Maternal recall of distant pregnancy events

Physiological response during exercise is preserved in children exposed to a suboptimal gestational environment

OBJECTIVE

This study investigated whether exposure to suboptimal gestational factors (SGFs) alters mechanical efficiency (ME) and substrate oxidation during rest and exercise in children as a mechanism contributing to obesity.

METHODS

Data from the Quebec Adiposity and Lifestyle Investigation in Youth cohort were used. Children aged 8 to 10 years performed an incremental maximal cycling test with indirect calorimetry. Their ME was measured during submaximal and maximal effort. The substrate oxidation during rest and submaximal effort was also computed. ME and substrate oxidation results between children exposed to each SGF during pregnancy (gestational diabetes mellitus: n = 68; hypertensive disorders: n = 49; maternal smoking: n = 77) and nonexposed children (n = 370) were compared.

RESULTS

No difference was observed for ME during submaximal (F[3,540] = 0.46, p = 0.713) and maximal effort (F[3,545] = 0.86, p = 0.463) between exposed and nonexposed children. The percentage contributions of lipids and carbohydrates did not differ during rest (F[3,545] =1.68, p = 0.169) or submaximal exercise (F[3,544] = 0.31, p = 0.534) between exposed and nonexposed children.

CONCLUSIONS

Children exposed to investigated SGFs display a similar physiological response regarding ME and substrate oxidation during rest and exercise compared to nonexposed children. Future studies should confirm these novel results and continue investigating other research avenues to explain the higher risk of obesity in this population.

BMI status and weight trajectories across females' reproductive years and risk of adverse pregnancy outcomes: a prospective cohort study

BACKGROUND

Prepregnancy body mass index (BMI) is a well-established risk factor of adverse pregnancy outcomes (APOs). The associations of long-term and short-term weight trajectories with APOs are less clear.

OBJECTIVES

This study aimed to determine the associations of weight trajectories during females' reproductive years, before and between pregnancies, with risk of APOs.

METHODS

We followed 16,241 females (25,386 singleton pregnancies) participating in a prospective cohort, the Nurses' Health Study II. Weight at age 18 y, current weight, and height were assessed at baseline (1989), and weight was updated biennially. Pregnancy history was self-reported in 2009. The primary outcome was a composite of hypertensive disorders of pregnancy (HDP), gestational diabetes (GDM), preterm birth, and stillbirth. Secondary outcomes were individual APOs. The associations of weight change with APOs were estimated using log-binomial regression, adjusting for demographic, lifestyle, reproductive factors, and baseline BMI (in kg/m2).

RESULTS

The mean (standard deviation [SD]) age at first in-study pregnancy was 33.7 (4.1) y. The mean (SD) time from age 18 y to pregnancy, baseline to pregnancy, and between pregnancies was 16.3 (4.0), 6.1 (3.0), and 2.9 (1.6) y, with a corresponding weight change of 6.4 (9.1), 3.1 (5.8), and 2.3 (4.8) kg, respectively. Of the pregnancies, 4628 (18.2%) were complicated by ≥1 APOs. Absolute weight change since age 18 y was most strongly associated with APOs. Compared with females whose weight remained stable (0-2 kg) since age 18, females who gained >2 kg had higher risk of APO (2.1-9.9 kg, relative risk [RR]: 1.12; 95% confidence interval [CI]: 1.02, 1.23; 10.0-14.9 kg, RR: 1.43; 95% CI: 1.29, 1.60; ≥15 kg, RR: 1.87; 95% CI: 1.69, 2.08), primarily driven by HDP and GDM. The associations of per 1 kg weight gain before and between pregnancies with HDP were nearly identical.

CONCLUSIONS

Weight trajectories prior to and between pregnancies were associated with the risk of APOs, particularly HDP. Longer periods of weight gain, corresponding to greater absolute weight gain, were most strongly associated with higher risk of APOs.

Parent-identified gaps in preparation for the postpartum period in the United States: An integrative review

BACKGROUND

In the United States, 35% of all pregnancy-related deaths occur between 24 h and 6 weeks after delivery, yet the first outpatient visit is not typically scheduled until 6 weeks postpartum. Thus, the ability to independently navigate this period is critical to maternal well-being and safety. However, previous research suggests that many women feel unprepared to manage the challenges they encounter during this time, and there is a current need to synthesize the existing evidence. Therefore, the purpose of this integrative review is to describe parent-identified gaps in preparation for the postpartum period in the United States.

METHODS

Using the Integrative Review framework by Whittemore and Knafl, a systematic search of Medline, CINAHL, PsychInfo, Web of Science, and a hand-search was conducted for peer-reviewed articles published in English between 1995 and 2023. Results were reported according to PRISMA 2020 guidelines. Studies that met eligibility criteria were synthesized in a literature matrix.

RESULTS

Twenty-two studies met inclusion criteria. Four themes were identified: Mental Health Concerns, Physical Concerns, Infant Feeding and Care Concerns, and General Concerns and Recommendations. Many women, regardless of parity, reported feeling unprepared for numerous postpartum experiences, including depression, anxiety, physical recovery, breastfeeding, and infant care. Parents reported difficulty differentiating normal postpartum symptoms from complications. Hospital discharge teaching was viewed as simultaneously overwhelming and inadequate. Parent recommendations included the need for earlier and more comprehensive postpartum preparation during pregnancy, delivered in multiple formats and settings. Parents also reported the need for earlier postpartum visits and improved outpatient support.

CONCLUSIONS

Our findings indicate that many parents in the United States feel unprepared to navigate a wide variety of emotional, physical, breastfeeding, and infant-care experiences. Future research should explore innovative educational approaches to postpartum preparation during pregnancy as well as outpatient programs to bridge the current gaps in postpartum care.

Maternal health and pregnancy outcomes in autosomal dominant tubulointerstitial kidney disease

Introduction

Autosomal dominant tubulointerstitial kidney disease (ADTKD) is an increasingly recognized cause of chronic kidney disease. ADTKD pregnancy outcomes have not previously been described.

Methods

A cross-sectional survey was sent to women from ADTKD families.

Results

Information was obtained from 85 afffected women (164 term pregnancies) and 23 controls (50 pregnancies). Only 16.5% of genetically affected women knew they had ADTKD during pregnancy. Eighteen percent of ADTKD mothers had hypertension during pregnancy versus 12% in controls (p  =  0.54) and >40% in comparative studies of chronic kidney disease in pregnancy. Eleven percent of births of ADTKD mothers were <37 weeks versus 0 in controls (p < 0.0001). Cesarean section occurred in 19% of pregnancies in affected women versus 38% of unaffected individuals (p  =  0.06). Only 12% of babies required a neonatal intensive care unit stay.

Conclusions

ADTKD pregnancies had lower rates of hypertension during pregnancy versus other forms of chronic kidney disease, which may have contributed to good maternal and fetal outcomes.

The co-occurrence and cumulative prevalence of hypertension, rheumatoid arthritis, and hypothyroidism in preterm-born women in the Women's Health Initiative

Emerging evidence suggests that preterm-born individuals (<37 weeks gestation) are at increased risk of developing chronic health conditions in adulthood. This study compared the prevalence, co-occurrence, and cumulative prevalence of three female predominant chronic health conditions - hypertension, rheumatoid arthritis [RA], and hypothyroidism - alone and concurrently. Of 82,514 U.S. women aged 50-79 years enrolled in the Women's Health Initiative, 2,303 self-reported being born preterm. Logistic regression was used to analyze the prevalence of each condition at enrollment with birth status (preterm, full term). Multinomial logistic regression models analyzed the association between birth status and each condition alone and concurrently. Outcome variables using the 3 conditions were created to give 8 categories ranging from no disease, each condition alone, two-way combinations, to having all three conditions. The models adjusted for age, race/ethnicity, and sociodemographic, lifestyle, and other health-related risk factors. Women born preterm were significantly more likely to have any one or a combination of the selected conditions. In fully adjusted models for individual conditions, the adjusted odds ratios (aORs) were 1.14 (95% CI, 1.04, 1.26) for hypertension, 1.28 (1.12, 1.47) for RA, and 1.12 (1.01, 1.24) for hypothyroidism. Hypothyroidism and RA were the strongest coexisting conditions [aOR 1.69, 95% CI (1.14, 2.51)], followed by hypertension and RA [aOR 1.48, 95% CI (1.20, 1.82)]. The aOR for all three conditions was 1.69 (1.22, 2.35). Perinatal history is pertinent across the life course. Preventive measures and early identification of risk factors and disease in preterm-born individuals are essential to mitigating adverse health outcomes in adulthood.

