Serum Cotinine and Adverse Cardiovascular Outcomes: A Cross-sectional Secondary Analysis of the nuMoM2b Heart Health Study

OBJECTIVE

We aimed to (1) compare serum cotinine with self-report for ascertaining smoking status among reproductive-aged women; (2) estimate the relative odds of adverse cardiovascular (CV) outcomes among women by smoking status; (3) assess whether the association between adverse pregnancy outcomes (APOs) and CV outcomes varies by smoking status.

STUDY DESIGN

We conducted a cross-sectional study of the nuMoM2b Heart Health Study. Women attended a study visit 2 to 7 years after their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine. Outcomes included incident chronic hypertension (HTN), metabolic syndrome (MetS), and dyslipidemia. Multivariable logistic regression estimated odds ratios (ORs) for each outcome by smoking status.

RESULTS

Of 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as secondhand smoke exposure, and 720 as smokers. Of 3,144 women who denied tobacco smoke exposure, serum cotinine was consistent with secondhand smoke exposure in 48 (1.5%) and current smoking in 131 (4.2%) After adjustment for APOs, smoking defined by serum cotinine was associated with MetS (adjusted OR [aOR] = 1.52, 95% confidence interval [CI]: 1.21, 1.91) and dyslipidemia (aOR = 1.28, 95% CI: 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR = 1.64, 95% CI: 1.32, 2.03) and stage 2 HTN (aOR = 2.92, 95% CI: 2.17, 3.93), MetS (aOR = 1.76, 95% CI: 1.42, 2.18), and dyslipidemia (aOR = 1.55, 95% CI: 1.25, 1.91) relative to women with no APO. Results were similar when smoking exposure was defined by self-report.

CONCLUSION

Whether determined by serum cotinine or self-report, smoking is associated with subsequent CV outcomes in reproductive-aged women. APOs are also independently associated with CV outcomes in women.

KEY POINTS

· Cotinine was detected in 5.7% of reported nonsmokers.. · Smoking and APOs were independently associated with CV health.. · Smoking was associated with MetS and dyslipidemia..

Association between community-level political affiliation and peripartum vaccination

BACKGROUND

Political affiliation has been associated with vaccine uptake, but whether this association holds in pregnancy, when individuals are recommended to receive multiple vaccinations, remains to be studied.

OBJECTIVE

This study aimed to examine the association between community-level political affiliation and vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in pregnant and postpartum individuals.

STUDY DESIGN

A survey was conducted about tetanus, diphtheria, and pertussis and influenza vaccinations in early 2021, with a follow-up survey of COVID-19 vaccination among the same individuals at a tertiary care academic medical center in the Midwest. Geocoded residential addresses were linked at the census tract to the Environmental Systems Research Institute 2021 Market Potential Index, which ranks a community in comparison to the US national average. The exposure for this analysis was community-level political affiliation, defined by the Market Potential Index as very conservative, somewhat conservative, centrist, somewhat liberal, and very liberal (reference). The outcomes were self-reported vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in the peripartum period. Modified Poisson regression was used and adjusted for age, employment, trimester at assessment, and medical comorbidities.

RESULTS

Of 438 assessed individuals, 37% lived in a community characterized by very liberal political affiliation, 11% as somewhat liberal, 18% as centrist, 12% as somewhat conservative, and 21% as very conservative. Overall, 72% and 58% of individuals reported receiving tetanus, diphtheria, and pertussis and influenza vaccinations, respectively. Of the 279 individuals who responded to the follow-up survey, 53% reported receiving COVID-19 vaccination. Individuals living in a community characterized by very conservative political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (64% vs 72%; adjusted risk ratio, 0.83; 95% confidence interval, 0.69-0.99); influenza (49% vs 58%; adjusted risk ratio, 0.79; 95% confidence interval, 0.62-1.00); and COVID-19 (35% vs 53%; adjusted risk ratio, 0.65; 95% confidence interval, 0.44-0.96) than those in a community characterized by very liberal political affiliation. Individuals living in a community characterized by centrist political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (63% vs 72%; adjusted risk ratio, 0.82; 95% confidence interval, 0.68-0.99) and influenza (44% vs 58%; adjusted risk ratio, 0.70; 95% confidence interval, 0.54-0.92) than those in a community characterized by very liberal political affiliation.

CONCLUSION

Compared with pregnant and postpartum individuals living in communities characterized by very liberal political beliefs, those living in communities characterized by very conservative political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19, and those in communities characterized by centrist political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis and influenza. Increasing vaccine uptake in the peripartum period may need to consider engaging an individual's broader sociopolitical milieu.

Outcomes of induction vs prelabor cesarean delivery at <33 weeks for hypertensive disorders of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy are the leading cause of indicated preterm birth; however, the optimal delivery approach for pregnancies complicated by preterm hypertensive disorders of pregnancy remains uncertain.

OBJECTIVE

This study aimed to compare maternal and neonatal morbidity in patients with hypertensive disorders of pregnancy who either went induction of labor or prelabor cesarean delivery at <33 weeks' gestation. In addition, we aimed to quantify the length of induction of labor and rate of vaginal delivery in those who underwent induction of labor.

