Disparities in Chronic Conditions Among Women Hospitalized for Delivery in the United States, 2005-2014

Prevalence of the number of pre-gestational diagnoses and trends in the United States in 2006 and 2016

Introduction: There is a trend in reproductive-aged women to live with more chronic conditions, likely resulting in pregnancies complicated by one or more pre-gestational diagnoses. The objective of this study is to determine the prevalence of women with pre-gestational diagnoses and pregnancy-related complications, and assess the trends of pre-gestational diagnoses between two time-points, ten-years apart from 2006 to 2016.Materials and methods: We abstracted pregnant patients from the Healthcare Cost and Utilization Project's National Inpatient Sample by the Agency for Healthcare Research and Quality in 2006 and 2016. We classified diagnosis codes, ICD 9 for 2006 and ICD 10 for 2016, as pre-gestational diagnoses or as pregnancy-related complications. Descriptive statistics were presented as frequencies and proportions for categorical variables. Chi-square analysis was performed. All statistical analyses were two-sided and p-value < .05 was considered to be statistically significant.Results: Between 2006 and 2016, the percentage of patients with at least one pre-gestational diagnoses increased from 35.3% in 2006 to 53.8% in 2016 (p < .0001) and the percentage of patients with at least one pregnancy-related complication increased from 62.6% to 69.1% (p < .0001). We found a trend of increasing pregnancy-related complications with an increasing number of pre-gestational diagnoses. The prevalence of asthma and obesity, either alone or in combination were found to rise over the ten-year time span.Conclusion: The percent of patients entering pregnancy with any pre-gestational diagnosis has increased, along with the number of pregnancy-related complications. Future research is needed to understand the effects of these diagnoses in combination and the possible impact on pregnancy outcomes.

Safe Start Community Health Worker Program: A Multisector Partnership to Improve Perinatal Outcomes Among Low-Income Pregnant Women With Chronic Health Conditions

Safe Start is a community health worker program representing a partnership between a high-volume, inner-city, hospital-based prenatal clinic; a community-based organization; a large Medicaid insurer; and a community behavioral health organization to improve perinatal outcomes among publicly insured pregnant women with chronic health conditions in Philadelphia, Pennsylvania. As of June 2019, 291 women participated in the program. Relative to a comparison group (n = 300), Safe Start participants demonstrate improved engagement in care, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays.

Enabling pregnant women and their physicians to make informed medication decisions using artificial intelligence

The role of artificial intelligence (AI) in healthcare for pregnant women. To assess the role of AI in women’s health, discover gaps, and discuss the future of AI in maternal health. A systematic review of English articles using EMBASE, PubMed, and SCOPUS. Search terms included pregnancy and AI. Research articles and book chapters were included, while conference papers, editorials and notes were excluded from the review. Included papers focused on pregnancy and AI methods, and pertained to pharmacologic interventions. We identified 376 distinct studies from our queries. A final set of 31 papers were included for the review. Included papers represented a variety of pregnancy concerns and multidisciplinary applications of AI. Few studies relate to pregnancy, AI, and pharmacologics and therefore, we review carefully those studies. External validation of models and techniques described in the studies is limited, impeding on generalizability of the studies. Our review describes how AI has been applied to address maternal health, throughout the pregnancy process: preconception, prenatal, perinatal, and postnatal health concerns. However, there is a lack of research applying AI methods to understand how pharmacologic treatments affect pregnancy. We identify three areas where AI methods could be used to improve our understanding of pharmacological effects of pregnancy, including: (a) obtaining sound and reliable data from clinical records (15 studies), (b) designing optimized animal experiments to validate specific hypotheses (1 study) to (c) implementing decision support systems that inform decision-making (11 studies). The largest literature gap that we identified is with regards to using AI methods to optimize translational studies between animals and humans for pregnancy-related drug exposures.

Pregnancy health in POWERMOM participants living in rural versus urban zip codes

Background:

Pregnant women living in rural locations in the USA have higher rates of maternal and infant mortality compared to their urban counterparts. One factor contributing to this disparity may be lack of representation of rural women in traditional clinical research studies of pregnancy. Barriers to participation often include transportation to research facilities, which are typically located in urban centers, childcare, and inability to participate during nonwork hours.

Methods:

POWERMOM is a digital research app which allows participants to share both survey and sensor data during their pregnancy. Through non-targeted, national outreach a study population of 3612 participants (591 from rural zip codes and 3021 from urban zip codes) have been enrolled so far in the study, beginning on March 16, 2017, through September 20, 2019.