The "Long-arm" of chronic conditions in childhood: Evidence from Canada using linked survey-administrative data

The objective of this study was to investigate the relationship between health conditions in childhood (ages 4-11), and health and socioeconomic outcomes in adulthood (ages 21-33). This study takes advantage of a new linkage between the National Longitudinal Survey of Children and Youth (NLSCY) and administrative tax data from the T1 Family File (T1FF) from Statistics Canada. The NLSCY includes rich longitudinal information on child development, while the T1FF includes administrative tax information on each child in adulthood (e.g., income, social assistance). The primary measures of child health relate to the diagnosis of a chronic condition, affecting the child's physical or mental/developmental health. The results suggest that mental/developmental health conditions in childhood more negatively influence adult health and socioeconomic conditions, compared to physical health conditions. Interaction models reveal modest heterogenous effects; for example, there is some evidence of a cushioning effect from higher household income in childhood, as well as an exacerbating negative effect from lower birth weight for mental/developmental health conditions. Using a covariate decomposition approach to explore underlying pathways, the results reveal that associations between health in early life and outcomes in adulthood are partially explained by differences in cognitive skills (i.e., mathematics test scores) in adolescence (ages 16-17). Results may encourage policy investments to mitigate the occurrence of health conditions in childhood and to ensure timely access to educational supports and health services for children with chronic conditions.

Testing effects of partner support and use of oral contraception during relationship formation on severity of nausea and vomiting in pregnancy

BACKGROUND

A recent study focusing on dietary predictors of nausea and vomiting in pregnancy (NVP) found that women with higher levels of partner support, and those who had used oral contraception (OC) when they met the father, both tended to report less severe NVP compared with previous non-users or those with less supportive partners. We provide a further test of these factors, using a large sample of women from four countries who retrospectively scored their NVP experience during their first pregnancy.

METHODS

We recruited women who had at least one child to participate in a retrospective online survey. In total 2321 women completed our questionnaire including items on demographics, hormonal contraception, NVP, and partner support. We used general linear models and path analysis to analyse our data.

RESULTS

Women who had used OC when they met the father of their first child tended to report lower levels of NVP, but the effect size was small and did not survive adding the participant's country to the model. There was no relationship between NVP and partner support in couples who were still together, but there was a significant effect among those couples that had since separated: women whose ex-partner had been relatively supportive reported less severe NVP. Additional analyses showed that women who were older during their first pregnancy reported less severe NVP, and there were also robust differences between countries.

CONCLUSIONS

These results provide further evidence for multiple influences on women's experience of NVP symptoms, including levels of perceived partner support.

Soy-Based Infant Formula Feeding and Uterine Fibroid Development in a Prospective Ultrasound Study of Black/African-American Women

BACKGROUND

Uterine fibroids are highly prevalent, benign tumors. They are the leading indication for hysterectomy, and Black women are disproportionally burdened. Soy-based infant formula contains phytoestrogens, and exposure during sensitive developmental windows may adversely affect the developing uterus; early phytoestrogen treatment in rodent studies led to detrimental uterine effects, including increased fibroid risk in Eker rats. Limited epidemiological studies also have suggested increased fibroid development with soy formula infant feeding.

OBJECTIVE

The goal of this study was to examine the association between soy formula feeding in infancy and fibroid development in adulthood.

METHODS

We evaluated this association among 1,610 Black/African-American women age 23-35 y in the Study of Environment, Lifestyle & Fibroids (SELF). Soy formula feeding data was gathered directly from the participants' mothers (89%). A standardized ultrasound examination was conducted during 4 clinic visits over 5 y to detect fibroids ≥0.5cm in diameter. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between soy formula feeding and incident fibroids adjusted for early-life and adult factors. Fibroid growth was calculated as change in log-volume for fibroids matched at successive visits.

RESULTS

Of 1,121 fibroid-free participants at baseline, 150 (13%) were ever fed soy formula as infants, and 269 (24%) developed incident fibroids. We did not observe an association between ever being fed soy formula and incident fibroid risk (HR=1.08; 95% CI: 0.75, 1.54). However, participants fed soy formula within 2 months of birth and for >6 months (n=53) had an elevated risk of fibroid incidence in comparison with those never fed soy formula (HR=1.56; 95% CI: 0.92, 2.65). Fibroid growth rates did not differ.

DISCUSSION

Adding support to limited human data, this prospective fibroid study found that soy-based formula feeding during infancy was associated with a suggestive increase in risk of ultrasound-identified incident fibroids in adulthood. https://doi.org/10.1289/EHP11089.

Experiences of pregnant women exposed to Hurricanes Irma and Maria in the US Virgin Islands: a qualitative study

INTRODUCTION

Hurricanes Irma and Maria made landfall in the US Virgin Islands (USVI) in 2017. To date, there is no published literature available on the experiences of pregnant women in the USVI exposed to these hurricanes. Understanding how hurricanes affect pregnant women is key to developing and executing targeted hurricane preparedness and response policies. The purpose of this study was to explore the experiences of pregnancy and birth among women in the USVI exposed to Hurricanes Irma and Maria.

METHODS

We employed a qualitative descriptive methodology to guide sampling, data collection, and analysis. Semi-structured interviews of 30-60 min in length were conducted with a purposive sample of women (N = 18) in the USVI who were pregnant during or became pregnant within two months after the hurricanes. Interviews were transcribed verbatim and data managed in MAXQDA. Team members developed a codebook, applied codes for content, and reconciled discrepancies. We thematically categorized text according to a socioecological conceptual framework of risk and resilience for maternal-neonatal health following hurricane exposure.

RESULTS

Women's experiences were organized into two main categories (risk and resilience). We identified the following themes related to risk at 3 socioecological levels including: (1) individual: changes in food access (We had to go without) and stress (I was supposed to be relaxing); (2) household/community: diminished psychosocial support (Everyone was dealing with their own things) and the presence of physical/environmental hazards (I was really scared); and (3) maternity system: compromised care capacity (The hospital was condemned). The themes related to resilience included: (1) individual: personal coping strategies (Being calm); (2) household/community: mutual psychosocial and tangible support (We shared our resources); and (3) the maternity system: continuity of high-quality care (On top of their game).

CONCLUSIONS

A socioecological approach provides a useful framework to understand how risk and resilience influence the experience of maternal hurricane exposure. As the frequency of the most intense hurricanes is expected to increase, clinicians, governments, and health systems should work collaboratively to implement hurricane preparedness and response plans that address pregnant women's unique needs and promote optimal maternal-infant health.

The prevalence of documented cardiovascular-related pregnancy complications: cross-sectional study in an academic primary care centre

BACKGROUND

Pregnancy and the postpartum period offer a unique opportunity to identify patients with risk factors leading to premature cardiovascular disease (CVD), which often go unrecognised.

AIM

This study investigates self-reported prevalence of CVD-related pregnancy complications and its documentation in electronic medical records (EMRs) in an academic family health team (AFHT).

DESIGN & SETTING

A retrospective cross-sectional survey conducted from 2016 to 2017 in an AFHT.

METHOD

The survey assessed self-reported pregnancy complications and obstetric histories of adult females. EMRs of responders who provided consent were appraised for documented pregnancy complications, and management of traditional cardiovascular risk factors post-pregnancy.

