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Bullard KA, Ramanadhan S, Caughey AB, Rodriguez MI. Immediate Postpartum Long-Acting Reversible Contraception for Preventing Severe Maternal Morbidity: A Cost-Effectiveness Analysis. Obstet Gynecol 2024; 144:294-303. [PMID: 39053007 DOI: 10.1097/aog.0000000000005679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/06/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To estimate the cost effectiveness of Medicaid covering immediate postpartum long-acting reversible contraception (LARC) as a strategy to reduce future short interpregnancy interval (IPI), severe maternal morbidity (SMM), and preterm birth. METHODS We built a decision analytic model using TreeAge software to compare maternal health and cost outcomes in two settings, one in which immediate postpartum LARC is a covered option and the other where it is not, among a theoretical cohort of 100,000 people with Medicaid insurance who were immediately postpartum and did not have permanent contraception. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represents the incremental cost increase per an incremental quality-adjusted life-years (QALY) gained from one health intervention compared with another. Secondary outcomes included subsequent short IPI , defined as time between last delivery and conception of less than 18 months, as well as SMM, preterm birth, overall costs, and QALYs. We performed sensitivity analyses on all costs, probabilities, and utilities. RESULTS Use of immediate postpartum LARC was the cost-effective strategy, with an ICER of -11,880,220,102. Use of immediate postpartum LARC resulted in 299 fewer repeat births overall, 178 fewer births with short IPI, two fewer cases of SMM, and 34 fewer preterm births. Coverage of immediate postpartum LARC resulted in 25 additional QALYs and saved $2,968,796. CONCLUSION Coverage of immediate postpartum LARC at the time of index delivery can improve quality of life and reduce health care costs for Medicaid programs. Expanding coverage to include immediate postpartum LARC can help to achieve optimal IPI and decrease SMM and preterm birth.
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Affiliation(s)
- Kimberley A Bullard
- Department of Obstetrics and Gynecology, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee; and the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
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Diop H, Declercq ER, Liu CL, Cui X, Amutah-Onukagha N, Meadows AR, Cabral HJ. Leveraging a Longitudinally Linked Dataset to Assess Recurrence of Severe Maternal Morbidity. Womens Health Issues 2024; 34:498-505. [PMID: 39019744 DOI: 10.1016/j.whi.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 05/20/2024] [Accepted: 06/07/2024] [Indexed: 07/19/2024]
Abstract
OBJECTIVES Among those with a severe maternal morbidity (SMM) event and a subsequent birth, we examined how the risk of a second SMM event varied by patient characteristics and intrapartum hospital utilization. METHODS We used a Massachusetts population-based dataset that longitudinally linked in-state births, hospital discharge records, prior and subsequent births, and non-birth-related hospital utilizations for birthing individuals and their children from January 1, 1999, to December 31, 2018, representing 1,460,514 births by 907,530 birthing people. We restricted our study sample to 2,814 people who had their first SMM event associated with a singleton birth and gave birth a second time within the study period. Our outcome measure was recurrence of SMM in the second birth. We calculated the prevalence of SMM at second birth, compared SMM conditions between births, and estimated the adjusted risk ratios and 95% confidence intervals for having an SMM event at second birth among those who had an SMM at the first birth. We also examined overall hospital utilization including inpatient admissions, emergency room visits, and observational stays, and hospital utilization by interpregnancy intervals (IPIs) between the first and second birth. RESULTS There were 2,814 birthing people with at least one birth after the first SMM singleton birth. Among those, 198 (7.0%) had a subsequent SMM. The percentage of people with a second SMM event varied by age, race/ethnicity, insurance, IPI, and history of hypertension at first case of SMM (all p < .05). Between births, people with a second SMM event had significantly higher proportions of inpatient admissions (60.1% vs. 33.2.0%; p < .001), emergency room visits (71.7% vs. 57.7%; p < .001), and observational stays (35.4% vs. 19.5%; p < .001) compared with those who did not experience a second SMM event. CONCLUSION Hospital utilization after a birth with SMM might indicate an elevated risk of a second SMM event. Providers should counsel their patients about prevention and warning signs.
