Georgia has the highest rate of maternal mortality in the United States, and ranks 40th for infant mortality. The Georgia Maternal and Infant Health Research Group was formed to investigate and address the shortage of obstetric care providers outside the Atlanta area. Because access to prenatal care (PNC) can improve maternal and infant health outcomes, we used qualitative methods to identify the access barriers experienced by women who live in rural and peri-urban areas of the state. Methods We conducted semi-structured, in-depth interviews with 24 mothers who gave birth between July and August 2013, and who live in either shortage or non-shortage obstetric care service areas. We also conducted key informant interviews with four perinatal case managers, and analyzed all data using applied thematic analysis. We then utilized Thaddeus and Maine's "Three Delays to Care" theoretical framework structure to describe the recognized barriers to care. Results We identified delays in a woman's decision to seek PNC (such as awareness of pregnancy and stigma); delays in accessing an appropriate healthcare facility (such as choosing a doctor and receiving insurance coverage); and delays in receiving adequate and appropriate care (such as continuity of care and communication). Moreover, many participants perceived low self-worth and believed this influenced their PNC exchanges. Conclusion As a means of supporting Georgia's pregnant women who face barriers and delays to PNC, these data provide a rationale for developing contextually relevant solutions to both mothers and their providers.

On the basis of our results, physicians' decisions to resuscitate seem to be context-specific, rather than based on prognosis or consistent application of best-interest or autonomy principles. Despite their different professional perspectives, neonatologists and high-risk obstetricians seemed to converge on these judgments.

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Vital signs monitoring is a fundamental component of ensuring the health and safety of women and newborns during pregnancy, labor, and childbirth. This monitoring is often the first step in early detection of pregnancy abnormalities, providing an opportunity for prompt, effective intervention to prevent maternal and neonatal morbidity and mortality. Contemporary pregnancy monitoring systems require numerous devices wired to large base units; at least five separate devices with distinct user interfaces are commonly used to detect uterine contractility, maternal blood oxygenation, temperature, heart rate, blood pressure, and fetal heart rate. Current monitoring technologies are expensive and complex with implementation challenges in low-resource settings where maternal morbidity and mortality is the greatest. We present an integrated monitoring platform leveraging advanced flexible electronics, wireless connectivity, and compatibility with a wide range of low-cost mobile devices. Three flexible, soft, and low-profile sensors offer comprehensive vital signs monitoring for both women and fetuses with time-synchronized operation, including advanced parameters such as continuous cuffless blood pressure, electrohysterography-derived uterine monitoring, and automated body position classification. Successful field trials of pregnant women between 25 and 41 wk of gestation in both high-resource settings (n = 91) and low-resource settings (n = 485) demonstrate the system’s performance, usability, and safety.

Objectives In 2011, a workforce assessment conducted by the Georgia Maternal and Infant Health Research Group found that 52 % of Primary Care Service Areas outside metropolitan Atlanta, Georgia, had an overburdened or complete lack of obstetric care services. In response to that finding, this study's aim was twofold: to describe challenges faced by providers who currently deliver or formerly delivered obstetric care in these areas, and to identify essential core components that can be integrated into alternative models of care in order to alleviate the burden placed on the remaining obstetric providers. Methods We conducted 46 qualitative in-depth interviews with obstetricians, maternal-fetal medicine specialists, certified nurse midwives, and maternal and infant health leaders in Georgia. Interviews were digitally recorded, transcribed verbatim, uploaded into MAXQDA software, and analyzed using a Grounded Theory Approach. Results Providers faced significant financial barriers in service delivery, including low Medicaid reimbursement, high proportions of self-pay patients, and high cost of medical malpractice insurance. Further challenges in provision of obstetric care in this region were related to patient's late initiation of prenatal care and lacking collaboration between obstetric providers. Essential components of effective models of care included continuity, efficient use of resources, and risk-appropriate services. Conclusion Our analysis revealed core components of improved models of care that are more cost effective and would expand coverage. These components include closer collaboration among stakeholder populations, decentralization of services with effective use of each type of clinical provider, improved continuity of care, and system-wide changes to increase Medicaid benefits.