RESULTS

Out of 211 responders, 28% (n = 60) had at least one pregnancy complication reported in the survey and/or in the EMR, of which 67% (n = 40) had the complication documented in their EMR. The most prevalent complications were preterm birth (PTB; 12%, n = 25), hypertensive disorders of pregnancy (HDP; 10%, n = 22), and gestational diabetes mellitus (GDM; 7%, n = 14). Twenty-nine per cent (n = 4) of the patients with GDM had a 75 g oral glucose tolerance test result documented post-pregnancy. Of those with HDP, 36% (n = 8) had body mass index and 50% (n = 11) had a blood pressure measurement recorded after delivery.

CONCLUSION

There has been a significant lack of documentation of pregnancy-related cardiovascular risk factors and subsequent management, introducing a missed opportunity for early cardiovascular intervention. Adequate documentation of pregnancy complications in the EMR and better transitions in care between obstetric and primary care teams could potentially enable clinicians to intervene early and better manage females at increased risk of CVD.

Pre-pregnancy fat intake in relation to hypertensive disorders of pregnancy

BACKGROUND

Many studies have linked intakes of fat and of specific fatty acids during pregnancy with preeclampsia; however, information on the association of intake before pregnancy with hypertensive disorders of pregnancy (HDP) is scant.

OBJECTIVES

We evaluated the associations of intakes of major and specific types of fat before pregnancy with the risks of HDP, including preeclampsia and gestational hypertension (GHTN).

METHODS

We followed 11,535 women without chronic disease participating in the Nurses' Health Study II from 1991 and 2009. Pre-pregnancy dietary fat was assessed by an FFQ. Intakes of total fat, saturated fat, trans fatty acid (TFA), MUFAs, PUFAs, and fat subtypes (omega-3 and omega-6) were categorized into quintiles of intake. HDP were self-reported. The RRs (95% CIs) of HDP were estimated by log-binomial generalized estimating equation regression models, with an exchangeable correlation matrix to account for repeated pregnancies while adjusting for potential confounders.

RESULTS

During 19 years of follow-up, there were 495 cases of preeclampsia (2.9%) and 561 (3.3%) cases of GHTN in 16,892 singleton pregnancies. The mean age at pregnancy was 34.6 years (SD, 3.9 years). Among major fat types, only pre-pregnancy TFA was related to a higher risk of HDP (RR, 1.32; 95% CI: 1.05-1.66), and only for preeclampsia (RR, 1.50; 95% CI: 1.07-2.10) but not for GHTN (RR, 1.21; 95% CI: 0.87-1.70). Among specific types of PUFAs, intake of arachidonic acid was positively related with GHTN (RR, 1.43; 95% CI: 1.00-2.04) but not preeclampsia (RR, 1.08; 95% CI: 0.75-1.57). In analyses restricted to pregnancies 1 year after the diet assessment, women with the highest intake of long-chain omega-3 fatty acids had a 31% lower risk of HDP (95% CI: 3%-51%), which was driven by preeclampsia (RR, 0.55; 95% CI: 0.33-0.92).

CONCLUSIONS

Pre-pregnancy intakes of total fat, saturated fat, and MUFA were unrelated to HDP, whereas TFA was positively related to HDP. These findings highlight the importance of ongoing efforts to eliminate TFA from the global food supply.

Biomarkers of pre-pregnancy allostatic load and subsequent adverse birth outcomes

Racial disparities in birth outcomes are seemingly intractable. Using person-centered methods and drawing from the life course and Weathering Hypothesis literatures, we used data from the National Longitudinal Study of Adolescent to Adult Health to group non-Hispanic White and non-Hispanic Black women ages 24-34 into latent classes based on pre-pregnancy biomarkers of allostatic load. Stratified analyses yielded four latent classes among non-Hispanic White women, characterized by: 1) high blood pressure, 2) high body mass index and waist circumference, 3) high total cholesterol and triglycerides, and low high-density lipoprotein, and 4) low-risk, and two latent classes among non-Hispanic Black women, characterized by: 1) high body mass index and waist circumference, and moderate-risk blood pressure, hbA1c, and c-reactive protein, and 2) low-risk. Allostatic load class membership and other maternal- and infant-level covariates were then included simultaneously as predictors of three separate dichotomous outcomes: preterm birth, macrosomia, and low birth weight in multilevel logistic regression models. In a separate multilevel linear regression model, the same variables were simultaneously entered to predict continuously measured birthweight. In multilevel, multivariate models, White women in the high-risk body mass index and waist circumference class, as compared to the high-risk blood pressure class, had infants with higher birthweights. Other comparisons were not significant or not of meaningful magnitude. Prioritizing temporality so that allostatic load measurement preceded first birth likely biased the composition of the analytical sample. Additional research is needed to help medical providers and public health practitioners understand the complex biological and social mechanisms underlying inequities in birth outcomes and identify prevention strategies.

To Be Active or to Stop? A Cross-Sectional Retrospective Study Exploring Provider Advice and Patient Fears Surrounding Physical Activity in Pregnancies Complicated by Fetal Growth Restriction

Exercise guidance for women with pregnancies complicated by fetal growth restriction (FGR) is vague, despite the fact that physical activity during pregnancy improves placental development, placental blood flow, and encourages healthy fetal growth. The goal of this study is to test the hypothesis that women with pregnancies complicated by FGR are fearful of physical activity and are being given unclear or limited advice from healthcare providers. Participants (N = 78) (women who delivered an infant diagnosed with FGR within the past 5 years) took an electronic survey including demographic information, pregnancy information, provider advice recall, and other health-related information relevant to growth-restricted pregnancies. Quantitative and qualitative (post-positivism paradigm) methods were employed to analyze the data. When asked specifically about how the FGR diagnosis impacted their activity levels, nearly 50% of participants said the diagnosis led them to decrease their activity levels. Participants reported that healthcare providers who do discuss activity with pregnant patients with FGR suggest low-intensity activities or ceasing activity, although the majority of providers did not discuss activity at all. More fears surrounding physical activity were reported post-FGR diagnosis, including worrying about fetal growth and development and causing fetal harm when engaging in physical activity.

Social Determinant of Housing Instability and Adverse Pregnancy Outcomes: A Scoping Review

BACKGROUND

We conducted a scoping review to examine the literature regarding pregnancy-related morbidities among birthing individuals and infants experiencing housing instability (HI).

METHODS

Articles were identified through electronic database searches, using numerous search terms related to pregnancy and housing. US studies published in English between 1991 and 2019 were included. Peer-reviewed qualitative and quantitative articles were synthesized and critically appraised by 2 reviewers using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

Inconsistent definitions for HI weakened the rigor of aggregate findings, and birthing individual outcomes were underreported compared with infant outcomes (n = 9 095 499 women, 11 articles). Many studies reported mental health-related outcomes among birthing individuals with HI.

DISCUSSION

Study sampling approaches and lack of a standard definition of HI limit review findings, but examining this relationship is critical to understanding the effect of social determinants on birthing individual health. Future research should address the nescience regarding birthing individual outcomes in this population. Policy-level advocacy addressing social determinants must also refine policy impacting community-based prenatal programs and services for the birthing individual with HI.

Racial inequities in the course of treating perinatal mental health challenges: Results from listening to mothers in California

BACKGROUND

Concern with depression during the perinatal period has resulted in multiple states enacting legislation to require universal screening of mothers for postpartum depression. Despite this concern, rates of women receiving mental health counseling during pregnancy and postpartum remain low. This study examines factors, especially inequities in race/ethnicity, associated with receiving perinatal mental health counseling.

METHODS

This study draws on data from the Listening to Mothers in California survey of 2539 women, based on a representative sample of birth certificate files of women who gave birth in 2016. The survey included a series of mental health questions, based on the 4-item Patient Health Questionnaire (PHQ-4), and questions on the receipt of counseling, whether a practitioner asked respondents about their mental health, and whether the respondent was taking medications for anxiety or depression.

RESULTS

We found non-Latina Black women to experience both higher rates of prenatal depressive symptoms and significantly lower use of postpartum counseling services and medications than non-Latina White women. Among women with depressive symptoms, those asked by a practitioner about their mental health status reported a 46% rate of counseling compared with 20% who were not asked, and in a multivariable analysis, those asked were almost six times more likely (aOR 5.96; 95% CI 1.6-21.7) to report counseling.