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Affiliation(s)
- Hafsatou Diop
- Massachusetts Department of Public Health, Boston, Massachusetts.
| | | | | | - Xiaohui Cui
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Ndidiamaka Amutah-Onukagha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Audra R Meadows
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, San Diego, California
| | - Howard J Cabral
- Boston University School of Public Health, Boston, Massachusetts
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3
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Eskild A, Skau I, Haavaldsen C, Saugstad OD, Grytten J. Short inter-pregnancy interval and birthweight: a reappraisal based on a follow-up study of all women in Norway with two singleton deliveries during 1970-2019. Eur J Epidemiol 2024:10.1007/s10654-024-01148-y. [PMID: 39179945 DOI: 10.1007/s10654-024-01148-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/07/2024] [Indexed: 08/26/2024]
Abstract
We studied mean changes in birthweight from the first to the second delivery according to length of the inter-pregnancy interval. We also studied recurrence risk of low birthweight, preterm birth and perinatal death. We followed all women in Norway from their first to their second singleton delivery at gestational week 22 or beyond during the years 1970-2019, a total of 654 100 women. Data were obtained from the Medical Birth Registry of Norway. Mean birthweight increased from the first to the second delivery, and the increase was highest in pregnancies conceived < 6 months after the first delivery; adjusted mean birthweight increase 227 g (g) (95% CI; 219-236 g), 90 g higher than in pregnancies conceived 6-11 months after the first delivery (137 g (95% CI; 130-144 g)). After exclusion of women with a first stillbirth, the mean increase in birthweight at inter-pregnancy interval < 6 months was attenuated (152 g, 95% CI; 143-160 g), but remained higher than at longer inter-pregnancy intervals. This finding was particularly prominent in women > 35 years (218 g, 95% CI; 139 -298 g). In women with a first live born infant weighing < 2500 g, mean birthweight increased by around 1000 g to the second delivery, and the increase was most prominent at < 6 months inter-pregnancy interval. We found increased recurrence risk of preterm birth at inter-pregnancy interval < 6 months, but no increased recurrence risk of low birthweight, small for gestational age infant or perinatal death. In conclusion, we found the highest mean increase in birthweight when the inter-pregnancy interval was short. Our results do not generally discourage short pregnancy intervals.
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Affiliation(s)
- Anne Eskild
- Division of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, 1478, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Irene Skau
- Department of Community Dentistry, University of Oslo, Oslo, Norway
| | - Camilla Haavaldsen
- Division of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, 1478, Norway
| | - Ola Didrik Saugstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Paediatric Research, Oslo University Hospital, Oslo, Norway
| | - Jostein Grytten
- Division of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, 1478, Norway
- Department of Community Dentistry, University of Oslo, Oslo, Norway
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Hu X, Yang Y, Wang L, Zhao C, Lyu X, Liu M, Wu H, Lei J, Li J, Yao M, Ding Y, Zhang H, He Y, Wang Y, Peng Z, Shen H, Wang Q, Zhang Y, Yan D, Yin J, Ma X. Interpregnancy Interval After Healthy Live Birth and Subsequent Spontaneous Abortion. JAMA Netw Open 2024; 7:e2417397. [PMID: 38884995 PMCID: PMC11184457 DOI: 10.1001/jamanetworkopen.2024.17397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Abstract
Importance Many studies have reported that the interpregnancy interval (IPI) is a potential modifiable risk factor for adverse perinatal outcomes. However, the association between IPI after live birth and subsequent spontaneous abortion (SA) is unclear. Objective To investigate the association of IPI after a healthy live birth and subsequent SA. Design, Setting, and Participants This prospective cohort study used data from 180 921 women aged 20 to 49 years who had a single healthy live birth and planned for another pregnancy and who participated in the Chinese National Free Prepregnancy Checkups Project from January 1, 2010, to December 31, 2020. Statistical analysis was conducted from June 20 to October 5, 2023. Exposure Interpregnancy interval, defined as the interval between the delivery date and conception of the subsequent pregnancy, was