Epidemiology of maternal morbidity and mortality

Are Racial Disparities in Cesarean Due to Differences in Labor Induction Management?

OBJECTIVE

 While there are known racial disparities in cesarean delivery (CD) rates, the exact etiologies for these disparities are multifaceted. We aimed to determine if differences in induction of labor (IOL) management contribute to these disparities.

STUDY DESIGN

 This retrospective cohort study evaluated all nulliparous patients with an unfavorable cervix and intact membranes who underwent IOL of a term, singleton gestation at a single institution from October 1, 2018, to September 30, 2020. IOL management was at clinician discretion. Patients were classified as Black, Indigenous, and People of Color (BIPOC) or White based on self-report. Overall rates of CD were compared for BIPOC versus White race. Chart review then evaluated various IOL management strategies as possible contributors to differences in CD by race.

RESULTS

 Of 1,261 eligible patients, 915 (72.6%) identified as BIPOC and 346 (27.4%) as White. BIPOC patients were more likely to be younger (26 years interquartile range (IQR): [22-30] vs. 32 years IQR: [30-35], p < 0.001) and publicly insured (59.1 vs. 9.9%, p < 0.001). Indication for IOL and modified Bishop score also differed by race (p < 0.001; p = 0.006). There was 40% increased risk of CD for BIPOC patients, even when controlling for confounders (30.7 vs. 21.7%, p = 0.001; adjusted relative risk (aRR) = 1.41, 95% confidence interval (CI): [1.06-1.86]). Despite this difference in CD, there were no identifiable differences in IOL management prior to decision for CD by race. Specifically, there were no differences in choice of cervical ripening agent, cervical dilation at or time to amniotomy, use and maximum dose of oxytocin, or dilation at CD. However, BIPOC patients were more likely to undergo CD for fetal indications and failed IOL.

CONCLUSION

 BIPOC nulliparas are 40% more likely to undergo CD during IOL than White patients within our institution. These data suggest that the disparity is not explained by differences in IOL management prior to cesarean, indicating that biases outside of induction management may be important to target to reduce CD disparities.

KEY POINTS

· The etiologies for racial disparities in cesarean are likely multifaceted.. · In this work, there were no differences by race in measures of labor induction management.. · Biases outside of induction management during labor may be targeted to reduce CD disparities..

Code Crimson: A Postpartum Hemorrhage Bundled Intervention Quality Improvement Project

BACKGROUND

Postpartum hemorrhage (PPH) is a leading cause of maternity mortality in the United States. The Code Crimson project aimed to enhance PPH management by implementing a standardized intervention bundle to mitigate morbidity and mortality associated with PPH.

LOCAL PROBLEM

At a large Philadelphia tertiary hospital, health disparities existed for severe maternal morbidity and mortality, and PPH was a significant factor.

METHODS

A quality improvement design, using Plan-Do-Study-Act cycles and interrupted time series analysis, was undertaken.

INTERVENTIONS

The Code Crimson project implemented a standardized bundle to manage PPH, including blood product administration and massive transfusion protocol activation.

RESULTS

After implementing the Code Crimson bundle, there was a significant decrease in blood product use ( P < .001), with minor reductions in packed red blood cell administration over 4 units and mean blood loss.

CONCLUSIONS

The Code Crimson bundle effectively reduced blood product utilization for PPH treatment.

Optimizing Postpartum Care in Rural Communities: Insights from Women in Arizona and Implications for Policy

OBJECTIVES

Optimal postpartum care promotes healthcare utilization and outcomes. This qualitative study investigated the experiences and perceived needs for postpartum care among women in rural communities in Arizona, United States.

METHODS

We conducted in-depth interviews with thirty childbearing women and analyzed the transcripts using reflexive thematic analysis to gauge their experiences, needs, and factors affecting postpartum healthcare utilization.

RESULTS

Experiences during childbirth and multiple structural factors, including transportation, childcare services, financial constraints, and social support, played crucial roles in postpartum care utilization for childbearing people in rural communities. Access to comprehensive health information and community-level support systems were perceived as critical for optimizing postpartum care and utilization.

CONCLUSIONS FOR PRACTICE

This study provides valuable insights for policymakers, healthcare providers, and community stakeholders in enhancing postpartum care services for individuals in rural communities in the United States.

Assessing the relationship between census tract rurality and severe maternal morbidity in California (1997-2018)

PURPOSE

Recent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census-tract level. This study assessed the relationship between census-tract-level rurality and SMM for birthing people in California.

METHODS

We used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural-Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2-category) and at 4 levels (4-category). Covariates included sociocultural-demographic, pregnancy-related, and neighborhood-level factors. We ran a series of mixed-effects logistic regression models with tract-level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines.

FINDINGS

Of 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2-category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4-category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%).

CONCLUSION

The observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality-related inequities in the risk of SMM.