DISCUSSION

These findings lend evidence to those advocating for state laws requiring universal screening for depressive symptoms to reduce inequities and help address the underuse of counseling services among all women with depressive symptoms, particularly women of color.

Physical activity before pregnancy and the risk of hypertensive disorders of pregnancy

BACKGROUND

It is unclear whether prepregnancy physical activity influences the risk of hypertensive disorders of pregnancy and whether any impact is similar for preeclampsia and gestational hypertension.

OBJECTIVE

To evaluate the relation of prepregnancy physical activity with hypertensive disorders of pregnancy and its alignment with the current recommendations for physical activity for the general population.

STUDY DESIGN

We studied 28,147 singleton pregnancies from 18,283 women without chronic hypertension, cardiovascular disease, or cancer, participating in the Nurses' Health Study-II between 1989 and 2010. The women self-reported their physical activity before pregnancy and pregnancy complications, including preeclampsia and gestational hypertension. Logistic regression models using generalized estimating equations to account for within-woman correlations across pregnancies were used to estimate the relative risk (95% confidence interval) of preeclampsia and gestational hypertension across quartiles of prepregnancy physical activity, adjusting for age at pregnancy, parity, smoking, multivitamin use, infertility history, marital status, race, year of pregnancy, and history of preeclampsia.

RESULTS

We identified 842 (3.0%) pregnancies with preeclampsia and 905 (3.2%) pregnancies with gestational hypertension. Physical activity before pregnancy was related to a lower risk of hypertensive disorders of pregnancy (relative risk, 0.75 [95% confidence interval, 0.65-0.87] for women in the highest quartile compared with the lowest quartile). This relation was driven by a 39% lower risk of gestational hypertension (relative risk, 0.61; 95% confidence interval, 0.50-0.76) comparing women in the highest quartile of physical activity (≥30.6 metabolic equivalents of task-hours/week) vs women in the lowest quartile (<6.0 metabolic equivalents of task-hours/week). Women whose moderate physical activity levels exceeded those recommended in the Physical Activity Guidelines for Americans (>5 hours/week) had a 50% lower (relative risk, 0.50; 95% confidence interval, 0.36-0.69) risk of gestational hypertension than women who did not meet this recommendation (<2.5 hours/week). For vigorous physical activity, the risk of gestational hypertension was lower among the women who met (1.25-2.5 hours/week; relative risk, 0.77; 95% confidence interval, 0.64-0.93) or exceeded (>2.5 hours/week; relative risk, 0.76; 95% confidence interval, 0.62-0.92) the recommendations than women whose activity levels were below those recommended. Physical activity was not related to the risk of preeclampsia (relative risk, 0.93; 95% confidence interval, 0.76-1.14).

CONCLUSION

Physical activity before pregnancy may lower the risk of developing gestational hypertension but not preeclampsia.

Causes of Death in End-Stage Kidney Disease: Comparison between the United States Renal Data System and a Large Integrated Health Care System

INTRODUCTION

Using a large diverse population of incident end-stage kidney disease (ESKD) patients from an integrated health system, we sought to evaluate the concordance of causes of death (CODs) between the underlying COD from the United States Renal Data System (USRDS) registry and CODs obtained from Kaiser Permanente Southern California (KPSC).

METHODS

A retrospective cohort study was performed among incident ESKD patients who had mortality records and CODs reported in both KPSC and USRDS databases between January 1, 2007, and December 31, 2016. Underlying CODs reported by the KPSC were compared to the CODs reported by USRDS. Overall and subcategory-specific COD agreements were assessed using Cohen's weighted kappa statistic (95% CI). Proportions of positive and negative agreement were also determined.

RESULTS

Among 4,188 ESKD patient deaths, 4,118 patients had CODs recorded in both KPSC and USRDS. The most common KPSC CODs were circulatory system diseases (35.7%), endocrine/nutritional/metabolic diseases (24.2%), genitourinary diseases (12.9%), and neoplasms (9.6%). Most common USRDS CODs were cardiac disease (46.9%), withdrawal from dialysis (12.6%), and infection (10.1%). Of 2,593 records with causes listed NOT as "Other," 453 (17.4%) had no agreement in CODs between the USRDS and the underlying, secondary, tertiary, or quaternary causes recorded by KPSC. In comparing CODs recorded within KPSC to the USRDS, Cohen's weighted kappa (95% CI) was 0.20 (0.18-0.22) with overall agreement of 36.4%.

CONCLUSION

Among an incident ESKD population with mortality records, we found that there was only fair or slight agreement between CODs reported between the USRDS registry and KPSC, a large integrated health care system.

African American Women's Experiences with Birth After a Prior Cesarean Section

OBJECTIVES

Women who have had a cesarean section (C-section) and become pregnant again may choose to have a planned repeat cesarean delivery (RCD) or vaginal birth after a cesarean (VBAC). This study aimed to characterize the pregnancy and birth experiences of African American (AA) women who had a successful VBAC, failed VBAC, or RCD.

METHODS

Eligible participants (N = 25) self-identified as AA, had a C-section and a subsequent birth(s) in the past 12 years, and were educated past high school. Each participant was individually interviewed via phone call. The Sort and Sift, Think and Shift method was used to evaluate interview transcripts to minimize researcher bias and emphasize the voices of the participants.

RESULTS

The resulting themes included the impact of providers on pregnancy and childbirth satisfaction, the value of autonomy in maternal health decision-making, and the role that racism plays in AA women's birth experiences. Although some participants recalled a positive experience, the presence of limited autonomy, lack of support, and negative experiences with providers indicate that birth after a prior C-section for AA women can be improved.

CONCLUSIONS

Providers should address their own racial biases and utilize the shared decision-making approach when their patients decide between a VBAC and RCD to improve patient satisfaction.

Accuracy of self-reported birth outcomes relative to birth certificate data in an Internet-based prospective cohort study

BACKGROUND

The accuracy of birth outcome data provided by Internet-based cohort study participants has not been well studied.

METHODS

We compared self-reported data on birth characteristics in Pregnancy Study Online (PRESTO), an Internet-based prospective cohort study of North American pregnancy planners, with birth certificate data. At enrolment, participants were aged 21-45 years, attempting conception, and not using fertility treatment. Women completed online questionnaires during preconception, early and late pregnancy, and postpartum. We requested birth certificate data during 2014-2019 from seven health departments in states with the most participants. After restricting to singleton births, we assessed specificity, sensitivity, and agreement comparing self-reported data from postpartum questionnaires with birth certificate data for gestational age at delivery (GA) and birthweight (grams). Our primary measure of self-reported GA (weeks) was calculated as [280-(due date-birth date)]/7. We used log-binomial regression to assess predictors of agreement.

RESULTS

We linked 85% (771/909) of women in selected states. Median age of women was 30 years (range: 21-42), 84% had ≥ 16 years of education, nearly 96% were married, 12% had household incomes <$50 000, 32% were parous, and 85% identified as non-Hispanic White. Median recall interval was 6 months. Among those with self-reported data, 89% reported the same GA as the birth certificate and 98% reported GA within 1 week of the birth certificate. Self-report of preterm birth (GA < 37 weeks) agreed with information from birth certificates for 100% of women; sensitivity was 100%, and specificity was 99%. Self-reported low birthweight (<2500 grams) agreed with birth certificates for 93% of women; sensitivity and specificity were 93% and ≥99%, respectively. Predictors of poorer agreement included higher parity and longer pregnancy attempt time for GA, and lower education and longer recall interval for birthweight.

CONCLUSION

Self-reported data on GA and birthweight from an Internet-based cohort showed high accuracy compared with birth certificates.

Association of Preeclampsia with Myocardial Injury Among Patients Undergoing Noncardiac Surgery: the PREECLAMPSIA-VISION study

BACKGROUND

In women, preeclampsia has a known association with increased long-term cardiovascular morbidity and mortality. However, it is unknown whether it is associated with increased post-operative cardiovascular morbidity and mortality in women. We aimed to determine if preeclampsia is an independent risk factor for myocardial injury after non-cardiac surgery (MINS) and post-operative 30-day mortality.