Results:

On average rural participants in our study were younger, had higher pre-pregnancy weights, were less racially diverse, and were more likely to plan a home birth compared to the urban participants. Both groups showed similar engagement in terms of week of pregnancy when they joined, percentage of surveys completed, and completion of the outcome survey after they delivered their baby. However, rural participants shared less HealthKit or sensor data compared to urban participants.

Discussion:

Our study demonstrated the feasibility and effectiveness of enrolling pregnant women living in rural zip codes using a digital research study embedded within a popular pregnancy app. Future efforts to conduct remote digital research studies could help fill representation and knowledge gaps related to pregnant women.

Maternal comorbidity index and severe maternal morbidity during delivery hospitalizations in Texas, 2011-2014

BACKGROUND

Severe maternal morbidity (SMM) prevalence was 194.0 per 10 000 deliveries in Texas in 2015. Chronic, behavioral, and pregnancy-induced conditions, as captured by a maternal comorbidity index, increase the risk for delivery-related morbidity and mortality. The objective of the study was to examine the association between maternal comorbidity index and SMM among delivery hospitalizations in Texas.

METHODS

Delivery-related hospitalizations among Texan women aged 15-49 years were identified using the 2011-2014 Texas all-payer inpatient hospitalization public use data files (n = 1 434 441). The primary outcome of interest was SMM, based on the Alliance for Innovation on Maternal Health's coding scheme. The exposure of interest was a maternal comorbidity index. Multivariable logistic regression model was used to examine the association between maternal comorbidity index and SMM.

RESULTS

SMM prevalence remained consistent between 2011 and 2014 (196.0-197.0 per 10 000 deliveries, P > .05; n = 1 434 441). Nearly 40% of delivery-related hospitalizations had a maternal comorbidity index of at least 1, and the proportion of deliveries in the highest risk category of comorbidity index (≥5) increased by 12.0% from 2011 to 2014. SMM prevalence was highest among the youngest and oldest age groups. With each unit increase in maternal comorbidity index, the odds of SMM increase was 1.43 (95% CI 1.42-1.43).

CONCLUSIONS

Maternal comorbidity index is associated with SMM; however, the low predictive power of the model suggests that other, unmeasured factors may influence SMM in Texas. These findings highlight a need to understand broader contextual factors (practitioner, facility, systems of care, and community) that may be associated with SMM to reduce maternal morbidity and mortality in Texas.

Maternal Mortality and Public Health Programs: Evidence from Florida

Policy Points US maternal mortality rates (MMRs) display considerable racial disparities and exceed those of other developed countries. While worldwide MMRs have dropped sharply since the 1990s, the US MMR appears to be rising. We provide strong evidence of the effectiveness of pregnancy-related public health spending on improvements in maternal health. Using longitudinal data from Florida counties, we found that spending on public health significantly reduced the MMR among black mothers and narrowed black-white outcome disparities. Each 10% increase in pregnancy-related public health expenditures was associated with a 13.5% decline in MMR among blacks and a 20.0% reduction in black-white disparities.

CONTEXT

Maternal mortality rates in the United States exceed those of other developed countries. Moreover, these rates show considerable racial disparities, in which black mothers are at three to four times the risk compared with their white counterparts. With more than half of all maternal deaths deemed to be preventable, public health interventions have the potential to improve maternal health along with other pregnancy outcomes. This rigorous longitudinal study examines the impact of a package of pregnancy-related public health programs on maternal mortality rates.

METHODS

We analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties between 2001 and 2014. Florida provides consistent counts of maternal deaths for the entire period of this analysis. We estimated both fixed-effects ordinary least squares regressions (OLS) and generalized method of moments (GMM) models. GMM enabled us to identify the impact of public health expenditures on maternal mortality rates while also addressing both potential endogeneity and serial correlation problems. We also provide a series of robustness and falsification tests.

FINDINGS

Overall, a 10% increase in targeted public health expenditures led to a weakly significant decline in overall maternal mortality rates of 3.9%. The estimated effect for white mothers was not statistically significant. However, we found statistically significant improvements for black mothers. Specifically, a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20.0% reduction in the black-white maternal mortality gap.

CONCLUSIONS

Our analysis provides strong evidence of the effectiveness of public health programs in reducing maternal mortality rates and addressing racial disparities.