Maternal Morbidity Risk Factors in Nulliparas

OBJECTIVE

For every incidence of maternal mortality, maternal morbidity is thought to occur in another 50 to 100 individuals in the United States. Multiple risk factors for severe maternal morbidity have been identified, but counseling about specific risk in pregnancy remains difficult, particularly nulliparous individuals as prior obstetric history is one of the factors influencing risk for severe maternal morbidity. The objective of this study is to examine the association between sociodemographic and laboratory assessments in the first trimester and maternal morbidity in nulliparas.

STUDY DESIGN

This was a secondary analysis of a large, multicenter prospective observational cohort of nulliparas. The primary maternal outcome was a composite of hypertensive disorders of pregnancy (HDP), hemorrhage (transfusion, hemorrhage, hysterectomy, other surgery, readmission for bleeding), infection (endometritis, wound infection or dehiscence, pneumonia, sepsis, infection during labor and delivery, readmission for infection through day 14), venous thromboembolic events (VTE) (deep venous thrombosis, or pulmonary embolus), or maternal death within 14 days of delivery. Sociodemographic and clinical factors were compared between people with and without maternal morbidity. Relative risk and 95% confidence interval for maternal morbidity was calculated using log-binomial regression, adjusted for baseline characteristics that had a significant independent relationship with maternal morbidity with a p-value <0.05.

RESULTS

Of 9,445 pregnant people in the analysis, 18.2% (n = 1,716) experienced the composite maternal morbidity; the most common component was HDP (13.1%, n = 1,244) followed by infection (4.43%, n = 420), hemorrhage (2.27%, n = 215), VTE (0.12%, n = 11), and death (0.01%, n = 1). In a multivariable model, self-identified Black race, first trimester obesity, pregestational diabetes, chronic hypertension, and chronic kidney disease were significantly associated with the primary maternal outcome.

CONCLUSION

More than one in six nulliparas experienced the composite maternal morbidities. Maternal morbidity was associated with self-identified Black race, obesity, and multiple preexisting medical comorbidities.

KEY POINTS

· One in six nulliparas experience maternal morbidity in their first pregnancy related to hypertensive disorders of pregnancy, infection, hemorrhage, and venous thromboembolism.. · Risk factors for maternal morbidity in nulliparas include Black race, prepregnancy body mass index, and preexisting medical conditions.. · The preexisting medical conditions with the strongest association with maternal morbidity included pregestational diabetes, chronic hypertension, and chronic kidney disease..

Antenatal Care: A Comparative Review of Guidelines

Importance

Antenatal care plays a crucial role in safely monitoring and ensuring the well-being of both the mother and the fetus during pregnancy, ultimately leading to the best possible perinatal outcomes.

Objective

The aim of this study was to review and compare the most recently published guidelines on antenatal care.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Public Health Agency of Canada, the World Health Organization, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists regarding antenatal care was conducted.

Results

There is a consensus among the reviewed guidelines regarding the necessary appointments during the antenatal period, the proper timing for induction of labor, the number and frequency of laboratory examinations for the assessment of mother's well-being, and management strategies for common physiological problems during pregnancy, such as nausea and vomiting, heartburn, pelvic pain, leg cramps, and symptomatic vaginal discharge. In addition, special consideration should be given for mental health issues and timely referral to a specialist, reassurance of complete maternal vaccination, counseling for safe use of medical agents, and advice for cessation of substance, alcohol, and tobacco use during pregnancy. Controversy surrounds clinical evaluation during the antenatal period, particularly when it comes to the routine use of an oral glucose tolerance test and symphysis-fundal height measurement for assessing fetal growth, whereas routine cardiotocography and fetal movement counting are suggested practices only by Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Of note, recommendations on nutritional interventions and supplementation are offered only by Public Health Agency of Canada and World Health Organization, with some minor discrepancies in the optimal dosage.

Conclusions

Antenatal care remains a critical factor in achieving positive outcomes, but there are variations depending on the socioeconomic status of each country. Therefore, the establishment of consistent international protocols for optimal antenatal care is of utmost importance. This can help provide safe guidance for healthcare providers and, consequently, improve both maternal and fetal outcomes.

The Intersection of Cardiovascular Health and Maternal Health: Portfolio Analysis of Federal Grant Funding 2016-2021