METHODS

This study was a large international multicentre cohort study of a representative sample of 40,004 patients recruited between August 2007 and November 2013. Participants were ≥45 years of age and underwent inpatient non-cardiac surgery. Within this cohort, our study examined women with a history of pregnancy. Using multivariable models, we explored the association between a history of pregnancy affected by preeclampsia and our primary outcome of MINS and secondary outcome of post-operative mortality within 30-days. MINS was defined as prognostically relevant myocardial injury due to ischemia that occurred during or within 30 days after non-cardiac surgery.

RESULTS

Analyses were restricted to the 13,902 participants with a history of pregnancy. Among these women, 976 (7.0%) had a history of preeclampsia. A history of preeclampsia was associated with an increased risk of MINS, with an adjusted hazard ratio of 1.26 (95% CI, 1.03-1.53; p=0.02). Preeclampsia was not significantly associated with 30-day mortality.

CONCLUSION

Preeclampsia is a risk factor for MINS and should be considered in the pre-operative cardiovascular risk assessment of women.

Prenatal exposure to paternal smoking and likelihood for autism spectrum disorder

LAY ABSTRACT

What is Already Known about This Subject: Genetics, (including de novo mutations), environmental factors (including toxic exposures), and their interactions impact autism spectrum disorder etiology. Paternal smoking is a candidate risk for autism spectrum disorder due to biological plausibility, high prevalence, and potential intervention.What This Study Adds: This original study and its replication confirms that paternal factors can substantially contribute to autism spectrum disorder risk for their offspring. It specifically indicates that paternal smoking both before and during pregnancy contributes significantly to autism spectrum disorder risk.Implications for practice, research, or policy: Smoking prevention, especially in pregnancy planning, may decrease autism spectrum disorder risk in offspring.

Survey of women's report for 33 maternal and newborn indicators: EN-BIRTH multi-country validation study

BACKGROUND

Population-based household surveys, notably the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), remain the main source of maternal and newborn health data for many low- and middle-income countries. As part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study, this paper focuses on testing validity of measurement of maternal and newborn indicators around the time of birth (intrapartum and postnatal) in survey-report.

METHODS

EN-BIRTH was an observational study testing the validity of measurement for selected maternal and newborn indicators in five secondary/tertiary hospitals in Bangladesh, Nepal and Tanzania, conducted from July 2017 to July 2018. We compared women's report at exit survey with the gold standard of direct observation or verification from clinical records for women with vaginal births. Population-level validity was assessed by validity ratios (survey-reported coverage: observer-assessed coverage). Individual-level accuracy was assessed by sensitivity, specificity and percent agreement. We tested indicators already in DHS/MICS as well as indicators with potential to be included in population-based surveys, notably the first validation for small and sick newborn care indicators.

RESULTS

33 maternal and newborn indicators were evaluated. Amongst nine indicators already present in DHS/MICS, validity ratios for baby dried or wiped, birthweight measured, low birthweight, and sex of baby (female) were between 0.90-1.10. Instrumental birth, skin-to-skin contact, and early initiation of breastfeeding were highly overestimated by survey-report (2.04-4.83) while umbilical cord care indicators were massively underestimated (0.14-0.22). Amongst 24 indicators not currently in DHS/MICS, two newborn contact indicators (kangaroo mother care 1.00, admission to neonatal unit 1.01) had high survey-reported coverage amongst admitted newborns and high sensitivity. The remaining indicators did not perform well and some had very high "don't know" responses.

CONCLUSIONS

Our study revealed low validity for collecting many maternal and newborn indicators through an exit survey instrument, even with short recall periods among women with vaginal births. Household surveys are already at risk of overload, and some specific clinical care indicators do not perform well and may be under-powered. Given that approximately 80% of births worldwide occur in facilities, routine registers should also be explored to track coverage of key maternal and newborn health interventions, particularly for clinical care.

Which healthy lifestyle habits mitigate the risk of obesity and cardiometabolic risk factors in Caucasian children exposed to in utero adverse gestational factors?

BACKGROUND AND AIMS

This study explored if lifestyle habits [physical activity (PA), sleep duration, intake of fruits and vegetables, grains, and dairy products] can moderate the positive associations between prenatal exposure to suboptimal gestational factors (SGF: i.e. gestational diabetes mellitus, hypertensive disorders during pregnancy, maternal smoking during pregnancy) and obesity and cardiometabolic risk factors in children.

METHODS AND RESULTS

Data from the "Quebec Adiposity and Lifestyle Investigation in Youth" (QUALITY) study collected between 2005 - 2008 in Montreal and Quebec City, were used. Analyses included a sample of 619 children aged 8-10 years. Children's PA and sleep duration were obtained using an accelerometer and daily servings of food were assessed using three 24 h diet recalls. Moderation analyses were performed to investigate if each lifestyle habit, in all children, and in boys and girls, could reduce the positive associations between SGF, and obesity and cardiometabolic risk factors. High LPA duration was protective against low levels of HDL cholesterol in boys who were exposed to more than one SGF (p = 0.005). Sleep duration did not have a protective effect respectively against high waist circumference and obesity in children and girls who were prenatally exposed to maternal smoking during pregnancy. Diet and MVPA did not moderate the positive associations between SGF, obesity and cardiometabolic risk factors in children.

CONCLUSION

Among the three lifestyle habits, only LPA had a protective effect against low levels of HDL-cholesterol in boys. More studies are needed to confirm these results to inform future lifestyle intervention in this population.

Parental ancestry and risk of early pregnancy loss at high altitude

High altitude pregnancy is associated with increased frequency of low birth weight infants and neonatal complications, the risks of which are higher in women of low-altitude ancestry. Does ancestry also influence the risk of miscarriage (pregnancy loss <20 weeks) in high-altitude pregnancy? To answer this, 5386 women from La Paz, Bolivia (3300-4150 m) with ≥1 live-born infant were identified. Data were extracted from medical records including maternal and paternal ancestry, demographic factors, and reproductive history. The risk of miscarriage by ancestry was assessed using multivariate logistic regression, adjusting for parity, and maternal age. Andean women experienced first live-births younger than Mestizo or European women (21.7 ± 4.6 vs 23.4 ± 8.0 vs 24.1 ± 5.1, P < .001). Andeans experienced more pregnancies per year of reproductive life (P < .001) and had significantly higher ratios of live-births to miscarriages than women of Mestizo or European ancestry (P < .001). Andean women were 24% less likely to have ever experienced a miscarriage compared to European women (OR:0.76; CI:0.62-0.90, P < .001). The woman's partner's ancestry wasn't a significant independent predictor of miscarriage. In conclusion, the risk of miscarriage at high altitude is lower in Andean women. The lack of a paternal ancestry effect suggests underlying mechanisms relate more to differential maternal adaptation in early pregnancy than fetal genetics.

Maternal perceptions of the experience of attempted labor induction and medically elective inductions: analysis of survey results from listening to mothers in California

BACKGROUND

The rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women's experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section.

METHODS

Study data are drawn from the 2119 respondents to the Listening to Mothers in California survey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective.

RESULTS

Almost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21-4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11-2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93-6.90).

CONCLUSION

Clinicians counselling mothers concerning the need for labor induction should be aware of mothers' perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction.

Prepregnancy adherence to dietary recommendations for the prevention of cardiovascular disease in relation to risk of hypertensive disorders of pregnancy

BACKGROUND

It is unclear whether adherence to diet recommendations for the prevention of cardiovascular disease (CVD) in the general population is also related to the risk of hypertensive disorders of pregnancy, including pre-eclampsia and gestational hypertension (GHTN).

OBJECTIVES

The aim was to evaluate the relation of prepregnancy adherence to the American Heart Association (AHA) diet recommendations and the Dietary Approaches to Stop Hypertension (DASH) with the risk of pre-eclampsia and GHTN.