Overview of US Maternal Mortality Policy

The United States maternal mortality rate has been rising for many years putting the US out of step with peer countries. There are many complex reasons for the rise in maternal deaths and recent data has demonstrated that there is a disproportionate risk for women of color. This article provides an overview of current policy and policy issues aimed at improving the maternal mortality rate in the United States.

Marijuana Use and Potential Implications of Marijuana Legalization

Most states in the United States have legalized medical and/or recreational cannabis in response to public demand. Trends in states adopting such legislation demonstrate an increasing prevalence of cannabis use coincident to decreasing perceptions of risk of harm from cannabis products. When providing anticipatory guidance, pediatricians should be prepared to address childhood unintentional ingestion management and prevention, adolescent problem use, and cannabis as an alternative therapy for seizure disorders and other conditions.

Perceptions and Behaviors Related to Contraceptive Use in the Postpartum Period Among Women With Pregestational Diabetes Mellitus

OBJECTIVE

To describe perceptions and behaviors related to contraception and preconception care and to test the association between these perceptions and contraceptive use in the postpartum period among women with pregestational diabetes mellitus.

DESIGN

Cross-sectional, descriptive survey.

SETTING

Three high-risk obstetric clinics in the Southeastern United States.

PARTICIPANTS

Fifty-five women who were 18 years or older with pregestational Type 1 or Type 2 diabetes mellitus.

METHODS

Between 4 and 8 weeks after birth, we used investigator-developed items and psychometrically validated scales to measure participants' perceptions and behaviors related to contraception and preconception care. We dichotomized use of contraception in the postpartum period as procedure/prescription or nonprescription/no method. We used multiple logistic regression to test the hypothesis that perceptions are associated with contraceptive use.

RESULTS

When data were collected 4 to 8 weeks after birth, almost half (49%, n = 27) of the participants had resumed sexual activity; however, most (95%, n = 52) did not want another pregnancy in the next 18 months. Fifty-six percent (n = 31) of participants used procedure/prescription contraception, and 44% (n = 24) used nonprescription/no method. Those who perceived contraception use and preconception care to be beneficial were more likely to use procedure/prescription contraception (adjusted odds ratio = 1.52; 95% confidence interval [1.07, 2.17]).

CONCLUSION

When caring for women in the postpartum period, providers should be mindful that women's perceptions of the benefits of contraception and preconception care may have implications for whether their use aligns with their reproductive goals and optimizes outcomes for future pregnancies.

The best perinatal depression screening: Is self-administered PHQ2 more feasible than a nurse-administered one?

PURPOSE

To assess perinatal depression screening via self-administered PHQ2 (SAP) vs nurse-administered PHQ2 (NAP).

DESIGN AND METHODS

NAP screening was performed for 3 months, followed by SAP. Data were gathered from visits at 24 to 28 weeks gestation.

FINDINGS

One hundred twenty-seven patients were in NAP arm, 100 in SAP arm. SAP had higher rates of screening (odds ratio [OR], 3.25; 95% confidence interval [CI], 1.63-6.49), but no difference in positive PHQ2 screens. The SAP rate of therapeutic action for positive screens was lower (OR, 0.24; 95% CI, 0.12-0.50).

PRACTICE IMPLICATIONS

SAP provided higher perinatal depression screening rates compared to NAP, but decreased therapeutic action.

Obstetric Deliveries in US Women With ESKD: 2002-2015

RATIONALE & OBJECTIVE

Women with end-stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Women aged 18 to 44 years with ESKD and registered in the US Renal Data System from 2002 to 2015.

EXPOSURE

ESKD modality (hemodialysis [HD], peritoneal dialysis, transplantation).

OUTCOMES

Infant delivery, preterm delivery, cesarean delivery.

ANALYTICAL APPROACH

Unadjusted delivery rates were expressed as number of delivering women per 1,000 patient-years among women aged 18 to 44 years within each year during the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, preterm delivery, and cesarean delivery with patient characteristics.

RESULTS

The delivery rate in women undergoing HD and women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1,000 patient-years, respectively (P<0.001 for each). The delivery rate in patients undergoing peritoneal dialysis was lower and did not increase significantly (P=0.9). Women with a transplant were less likely to deliver preterm compared with women undergoing HD (OR, 0.92; 95% CI, 0.84-1.00), though more likely have a cesarean delivery (OR, 1.18; 95% CI, 1.06-1.31). For deliveries occurring in the 2012 to 2015 period, 75% of women treated with HD were prescribed 4 or fewer outpatient HD treatments per week and 25% were prescribed 5-plus treatments per week in the 30 days before delivery.

