The role of pediatric interconception care in preventing adverse birth outcomes

摘要/摘要 美国10%的新生儿发生早产，36%的婴儿死亡，每年造成260亿美元的损失。重复 早产儿约占早产儿总数的20%。有效解决问题的预防性护理 既往早产妇女的可改变风险(如吸烟、体重状况、解释间隔) 生育似乎可以将整体早产率降低10%或更多。不过，我们的初步工作发现， 之前早产的有医疗补助保险的女性中，39%在第二年没有得到预防保健 怀孕了。利用儿科卫生系统和新妈妈之间的现有联系，这项研究 提出了一种以儿科护士为基础的干预措施，作为减少早产的新策略。我们假设 护士护理协调将增加预防性护理的接受度。此外，我们还提出了嵌入 在护理协调模式内进行激励性访谈，以应对可改变的健康风险。我们 假设这种护理协调加上激励性访谈干预将增加 预防保健和减少可改变的行为风险，从而改善随后的生育结果。这个 拟议的干预措施建立在现有护理协调模式和证明可行性的先前工作的基础上 在儿科进行孕产妇风险筛查。这种干预创新了现有的概念间(IC)护理 模式：(1)定位我们在儿科保健系统中的干预措施，以利用现有的相互作用， (2)专注于通过筛选确定的应对需求和风险的战略，以及(3)实施 在护理协调中进行激励性访谈，以更好地应对可修改的风险。这位候选人是Dr。 Gregory之前曾进行过专注于IC时期的母婴健康研究。她的长期目标是 成为独立的母婴健康研究人员，开发改善生育的临床计划 结果。这项为期五年的指导研究计划将通过课程学习和 完成有指导的研究。应聘者培训将侧重于三个目标：(1)激励 访谈，一种基于证据的行为改变策略，(2)实施科学，(3)务实 临床试验。研究将涉及两个具体目标。(目标1)将调整护理协调和激励 采访有过早产经历的妇女。使用混合方法，并从现有模型开始 儿科护理协调、适应将侧重于有早产史和 激励性访谈的整合。(目标1a：定性访谈；目标1b：迭代测试。)(目标2)意志 进行常规护理与护理协调加激励性访谈的试点务实随机试验 有过早产经历的妇女。这项试验将论证干预的可行性，并估计效果大小。 对卫生服务利用的干预情况。调查结果将通知R01级试验，将此干预作为一种 减少重复早产的策略。这一建议符合NICHD的研究优先事项，即改善 妇女在怀孕前、怀孕期间和怀孕后的健康状况，以及改善妊娠结局。

Summary/Abstract Preterm births occur in 10% of US births, cause 36% of infant mortality, and cost $26 billion each year. Repeat preterm births represent approximately 20% of total prematurity. Preventive care that effectively addresses modifiable risks (e.g. tobacco use, weight status, interpregnancy interval) among women with a prior preterm birth could plausibly reduce overall preterm birth rates by 10% or more. However, our preliminary work found that 39% of Medicaid-insured women with a prior preterm birth received no preventive care in the year after pregnancy. Leveraging existing contact between pediatric health systems and new mothers, this research proposes a pediatric-based nurse intervention as a novel strategy to reduce prematurity. We hypothesize that nurse care coordination will increase receipt of preventive care. In addition, we propose embedding motivational interviewing within the care coordination model to address modifiable health risks. We hypothesize that this care coordination plus motivational interviewing intervention will increase receipt of preventive care and reduce modifiable behavioral risks, thus improving subsequent birth outcomes. The proposed intervention builds on existing care coordination models and on prior work demonstrating feasibility of maternal risk screening in pediatrics. This intervention innovates over existing interconception (IC) care models by: (1) locating our intervention in the pediatric health care system to capitalize on existing interactions, (2) focusing on strategies to address needs and risks identified through screening, and (3) implementing motivational interviewing within care coordination to better address modifiable risks. The candidate, Dr. Gregory, has conducted prior maternal-child health research focused on the IC period. Her long-term goal is to become an independent maternal-child health researcher developing clinical programs to improve birth outcomes. This five-year mentored research proposal will support her goal through course work and completion of mentored research. Candidate training will focus on three objectives: (1) motivational interviewing, an evidence-based behavior change strategy, (2) implementation science, and (3) pragmatic clinical trials. Research will address two specific aims. (Aim 1) will adapt care coordination and motivational interviewing for women with a prior preterm birth. Using mixed methods, and starting with existing models of pediatric care coordination, adaptation will focus on the needs of women with a history of preterm birth and on integration of motivational interviewing. (Aim 1a: qualitative interviews; Aim 1b: iterative testing.) (Aim 2) will conduct a pilot pragmatic randomized trial of usual care vs care coordination plus motivational interviewing for women with a prior preterm birth. This trial will demonstrate intervention feasibility and estimate the effect size of the intervention on health care utilization. Findings will inform an R01 level trial testing this intervention as a strategy to reduce repeat preterm birth. This proposal aligns with NICHD research priorities of improving the health of women before, during, and after pregnancy and improving pregnancy outcomes.