METHODS

Between 1991 and 2009, we prospectively followed 16,892 singleton pregnancies among 11,535 women who participated in the Nurses' Health Study II. Prepregnancy diet was assessed every 4 y, from which we calculated dietary pattern scores from the DASH diet (8 components) and the diet recommendations from the AHA 2020 Strategic Impact Goals (primary score: 5 components; secondary score: primary score plus 3 components). Pregnancy outcomes were self-reported, and we estimated the RR (95% CI) of pre-eclampsia and GHTN with log-binomial regression using generalized estimating equations to account for repeat pregnancies and adjusting for potential confounders.

RESULTS

Women had a mean (SD) age of 34.4 (34.0) y at pregnancy. Pre-eclampsia was reported in 495 (2.9%) pregnancies and GHTN in 561 (3.3%) pregnancies. The RR (95% CI) of pre-eclampsia for women in the highest quintile of the DASH was 0.65 (0.48, 0.87) compared with women in the lowest score quintile. A similar inverse trend was observed for the AHA primary (0.74; 95% CI: 0.55, 1.00) and secondary (0.81; 95% CI: 0.61, 1.07) scores comparing women in the highest versus the lowest score quintile. Neither the DASH nor the AHA scores were related to GHTN.

CONCLUSIONS

Women with higher adherence to dietary recommendations for the prevention of CVD in the general population had a lower risk of pre-eclampsia-a common pregnancy complication related to higher CVD risk among women-than women with lower adherence to these recommendations.

Women's preferences for mode of second birth-A prospective study of two Israeli birth cohorts

INTRODUCTION

Various biopsychosocial factors affect women's preferences with respect to mode of birth, but they are usually not examined simultaneously and prospectively. In the current study, we assessed the contribution of personal characteristics of first-time mothers, their prior prenatal perceptions, events during birth, and subjective birth experiences, on their preference about mode of second birth.

METHODS

This was a secondary analysis of two prospective birth cohort studies. Participants included 832 primiparous women recruited mostly from women's health centers in Israel, and through natural birth communities and cesarean birth websites. Women completed questionnaires prenatally and were followed up at 6-8 weeks postpartum to understand their preferences for a second birth.

RESULTS

Regression models indicated that after vaginal first birth, being less religious, believing that birth is a medical process, and having a negative experience increased the odds of preferring primary cesarean for the second birth. After cesarean birth, being more religious, having higher education, conceiving spontaneously, having a more negative birth experience, and perceiving better treatment from the staff during birth contributed to preferring vaginal birth for the second birth.

CONCLUSIONS

Religiosity is central to women's preferences, probably because of its association with the desire to have many children. Modifiable factors, such as women's beliefs about the nature of birth, their overall birth experience, and their perceived treatment from the staff, could influence the uptake of having vaginal births. Intrapartum care that is empathic and encouraging, along with education about modes of birth, could help decrease cesarean birth rates.

Obstetric complications in patients with schizophrenia and their unaffected siblings

Objective

We sought to explore whether obstetric complications (OCs) are more likely to occur in the presence of familial/genetic susceptibility for schizophrenia or whether they themselves represent an independent environmental risk factor for schizophrenia.

Methods

The presence of OCs was assessed through maternal interview on 216 subjects, comprising 36 patients with schizophrenia from multiply affected families, 38 of their unaffected siblings, 31 schizophrenic patients with no family history of psychosis, 51 of their unaffected siblings and 60 normal comparison subjects. We examined the familiality of OCs and whether OCs were commoner in the patient and sibling groups than in the control group.

Results

OCs tended to cluster within families, especially in multiply affected families. Patients with schizophrenia, especially those from multiply affected families, had a significantly higher rate of OCs compared to normal comparison subjects, but there was no evidence for an elevated rate of OCs in unaffected siblings.

Conclusion

Our data provides little evidence for a link between OCs and genetic susceptibility to schizophrenia. If high rates of OCs are related to schizophrenia genes, this relationship is weak and will only be detected by very large sample sizes.

In-kind incentives and health worker performance: Experimental evidence from El Salvador

We experimentally evaluated the effects of in-kind team incentives on health worker performance in El Salvador, with 38 out of 75 community health teams randomly assigned to performance incentives over a 12-month period. All teams received monitoring, performance feedback and recognition for their achievements allowing us to isolate the effect of the incentive. While both treatment and control groups exhibit improvements in performance measures over time, the in-kind incentives generated significant improvements in community outreach, quality of care, timeliness of care, and utilization of maternal and child health services after 12 months. Gains were largest for teams at the bottom and top of the baseline performance distribution. We find no evidence of results being driven by changes in reporting or by shifting away effort from non-contracted outcomes. These results suggest that in-kind team incentives may be a viable alternative to monetary or individual incentives in certain contexts.

Heightened susceptibility: A review of how pregnancy and chemical exposures influence maternal health

Pregnancy is a unique period when biological changes can increase sensitivity to chemical exposures. Pregnant women are exposed to multiple environmental chemicals via air, food, water, and consumer products, including flame retardants, plasticizers, and pesticides. Lead exposure increases risk of pregnancy-induced hypertensive disorders, although women's health risks are poorly characterized for most chemicals. Research on prenatal exposures has focused on fetal outcomes and less on maternal outcomes. We reviewed epidemiologic literature on chemical exposures during pregnancy and three maternal outcomes: preeclampsia, gestational diabetes, and breast cancer. We found that pregnancy can heighten susceptibility to environmental chemicals and women's health risks, although variations in study design and exposure assessment limited study comparability. Future research should include pregnancy as a critical period for women's health. Incorporating biomarkers of exposure and effect, deliberate timing and method of measurement, and consistent adjustment of potential confounders would strengthen research on the exposome and women's health.

Altered Cortical Brain Structure and Increased Risk for Disease Seen Decades After Perinatal Exposure to Maternal Smoking: A Study of 9000 Adults in the UK Biobank

Secondhand smoke exposure is a major public health risk that is especially harmful to the developing brain, but it is unclear if early exposure affects brain structure during middle age and older adulthood. Here we analyzed brain MRI data from the UK Biobank in a population-based sample of individuals (ages 44-80) who were exposed (n = 2510) or unexposed (n = 6079) to smoking around birth. We used robust statistical models, including quantile regressions, to test the effect of perinatal smoke exposure (PSE) on cortical surface area (SA), thickness, and subcortical volumes. We hypothesized that PSE would be associated with cortical disruption in primary sensory areas compared to unexposed (PSE-) adults. After adjusting for multiple comparisons, SA was significantly lower in the pericalcarine (PCAL), inferior parietal (IPL), and regions of the temporal and frontal cortex of PSE+ adults; these abnormalities were associated with increased risk for several diseases, including circulatory and endocrine conditions. Sensitivity analyses conducted in a hold-out group of healthy participants (exposed, n = 109, unexposed, n = 315) replicated the effect of PSE on SA in the PCAL and IPL. Collectively our results show a negative, long term effect of PSE on sensory cortices that may increase risk for disease later in life.

Intrapartum Care and Experiences of Women with Midwives Versus Obstetricians in the Listening to Mothers in California Survey

Introduction

Many studies based on hospital records or vital statistics have found that childbearing women experience benefits of lower rates of intervention with midwifery care versus obstetric care during labor and birth. Surveys of women's views and experiences can provide a richer analysis when comparing intrapartum care of midwives and obstetricians.

Methods

This study was a secondary analysis of data from the population‐based Listening to Mothers in California survey. The sample, which was representative of 2016 California hospital births, was drawn from birth certificate files and oversampled midwife‐attended births. Women responded to the survey in English or Spanish on any device or with a telephone interviewer. The present analysis is based on 1421 of the 2539 participants who identified a midwife or obstetrician as their attendant at a vaginal birth. A bivariate analysis of demographic, attitudinal, and intrapartum variables was conducted. A multivariable model included sociodemographic and attitudinal variables as covariates.

Results

Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making.

Discussion

Using women's own reports of their care experiences and adjusting for possible differences in women's attitudes and case mix, we found that midwifery care of women who had vaginal births was associated with reduced use of medical interventions and increased women's decisional latitude during labor and birth.