STUDY DESIGN

This is a secondary analysis of an observational study which included 115,502 patients in 25 hospitals in the United States from 2008 to 2011. Patients were included in the secondary analysis if they were delivered for pregnancy associated hypertension (gestational hypertension or preeclampsia) between 230 and <330 weeks' gestation; and were excluded for known fetal anomalies, multiple gestation, fetal malpresentation or demise, or a contraindication to labor. Maternal and neonatal adverse composite outcomes were evaluated by intended mode of delivery. Secondary outcomes were duration of labor induction and rate of cesarean delivery in those who underwent labor induction.

RESULTS

A total of 471 patients met inclusion criteria, of whom 271 (58%) underwent induction of labor and 200 (42%) underwent prelabor cesarean delivery. Composite maternal morbidity was 10.2% in the induction group and 21.1% in the cesarean delivery group (unadjusted odds ratio, 0.42 [0.25-0.72]; adjusted odds ratio, 0.44 [0.26-0.76]). Neonatal morbidity in the induction group vs the cesarean delivery was 51.9% and 63.8 %, respectively (unadjusted odds ratio, 0.61 [0.42-0.89]; adjusted odds ratio, 0.71 [0.48-1.06]). The frequency of vaginal delivery in the induction group was 53% (95% confidence interval, 46.8-58.7) and the median duration of labor was 13.9 hours (interquartile range, 8.7-22.2). The frequency of vaginal birth was higher in patients at or beyond 29 weeks (39.9% at 240-286 weeks, 56.3% at 290-<330 weeks; P=.01).

CONCLUSION

Among patients delivered for hypertensive disorders of pregnancy <330 weeks, labor induction compared with prelabor cesarean delivery is associated with significantly lower odds of maternal but not neonatal morbidity. More than half of patients induced delivered vaginally, with a median duration of labor induction of 13.9 hours.

Association of Living in a Food Desert and Poor Periconceptional Diet Quality in a Cohort of Nulliparous Pregnant Individuals

BACKGROUND

A poor diet can result from adverse social determinants of health and increases the risk of adverse pregnancy outcomes.

OBJECTIVE

We aimed to assess, using data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be prospective cohort, whether nulliparous pregnant individuals who lived in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.

METHODS

The exposure was living in a food desert based on a spatial overview of food access indicators by income and supermarket access per the Food Access Research Atlas. The outcome was periconceptional diet quality per the Healthy Eating Index (HEI)-2010, analyzed by quartile (Q) from the highest or best (Q4, reference) to the lowest or worst dietary quality (Q1); and secondarily, nonadherence (yes or no) to 12 key aspects of dietary quality.

RESULTS

Among 7,956 assessed individuals, 24.9% lived in a food desert. The mean HEI-2010 score was 61.1 of 100 (SD: 12.5). Poorer periconceptional dietary quality was more common among those who lived in a food desert compared with those who did not live in a food desert (Q4: 19.8%, Q3: 23.6%, Q2: 26.5%, and Q1: 30.0% vs. Q4: 26.8%, Q3: 25.8%, Q2: 24.5%, and Q1: 22.9%; overall P < 0.001). Individuals living in a food desert were more likely to report a diet in lower quartiles of the HEI-2010 (i.e., poorer dietary quality) (aOR: 1.34 per quartile; 95% CI: 1.21, 1.49). They were more likely to be nonadherent to recommended standards for 5 adequacy components of the HEI-2010, including fruit, total vegetables, greens and beans, seafood and plant proteins, and fatty acids, and less likely to report excess intake of empty calories.

CONCLUSIONS

Nulliparous pregnant individuals living in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.

Cervical Pessary for Prevention of Preterm Birth in Individuals With a Short Cervix: The TOPS Randomized Clinical Trial

Importance

A short cervix as assessed by transvaginal ultrasound is an established risk factor for preterm birth. Study findings for a cervical pessary to prevent preterm delivery in singleton pregnancies with transvaginal ultrasound evidence of a short cervix have been conflicting.

Objective

To determine if cervical pessary placement decreases the risk of preterm birth or fetal death prior to 37 weeks among individuals with a short cervix.

Design, Setting, and Participants

We performed a multicenter, randomized, unmasked trial comparing a cervical pessary vs usual care from February 2017 through November 5, 2021, at 12 centers in the US. Study participants were nonlaboring individuals with a singleton pregnancy and a transvaginal ultrasound cervical length of 20 mm or less at gestations of 16 weeks 0 days through 23 weeks 6 days. Individuals with a prior spontaneous preterm birth were excluded.

Interventions

Participants were randomized 1:1 to receive either a cervical pessary placed by a trained clinician (n = 280) or usual care (n = 264). Use of vaginal progesterone was at the discretion of treating clinicians.

Main Outcome and Measures

The primary outcome was delivery or fetal death prior to 37 weeks.