Background: The United States has high and increasing rates of maternal morbidity and mortality, large proportions of which are related to cardiovascular health (CVH). Methods: We searched for National Institutes of Health (NIH) supported research as well as that of two other Agencies in the U.S. Department of Health and Human Services (DHHS) for fiscal years (FY) 2016-2021. Grants included maternal health conditions or exposures across all pregnancy stages, but excluded grants that focused entirely on birth, neonatal, infant/childhood outcomes. Results were manually curated by reviewing the abstract and specific aims. Grants deemed to be relevant were grouped by category. Results: Between FY 2016-2021, overall Maternal Health grants remained unchanged at an average of 1.4% of total DHHS grant funding. Maternal CVH-specific (MCVH) funding amounted to $278,926,105 for 755 grants, $191,344,649 was for 534 Type-1 grants, representing a twofold increase. Non-NIH DHHS agencies most commonly funded general Maternal Health related to CVH; NIH focused funding classified as hypertensive disorders of pregnancy, maternal morbidity and mortality, obesity, and diabetes. Non-NIH DHSS Agencies most commonly funded clinical applied research. In addition to clinical applied grants, NIH funded substantial proportions of grants classified as basic research, clinical trials, and/or translational. National Heart, Lung, and Blood Institute (NHLBI) MCVH grants studied participants in the pre-partum period (78.5%), followed by the post-partum period (50.5%), with relatively few in pre-pregnancy and peri-partum periods (10.8% and 9.7%, respectively); at the NIH level, the peri-partum period had better representation at 20.3%, whereas the pre-pregnancy period remained low at 9.9%. Conclusions: Federal grant funding for maternal health including MCVH increased at the same rate as its funding for overall research, and represented only 1.4% of overall total funding. The pre-pregnancy period was understudied in overall NIH funding and represents a gap area whereby funding agencies could further foster research advances.

Material properties of nonpregnant and pregnant human uterine layers

The uterus has critical biomechanical functions in pregnancy and undergoes dramatic material growth and remodeling from implantation to parturition. The intrinsic material properties of the human uterus and how they evolve in pregnancy are poorly understood. To address this knowledge gap and assess the heterogeneity of these tissues, the time-dependent material properties of all human uterine layers were measured with nanoindentation. The endometrium-decidua layer was found to be the least stiff, most viscous, and least permeable layer of the human uterus in nonpregnant and third-trimester pregnant tissues. In pregnancy, the endometrium-decidua becomes stiffer and less viscous with no material property changes observed in the myometrium or perimetrium. Additionally, uterine material properties did not significantly differ between third-trimester pregnant tissues with and without placenta accreta. The foundational data generated by this study will facilitate the development of physiologically accurate models of the human uterus to investigate gynecologic and obstetric disorders.

Pregnancy-associated mortality due to cardiovascular disease: Impact of hypertensive disorders of pregnancy

BACKGROUND

Reported rates of maternal mortality in the United States have been staggeringly high and increasing, and cardiovascular disease (CVD) is a chief contributor to such deaths. However, the impact of hypertensive disorders of pregnancy (HDP) on the short-term risk of cardiovascular death is not well understood.

OBJECTIVES

To evaluate the association between HDP (chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and superimposed preeclampsia) and pregnancy-associated mortality rates (PMR) from all causes, CVD-related causes both at delivery and within 1 year following delivery.

METHODS

We used the Nationwide Readmissions Database (2010-2018) to examine PMRs for females 15-54 years old. International Classification of Disease 9 and 10 diagnosis codes were used to identify pregnancy-associated deaths due to HDP and CVD. Discrete-time Cox proportional hazards regression models were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for mortality at delivery (0 days) and at <30, <60, <90, <180, and <365 days after delivery in relation to HDP.

RESULTS

Of 33,417,736 hospital deliveries, the rate of HDP was 11.0% (n = 3,688,967), and the PMR from CVD was 6.4 per 100,000 delivery hospitalisations (n = 2141). Compared with normotensive patients, HRs for CVD-related PMRs increased with HDP severity, reaching over 58-fold for eclampsia patients. HRs were higher for stroke-related (1.2 to 170.9) than heart disease (HD)-related (0.99 to 39.8) mortality across all HDPs. Except for gestational hypertension, the increased risks of CVD mortality were evident at delivery and persisted 1 year postpartum for all HDPs.

CONCLUSIONS

HDPs are strong risk factors for pregnancy-associated mortality due to CVD at delivery and within 1 year postpartum; the risks are stronger for stroke than HD-related PMR. While absolute PMRs are low, this study supports the importance of extending postpartum care beyond the traditional 42-day postpartum visit for people whose pregnancies are complicated by hypertension.

Redesigning the First Prenatal Visit: A Quality Improvement Initiative

BACKGROUND/PURPOSE

In an era of rising maternal mortality, a thorough first prenatal visit is essential; however, in our clinic we confirmed that many important topics were not being addressed. To rectify this problem, we redesigned the first prenatal visit to improve the coverage of topics, collect social determinants of health, increase patient access, and maintain patient satisfaction.

METHODS

We designed a quality improvement project to improve the first prenatal visit in a faculty obstetrics and gynecology clinic. To assess effectiveness, data before and after the implementation were compared. The intervention divided the first prenatal visit into two patient encounters: a nurse-led telemedicine visit and an in-person visit with an obstetric clinician.

RESULTS

The median percentage of topics covered in the first prenatal visit increased from 70.0% to 95.6%, and improvements were observed for all key themes ( p < .001). Social determinants of health was routinely collected postintervention (98.8%). A reduction in no-shows (9.9%-4.2%) improved patient access for all patients. Patient satisfaction for the first prenatal visit remained unchanged ( p = .370).