LIMITATIONS

Ascertainment of outcomes and comorbid conditions using administrative claims data.

CONCLUSIONS

The delivery rate in women of reproductive age with ESKD increased from 2002 to 2015 among those treated with transplantation or HD. Women with a functioning transplant were less likely to deliver preterm, but more likely to have a cesarean delivery. Prescriptions for outpatient intensified HD for pregnant women with ESKD were infrequent in 2012 to 2015.

Collective impact of chronic medical conditions and poverty on perinatal mental illness: population-based cohort study

BACKGROUND

Chronic medical conditions (CMCs) and poverty commonly co-occur and, while both have been shown to independently increase the risk of perinatal mental illness, their collective impact has not been examined.

METHODS

This population-based study included 853 433 Ontario (Canada) women with a singleton live birth and no recent mental healthcare. CMCs were identified using validated algorithms and disease registries, and poverty was ascertained using neighbourhood income quintile. Perinatal mental illness was defined as a healthcare encounter for a mental health or substance use disorder in pregnancy or the first year postpartum. Modified Poisson regression was used to test the independent impacts of CMC and poverty on perinatal mental illness risk, adjusted for covariates, and additive interaction between the two exposures was assessed using the relative excess risk due to interaction (RERI) and synergy index (SI).

RESULTS

CMC and poverty were each independently associated with increased risk of perinatal mental illness (CMC vs no CMC exposure: 19.8% vs 15.6%, adjusted relative risk (aRR) 1.21, 95% CI (CI) 1.20 to 1.23; poverty vs no poverty exposure: 16.7% vs 15.5%, aRR 1.06, 95% CI 1.05 to 1.07). However, measures of additive interaction for the collective impact of both exposures on perinatal mental illness risk were not statistically significant (RERI 0.02, 95% CI -0.01 to 0.06; SI 1.09, 95% CI 0.95 to 1.24).

CONCLUSION

CMC and poverty are independent risk factors for perinatal mental illness and should be assessed as part of a comprehensive management programme that includes prevention strategies and effective screening and treatment pathways.

Antenatal Testing for Women With Preexisting Medical Conditions Using Only the Ultrasonographic Portion of the Biophysical Profile

OBJECTIVE

To report the utility of the ultrasonographic biophysical profile, which includes all the components of a biophysical profile minus the nonstress test, in women with maternal indications for antepartum surveillance.

METHODS

We conducted a case series reviewing the records of all women at 32 weeks of gestation or greater with at least one indication for antenatal testing (per the American College of Obstetricians and Gynecologists) delivered by a single maternal-fetal medicine practice between 2006 and 2018. Indications included diabetes, hypertension, lupus, antiphospholipid syndrome, sickle cell disease, renal disease, heart disease, hyperthyroidism, isoimmunization, inherited thrombophilia, and prior intrauterine fetal demise. Weekly ultrasonographic biophysical profiles were initiated at 32 weeks of gestation. We calculated the test-positive rate, the percentage of women delivered for an abnormal ultrasonography biophysical profile, and the intrauterine fetal demise rate (false-negative rate).

RESULTS

Nine hundred eighty-five women underwent 3,981 ultrasonographic biophysical profiles (four per woman; range 1-11). Sixteen women had an abnormal ultrasonographic biophysical profile, for a test positive rate of 1.6% (95% CI 1.0-2.6%) per woman, or 0.4% (95% CI 0.3-0.7%) per ultrasonographic biophysical profile. Of the 16 women with abnormal ultrasonographic biophysical profiles, 13 were delivered with good outcomes and three women had normal follow-up testing and uncomplicated deliveries at a later date. There were three women with intrauterine fetal demise (false-negative rate of 0.3%, 95% CI 0.1-0.9%). One woman with intrauterine fetal demise had a factor V Leiden mutation, fetal ventriculomegaly, and fetal growth restriction. The second woman with intrauterine fetal demise had advanced maternal age, a factor V Leiden mutation, and fetal growth restriction. The third woman with intrauterine fetal demise had class B diabetes. All three intrauterine fetal demises were diagnosed antepartum with an interval from normal ultrasonographic biophysical profile to intrauterine fetal demise of 7, 7, and 6 days, respectively.