Results

A total of 544 participants (64%) of a planned sample size of 850 were enrolled in the study (mean age, 29.5 years [SD, 6 years]). Following the third interim analysis, study recruitment was stopped due to concern for fetal or neonatal/infant death as well as for futility. Baseline characteristics were balanced between participants randomized to pessary and those randomized to usual care; 98.9% received vaginal progesterone. In an as-randomized analysis, the primary outcome occurred in 127 participants (45.5%) randomized to pessary and 127 (45.6%) randomized to usual care (relative risk, 1.00; 95% CI, 0.83-1.20). Fetal or neonatal/infant death occurred in 13.3% of those randomized to receive a pessary and in 6.8% of those randomized to receive usual care (relative risk, 1.94; 95% CI, 1.13-3.32).

Conclusions and Relevance

Cervical pessary in nonlaboring individuals with a singleton gestation and with a cervical length of 20 mm or less did not decrease the risk of preterm birth and was associated with a higher rate of fetal or neonatal/infant mortality.

Trial Registration

ClinicalTrials.gov Identifier: NCT02901626.

Maternal and Delivery Characteristics and Self-Reported Perceived Control During Labor

OBJECTIVE

To evaluate the association between maternal and delivery characteristics and self-reported perceived control during childbirth.

METHODS

A secondary analysis of a multicenter randomized trial was conducted to compare labor induction at 39 weeks of gestation with expectant management in low-risk nulliparous people. Six to 96 hours after delivery, participants who experienced labor completed the Labor Agentry Scale, a validated self-administered questionnaire to ascertain perceived control during childbirth. Scores range from 29 to 203, with higher scores indicating a sense of greater control. Multivariable linear regression was used to determine which maternal and delivery characteristics were associated with the Labor Agentry Scale score. Eligible characteristics included age, self-reported race and ethnicity, marital status, employment status, type of insurance, previous pregnancy loss before 20 weeks of gestation, body mass index (BMI), smoking, alcohol use, mode of delivery, labor pain (0-10 points), and a composite of perinatal death or severe neonatal complications. Significant variables ( P <.05) were retained in the final multivariable model, and adjusted mean differences (95% CIs) between groups were estimated.

RESULTS

Of 6,106 people enrolled in the trial, 6,038 experienced labor, of whom 5,750 (95.2%) completed the Labor Agentry Scale and were included in this analysis. Mean [95% CI] adjusted Labor Agentry Scale scores were significantly lower among those who identified as Asian (-6.4 [-10.5 to -2.3]) or Hispanic (-3.7 [-5.7 to -1.7]) compared with White, smoked compared with did not smoke (-2.8 [-5.5 to -0.1]), had BMIs of 35 or higher compared with less than 30 (-2.0 [-3.8 to -0.2]), were unemployed (-3.15 [-4.76 to -1.55]), did not have private health insurance (-2.61 [-4.47 to -0.76]), underwent operative vaginal (-5.1 [-7.7 to -2.6]) or cesarean (-14.4 [-16.1 to -12.6]) delivery compared with spontaneous vaginal delivery, and reported greater labor pain score of 8 or higher compared with less than 8 (-11.9 [-13.4 to -10.4]). Mean [95% CI] adjusted Labor Agentry Scale scores were significantly higher among people who were employed compared with unemployed (3.2 [1.6-4.8]) and had private compared with nonprivate insurance (2.6 [0.76-4.5]).

CONCLUSION

In nulliparous people at low risk, unemployment, lack of private health insurance, Asian race, Hispanic ethnicity, smoking, operative delivery, and more labor pain were associated with lower perceived control during labor.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT01990612.

Searching and visualizing genetic associations of pregnancy traits by using GnuMoM2b

Adverse pregnancy outcomes (APOs) are major risk factors for women's health during pregnancy and even in the years after pregnancy. Due to the heterogeneity of APOs, only few genetic associations have been identified. In this report, we conducted genome-wide association studies (GWAS) of 479 traits that are possibly related to APOs using a large and racially diverse study, Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b). To display the extensive results, we developed a web-based tool GnuMoM2b ( https://gnumom2b.cumcobgyn.org/ ) for searching, visualizing, and sharing results from GWAS of 479 pregnancy traits as well as phenome-wide association studies (PheWAS) of more than 17 million single nucleotide polymorphisms (SNPs). The genetic results from three ancestries (Europeans, Africans, and Admixed Americans) and meta-analyses are populated in GnuMoM2b. In conclusion, GnuMoM2b is a valuable resource for extraction of pregnancy-related genetic results and shows the potential to facilitate meaningful discoveries.

The value and limitations of using predetermined criteria in decision making for maternal-fetal interventions

Maternal-fetal interventions-such as prenatal fetal myelomeningocele (MMC) repair-are at the forefront of clinical innovation within maternal-fetal medicine, pediatric surgery, and neonatology. Many centers determine eligibility for innovative procedures using pre-determined inclusion and exclusion criteria based on seminal studies, for example, the "Management of Myelomeningocele Study" for prenatal MMC repair. What if a person's clinical presentation does not conform to predetermined criteria for maternal-fetal intervention? Does changing criteria on a case-by-case basis (i.e., ad hoc) constitute an innovation in practice and flexible personalized care or transgression of commonly held standards with potential negative consequences? We outline principle-based, bioethically justified answers to these questions using fetal MMC repair as an example. We pay special attention to the historical origins of inclusion and exclusion criteria, risks and benefits to the pregnant person and the fetus, and team dynamics. We include recommendations for maternal-fetal centers facing these questions.