CONCLUSIONS

Significant improvements in addressing important topics at the first prenatal visit are achievable by separating one prenatal visit into two visits while increasing patient access and maintaining high patient satisfaction.

Study Design and Protocol of the Multisite Pregnancy 24/7 Cohort Study

Hypertensive disorders of pregnancy and other adverse pregnancy outcomes (APOs) are associated with an increased risk of future maternal cardiovascular disease. Physical activity during pregnancy reduces the risk of these APOs, yet few meet physical activity guidelines during pregnancy. Little is known about the role of sedentary behavior or sleep in APOs, a critical gap in knowledge given these behaviors comprise the majority of a 24-hour day. To address this knowledge gap, the Pregnancy 24/7 cohort study (2020-2025) uses 2 devices for 24-hour activity assessment in each trimester of pregnancy to examine associations of sedentary behavior, sleep, and the 24-hour activity cycle (composition of sedentary behavior, physical activity, and sleep) with hypertensive disorders and other APOs. Participants (n = 500) are recruited from the University of Iowa, University of Pittsburgh, and West Virginia University in early pregnancy and followed through delivery. The activPAL3 micro and Actiwatch Spectrum Plus are worn in each trimester for 7 days of 24-hour wear to assess the 24-hour activity cycle. APOs are abstracted from medical charts. This study will provide critical data to fuel future research examining how modifying the 24-hour activity cycle in pregnancy can improve maternal health.

Transversus abdominis plane block improves postoperative recovery following cesarean delivery under general anesthesia: A propensity score matched retrospective cohort study

OBJECTIVE

To evaluate the effects of transversus abdominis plane (TAP) block on postoperative recovery 24 h after cesarean delivery under general anesthesia.

METHODS

A propensity-score-matched, retrospective cohort study was used. A total of 173 pregnancies resulting in elective cesarean delivery under general anesthesia between March 2021 and March 2022 were analyzed retrospectively. Patients receiving TAP block were compared with those receiving only intravenous analgesia. The Quality of Recovery 15 (QoR-15) score, assessed 24 h postoperatively using a 15-item questionnaire, was the primary outcome. Secondary outcomes included time to first ambulation, time to first flatus postoperatively, ability to tolerate ambulation, visual analog scale (VAS) score, hospitalization cost, and postoperative nausea and/or vomiting.

RESULTS

The total QoR-15 score 24 h postoperatively in the TAP group was significantly higher than in the Control group (P < 0.001). Patients in the TAP group had higher Bruggemann comfort scale scores (P < 0.001), could better tolerate early postoperative ambulation (P < 0.001), and had shorter time to first ambulation (P < 0.001) and flatus (P < 0.001). Correlation analysis demonstrated an inverse relationship between the cumulative VAS pain scores, time to first postoperative ambulation, time to first flatus, and total QoR-15 score 24 h postoperatively.

CONCLUSIONS

Following cesarean delivery under general anesthesia, TAP block combined with intravenous analgesia can improve postoperative recovery and shorten the time to postoperative ambulation and recovery of intestinal function.

Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys

Background

After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh.

Methods

We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors.

Results

Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016.

Conclusions

Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

Decomposing the Black-White Racial Disparity in Severe Maternal Morbidity Risk: The Role of Hypertensive Disorders of Pregnancy

BACKGROUND

To our knowledge, no studies have explicitly studied the role of hypertensive disorders of pregnancy (HDP) in racial disparities in severe maternal morbidity (SMM).

METHODS

Using causal mediation models, we estimated the proportion of the non-Hispanic (NH) Black-White racial disparity in risk of SMM that is explained through the pathway of HDP. We linked 2006-2019 Georgia hospital discharge records with vital statistics birth and fetal death records for NH Black and NH White birthing persons. We used G-estimation of a structural nested mean model to decompose the absolute racial disparity in the incidence of SMM into pathways operating through HDP.

RESULTS

NH Black birthing people experienced an excess 56 SMM events (95% confidence interval [CI] = 52, 59) per 10,000 delivery hospitalizations compared with NH White birthing people. If counterfactual disparity measure estimation assumptions hold, the estimated absolute disparity remaining after blocking the causal pathways through HDP was 41 SMM events per 10,000 deliveries (95% CI = 38, 44), suggesting that 26% (95% CI = 12, 40) of the absolute racial disparity would be eliminated if there was no contribution of HDP to SMM risk.

CONCLUSION

Our results are consistent with the hypothesis that intervening to prevent HDP is an important (yet incomplete) pathway for reducing the excess risk among NH Black pregnancies compared with NH White pregnancies.