categorized as follows: less than 18 months, 18 to 23 months, 24 to 35 months, 36 to 59 months, and 60 months or longer. Main Outcomes and Measures The main outcome was SA. Multivariable-adjusted odds ratios (ORs) were calculated by logistic regression models to examine the association between IPI and the risk of SA. Dose-response associations were evaluated by restricted cubic splines. Results The analyses included 180 921 multiparous women (mean [SD] age at current pregnancy, 26.3 [2.8] years); 4380 SA events (2.4% of all participants) were recorded. A J-shaped association between IPI levels and SA was identified. In the fully adjusted model, compared with IPIs of 18 to 23 months, both short (<18 months) and long (≥36 months) IPIs showed an increased risk of SA (IPIs of <18 months: OR, 1.15 [95% CI, 1.04-1.27]; IPIs of 36-59 months: OR, 1.28 [95% CI, 1.15-1.43]; IPIs of ≥60 months: OR, 2.13 [95% CI, 1.78-2.56]). Results of the subgroup analysis by mode of previous delivery were consistent with the main analysis. Conclusions and Relevance This cohort study of multiparous women suggests that an IPI of shorter than 18 months or an IPI of 36 months or longer after a healthy live birth was associated with an increased risk of subsequent SA. The findings are valuable to make a rational prepregnancy plan and may facilitate the prevention of SA and improvement in neonatal outcomes.
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Affiliation(s)
- Xuan Hu
- National Research Institute for Family Planning, Beijing, China
- Department of Epidemiology and Health Statistics, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, China
- National Human Genetic Resources Center, Beijing, China
| | - Ying Yang
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Long Wang
- Institute of Epidemiology and Statistics, School of Public Health, Lanzhou University, Lanzhou, China
| | - Chuanyu Zhao
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Xinyi Lyu
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Meiya Liu
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
| | - Hanbin Wu
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
| | - Jueming Lei
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
| | - Jiaxin Li
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Mengxin Yao
- Department of Epidemiology and Health Statistics, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Yaling Ding
- Department of Epidemiology and Health Statistics, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Hongguang Zhang
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
| | - Yuan He
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Yuanyuan Wang
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Zuoqi Peng
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
| | - Haiping Shen
- Department of Maternal and Child Health, National Health Commission of the People's Republic of China, Beijing, China
| | - Qiaomei Wang
- Department of Maternal and Child Health, National Health Commission of the People's Republic of China, Beijing, China
| | - Yiping Zhang
- Department of Maternal and Child Health, National Health Commission of the People's Republic of China, Beijing, China
| | - Donghai Yan
- Department of Maternal and Child Health, National Health Commission of the People's Republic of China, Beijing, China
| | - Jieyun Yin
- Department of Epidemiology and Health Statistics, School of Public Health, Medical College of Soochow University, Suzhou, Jiangsu, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Major Chronic Non-communicable Diseases, Soochow University, Jiangsu, China
- MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Xu Ma
- National Research Institute for Family Planning, Beijing, China
- National Human Genetic Resources Center, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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Liang Y, Zhang L, Huang L, Li Y, Chen J, Bi S, Huang M, Tan H, Lai S, Liang J, Gu S, Jia J, Wen S, Wang Z, Cao Y, Wang S, Xu X, Feng L, Zhao X, Zhao Y, Zhu Q, Qi H, Zhang L, Li H, Du L, Chen D. Association between short inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery. J Matern Fetal Neonatal Med 2023; 36:2192853. [PMID: 36966813 DOI: 10.1080/14767058.2023.2192853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE To explore the association between inter-pregnancy intervals and placenta previa and placenta accreta spectrum among women who had prior cesarean deliveries with respect to maternal age at first cesarean delivery. METHODS This retrospective study included clinical data from 9981 singleton pregnant women with a history of cesarean delivery at 11 public tertiary