The Temporal Relationship Between the Coronavirus Disease 2019 (COVID-19) Pandemic and Preterm Birth

OBJECTIVE

To evaluate whether preterm birth rates changed in relation to the onset of the coronavirus disease 2019 (COVID-19) pandemic and whether any change depended on socioeconomic status.

METHODS

This is an observational cohort study of pregnant individuals with a singleton gestation who delivered in the years 2019 and 2020 at 1 of 16 U.S. hospitals of the Maternal-Fetal Medicine Units Network. The frequency of preterm birth for those who delivered before the onset of the COVID-19 pandemic (ie, in 2019) was compared with that of those who delivered after its onset (ie, in 2020). Interaction analyses were performed for people of different individual- and community-level socioeconomic characteristics (ie, race and ethnicity, insurance status, Social Vulnerability Index (SVI) of a person's residence).

RESULTS

During 2019 and 2020, 18,526 individuals met inclusion criteria. The chance of preterm birth before the COVID-19 pandemic was similar to that after the onset of the pandemic (11.7% vs 12.5%, adjusted relative risk 0.94, 95% CI 0.86-1.03). In interaction analyses, race and ethnicity, insurance status, and the SVI did not modify the association between the epoch and the chance of preterm birth before 37 weeks of gestation (all interaction P >.05).

CONCLUSION

There was no statistically significant difference in preterm birth rates in relation to the COVID-19 pandemic onset. This lack of association was largely independent of socioeconomic indicators such as race and ethnicity, insurance status, or SVI of the residential community in which an individual lived.

Maternal psychosocial factors associated with postpartum pain

BACKGROUND

The experience of pain is shaped by a host of psychological, cultural, and social factors. Although pain is the most common postpartum complaint, data on its relationship with psychosocial factors and postpartum pain are limited.

OBJECTIVE

This study aimed to examine the relationship between self-reported postpartum pain scores and patient-level psychosocial factors, including relationship status, pregnancy intendedness, employment, education, and psychiatric diagnosis.

STUDY DESIGN

This was a secondary analysis of data from a prospective observational study of postpartum patients at 1 institution (May 2017 to July 2019) who used an oral opioid at least once during their postpartum hospitalization. Enrolled participants completed a survey, which included questions regarding their social situation (including relationship status), psychiatric diagnoses, and perceptions of their pain control during their postpartum hospitalization. The primary outcome was self-reported overall pain during the postpartum hospitalization (score of 0-100). Multivariable analyses accounted for age, body mass index, nulliparity, and mode of delivery.

RESULTS

In this cohort of 494 postpartum patients, most patients (84.0%) underwent cesarean delivery, and 41.3% of patients were nulliparous. In a pain score of 0 to 100, participants reported a median pain score of 47. On bivariable analyses, there was no significant difference in pain score between patients with and without an unplanned pregnancy or a psychiatric diagnosis. Patients who were unpartnered, those without a college education, and those who were unemployed reported significantly higher pain scores (57.5 vs 44.8 [P<.01], 52.6 vs 44.6 [P<.01], and 53.6 vs 44.6 [P<.01], respectively). In multivariable analyses, patients who were unpartnered and unemployed reported significantly higher adjusted pain scores than patients who were partnered and employed (adjusted beta coefficients: 7.93 [95% confidence interval, 2.29-13.57] vs 6.67 [95% confidence interval, 2.28-11.05]).

CONCLUSION

Psychosocial factors, such as relationship and employment statuses, which are indicators of social support, are associated with the experience of pain postpartum. These findings suggest that addressing social support, such as via enhanced support from the health care team, warrants exploration as a nonpharmacologic means of improving the postpartum pain experience.

Association of Neighborhood Socioeconomic Disadvantage and Postpartum Readmission

We assessed whether neighborhood socioeconomic disadvantage, as measured by the Area Deprivation Index (ADI), was associated with an increased risk of postpartum readmission. This is a secondary analysis from nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be), a prospective cohort of nulliparous pregnant individuals from 2010 to 2013. The exposure was the ADI in quartiles, and the outcome was postpartum readmission; Poisson regression was used. Among 9,061 assessed individuals, 154 (1.7%) were readmitted postpartum within 2 weeks of delivery. Individuals living with the most neighborhood deprivation (ADI quartile 4) were at increased risk of postpartum readmission compared with those living with the lowest neighborhood deprivation (ADI quartile 1) (adjusted risk ratio 1.80, 95% CI 1.11-2.93). Measures of community-level adverse social determinants of health, such as the ADI, may inform postpartum care after delivery discharge.

Can allostatic load in pregnancy explain the association between race and subsequent cardiovascular disease risk: A cohort study

OBJECTIVE

To assess the relationship between allostatic load, a measure of cumulative chronic stress in early pregnancy and cardiovascular disease risk, 2-7 years postpartum, and pathways contributing to racial disparities in cardiovascular disease risk.