Naloxone administration is an important component of resuscitation attempts by emergency medical services (EMS) for opioid drug overdoses. However, EMS providers must first recognize the possibility of opioid overdose in clinical encounters. As part of a public health response to an outbreak of opioid overdoses in Rhode Island, we examined missed opportunities for naloxone administration and factors potentially influencing EMS providers’ decision to administer naloxone. We reviewed medical examiner files on all individuals who died of an opioid-related drug overdose in Rhode Island from January 1, 2012 through March 31, 2014, underwent attempted resuscitation by EMS providers, and had records available to assess for naloxone administration. We evaluated whether these individuals received naloxone as part of their resuscitation efforts and compared patient and scene characteristics of those who received naloxone to those who did not receive naloxone via chi-square, t-test, and logistic regression analyses. One hundred and twenty-four individuals who underwent attempted EMS resuscitation died due to opioid overdose. Naloxone was administered during EMS resuscitation attempts in 82 (66.1%) of cases. Females were nearly three-fold as likely not to receive naloxone as males (OR 2.9; 95% CI 1.2–7.0; p-value 0.02). Additionally, patients without signs of potential drug abuse also had a greater than three-fold odds of not receiving nalox-one (OR 3.3; 95% CI 1.2–9.2; p-value 0.02). Older individuals, particularly those over age 50, were more likely not to receive naloxone than victims younger than age 30 (OR 4.8; 95% CI 1.3–17.4; p-value 0.02). Women, older individuals, and those patients without clear signs of illicit drug abuse, were less likely to receive naloxone in EMS resuscitation attempts. Heightened clinical suspicion for opioid overdose is important given the recent increase in overdoses among patients due to prescription opioids.

Purpose Drug overdose deaths are epidemic in the U.S. Prescription opioid pain relievers (OPR) and heroin account for the majority of drug overdoses. Preventing death after an opioid overdose by naloxone administration requires the rapid identification of the overdose by witnesses. This study used a state medical examiner database to characterize fatal overdoses, evaluate witness-reported signs of overdose, and identify opportunities for intervention. Methods We reviewed all unintentional drug overdose deaths that occurred in New Mexico during 2012. Data were abstracted from medical examiner records at the New Mexico Office of the Medical Investigator. We compared mutually exclusive groups of OPR and heroin-related deaths. Results Of the 489 overdose deaths reviewed, 49.3% involved OPR, 21.7% involved heroin, 4.7% involved a mixture of OPR and heroin, and 24.3% involved only non-opioid substances. The majority of OPR-related deaths occurred in non-Hispanic whites (57.3%), men (58.5%), persons aged 40–59 years (55.2%), and those with chronic medical conditions (89.2%). Most overdose deaths occurred in the home (68.7%) and in the presence of bystanders (67.7%). OPR and heroin deaths did not differ with respect to paramedic dispatch and CPR delivery, however, heroin overdoses received naloxone twice as often (20.8% heroin vs. 10.0% OPR; p < 0.01). Conclusion OPR overdose deaths differed by age, health status, and the presence of bystanders, yet received naloxone less often when compared to heroin overdose deaths. These findings suggest that naloxone education and distribution should be targeted in future prevention efforts.

Aim To quantify the cost and prediction of futile care in the Neonatal Intensive Care Unit (NICU). Methods We observed 1813 infants on 100 000 NICU bed days between 1999 and 2008 at the University of Chicago. We determined costs and assessed predictions of futility for each day the infant required mechanical ventilation. Results Only 6% of NICU expenses were spent on nonsurvivors, and in this sense, they were futile. If only money spent after predictions of death is considered, futile expenses fell to 4.5%. NICU care was preferentially directed to survivors for even the smallest infants, at the highest risk to die. Over 75% of ventilated NICU infants were correctly predicted to survive on every day of ventilation by every caretaker. However, predictions of ‘die before discharge’ were wrong more than one time in three. Attendings and neonatology fellows tended to be optimistic, while nurses and neonatal nurse practitioners tended to be pessimistic. Conclusions Criticisms of the expense of NICU care find little support in these data. Rather, NICU care is remarkably well targeted to patients who will survive, particularly when contrasted with care in adult ICUs. We continue to search for better prognostic tools for individual infants.