The utility of a follow-up interview for respondents to a longitudinal survey with frequent measurement

Social processes that change quickly are difficult to study, because they require frequent survey measurement. Weekly, daily, or even hourly measurement may be needed depending on the topic. With more frequent measurement comes the prospect of more complex patterns of missing data. The mechanisms creating the missing data may be varied, ranging from technical issues such as lack of an Internet connection to refusal to complete a requested survey. We examine one approach to mitigating the damage of these missing data - a follow-up or closeout interview that is completed after the frequent measurement. The Relationship Dynamics and Social Life (RDSL) study used this approach. The study asked women weekly about their attitudes and behaviors related to sexual relationships and pregnancy. The surveys were carried out for 130 weeks and concluded with a closeout interview. We explore the patterns of missing data in the RDSL study and then examine associations between the data collected in the closeout survey and key variables collected in the weekly survey. We then assess the extent to which data from the closeout survey are useful in repairing the damage caused by missing data.

Is there a relationship between female genital mutilation/cutting and fistula? A statistical analysis using cross-sectional data from Demographic and Health Surveys in 10 sub-Saharan Africa countries

OBJECTIVES

Literature on associations between female genital mutilation/cutting (FGM/C) and fistula points to a common belief that FGM/C predisposes women to developing fistula. This study explores this association using nationally representative survey data.

DESIGN

A secondary statistical analysis of cross-sectional data from Demographic and Health Surveys was conducted to explore the association between FGM/C and fistula.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

Women aged 15-49 years in Burkina Faso (n=17 087), Chad (n=17 719), Côte d'Ivoire (n=10 060), Ethiopia (n=14 070), Guinea (n=9142), Kenya (n=31 079), Mali (n=10 424), Nigeria (n=33 385), Senegal (n=15 688) and Sierra Leone (n=16 658).

MAIN OUTCOME MEASURES

Fistula symptoms.

RESULTS

Multivariate logit modelling using pooled data from 10 countries showed that the odds of reporting fistula symptoms were 1.5 times (CI 1.06 to 2.21) higher for women whose genitals were cut and sewn closed than those who had undergone other types of FGM/C. Women who attended antenatal care (ANC) (adjusted odds ratio (AOR) 0.51, CI 0.36 to 0.71) and those who lived in urban areas (AOR 0.62, CI 0.44 to 0.89) were less likely to report fistula symptoms than those who did not attend ANC or lived in rural areas.

CONCLUSIONS

Severe forms of FGM/C (infibulation) may predispose women to fistula. Contextual and socioeconomic factors may increase the likelihood of fistula. Multisectoral interventions that concurrently address harmful traditional practices such as FGM/C and other contextual factors that drive the occurrence of fistula are warranted. Promotion of ANC utilisation could be a starting point in the prevention of fistulas.

Fluid Reasoning Mediates the Association of Birth Weight With ADHD Symptoms in Youth From Multiplex Families With ADHD

OBJECTIVE

We tested mediation of birth weight and ADHD symptoms by multiple biologically plausible neurocognitive functions and evaluated familiality of observed indirect effects.

METHOD

647 youth from 284 multiplex families with ADHD completed the Arithmetic, Digit Span, Vocabulary, and Block Design subtests of the Wechsler Intelligence Scale for Children (WISC). Multiple mediation tested WISC subtests as mediators of birth weight and multi-informant ADHD symptoms. Familiality of indirect effects was estimated via moderated mediation comparing conditional indirect effects across siblings concordant and discordant for ADHD.

RESULTS

Controlling for IQ and demographic factors, Arithmetic uniquely mediated birth weight and ADHD symptoms. Conditional indirect effects through Arithmetic did not differ across ADHD concordant and discordant siblings.

CONCLUSION

These cross-sectional findings support previous prospective longitudinal research implicating Arithmetic (i.e., fluid reasoning) as a preliminary causal mediator of birth weight and ADHD symptoms, and suggest that this pathway is independent of genetic influences on ADHD.

Validity and reliability of maternal recall of pregnancy history and service use among signing Deaf women: a cross-sectional descriptive study from South Africa

INTRODUCTION

There is little credible quantitative data on pregnancy histories and outcomes for disabled women in low-income and middle-income countries. The purpose of this study, based in Cape Town, South Africa, was to test the reliability and validity of maternal recall of pregnancy history and service use among a sample of Deaf women who use South African Sign Language (SASL).

METHODS

We interviewed 42 signing Deaf women of childbearing age (18-49 years) in SASL using a structured questionnaire in July 2016. To assess reliability, seven participants (16% of the sample) were reinterviewed by different interviewers under the same conditions after 10-30 min. For the analysis we used (1) Cohen's kappa, an inter-rater statistical method, and (2) overall percentage agreement. Validity was explored by comparing the participants' pregnancy history to the Western Cape Provincial Health Data Centre (PHDC) database.

RESULTS

The reliability results showed that out of 19 questions 14 demonstrated substantial to perfect agreement kappa scores (kappa between 0.61 and 1) and 5 had the lowest kappa agreement scores (kappa <0.61). With respect to percentage agreement, participants provided identical responses in 87% cases. Overall, women provided more reliable responses to pregnancy outcomes compared with demographic information. Validity results showed that 29 out of 35 Deaf women provided survey responses that matched or nearly matched (83% agreement) the PHDC database for birth history and delivery location.

CONCLUSION

This study suggests that for this sample of signing Deaf women recall of pregnancy history and service use is reliable and valid. Extending this approach to other similar populations will require further research, but it is important that methods to access hard-to-reach disabled populations are developed so that health system responsiveness to marginal populations can be based on robust evidence.

Restricted, Repetitive, and Reciprocal Social Behavior in Toddlers Born Small for Gestation Duration

OBJECTIVE

To characterize restricted and repetitive behaviors (RRBs) and reciprocal social behaviors (RSBs) in a large sample of toddlers who represent a range of birth weights and gestation durations.

STUDY DESIGN

A battery of questionnaires characterizing demographic information and measuring RRBs and RSBs were completed by parents of toddlers between the ages of 17-26 months (n = 1589 total; n = 98 preterm). The association between birth weight and/or gestation duration and the primary outcome measures (RRBs and RSBs as ascertained through the Repetitive Behavior Scale for Early Childhood and the Video-Referenced Rating of Reciprocal Social Behavior) were tested by using hierarchical multivariate multiple regression.

RESULTS

Toddlers born preterm and full term did not differ on RRBs or RSBs. However, there were significant associations between birth weight percentile for gestation duration (BPGD) and RRBs (β = -2.1, P = .03), above and beyond the effects of age, sex, and vocabulary production. Similarly, there was a significant association between BPGD and RSBs (β = -1.8, P = .02), above and beyond the effects of age, sex, and vocabulary production.

CONCLUSIONS

These findings demonstrate that BPGD better predicted putative antecedents of adverse psychological outcomes-specifically, RRBs and RSBs-than gestation duration alone. These findings provide insight to the link between preterm birth and suboptimal behavioral/psychological outcomes and suggest that high birth weight, which may reflect a more optimal intrauterine environment, may serve as a protective factor irrespective of gestation duration.

Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.

Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy

Background

Increasingly, women of reproductive age participate in recreational running, but its impact on pregnancy outcome is unknown. We investigated whether running affects gestational age at delivery and birth weight as indicators of cervical integrity and placental function, respectively.

Methods

1293 female participants were recruited from parkrun, which organises weekly runs involving 1.25 million runners across 450 parks worldwide. Those under 16 or unable to provide outcome data were excluded. Women were categorised according to whether they continued to run during pregnancy or not. Those who continued were further stratified dependent on average weekly kilometres, and which trimester they ran until. Retrospectively collected primary outcomes were gestational age at delivery and birthweight centile. Other outcomes included assisted vaginal delivery rate and prematurity at clinically important gestations.