Material Properties of Nonpregnant and Pregnant Human Uterine Layers

The uterus has critical biomechanical functions in pregnancy and undergoes dramatic material growth and remodeling from implantation to parturition. The intrinsic material properties of the human uterus and how they evolve in pregnancy are poorly understood. To address this knowledge gap and assess the heterogeneity of these tissues, the time-dependent material properties of all human uterine layers were measured with nanoindentation. The endometrium-decidua layer was found to be the least stiff, most viscous, and least permeable layer of the human uterus in nonpregnant and third-trimester pregnant tissues. In pregnancy, endometrium-decidua becomes stiffer and less viscous with no material property changes observed in the myometrium or perimetrium. Additionally, uterine material properties did not significantly differ between third-trimester pregnant tissues with and without placenta accreta. The foundational data generated by this study will facilitate the development of physiologically accurate models of the human uterus to investigate gynecologic and obstetric disorders.

An evaluation of implementation climate in inpatient maternity care: a cross-sectional survey study

OBJECTIVE

Researchers in obstetrics and gynecology are continuously generating new evidence to inform clinical care delivery. Yet, much of this newly emerging evidence fails to be rapidly and effectively integrated into routine clinical practice. Implementation climate refers to clinicians' perceptions of to what degree organizations support and reward use of an evidence-based practice (EBP) and is an important construct in the science of implementation in healthcare. Little is known about implementation climate for EBPs in maternity care. Thus, we aimed to (a) determine the reliability of the Implementation Climate Scale (ICS) for use in inpatient maternity care, (b) describe implementation climate in inpatient maternity care overall, and (c) compare individual perceptions of implementation climate between physician and nursing clinicians on these units.

STUDY DESIGN

We performed a cross-sectional survey of clinicians in inpatient maternity units across 2 urban, academic hospitals in the northeastern United States in 2020. Clinicians completed the 18-question validated ICS [scored 0-4]. Scale reliability by role was evaluated using Cronbach's α. Subscale and total scores were described overall and compared by physician versus nursing role using independent t-tests, as well as linear regression to control for confounders.

RESULTS

111 clinicians completed the survey (physicians = 65; nursing = 46). Physicians were less likely to identify as female (75.4% vs. 100.0%, p < .001), but were of similar age and years of experience as nursing clinicians. Reliability of the ICS was excellent, with Cronbach's α of 0.91 and 0.86 among physicians and nursing clinicians, respectively. Scores were notably low for implementation climate in maternity care overall and for all subscales. ICS total scores were also higher among physicians as compared to nurses (2.18(±0.56) vs. 1.92(±0.50), p = .02), which remained significant in multivariable modeling (p = .02). Unadjusted subscale scores were higher among physicians in Recognition for EBP (2.68(±0.89) vs. 2.30(±0.86), p = .03) and Selection for EBP (2.24(±0.93) vs. 1.62(±1.04), p = .002). After adjustment for potential confounders, subscale scores for Focus on EBP (p = .04) and Selection for EBP (p = .002) were all higher among physicians.

CONCLUSIONS

This study supports the ICS as a reliable scale for measuring implementation climate in the inpatient maternity care setting. Notably lower implementation climate scores across subscales and roles compared to other settings may underlie the vast evidence to practice gap in obstetrics. In order to successfully implement practices that reduce maternal morbidity, we may need to focus on building educational support and rewarding EBP utilization on labor and delivery units, with an emphasis on nursing clinicians.

Standardized Cesarean Risk Counseling with Induction: Impact on Racial Disparities in Birth Satisfaction

OBJECTIVE

Our prior work demonstrated decreased birth satisfaction for Black women undergoing labor induction. We aimed to determine if implementation of standardized counseling around calculated cesarean risk during labor induction could reduce racial disparities in birth satisfaction.

STUDY DESIGN

We implemented use of a validated calculator that provides an individual cesarean risk score for women undergoing induction into routine care. This prospective cohort study compared satisfaction surveys for 6 months prior to implementation (preperiod: January 2018-June 2018) to 1 year after (postperiod: July 2018-June 2019). Women with full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix undergoing induction were included. In the postperiod, providers counseled patients on individual cesarean risk at the beginning of induction using standardized scripts. This information was incorporated into care at patient-provider discretion. The validated 10-question Birth Satisfaction Scale-Revised (BSS-R) subdivided into three domains was administered throughout the study. Patients were determined to be "satisfied" or "unsatisfied" if total BSS-R score was above or below the median, respectively. In multivariable analysis, interaction terms evaluated the differential impact of the calculator on birth satisfaction by race (Black vs. non-Black women).

RESULTS

A total of 1,008 of 1,236 (81.6%) eligible women completed the BSS-R (preperiod: 330 [79.7%] versus postperiod: 678 [82.5%], p = 0.23), 63.8% of whom self-identified as Black. In the preperiod, Black women were 50% less likely to be satisfied than non-Black women, even when controlling for differences in parity (Black: 39.0% satisfied vs. non-Black: 53.9%, adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI]: 0.30-0.79). In the postperiod, there was no difference in satisfaction by race (Black: 43.7% satisfied vs. non-Black: 44.0%, aOR = 0.97. 95% CI: 0.71-1.33). Therefore, disparities in birth satisfaction were no longer present at postimplementation (interaction p = 0.03).