hospitals in seven provinces of China between January 2017 and December 2017. The study population was divided into four groups (<2, 2-5, 5-10, ≥10 years of the interval) according to the inter-pregnancy interval. The rate of placenta previa and placenta accreta spectrum among the four groups was compared, and multivariate logistic regression was used to analyze the relationship between inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery. RESULTS Compared to women aged 30-34 years old at first cesarean delivery, the risk of placenta previa (aRR, 1.48; 95% CI, 1.16-1.88) and placenta accreta spectrum (aRR, 1.74; 95% CI, 1.28-2.35) were higher among women aged 18-24. Multivariate regression results showed that women at 18-24 with <2 years intervals exhibited a 5.05-fold increased risk for placenta previa compared with those with 2-5-year intervals (aRR, 5.05; 95% CI, 1.13-22.51). In addition, women aged 18-24 with less than 2 years intervals had an 8.44 times greater risk of developing PAS than women aged 30-34 with 2 to 5 years intervals (aRR, 8.44; 95% CI, 1.82-39.26). CONCLUSIONS The findings of this study suggested that short inter-pregnancy intervals were associated with increased risks for placenta previa, and placenta accreta spectrum for women under 25 years at first cesarean delivery, which may be partly attributed to obstetrical outcomes.
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Shao SJ, Cassidy AG, Alanizi A, Agarwal A, Sobhani NC. Contraceptive counseling and choices in pregnancies with maternal cardiac disease. J Matern Fetal Neonatal Med 2023; 36:2217318. [PMID: 37263627 DOI: 10.1080/14767058.2023.2217318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy. METHODS All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score. RESULTS Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was 'excellent' or 'good' in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options. CONCLUSION Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.
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Affiliation(s)
- Shirley J Shao
- School of Medicine, University of California San Francisco, CA, USA
| | - Arianna G Cassidy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco, CA, USA
| | - Aryn Alanizi
- School of Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Anushree Agarwal
- Department of Medicine, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Nasim C Sobhani
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of California, San Francisco, CA, USA
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Grünebaum A, Chervenak J, Pollet SL, Katz A, Chervenak FA. The exciting potential for ChatGPT in obstetrics and gynecology. Am J Obstet Gynecol 2023; 228:696-705. [PMID: 36924907 DOI: 10.1016/j.ajog.2023.03.009] [Citation(s) in RCA: 83] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
Natural language processing-the branch of artificial intelligence concerned with the interaction between computers and human language-has advanced markedly in recent years with the introduction of sophisticated deep-learning models. Improved performance in natural language processing tasks, such as text and speech processing, have fueled impressive demonstrations of these models' capabilities. Perhaps no demonstration has been more impactful to date than the introduction of the publicly available online chatbot ChatGPT in November 2022 by OpenAI, which is based on a natural language processing model known as a Generative Pretrained Transformer. Through a series of questions posed by the authors about obstetrics and gynecology to ChatGPT as prompts, we evaluated the model's ability to handle clinical-related queries. Its answers demonstrated that in its current form, ChatGPT can be valuable for users who want preliminary information about virtually any topic in the field. Because its educational role is still being defined, we must recognize its limitations. Although answers were generally eloquent, informed, and lacked a significant degree of mistakes or misinformation, we also observed evidence of its weaknesses. A significant drawback is that the data on which the model has been trained are apparently not readily updated. The specific model that was assessed here, seems to not reliably (if at all) source data from after 2021. Users of ChatGPT who expect data to be more up to date need to be aware of this drawback. An inability to cite sources or to truly understand what the user is asking suggests that it has the capability to mislead. Responsible use of models like ChatGPT will be important for ensuring that they work to help but not harm users seeking information on obstetrics and gynecology.