CONCLUSION

The use of ultrasonographic biophysical profile in a high-risk cohort is associated with a very low test-positive rate and a very low incidence of intrauterine fetal demise. In women with preexisting medical conditions that place them at higher risk for intrauterine fetal demise, ultrasonographic biophysical profile can be used for antenatal testing.

Colon-Gonzalez M. Reforming Women's Health Care: A Call to Action for Lifestyle Medicine Practitioners to Save Lives of Mothers and Infants

Maternal and infant mortality are fundamental indicators of a society's health and wellness. These measures depict a health crisis in the United States. Compared with other rich countries, women in the United States more frequently die from pregnancy or childbirth, and infants are less likely to survive to their first birthday. Most of these deaths are preventable; disproportionately affect diverse, low-income groups; and are perpetuated by social and health care inequities and subpar preventive care. Lifestyle medicine (LM) is uniquely positioned to ameliorate this growing crisis. The article presents key prescriptions for LM practitioners to build health and health equity for women. These prescriptions, summarized by the acronym PURER, include action in the areas of (1) practice, (2) understanding/empathy, (3) reform, (4) empowerment, and (5) relationship health. The PURER approach focuses on partnering with diverse female patients to promote resilience, promoting social connection and engagement, facilitating optimal family planning and advocating for culturally responsive, equitable health care systems. Through PURER, LM practitioners can help women and partners resiliently overcome the harmful challenges of discrimination and stress characterizing present-day American life. Over time, the equitable and collective practice of LM can help ameliorate the health care barriers undermining the health of women, families, and society.

Patient and hospital characteristics associated with severe maternal morbidity among postpartum readmissions

OBJECTIVE

To examine the influence of socioeconomic, clinical, and hospital characteristics on the risk of severe maternal morbidity among postpartum readmissions.

STUDY DESIGN

A cross-sectional analysis was conducted using the National Inpatient Sample 2006-2012 to estimate the risk of severe maternal morbidity and identify potential risk factors. Odds ratios were calculated using multivariate logistic regression.

RESULTS

Women aged ≥35 years (ages 35-39: OR 1.12 [CI 1.06, 1.19]; ages 40+: OR 1.27 [CI 1.17, 1.39]), non-Hispanic blacks (OR 1.16 [CI 1.10, 1.22]), and women with pre-existing medical conditions (OR 1.62 [CI 1.56, 1.68]) were at greater risk of severe maternal morbidity during postpartum readmissions. Women hospitalized outside the Northeast region (Midwest: OR 1.20 [CI 1.10, 1.30]; South: OR 1.29 [CI 1.20, 1.38]; West: OR 1.33 [CI 1.22, 1.44]) were also at increased risk.

CONCLUSION

The risk of severe maternal morbidity is heightened beyond delivery hospitalization for a subset of high-risk women.

Preconception Health: Changing the Paradigm on Well-woman Health

An investment in assuring the health of women, before pregnancy, can reap improved health for women, children, and their families. A paradigm shift of health must occur if perinatal outcomes are to improve, moving beyond reactive care to preventive or preconception care. Preconception health is centered on an assumption a woman is planning on becoming pregnant. But for many women, pregnancy is unplanned and medical conditions may have a negative impact on the trajectory of pregnancy and health. A new paradigm focusing on prevention and wellness can prepare women for lifelong health and healthy perinatal outcomes.

Interdelivery Interval and Diabetes Mellitus in a Subsequent Pregnancy

OBJECTIVE

We determined whether time between deliveries is associated with developing diabetes at the time of a subsequent delivery.

STUDY DESIGN

This is a case-control study of women who had two consecutive singleton births at the same institution with no pregestational diabetes in the baseline pregnancy. Cases were defined as women who were diagnosed with any type of diabetes at the time of the subsequent delivery. Controls were defined as women who had no diagnosis of diabetes at the time of the subsequent delivery. Interdelivery interval (IDI) was categorized as < 18, 18 to 60, or > 60 months.

RESULTS

Of 12,263 women, 4.1% (N = 501) were diagnosed with diabetes at the subsequent delivery. Women with diabetes were more likely to have an IDI of >60 months than women without diabetes (9.0 vs. 4.2%, p < 0.001). After controlling for confounding factors, an IDI > 60 months remained associated with development of pregestational or gestational diabetes by the conclusion of the subsequent pregnancy (adjusted odds ratio = 2.13 compared with an IDI of 18-60 months, 95% confidence interval 1.44-3.15).