CONCLUSION

Implementation of standardized counseling with a validated calculator to predict cesarean risk after labor induction is associated with a decrease in racial disparities in birth satisfaction.

KEY POINTS

· Preintervention, Black women were less likely to have above-median birth satisfaction.. · We implemented standardized counseling around cesarean risk with labor induction.. · Implementation was associated with reduced racial disparities in birth satisfaction scores..

The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature

BACKGROUND

The maternal mortality rate (MMR) in the United States (USA) continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women.

METHODS

A literature review was conducted to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. PubMed and key organizations (World Health Organization, Center for Disease Control and Prevention, American College of Obstetricians and Gynecologists, Alliance for Innovation on Maternal Health, Association of American Medical Colleges, U.S. Census Bureau, and U.S. Congress) were searched for publications after 2014.

RESULT

Forty-two articles were reviewed to identify the role of structural racism, implicit biases, lack of cultural competence, and disparity education on pregnant Black women. This review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications (PRC) among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women.

CONCLUSIONS

The surging MMR for Black women is a public health crisis that requires a multi-tiered approach. Interventions should be implemented at the provider and healthcare institution level to dismantle implicit biases and structural racism. Improving patient-provider relationships through increased cultural competency and disparity education will increase patient engagement with the maternal healthcare (MHC) system.

A Simple Intervention to Improve Equity in Obstetric Research

Introduction

To evaluate if a simple intervention, including formation of a Research Equity Committee and a dashboard detailing study approach and enrollment statistics by race, could improve equitable inclusion in obstetric research.

Methods

Our intervention had four components: (1) research personnel submitted dashboards every 3 months to the Research Equity Committee; (2) approach and enrollment by race were compared with expected racial breakdown; (3) study teams with rates of approach and/or enrollment of black birthing people below goal met with the committee for root cause analysis (RCA) and action planning; (4) all dashboards, RCAs, and action plans were presented at 3-month intervals. We prospectively evaluated the impact of this intervention on the inclusion of self-reported black birthing people in actively enrolling obstetrical studies at an academic university from July 2021 to June 2022.

Results

Seven qualifying prospective studies submitted 23 equity dashboards, which encompassed 692 patients. Six RCAs and action planning were held. Themes of developed action plans included: (1) standardizing how, when, and which patients to approach to eliminate approach bias, (2) standardized scripts for patient recruitment, and (3) study expansion to more diverse clinics. All four studies that underwent an RCA demonstrated improvements after the intervention; however, only one study demonstrated a statistically significant increase in approach (p=0.002) and enrollment (p=0.02) of black birthing people across the study period.

Discussion and Health Equity Implications

A simple intervention can improve approach and enrollment of black birthing people in obstetric research.

Neighborhood gentrification, displacement, and severe maternal morbidity in California

Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.

Adverse maternal outcomes associated with major fetal malformations after singleton live birth

BACKGROUND

Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity.

OBJECTIVE

This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations.

STUDY DESIGN

This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders.

RESULTS

Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07-2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50-2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31-1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45-1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48-2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18-17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41-1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41-1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14-1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35-1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29-1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31-1.90).

CONCLUSION

Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.

Analysis of Heat Exposure During Pregnancy and Severe Maternal Morbidity

Importance

The rate of severe maternal morbidity (SMM) is continuously increasing in the US. Evidence regarding the associations of climate-related exposure, such as environmental heat, with SMM is lacking.

Objective

To examine associations between long- and short-term maternal heat exposure and SMM.

Design, Setting, and Participants

This retrospective population-based epidemiological cohort study took place at a large integrated health care organization, Kaiser Permanente Southern California, between January 1, 2008, and December 31, 2018. Data were analyzed from February to April 2023. Singleton pregnancies with data on SMM diagnosis status were included.

Exposures

Moderate, high, and extreme heat days, defined as daily maximum temperatures exceeding the 75th, 90th, and 95th percentiles of the time series data from May through September 2007 to 2018 in Southern California, respectively. Long-term exposures were measured by the proportions of different heat days during pregnancy and by trimester. Short-term exposures were represented by binary variables of heatwaves with 9 different definitions (combining percentile thresholds with 3 durations; ie, ≥2, ≥3, and ≥4 consecutive days) during the last gestational week.

Main Outcomes and Measures

The primary outcome was SMM during delivery hospitalization, measured by 20 subconditions excluding blood transfusion. Discrete-time logistic regression was used to estimate associations with long- and short-term heat exposure. Effect modification by maternal characteristics and green space exposure was examined using interaction terms.