Results

There was no significant difference in gestational age at delivery: 279.0 vs 279.6 days (mean difference 0.6 days, CI −1.3 to 2.4 days; P=0.55) or birthweight centile: 46.9%vs 44.9% (mean difference 2.0%, CI −1.3% to −5.3%; P=0.22) in women who stopped running and those who continued, respectively. Assisted vaginal delivery rate was increased in women who ran: 195/714 (27%) vs 128/579 (22%) (OR 1.32; CI 1.02 to 1.71; P=0.03).

Conclusion

Continuing to run during pregnancy does not appear to affect gestational age or birthweight centile, regardless of mean weekly distance or stage of pregnancy. Assisted vaginal delivery rates were higher in women who ran, possibly due to increased pelvic floor muscle tone. Randomised prospective analysis is necessary to further explore these findings.

Long-term Recall of Pregnancy-related Events

BACKGROUND

Early-life factors can be associated with future health outcomes and are often measured by maternal recall.

METHODS

We used data from the North Carolina Early Pregnancy Study and Follow-up to characterize long-term maternal recall. We used data from the Early Pregnancy Study as the gold standard to evaluate the accuracy of prepregnancy weight, early pregnancy behaviors, symptoms and duration of pregnancy, and child's birthweight reported at follow-up, for 109 women whose study pregnancies had resulted in a live birth.

RESULTS

Most (81%) participants reported a prepregnancy weight at follow-up that correctly classified them by BMI category. Women reported experiencing pregnancy symptoms later at follow-up than what they reported in the Early Pregnancy Study. Accuracy of reporting of early pregnancy behaviors varied based on exposure. Overall, women who had abstained from a behavior were more likely to be classified correctly. Sensitivity of reporting was 0.14 for antibiotics, 0.30 for wine, 0.71 for brewed coffee, and 0.82 for vitamins. Most misclassification at follow-up was due to false-negative reporting. Among women who gave birth to singletons, 94% could report their child's correct birthweight within ½ pound and 86% could report duration of pregnancy within 7 days at follow-up.

CONCLUSIONS

Self-report of prepregnancy weight, duration of pregnancy, and child's birthweight after almost 30 years was good, whereas self-reported pregnancy-related exposures resulted in higher levels of reporting error. Social desirability appeared to influence women's report of their behaviors at follow-up. Self-reported assessment of confidence in the recalled information was unrelated to accuracy.

Associating Symptom Phenotype and Genotype in Preeclampsia

Preeclampsia is a complex genetic disorder with an incompletely understood pathogenesis. Its phenotype may be better elucidated by integrating symptoms. This study aimed to identify symptoms by gestational age and associations with novel preeclampsia candidate genes. Women with a history of preeclampsia recruited from The Preeclampsia Registry completed clinical/demographic, symptom surveys and provided medical records. DNA extracted from saliva was processed with multiplexed assays for eight single-nucleotide polymorphisms (SNPs) selected to tag candidate genes and/or located in symptom susceptibility regions. Groups with versus without symptoms were compared using χ2. Associations between SNPs and symptoms were analyzed as genotype categories and presence/absence of the variant allele. Logistic regression modeling was conducted with exploratory p = .05. In 114 participants, 113 reported at least 1 of the 18 symptoms. Symptoms varied by trimester. Nine symptoms were associated with seven SNPs. Visual disturbances were associated with three SNPs and nausea/vomiting with two SNPs. Modeling adjustment for maternal age and parity resulted in 15 associations between 9 symptoms and 8 SNPs. Medical records demonstrated 100% concordance with self-reported diagnosis and 48% concordance with reported severity. Findings indicated novel symptom-genotype associations in preeclampsia. The small sample was self-selected, but results support future studies including medical records review. When validated, these results may lead to holistic phenotyping of women to characterize subsets of preeclampsia. This approach may optimize health in pregnancy and later life for mothers and offspring through prediction, prevention, and precision nursing care.

External validity of a hierarchical dimensional model of child and adolescent psychopathology: Tests using confirmatory factor analyses and multivariate behavior genetic analyses

Several recent studies of the hierarchical phenotypic structure of psychopathology have identified a General psychopathology factor in addition to the more expected specific Externalizing and Internalizing dimensions in both youth and adult samples and some have found relevant unique external correlates of this General factor. We used data from 1,568 twin pairs (599 MZ & 969 DZ) age 9 to 17 to test hypotheses for the underlying structure of youth psychopathology and the external validity of the higher-order factors. Psychopathology symptoms were assessed via structured interviews of caretakers and youth. We conducted phenotypic analyses of competing structural models using Confirmatory Factor Analysis and used Structural Equation Modeling and multivariate behavior genetic analyses to understand the etiology of the higher-order factors and their external validity. We found that both a General factor and specific Externalizing and Internalizing dimensions are necessary for characterizing youth psychopathology at both the phenotypic and etiologic levels, and that the 3 higher-order factors differed substantially in the magnitudes of their underlying genetic and environmental influences. Phenotypically, the specific Externalizing and Internalizing dimensions were slightly negatively correlated when a General factor was included, which reflected a significant inverse correlation between the nonshared environmental (but not genetic) influences on Internalizing and Externalizing. We estimated heritability of the general factor of psychopathology for the first time. Its moderate heritability suggests that it is not merely an artifact of measurement error but a valid construct. The General, Externalizing, and Internalizing factors differed in their relations with 3 external validity criteria: mother's smoking during pregnancy, parent's harsh discipline, and the youth's association with delinquent peers. Multivariate behavior genetic analyses supported the external validity of the 3 higher-order factors by suggesting that the General, Externalizing, and Internalizing factors were correlated with peer delinquency and parent's harsh discipline for different etiologic reasons. (PsycINFO Database Record

Preterm Delivery and Future Risk of Maternal Cardiovascular Disease: A Systematic Review and Meta-Analysis

Background

Preterm delivery (<37 weeks gestational age) affects 11% of all pregnancies, but data are conflicting whether preterm birth is associated with long‐term adverse maternal cardiovascular outcomes. We aimed to systematically evaluate and summarize the evidence on the relationship between preterm birth and future maternal risk of cardiovascular diseases.

Methods and Results

A systematic search of MEDLINE and EMBASE was performed to identify relevant studies that evaluated the association between preterm birth and future maternal risk of composite cardiovascular disease, coronary heart disease, stroke, and death caused by cardiovascular or coronary heart disease and stroke. We quantified the associations using random effects meta‐analysis. Twenty‐one studies with over 5.8 million women, including over 338 000 women with previous preterm deliveries, were identified. Meta‐analysis of studies that adjusted for potential confounders showed that preterm birth was associated with an increased risk of maternal future cardiovascular disease (risk ratio [RR] 1.43, 95% confidence interval [CI], 1.18, 1.72), cardiovascular disease death (RR 1.78, 95% CI, 1.42, 2.21), coronary heart disease (RR 1.49, 95% CI, 1.38, 1.60), coronary heart disease death (RR 2.10, 95% CI, 1.87, 2.36), and stroke (RR 1.65, 95% CI, 1.51, 1.79). Sensitivity analysis showed that the highest risks occurred when the preterm deliveries occurred before 32 weeks gestation or were medically indicated.

Conclusions

Preterm delivery is associated with an increase in future maternal adverse cardiovascular outcomes, including a 2‐fold increase in deaths caused by coronary heart disease. These findings support the assessment of preterm delivery in cardiovascular risk assessment in women.

Faecal incontinence: a narrative review of clinic-based management for the general gynaecologist

The objective of this article is to provide an informative and narrative review for the general Gynaecologist regarding the pathophysiology and conservative treatments available for faecal incontinence (FI). A PubMed search was performed by library staff and an author using the keywords: anal incontinence, faecal incontinence, accidental bowel leakage, outpatient clinic management of faecal incontinence and defecatory dysfunction. As the social limitations of FI can be devastating and long-term patient satisfaction rates after anal sphincteroplasty remain reportedly-low, the role of clinic-based management of FI has continued to grow. The purpose of this article is to provide the Obstetrician and Gynaecologist with a basic template for screening, evaluation and management of faecal incontinence in the clinical setting.