CONCLUSION

A longer IDI is an independent risk factor for the development of diabetes at the time of a subsequent delivery.

Pulmonary Hypertension During Pregnancy in New York State, 2003-2014

Objectives This study examined the prevalence and temporal trends in (a) pulmonary hypertension (PH) during pregnancy and (b) mortality and morbidity during pregnancy with and without PH. Methods This was a retrospective observational study of the 2003-2014 New York State Inpatient Database. PH was categorized as primary or secondary and pregnancy as loss or termination of pregnancy, preterm birth, or term birth. The Centers for Disease Control and Prevention definition of maternal morbidity was used, including 17 diagnoses and 5 procedures. Changes were assessed using Cochran-Armitage trend tests. Results Of 2,940,868 pregnancy-related discharges, 746 indicated a diagnosis of PH (25/100,000; 95% CI 24-27). PH was secondary in 677/746 (91%) discharges and 488/746 were term births (65%). Prevalence of secondary PH increased from 17 to 30/100,000 between 2003- 2004 and 2013-2014 (+ 69%; P < 0.001), with an increase in the prevalence of heart valve disease, obesity, and systemic hypertension. Primary PH decreased 81% (P = 0.002). Term-birth PH discharges increased from 13 to 22/100,000 between 2003-2004 and 2013-2014 (+ 66%; P = 0.003), without change in preterm births and loss or termination of pregnancies. No change in morbidity in PH discharges was observed between 2003-2004 and 2013-2014, contrasting with a 64% increase in discharges without PH. Conclusions for Practice Prevalence of secondary PH during pregnancy markedly increased since 2003, underscoring the importance of screening for PH, especially in women with heart valve disease, obesity, or systemic hypertension.

Comorbid hypertension and diabetes among U.S. women of reproductive age: Prevalence and disparities

AIMS

Diabetes is associated with significant pregnancy complications, which can be further exacerbated by comorbid hypertension. Racial/ethnic differentials in the burden of comorbid hypertension and diabetes among women of reproductive age have not been described.

METHODS

Using Wave IV of the nationally representative National Longitudinal Study of Adolescent to Adult Health (Add Health), we analyzed survey and biological data from 6576 non-pregnant women who were aged 24-32 in 2007-2008. Hypertension and diabetes were identified by self-report of diagnosis and biological measurements taken during in-home interviews. We used logistic regression models to predict the presence of comorbid hypertension and diabetes and whether each was diagnosed.

RESULTS

Over a third (36.0%) of women with diabetes had comorbid hypertension. Compared to non-Hispanic white women, more non-Hispanic black women had comorbid hypertension and diabetes (adjusted odds ratio (aOR) 5.93, 95% CI 3.84-9.16), and, if comorbid, were less likely to have a diabetes diagnosis (aOR 0.03, 95% CI 0.007-0.1) or hypertension diagnosis (aOR 0.22, 95% CI 0.08-0.65).

CONCLUSION

Comorbid hypertension and diabetes are more common among non-Hispanic black women and less likely to be diagnosed, signaling disparities threatening maternal and child health among women with diabetes.

Amphetamine- and Opioid-Affected Births: Incidence, Outcomes, and Costs, United States, 2004-2015

Objectives. To estimate trends in incidence, outcomes, and costs among hospital deliveries related to amphetamines and opioids.Methods. We analyzed 2004-to-2015 data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States compiled by the Healthcare Cost and Utilization Project, by using a repeated cross-sectional design. We estimated the incidence of hospital deliveries related to maternal amphetamine or opioid use with weighted logistic regression. We measured clinical outcomes and costs with weighted multivariable logistic regression and generalized linear models.Results. Amphetamine- and opioid-related deliveries increased disproportionately across rural compared with urban counties in 3 of 4 census regions between 2008 to 2009 and 2014 to 2015. By 2014 to 2015, amphetamine use was identified among approximately 1% of deliveries in the rural West, which was higher than the opioid-use incidence in most regions. Compared with opioid-related and other hospital deliveries, amphetamine-related deliveries were associated with higher incidence of preeclampsia, preterm delivery, and severe maternal morbidity and mortality.Conclusions. Increasing incidence of amphetamine and opioid use among delivering women and associated adverse gestational outcomes indicate that amphetamine and opioid use affecting birth represent worsening public health crises.