Results

There were 3446 SMM cases (0.9%) among 403 602 pregnancies (mean [SD] age, 30.3 [5.7] years). Significant associations were observed with long-term heat exposure during pregnancy and during the third trimester. High exposure (≥80th percentile of the proportions) to extreme heat days during pregnancy and during the third trimester were associated with a 27% (95% CI, 17%-37%; P < .001) and 28% (95% CI, 17%-41%; P < .001) increase in risk of SMM, respectively. Elevated SMM risks were significantly associated with short-term heatwave exposure under all heatwave definitions. The magnitude of associations generally increased from the least severe (HWD1: daily maximum temperature >75th percentile lasting for ≥2 days; odds ratio [OR], 1.32; 95% CI, 1.17-1.48; P < .001) to the most severe heatwave exposure (HWD9: daily maximum temperature >95th percentile lasting for ≥4 days; OR, 2.39; 95% CI, 1.62-3.54; P < .001). Greater associations were observed among mothers with lower educational attainment (OR for high exposure to extreme heat days during pregnancy, 1.43; 95% CI, 1.26-1.63; P < .001) or whose pregnancies started in the cold season (November through April; OR, 1.37; 95% CI, 1.24-1.53; P < .001).

Conclusions and Relevance

In this retrospective cohort study, long- and short-term heat exposure during pregnancy was associated with higher risk of SMM. These results might have important implications for SMM prevention, particularly in a changing climate.

A Web-Based Intervention to Address Risk Factors for Maternal Morbidity and Mortality (MAMA LOVE): Development and Evaluation Study

Background

Maternal mortality in the United States is a public health crisis and national emergency. Missed or delayed recognition of preventable life-threatening symptoms and untimely treatment of preventable high-risk medical conditions have been cited as key contributors to the nation's worsening mortality rates. Effective strategies are urgently needed to address this maternal health crisis, particularly for Black birthing populations. Morbidity and Mortality Assessment: Lifting Outcomes Via Education (MAMA LOVE) is a web-based platform that focuses on the identification of maternal morbidity and mortality risk factors.

Objective

The purpose of this paper is to present the conceptualization, development, heuristics, and utility evaluation of the web-based maternal mortality risk assessment and educational tool MAMA LOVE.

Methods

A user-centered design approach was used to gain feedback from clinical experts and potential end users to ensure that the tool would be effective among groups most at risk for maternal morbidity and mortality. A heuristic evaluation was conducted to evaluate usability and need within the current market. Algorithms describing key clinical, mental health, and social conditions were designed using digital canvas software (Miro) and incorporated into the final wireframes of the revised prototype. The completed version of MAMA LOVE was designed in Figma and built with the SurveyJS platform.

Results

The creation of the MAMA LOVE tool followed three distinct phases: (1) the content development and creation of an initial prototype; (2) the feedback gathering and usability assessment of the prototype; and (3) the design, development, and testing of the final tool. The tool determines the corresponding course of action using the algorithm developed by the authors. A total of 38 issues were found in the heuristic evaluation of the web tool's initial prototype.

Conclusions

Maternal morbidity and mortality is a public health crisis needing immediate effective interventions. In the current market, there are few digital resources available that focus specifically on the identification of dangerous symptoms and risk factors. MAMA LOVE is a tool that can address that need by increasing knowledge and providing resources and information that can be shared with health care professionals.

Southeastern US anesthesia providers' perspectives on abortion provision: Inductive findings from a qualitative study

OBJECTIVES

Health care providers, including anesthesia providers, hold varied personal views on abortion, which influences their involvement in multidisciplinary abortion care. We aimed to explore Southeastern US anesthesia providers' perspectives on abortion provision and factors impacting their decision to provide anesthesia for hospital-based induced abortion.

STUDY DESIGN

We conducted in-depth, individual interviews with currently practicing anesthesia providers in the Southeastern United States. We recruited participants from regional anesthesiology conferences and via snowball sampling. A semistructured interview guide explored domains of obstetric experiences, standardized abortion cases, and personal abortion attitudes. We coded data iteratively and analyzed data thematically using inductive approaches with qualitative software.

RESULTS

Fifteen participants completed interviews, at which point thematic saturation occurred. Participants represented a range of provider type and prior abortion experience. Participants weighed "personal and professional viewpoints" in considering their willingness to provide anesthesia care for hospital-based abortion. Many participants who personally disagreed with some abortion indications were still willing to provide anesthesia in those cases, some implicitly naming principles of medical ethics to justify differing professional and personal opinions. Participants also considered their "role in abortion decision-making": all participants reported that the abortion decision belongs to the patient or their obstetrician and not the anesthesia provider.

CONCLUSIONS

Southeastern US anesthesia providers are influenced by multiple factors when considering their participation in hospital-based abortion care. Acknowledging differences in professional and personal viewpoints and identifying roles in abortion decision-making might be important to engaging anesthesia providers in abortion care, especially for high-risk medical or fetal indications.