DESIGN

Secondary analysis of a prospective cohort study.

SETTING MULTICENTER POPULATION

Pregnant women.

METHODS

Our primary exposure was high allostatic load in the first trimester, defined as at least 4 of 12 biomarkers (systolic blood pressure, diastolic blood pressure, body mass index, cholesterol, low-density lipoprotein, high-density lipoprotein, high-sensitivity C-reactive protein, triglycerides, insulin, glucose, creatinine and albumin) in the unfavourable quartile. Logistic regression was used to test the association between high allostatic load and main outcome adjusted for confounders: time from index pregnancy and follow up, age, education, smoking, gravidity, bleeding in the first trimester, index adverse pregnancy outcomes, and health insurance. Each main outcome component and allostatic load were analysed secondarily. Mediation and moderation analyses assessed the role of high allostatic load in racial disparities of cardiovascular disease risk.

MAIN OUTCOME MEASURE

Incident cardiovascular disease risk: hypertension, or metabolic disorders.

RESULTS

Cardiovascular disease risk was identified in 1462/4022 individuals (hypertension: 36.6%, metabolic disorder: 15.4%). After adjustment, allostatic load was associated with cardiovascular disease risk (adjusted odds ratio [aOR] 2.0, 95% CI 1.8-2.3), hypertension (aOR 2.1, 95% CI 1.8-2.4) and metabolic disorder (aOR 1.7, 95% CI 1.5-2.1). Allostatic load was a partial mediator between race and cardiovascular disease risk. Race did not significantly moderate this relationship.

CONCLUSIONS

High allostatic load during pregnancy is associated with cardiovascular disease risk. The relationships between stress, subsequent cardiovascular risk and race warrant further study.

Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery

BACKGROUND

Prophylactic use of tranexamic acid at the time of cesarean delivery has been shown to decrease the calculated blood loss, but the effect on the need for blood transfusions is unclear.

METHODS

We randomly assigned patients undergoing cesarean delivery at 31 U.S. hospitals to receive either tranexamic acid or placebo after umbilical-cord clamping. The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days post partum, whichever came first. Key secondary outcomes were estimated intraoperative blood loss of more than 1 liter (prespecified as a major secondary outcome), interventions for bleeding and related complications, the preoperative-to-postoperative change in the hemoglobin level, and postpartum infectious complications. Adverse events were assessed.

RESULTS

A total of 11,000 participants underwent randomization (5529 to the tranexamic acid group and 5471 to the placebo group); scheduled cesarean delivery accounted for 50.1% and 49.2% of the deliveries in the respective groups. A primary-outcome event occurred in 201 of 5525 participants (3.6%) in the tranexamic acid group and in 233 of 5470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% confidence interval [CI], 0.74 to 1.07; P = 0.19). Estimated intraoperative blood loss of more than 1 liter occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI, 0.79 to 1.05). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82 to 0.97); the change in the hemoglobin level was -1.8 g per deciliter and -1.9 g per deciliter, respectively (mean difference, -0.1 g per deciliter; 95% CI, -0.2 to -0.1); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI, 1.02 to 1.61). The frequencies of thromboembolic events and other adverse events were similar in the two groups.

CONCLUSIONS

Prophylactic use of tranexamic acid during cesarean delivery did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT03364491.).

Associations of the Neighborhood Built Environment with Gestational Weight Gain

OBJECTIVE

This study aimed to determine whether specific factors of the built environment related to physical activity and diet are associated with inadequate and excessive gestational weight gain (GWG).

STUDY DESIGN

This analysis is based on data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be, a prospective cohort of nulliparous women who were followed from the beginning of their pregnancies through delivery. At each study visit, home addresses were recorded and geocoded. Locations were linked to several built-environment characteristics such as the census tract National Walkability Score (the 2010 Walkability Index) and the number of gyms, parks, and grocery stores within a 3-km radius of residential address. The primary outcome of GWG (calculated as the difference between prepregnancy weight and weight at delivery) was categorized as inadequate, appropriate, or excessive based on weight gained per week of gestation. Multinomial regression (generalized logit) models evaluated the relationship between each factor in the built environment and excessive or inadequate GWG.

RESULTS

Of the 8,182 women in the analytic sample, 5,819 (71.1%) had excessive GWG, 1,426 (17.4%) had appropriate GWG, and 937 (11.5%) had inadequate GWG. For the majority of variables examined, built environments more conducive to physical activity and healthful food availability were associated with a lower odds of excessive or inadequate GWG category. For example, a higher number of gyms or parks within 3 km of a participant's residential address was associated with lower odds of having excessive (gyms: adjusted odds ratio [aOR] = 0.93 [0.89-0.96], parks: 0.94 [0.90-0.98]) or inadequate GWG (gyms: 0.91 [0.86-0.96]; parks: 0.91 [0.86-0.97]). Similarly, a higher number of grocery stores was associated with lower odds of having excessive GWG (0.94 [0.91-0.97]).

