<p> <b>OBJECTIVE:</b> To improve 6-week postpartum visit attendance, glucose test ordering, and test completion among postpartum GDM patients. </p><p> <b>METHODS:</b> Pre- and post-intervention GDM women at Mount Sinai were studied via chart review. Interventions included advanced order sets for glucose monitoring at the 35-week pregnancy visit, educational modules, and nutritionist phone calls reminding patients to attend postpartum visits fasting. </p><p> <b>RESULTS:</b> 107 pre-intervention and 42 post-intervention women were studied. Percentages of orders placed for postpartum testing was higher post-intervention vs. pre-intervention (57% vs. 42%, p=0.03). There were higher test completion rates post-intervention vs. pre-intervention (36% vs. 17%, p=0.01). Postpartum visit attendance rates didn&rsquo;t vary between groups (73% vs. 69% p=0.60). 6% pre-intervention fasted for postpartum visits vs. 60% post-intervention. </p><p> <b>CONCLUSION:</b> There was no increase in women attending their 6-week postpartum visits, yet rates of completed orders for postpartum testing, women attending visits fasting, and postpartum test completions were higher post-intervention. More research may identify the barriers to attendance at 6-week post-partum visits.</p>

<p> <b>Objectives:</b> Mothers of low socioeconomic status (SES) and of non-Hispanic black race deliver prematurely more often. The goal of my dissertation was to improve understanding of the mechanism of disproportionate premature birth in low SES women. I tested a psychological and physiological stress explanation of prematurity risk, estimated the effect of the Affordable Care Act (ACA) Medicaid expansion on gestational age (GA), and estimated how the ACA Medicaid expansion effect was influenced by race. <i><b>Data and Methods:</b></i> I developed a conceptual framework of how psychological and physiological stress increase premature birth risk utilizing Appraisal and pathophysiology theory. I generated hypotheses about how financial risk removal would impact GA and tested them utilizing variation in expansions in Medicaid eligibility for pregnant women in three matched state pairs and distribution of the Earned Income Tax Credit (EITC). I utilized data from the Pregnancy Risk Assessment Monitoring System and performed multivariate ordinal regressions. I also used national birth record data and exploited state variation in ACA Medicaid expansion status to estimate the impact on GA in non-Hispanic black and all other mothers using multivariate linear regressions and linear probability models. </p><p> <b>Results:</b> Hypothesis testing based on two of the three Medicaid expansion for pregnant women state pairs and the EITC analyses resulted in significant evidence (one-sided p-values &lt; 0.05) for a direct pathway between psychological stress concerning financial risk, physiological stress, and GA. The ACA Medicaid expansion was associated with an increase in GA for non-Hispanic black mothers (+34 hours), a decrease for all other mothers (&ndash;6 hours), and a 3% decrease (95% CI = &ndash;5% to &ndash;2%) in the incidence of early term or shorter gestation births for non-Hispanic black mothers. </p><p> <b>Conclusions:</b> Decreasing financial risk for low SES women with Medicaid or the EITC is associated with increased GA. The higher premature birth risk in this population is likely the result of a direct pathway involving psychological and physiological stress. Other financial risk removal strategies should be investigated. The ACA Medicaid expansion did not meaningfully influence GA on a weekly scale but did moderately decrease overall preterm birth risk in non-Hispanic black mothers.</p><p>