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Affiliation(s)
- Amos Grünebaum
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY.
| | - Joseph Chervenak
- Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Montefiore Hospital, Bronx, NY
| | - Susan L Pollet
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Adi Katz
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY
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Dong H, Chi J, Wang W, Liu L. Association between interpregnancy interval and maternal and neonatal adverse outcomes in women with a cesarean delivery: a population-based study. BMC Pregnancy Childbirth 2023; 23:284. [PMID: 37098470 PMCID: PMC10127338 DOI: 10.1186/s12884-023-05600-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/12/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Interpregnancy interval (IPI) has been linked with several maternal and neonatal adverse events in the general population. However, the association between IPI and maternal and neonatal outcomes in women whose first delivery was by cesarean delivery is unclear. We aimed to investigate the association between IPI after cesarean delivery and the risk of maternal and neonatal adverse events. METHODS Women (aged ≥ 18 years) whose first delivery was cesarean delivery with 2 consecutive singleton pregnancies from the National Vital Statistics System (NVSS) database between 2017 and 2019 were included in this retrospective cohort study. In this post-hoc analysis, logistic regression analyses were used to examine IPI (≤ 11, 12-17, 18-23 [reference], 24-35, 36-59, and ≥ 60 months) in relation to the risk of repeat cesarean delivery, maternal adverse events (maternal transfusion, ruptured uterus, unplanned hysterectomy, and admission to an intensive care unit), and neonatal adverse events (low birthweight, premature birth, Apgar score at 5 min < 7, and abnormal conditions of the newborn). Stratified analysis based on age (< 35 and ≥ 35 years) and previous preterm birth. RESULTS We included 792,094 maternities, 704,244 (88.91%) of which underwent a repeat cesarean delivery, 5,246 (0.66%) women had adverse events, and 144,423 (18.23%) neonates had adverse events. After adjusting for confounders, compared to an IPI of 18-23 months, the IPI of ≤ 11 months [odds ratio (OR) = 1.55, 95% confidence interval (CI): 1.44-1.66], 12-17 months (OR = 1.38, 95%CI: 1.33-1.43), 36-59 months (OR = 1.12, 95%CI: 1.10-1.15), and ≥ 60 months (OR = 1.19, 95%CI: 1.16-1.22) were associated with an increased risk of repeat cesarean delivery. In terms of maternal adverse events, only IPI of ≥ 60 months (OR = 0.85, 95%CI: 0.76-0.95) was observed to be associated with decreased risk of maternal adverse events in women aged < 35 years. In analysis of neonatal adverse events, IPI of ≤ 11 months (OR = 1.14, 95%CI: 1.07-1.21), 12-17 months (OR = 1.07, 95%CI: 1.03-1.10), and ≥ 60 months (OR = 1.05, 95%CI: 1.02-1.08) were related to an increased risk of neonatal adverse events. CONCLUSION Both short and long IPI were associated with an increased risk of repeat cesarean delivery and neonatal adverse events, and women < 35 years may benefit from a longer IPI.
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Affiliation(s)
- Hong Dong
- Department of Children's Medical Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jinghan Chi
- Senior Department of Pediatrics, The Seventh Medical Center of PLA General Hospital, Beijing, 100700, People's Republic of China
| | - Wei Wang
- Department of Radiology, The Seventh Medical Center of PLA General Hospital, Beijing, 100700, People's Republic of China
| | - Lei Liu
- Department of Comprehensive Treatment, The Second Medical Center of PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing, 100036, People's Republic of China.