CONCLUSION

Among a diverse population of nulliparous women, multiple aspects of the built environment are associated with excessive and inadequate GWG.

KEY POINTS

· There are little data on the association between the built environment and pregnancy outcomes.. · Multiple aspects of the built environment are associated with excessive and inadequate GWG.. · These results suggest the role that neighborhood investment may play in improving pregnancy outcomes..

Racial and Ethnic Disparities in Adverse Perinatal Outcomes at Term

OBJECTIVE

 This study aimed to evaluate whether racial and ethnic disparities in adverse perinatal outcomes exist at term.

STUDY DESIGN

 We performed a secondary analysis of a multicenter observational study of 115,502 pregnant patients and their neonates (2008-2011). Singleton, nonanomalous pregnancies delivered from 37 to 41 weeks were included. Race and ethnicity were abstracted from the medical record and categorized as non-Hispanic White (White; referent), non-Hispanic Black (Black), non-Hispanic Asian (Asian), or Hispanic. The primary outcome was an adverse perinatal composite defined as perinatal death, Apgar score < 4 at 5 minutes, ventilator support, hypoxic-ischemic encephalopathy, subgaleal hemorrhage, skeletal fracture, infant stay greater than maternal stay (by ≥ 3 days), brachial plexus palsy, or facial nerve palsy.

RESULTS

 Of the 72,117 patients included, 48% were White, 20% Black, 5% Asian, and 26% Hispanic. The unadjusted risk of the primary outcome was highest for neonates of Black patients (3.1%, unadjusted relative risk [uRR] = 1.16, 95% confidence interval [CI]: 1.04-1.30), lowest for neonates of Hispanic patients (2.1%, uRR = 0.80, 95% CI: 0.71-0.89), and no different for neonates of Asian (2.6%), compared with those of White patients (2.7%). In the adjusted model including age, body mass index (BMI), smoking, obstetric history, and high-risk pregnancy, differences in risk for the primary outcome were no longer observed for neonates of Black (adjusted relative risk [aRR] = 1.06, 95% CI: 0.94-1.19) and Hispanic (aRR = 0.92, 95% CI: 0.81-1.04) patients. Adding insurance to the model lowered the risk for both groups (aRR = 0.85, 95% CI: 0.75-0.96 for Black; aRR = 0.68, 95% CI: 0.59-0.78 for Hispanic).

CONCLUSION

 Although neonates of Black patients have the highest frequency of adverse perinatal outcomes at term, after adjustment for sociodemographic factors, this higher risk is no longer observed, suggesting the importance of developing strategies that address social determinants of health to lessen extant health disparities.

KEY POINTS

· Term neonates of Black patients have the highest crude frequency of adverse perinatal outcomes.. · After adjustment for confounders, higher risk for neonates of Black patients is no longer observed.. · Disparities in outcomes are strongly related to insurance status..

Association Between Antenatal Depression Symptom Trajectories and Preterm Birth

OBJECTIVE

To evaluate whether, among pregnant people referred for mental health care, improvement in antenatal depression symptoms before delivery was associated with a reduction in preterm birth.

METHODS

This retrospective cohort study included all pregnant people referred to a perinatal collaborative care program for mental health care who delivered between March 2016 and March 2021. Those referred to the collaborative care program had access to subspecialty mental health treatment, including psychiatric consultation, psychopharmacotherapy, and psychotherapy. Depression symptoms were monitored with the self-reported PHQ-9 (Patient Health Questionnarie-9) screens in a patient registry. Antenatal depression trajectories were determined by comparing the earliest prenatal PHQ-9 score after collaborative care referral with the score closest to delivery. Trajectories were categorized as improved, stable, or worsened according to whether PHQ-9 scores changed by at least 5 points. Bivariable analyses were performed. A propensity score was generated to control for confounders that were significantly different on bivariable analyses according to trajectories. This propensity score was then included in multivariable models.

RESULTS

Of the 732 pregnant people included, 523 (71.4%) had mild or more severe depressive symptoms (PHQ-9 score 5 or higher) on their initial screen. Antenatal depression symptoms improved in 256 (35.0%), remained stable in 437 (59.7%), and worsened in 39 (5.3%); the corresponding incidence of preterm birth was 12.5%, 14.0%, and 30.8%, respectively ( P =.009). Compared with those with a worsened trajectory, pregnant people who had an improved antenatal depression symptom trajectory had a significantly decreased odds of preterm birth (adjusted odds ratio 0.37, 95% CI 0.15-0.89).

CONCLUSION

Compared with worsened symptoms, an improved antenatal depression symptom trajectory is associated with decreased odds of preterm birth for pregnant people referred for mental health care. These data further underscore the public health importance of incorporating mental health care into routine obstetric care.

Obstetric Provider Perspectives on Postpartum Patient Navigation for Low-Income Patients

BACKGROUND

Patient navigation programs have shown promise for improving health but are not widely used in obstetric care. Our objective was to understand obstetric provider perspectives on how to implement patient navigation to optimize care during the postpartum period for low-income patients.