A Planning Checklist for Interprofessional Consultations for Women in Midwifery Care

Team-based, interprofessional models of maternity care can allow women to receive personalized care based on their health needs and personal preferences. However, involvement of multiple health care providers can fragment care and increase communication errors, which are a major cause of preventable maternal morbidity and mortality. In order to improve communication within one health system, a community-engaged approach was used to develop a planning checklist for the care of women who began care with midwives but developed risks for poor perinatal outcomes. The planning checklist was constructed using feedback from women, nurses, midwives, and physicians in one interprofessional, collaborative network. In feasibility testing during 50 collaborative visits, the planning checklist provided a prompt to generate a comprehensive plan for maternity care and elucidate the rationale for interventions to women and future health care providers. In interviews after implementation of the checklist within a new collaborative format of prenatal physician consultations, women were pleased with the information received, and nurses, midwives, and physicians were positive about improved communication. This tool, developed with stakeholder input, was easy to implement and qualitatively beneficial to satisfaction and health system function. This article details the creation, implementation, and qualitative evaluation of the planning checklist. The checklist is provided and can be modified to meet the needs of other health systems.

The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of Design and Methodology

Data System. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state-based surveillance system of maternal behaviors, attitudes, and experiences before, during, and shortly after pregnancy. PRAMS is conducted by the Centers for Disease Control and Prevention's Division of Reproductive Health in collaboration with state health departments. Data Collection/Processing. Birth certificate records are used in each participating jurisdiction to select a sample representative of all women who delivered a live-born infant. PRAMS is a mixed-mode mail and telephone survey. Annual state sample sizes range from approximately 1000 to 3000 women. States stratify their sample by characteristics of public health interest such as maternal age, race/ethnicity, geographic area of residence, and infant birth weight. Data Analysis/Dissemination. States meeting established response rate thresholds are included in multistate analytic data sets available to researchers through a proposal submission process. In addition, estimates from selected indicators are available online. Public Health Implications. PRAMS provides state-based data for key maternal and child health indicators that can be tracked over time. Stratification by maternal characteristics allows for examinations of disparities over a wide range of health indicators.

Concurrent medical conditions among pregnant women - ignore at their peril: report from an antenatal anesthesia clinic

Background

Care of pregnant women with concurrent medical conditions can be optimized by multidisciplinary antenatal management. In the current study we describe women with concurrent medical conditions who attended our antenatal anesthesia clinic over a 14-year period, 2002–2015 and, based on the findings, we suggest new policies, strategies and practices to improve antenatal care.

Methods

In 2002, an antenatal anesthesia clinic was established in Hadassah Medical Center. Each consultation focused on the concurrent medical condition. A written anesthesia strategy according to the medical condition and its anesthesia considerations was discussed and given to the patient. Data regarding clinic visits were recorded.

Results

A total of 451 clinic women attended the antenatal anesthesia clinic. Maternal age was 31.7 ± 6.0 years (mean ± SD), with gestational age of pregnancy 33.0 ± 5.4 weeks at the clinic visit. Musculoskeletal conditions (23% of all the women seen) were the most frequent concurrent conditions, followed by anesthesia related concerns 20%, neurologic conditions 19%, and cardiac conditions 15%. Women were provided plans that were deliberated carefully rather than being concocted during labor.

Conclusions

A wide range of concurrent medical conditions was seen in the antenatal anesthesia clinic, however fewer women attended the clinic than expected according to known population frequencies of concurrent medical conditions. Women with concurrent medical conditions should have labor and anesthesia plans considered during the nine months of pregnancy, prior to delivery, and hospitals should have a means of obtaining this information in a timely manner. Finally, there is a need to develop additional antenatal anesthesia clinics.

Obstetric Outcomes and Delivery-Related Health Care Utilization and Costs Among Pregnant Women With Multiple Chronic Conditions

Our objective was to measure obstetric outcomes and delivery-related health care utilization and costs among pregnant women with multiple chronic conditions. We used 2013-2014 data from the National Inpatient Sample to measure obstetric outcomes and delivery-related health care utilization and costs among women with no chronic conditions, 1 chronic condition, and multiple chronic conditions. Women with multiple chronic conditions were at significantly higher risk than women with 1 chronic condition or no chronic conditions across all outcomes measured. High-value strategies are needed to improve birth outcomes among vulnerable mothers and their infants.