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Abstract
PURPOSE OF REVIEW This review will focus on those who are at greatest risk of maternal and neonatal morbidity from a subsequent unplanned or short interval pregnancy and the interventions to increase contraceptive uptake in the postpartum period. RECENT FINDINGS Populations at highest risk of maternal or neonatal morbidity - those with a history of preterm birth or those with complex medical conditions - are also those at the highest risk for unintended pregnancies attributed to low-efficacy contraceptive failure/ noncontraceptive use, and many are discharged from birth hospitalization without understanding the importance of birth spacing related to their high-risk pregnancies. Current innovative strategies to improve postpartum contraception access and uptake among high-risk populations include utilizing the antenatal period to initiate contraception counseling, developing multidisciplinary teams, and incorporating multimedia-based educational tools. However, ongoing challenges that continue to pose barriers to contraception access include racial and economic disparities and the restructuring of obstetric care during the COVID-19 pandemic. SUMMARY Preventing an unintended short interval pregnancy by providing contraception in the postpartum period is one of the most modifiable risk factors for those at highest risk of subsequent maternal or neonatal morbidity and therefore should be prioritized by clinicians, hospitals, and insurance coverage.
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10
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Rodriguez MI, Martinez Acevedo A, Swartz JJ, Caughey AB, Valent A, McConnell KJ. Association of Prenatal Care Expansion With Use of Antidiabetic Agents During Pregnancies Among Latina Emergency Medicaid Recipients With Gestational Diabetes. JAMA Netw Open 2022; 5:e229562. [PMID: 35486400 PMCID: PMC9055460 DOI: 10.1001/jamanetworkopen.2022.9562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/12/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Access to necessary prenatal care is not guaranteed through Medicaid for some people with low income based on their immigration status. Although states have the option to extend emergency Medicaid coverage for prenatal care, many states have not expanded coverage. Objective To evaluate whether the receipt of prenatal care services through the extension of emergency Medicaid coverage is associated with an increase in antidiabetic medication use among Latina patients with gestational diabetes. Design, Setting, and Participants This cohort study used linked Medicaid claims and birth certificate data on live births to 4869 Latina patients from October 1, 2010, to December 31, 2019, with a difference-in-differences design to compare the rollout of prenatal care and services in Oregon in 2013 with a comparison state, South Carolina, that did not cover prenatal or postpartum care. Exposure Medicaid coverage of prenatal care. Main Outcomes and Measures The main outcome was the receipt of antidiabetic agents. Secondary outcomes included hypertensive disorders, cesarean delivery, postpartum contraception, and a newborn morbidity composite outcome (large size for gestational age, neonatal intensive care unit admission, and preterm birth). Results The study sample included live births to 4869 Latina patients (mean [SD] age, 32.7 [5.5] years [range, 12-44 years]) enrolled in emergency Medicaid who were mainly aged 25 to 34 years (1499 of 2907 [51.6%]), multiparous (2626 of 2907 [90.3%]), and living in urban areas (2299 of 2907 [79.1%]). After Oregon's policy change to offer prenatal coverage to individuals receiving emergency Medicaid, there was a large and significant increase in the receipt of antidiabetic agents among all people with diabetes during pregnancy (gestational diabetes). Prior to the policy, only 0.3% of all Latina emergency Medicaid recipients with gestational diabetes (2 of 617) received any medication (oral agents or insulin) to manage their blood glucose level. After the policy change, 28.8% of all patients with gestational diabetes (295 of 1023) received medication to manage their blood glucose level, translating to a 27.9-percentage-point increase (95% CI, 24.5-31.2 percentage points) in the receipt of antidiabetic agents in the adjusted model. The policy was also associated with a 10.4-percentage-point (95% CI, 5.3-15.5 percentage points) increase in insulin use during pregnancy among all patients with gestational diabetes. We observed an increase in postpartum contraceptive use (21.2 percentage points; 95% CI, 14.9-27.5 percentage points), the majority of which was due to postpartum sterilization (increase of 16.1 percentage points; 95% CI, 10.4-21.8 percentage points). We did not observe a significant association with gestational hypertension, cesarean births, or newborn health. Conclusions and Relevance This retrospective cohort study suggests that expanded emergency Medicaid benefits that included prenatal care were associated with an increased use of antidiabetic medications and postpartum contraception during pregnancy.