METHOD

Focus groups were conducted with obstetric physicians, nurses, and social workers who care for low-income pregnant and postpartum patients in an academic medical center. Semistructured interview guides were developed to elicit conversations about the potential value of patient navigators, recommendations for navigator training, and how navigators could be most effective in improving postpartum care. Analysis of themes was based on the constant comparative method.

RESULTS

Twenty-six obstetric providers (six focus groups) discussed elements for a successful obstetric navigation program. Successful implementation themes included selecting navigators with appropriate interpersonal attributes, arranging navigator training, and identifying the most valuable services navigators could render. Desirable navigator attributes included persistence in patient advocacy, consistency, relatability, and a supportive manner. Training recommendations included learning the health care system, identifying where to obtain health system and community resources, and learning how be effective health educators. Suggested services were broad, ranging from traditional care coordination to specific educational and resource-driven tasks.

CONCLUSIONS

Obstetric providers perceive patient navigation to be a potentially beneficial resource to support low-income patients and offered recommendations for navigation implementation. These included suggestions for patient-centered navigators, with specific training and services focused on promoting care continuity and coordination.

Disparities in Continuous Glucose Monitoring Use Among Women of Reproductive Age with Type 1 Diabetes in the T1D Exchange

We identified characteristics associated with continuous glucose monitoring (CGM) use in women of reproductive age with type 1 diabetes (T1D) in the T1D Exchange clinic registry from 2015 to 2018. Among 6643 assessed women, the frequency of CGM increased from 2015 to 2018 (20.6% vs. 30.0%; adjusted odds ratios [aOR]: 1.72; confidence interval [95% CI]: 1.51-1.95) and was more likely with recent pregnancy (45.3% vs. 25.8%; aOR: 1.63; 95% CI: 1.23-2.16). Non-Hispanic Black and Hispanic race and ethnicity, younger age, lower educational attainment, lower income, and Medicaid insurance were associated with lower odds of CGM. The use of CGM was associated with lower odds of diabetic ketoacidosis and lower hemoglobin A1c without any difference in the odds of symptomatic severe hypoglycemia. In conclusion, although CGM use was associated with better glycemic control, the majority of reproductive-age women still did not use it. Those who did not use CGM were more likely to be those at greatest risk of adverse pregnancy outcomes.

Association of Social Determinants of Health and Clinical Factors with Postpartum Hospital Readmissions among Nulliparous Individuals

OBJECTIVE

Prior data suggest that there are racial and ethnic disparities in postpartum readmission among individuals, especially among those with hypertensive disorders of pregnancy. Existing reports commonly lack granular information on social determinants of health. The objective of this study was to investigate factors associated with postpartum readmission for individuals and address whether such risk factors differed by whether an individual had an antecedent diagnosis of a hypertensive disorder of pregnancy (HDP).

STUDY DESIGN

This is a secondary analysis of a large, multicenter prospective cohort study of 10,038 nulliparous participants. The primary outcome of this analysis was postpartum readmission. A priori, participants were analyzed separately based on whether they had HDP. Participant characteristics previously associated with a greater risk of perinatal morbidity or readmission (including social determinants of health, preexisting and chronic comorbidities, and intrapartum characteristics) were compared with bivariable analyses and retained in multivariable models if p < 0.05. Social determinants of health evaluated in this analysis included insurance status, self-identified race and ethnicity (as a proxy for structural racism), income, marital status, primary language, and educational attainment.

RESULTS

Of 9,457 participants eligible for inclusion, 1.7% (n = 165) were readmitted following initial hospital discharge. A higher proportion of individuals with HDP were readmitted compared with individuals without HDP (3.4 vs 1.3%, p < 0.001). Among participants without HDP, the only factors associated with postpartum readmission were chorioamnionitis and cesarean delivery. Among participants with HDP, gestational diabetes and postpartum hemorrhage requiring transfusion were associated with postpartum readmission. While the number of postpartum readmissions included in our analysis was relatively small, social determinants of health that we examined were not associated with postpartum readmission for either group.

CONCLUSION

In this diverse cohort of nulliparous pregnant individuals, there was a higher frequency of postpartum readmission among participants with HDP. Preexisting comorbidity and intrapartum complications were associated with postpartum readmission among this population engaged in a longitudinal study.

KEY POINTS

· Non-HDP patients had higher odds of PPR with chorioamnionitis or cesarean.. · HDP patients had higher odds of PPR if they had GDM or PPH.. · Characterizing PPR may identify and highlight modifiable factors..

The association between multidimensional sleep health and gestational weight gain: nuMoM2b Sleep Duration and Continuity Study

Background

Although poor sleep health is associated with weight gain and obesity in the non-pregnant population, research on the impact of sleep health on weight change among pregnant people using a multidimensional sleep-health framework is needed. This study examined associations among mid-pregnancy sleep health indicators, multidimensional sleep health, and gestational weight gain (GWG).