<p> With the goal of eliminating mother-to-child transmission by 2015, a wide range of governmental and other efforts within low- and middle-income countries have sought to provide services for the prevention of mother-to-child transmission of HIV (PMTCT) to the estimated 1.2 million pregnant women in need. In support of this goal, the World Health Organization (WHO), as the leading normative international body in the area of evidence-based clinical guidelines, issued policy recommendations on the use of antiretroviral drugs for PMTCT. Through various mechanisms, including guidance notes and dissemination workshops, WHO supports countries to adopt and adapt the guidelines within their national policy frameworks. Through three analyses, this dissertation examines the diffusion of WHO PMTCT guidelines in five Eastern and Southern African countries over a 16-year period (1998-2013) and estimates the effect of PMTCT policy adoption on delivery of key services. </p><p> <b>The first analysis</b> of the adoption of specific PMTCT guideline updates between 1998 and 2013 seeks to ascertain which internal factors may explain why and when countries decided to adopt new technical guidance. The policy analysis shows that the five countries adopted a majority of the key international PMTCT technical guidance updates. It can be concluded that international to national policy diffusion was taking place and that national policies converged to be more similar and more in line with international guidelines over the time period studied. Variation in adoption and in the internal determinants at play in each country was minimal, making it difficult to assess the influence of determinants qualitatively. The three internal determinants that appeared to most influence adoption of key PMTCT updates were: 1) the severity of the MTCT problem 2) governance effectiveness, and 3) prior PMTCT policy adoption. The lag between adoption and implementation in these countries is discussed. The findings indicate that in the countries studied, policies promoted by WHO and other international bodies can play a critical role in supporting national policy adoption for program advancement in the area of PMTCT. </p><p> <b>The second and third analyses</b> investigate whether the completeness of a country&rsquo;s body of PMTCT-supporting policies was associated with the delivery of two key PMTCT services &ndash; the offer of an HIV test and the receipt of HIV counseling as a part of antenatal care (ANC) &ndash; in four of the five countries included in the first analysis. Two nationally representative surveys per country were used to conduct a quasi-experimental fixed-effects analysis of the role of policy in predicting a woman&rsquo;s probability of being offered an HIV test or receiving HIV counseling in ANC, controlling for other key individual- and country-level covariates. </p><p> According to the &lsquo;testing&rsquo; model, a one-unit increase in policy score was associated with a 0.042 (p&lt;0.000) increase in the probability that a woman was offered an HIV test as a part of antenatal care. According to the &lsquo;counseling&rsquo; model, a one-unit increase in policy score was associated with a 0.014 (p&lt;0.001) increase in the probability that a woman received HIV counseling as a part of antenatal care. In both the testing and counseling models, the policy/education interaction was statistically significant in the final model, with a greater policy effect estimated at among those with higher education levels. Time statistically significantly influenced the probability of the outcome, as did government health spending, governance effectiveness, and donor health spending. Further study is needed to identify the policy elements that have the most impact on improving service delivery. </p><p> <b>The three analyses</b> presented here support the premise that international health policies influence national-level policy adoption, and that national-level policy adoption in turn influences national service outputs. As countries and their development partners mobilize for the Sustainable Development Goal era, policy adoption at the international level will continue to be an important influence in national policy adoption in the area of PMTCT. This research has described a number of potential internal and external determinants that will influence national adoption in this next round of global health policy advocacy. Looking forward, this study shows that countries and their development partners should continue to invest in the work of policy adoption to complement other efforts to reach health goals, including increased government health spending.</p>

Aims: The aims of this thesis were to investigate the risk of severe maternal morbidity amongst women from different socioeconomic groups in the UK, explore why these differences exist and compare these findings to the setting in Australia. Methods: Three separate analyses were conducted. The first used UK Obstetric Surveillance System (UKOSS) data to assess the incidence and independent odds of severe maternal morbidity by socioeconomic group in the UK. The second analysis used quantitative and qualitative data from the 2010 UK National Maternity Survey (NMS) to explore the possible reasons for the difference in odds of morbidity between socioeconomic groups in the UK. The third analysis used data from the Victorian Perinatal Data Collection (VPDC) unit in Austra lia to assess the incidence and odds of severe maternal morbidity by socioeconomic group in Victoria. Results: The UKOSS analysis showed that compared with women from the highest socioeconomic group, women in the lowest 'unemployed' group had 1.22 (95%CI: 0.92 - 1.61) times greater odds associated with severe maternal morbidity. The NMS analysis demonstrated that independent of ethnicity, age and parity, women from the lowest socioeconomic quintiJe were 60% less likely to have had any antenatal care (aOR 0.40; 95%CI 0.18 - 0.87), 40% less likely to have been seen by a health professional prior to 12 weeks gestation (aOR 0.62; 95%CI 0.45 - 0.85) and 45% less likely to have had a postnatal check with their doctor (aOR 0.55; 95%CI 0.42 - 0.70) compared to women from the highest quintile. The Victorian analysis showed that women from the lowest socioeconomic group were 21% (aOR 1.21 ; 95% CI 1.00 - 1.47) more likely and that Aboriginal and Torres Strait Islander women were twice (aOR 2.02; 95%CI 1.32 - 3.09) as likely to experience severe morbidity. Discussion: The resu lts suggest that women from the lowest socioeconomic group in the UK and in Victoria have increased odds of severe maternal morbidity. Further research is needed into why these differences exist and efforts must be made to ensure that these women are appropriately prioritised in the future planning of maternity services provisio n in the UK and Australia.