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Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Ann Martinez Acevedo
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Jonas J. Swartz
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Amy Valent
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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Nsiah I, Mali NV, Barnard M, Goswami S, Lyle C, Ramachandran S. The Influence of Social Determinants of Health on the Provision of Postpartum Contraceptives in Medicaid. Healthcare (Basel) 2022; 10:healthcare10020298. [PMID: 35206912 PMCID: PMC8871824 DOI: 10.3390/healthcare10020298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 12/10/2022] Open
Abstract
Disparities continue to exist in the timely provision of postpartum contraception. This study aimed to identify prevalence and factors associated with postpartum contraception provision among women enrolled in Medicaid. A retrospective cohort study was conducted using the 2014 National Medicaid data, linked to county-level social vulnerability index (SVI) data. Women aged 15–44 with a live birth in 2014 were included. Multivariable logistic regression was used to predict 3-day provision of long-acting reversible contraception (LARC) and 60-day provision of most effective or moderately effective contraceptives (MMEC). Overall, 3-day LARC provision was 0.2% while 60-day MMEC was 36.3%. Significantly lower odds of receiving MMEC was found among women aged 15–20 (adjusted odds ratio [aOR] = 0.87; 95% CI:0.86–0.89) compared to women 20–44 years as well as among Asian women (aOR = 0.69; 95% CI:0.66–0.72) and Hispanic women (aOR = 0.73; 95% CI:0.72–0.75) compared to White women. The provision of postpartum contraception remains low, generally, and needs attention in communities experiencing poor maternal outcomes.
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Affiliation(s)
- Irene Nsiah
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
| | - Nidhi Vij Mali
- Department of Public Policy Leadership, University of Mississippi, Oxford, MS 38677, USA;
| | - Marie Barnard
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
| | - Swarnali Goswami
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
| | - Christy Lyle
- Gainwell Technologies, 381 Highland Colony Parkway, Ridgeland, MS 39157, USA;
| | - Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, Oxford, MS 38677, USA
- Correspondence:
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Kurze und lange Schwangerschaftsintervalle begünstigen maternale Komplikationen. Geburtshilfe Frauenheilkd 2021. [DOI: 10.1055/a-1605-8179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Munoz JL, Hernandez B, Ireland KE, Ramsey PS. Short interval pregnancy is associated with pathology severity in placenta accreta spectrum (PAS). J Matern Fetal Neonatal Med 2021; 35:8863-8868. [PMID: 34818975 DOI: 10.1080/14767058.2021.2005571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a continuum of invasive pathologies associated with significant maternal morbidity and mortality. Pregnancies with short intervals present additional complications which may result from suboptimal wound healing. The impact of short interval pregnancy on placental invasion is unknown our primary objective was to characterize the impact of short interval pregnancy in the subsequent invasive degree of PAS. METHODS Here we present a retrospective case-control analysis of 133 patients with pathology-confirmed PAS who presented to our Placenta Accreta program and assessed for the impact of short interval pregnancy (<18 months) as an independent risk factor for the development of advanced pathology. RESULTS 33.8% (45/133) of patients with PAS had pregnancies complicated by short intervals between gestations. Short interval pregnancies were significantly associated with placenta percreta/increta pathology (p = .006). Ordinal logistic regression showed an inversely proportional relationship between short-interval pregnancy and the degree of placental invasion (OR 2.91 [95% CI 1.02, 4.05]). CONCLUSION Short interval pregnancies are at increased risk for greater degrees of placenta invasion seen in placenta increta and percreta when compared to interpregnancy interval >18 months. This relationship is inversely proportional and consistent at shorter intervals. Thus, when counseling patients on their overall risk of placental invasive pathology, short interval pregnancy may be considered a significant risk factor.
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Brian Hernandez
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Kayla E Ireland
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Patrick S Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health San Antonio, San Antonio, TX, USA
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