Methods

We conducted a secondary data analysis of the Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be Sleep Duration and Continuity Study (n=745). Indicators of individual sleep domains (i.e., regularity, nap duration, timing, efficiency, and duration) were assessed via actigraphy between 16 and 21 weeks of gestation. We defined "healthy" sleep in each domain based on empirical thresholds. Multidimensional sleep health was based on sleep profiles derived from latent class analysis. Total GWG, the difference between self-reported pre-pregnancy weight and the last measured weight before delivery, was converted to z-scores using gestational age- and BMI-specific charts. GWG was defined as low (<-1 SD), moderate (-1 or +1 SD), and high (>+1 SD).

Results

Nearly 50% of the participants had a healthy sleep profile (i.e., healthy sleep in most domains), whereas others had a sleep profile defined as having varying degrees of poor health in each domain. While indicators of individual sleep domains were not associated with GWG, multidimensional sleep health was related to low and high GWG. Participants with a sleep profile characterized as having low efficiency, late timing, and long sleep duration (vs. healthy sleep profile) had a higher risk (RR 1.7; 95% CI 1.0, 3.1) of low GWG a lower risk of high GWG (RR 0.5 95% CI 0.2, 1.1) (vs. moderate GWG).

Conclusions

Multidimensional sleep health was more strongly associated with GWG than individual sleep domains. Future research should determine whether sleep health is a valuable intervention target for optimizing GWG.

Synopsis

Study question: What is the association between mid-pregnancy multidimensional sleep health and gestational weight gain?What's already known?: Sleep is associated with weight and weight gain outside of pregnancyWhat does this study add?: We identified patterns of sleep behaviors associated with an increased risk of low gestational weight gain.

Implementation of postpartum navigation for low-income individuals at an urban academic medical center

BACKGROUND

Patient navigation, a patient-centered intervention to promote comprehensive health care, is an emerging innovation in obstetrics to optimize postpartum care. We aimed to evaluate the implementation of a novel postpartum patient navigation program at an urban academic medical center.

METHODS

This mixed-methods study analyzed the implementation of a postpartum patient navigation program within an ongoing randomized control trial. This study analyzed three navigators' logs of interactions with 50 patients, care team members, and community organizations throughout patients' first year postpartum. We categorized and quantified interactions by topic addressed, care team member interacted with, and communication mode used. We also conducted semi-structured interviews with each navigator every three months (5 interviews per navigator), emphasizing navigation experiences, relationships with patients and care teams, integration in the care team, and healthcare system gaps. Interview data were analyzed using the constant comparative method to identify themes using the constructs of the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Analysis of navigator logs revealed a high patient need level, especially in the first 3 months postpartum. CFIR-guided analysis of intervention characteristics revealed positive perceptions of navigation's utility due to its adaptability. Navigation's complexity, however, posed an early obstacle to implementation that diminished over time. Outer setting analysis indicated navigators addressed patient needs through interactions with multiple systems. Despite clinicians' initial unfamiliarity with navigation, inner setting analysis suggested ongoing communication and electronic medical record use facilitated integration into the care team. Regarding individual and process characteristics, findings emphasized how navigator self-efficacy and confidence increased with experience (individual) and was facilitated by comprehensive training and reflection (process). Overall, barriers to implementation included unfamiliarity, varied patient engagement, and innovation complexity. Facilitators included high patient need, communication with outside organizations, medical record usage, navigator characteristics (self-efficacy, communication skills, and personal growth), a comprehensive training period, consistent reflection, high relative advantage, and high adaptability to patient need.

CONCLUSION

Patient navigation is a promising innovation to improve postpartum care coordination and support care team efforts. The successful implementation of navigation in this study indicates that, if shown to improve patient outcomes, obstetric navigation could be a component of patient-centered postpartum care.

Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association

This scientific statement summarizes the available preclinical, epidemiological, and clinical trial evidence that supports the contributions of prepregnancy (and interpregnancy) cardiovascular health to risk of adverse pregnancy outcomes and cardiovascular disease in birthing individuals and offspring. Unfavorable cardiovascular health, as originally defined by the American Heart Association in 2010 and revised in 2022, is prevalent in reproductive-aged individuals. Significant disparities exist in ideal cardiovascular health by race and ethnicity, socioeconomic status, and geography. Because the biological processes leading to adverse pregnancy outcomes begin before conception, interventions focused only during pregnancy may have limited impact on both the pregnant individual and offspring. Therefore, focused attention on the prepregnancy period as a critical life period for optimization of cardiovascular health is needed. This scientific statement applies a life course and intergenerational framework to measure, modify, and monitor prepregnancy cardiovascular health. All clinicians who interact with pregnancy-capable individuals can emphasize optimization of cardiovascular health beginning early in childhood. Clinical trials are needed to investigate prepregnancy interventions to comprehensively target cardiovascular health. Beyond individual-level interventions, community-level interventions must include and engage key stakeholders (eg, community leaders, birthing individuals, families) and target a broad range of antecedent psychosocial and social determinants. In addition, policy-level changes are needed to dismantle structural racism and to improve equitable and high-quality health care delivery because many reproductive-aged individuals have inadequate, fragmented health care before and after pregnancy and between pregnancies (interpregnancy). Leveraging these opportunities to target cardiovascular health has the potential to improve health across the life course and for subsequent generations.