IMPLICATIONS

This original, qualitative study identified several inductive themes that characterize how Southeastern US anesthesia providers formulate their level of participation in hospital-based abortion care. Acknowledging differences in professional and personal viewpoints and identifying roles in abortion decision-making might facilitate interdisciplinary abortion care, especially for high-risk medical or fetal indications.

A Pilot Goal-Oriented Episodic Future Thinking Weight Loss Intervention for Low-Income Overweight or Obese Young Mothers

BACKGROUND

Episodic future thinking (EFT) has shown efficacy in laboratory settings. We conducted a pilot goal-oriented EFT (GoEFT) intervention in a real-world setting to help low-income overweight or obese mothers lose weight. This paper presents intervention acceptability and efficacy.

METHODS

The study used a single-group, before-after design. During the 3-week intervention, participants (N = 15) completed weekly web-based lessons and online health coaching sessions to manage stress and emotion, eat healthier, and be more physically active. Participants completed online surveys at baseline and immediately after the intervention. They also completed an interview to evaluate intervention acceptability. We applied paired t-tests to evaluate efficacy and used content analysis to discover interview themes.

RESULTS

Participants consistently identified the intervention as acceptable, noting the usefulness of pre-written goals, GoEFT strategies, and goal progress evaluations. The intervention effectively promoted weight loss (d = -0.69), fruit and vegetable intake (d = 0.45-0.49), and emotion control (d = 0.71). It also reduced fat (d = -0.51) and added sugar intake (d = -0.48) and alleviated stress (d = -0.52). Moreover, the intervention increased autonomous motivation (d = 0.75-0.88) and self-efficacy (d = 0.46-0.61).

CONCLUSION

The GoEFT intervention was acceptable to participants, showing strong preliminary efficacy.

Remapping racial and ethnic inequities in severe maternal morbidity: The legacy of redlining in California

BACKGROUND

Historical mortgage redlining, a racially discriminatory policy designed to uphold structural racism, may have played a role in producing the persistently elevated rate of severe maternal morbidity (SMM) among racialised birthing people.

OBJECTIVE

This study examined associations between Home-Owner Loan Corporation (HOLC) redlining grades and SMM in a racially and ethnically diverse birth cohort in California.

METHODS

We leveraged a population-based cohort of all live hospital births at ≥20 weeks of gestation between 1997 and 2017 in California. SMM was defined as having one of 21 procedures and diagnoses, per an index developed by Centers for Disease Control and Prevention. We characterised census tract-level redlining using HOLC's security maps for eight California cities. We assessed bivariate associations between HOLC grades and participant characteristics. Race and ethnicity-stratified mixed effects logistic regression models assessed the risk of SMM associated with HOLC grades within non-Hispanic Black, Asian/Pacific Islander, American Indian/Alaskan Native and Hispanic groups, adjusting for sociodemographic information, pregnancy-related factors, co-morbidities and neighbourhood deprivation index.

RESULTS

The study sample included 2,020,194 births, with 24,579 cases of SMM (1.2%). Living in a census tract that was graded as "Hazardous," compared to census tracts graded "Best" and "Still Desirable," was associated with 1.15 (95% confidence interval [CI] 1.03, 1.29) and 1.17 (95% CI 1.09, 1.25) times the risk of SMM among Black and Hispanic birthing people, respectively, independent of sociodemographic factors. These associations persisted after adjusting for pregnancy-related factors and neighbourhood deprivation index.

CONCLUSIONS

Historical redlining, a tool of structural racism that influenced the trajectory of neighbourhood social and material conditions, is associated with increased risk of experiencing SMM among Black and Hispanic birthing people in California. These findings demonstrate that addressing the enduring impact of macro-level and systemic mechanisms that uphold structural racism is a vital step in achieving racial and ethnic equity in birthing people's health.

The contributions of parental lactation on offspring development: It's not udder nonsense!

The Developmental Origins of Health and Disease (DOHaD) hypothesis describes how maternal stress exposures experienced during critical periods of perinatal life are linked to altered developmental trajectories in offspring. Perinatal stress also induces changes in lactogenesis, milk volume, maternal care, and the nutritive and non-nutritive components of milk, affecting short and long-term developmental outcomes in offspring. For instance, selective early life stressors shape the contents of milk, including macro/micronutrients, immune components, microbiota, enzymes, hormones, milk-derived extracellular vesicles, and milk microRNAs. In this review, we highlight the contributions of parental lactation to offspring development by examining changes in the composition of breast milk in response to three well-characterized maternal stressors: nutritive stress, immune stress, and psychological stress. We discuss recent findings in human, animal, and in vitro models, their clinical relevance, study limitations, and potential therapeutic significance to improving human health and infant survival. We also discuss the benefits of enrichment methods and support tools that can be used to improve milk quality and volume as well as related developmental outcomes in offspring. Lastly, we use evidence-based primary literature to convey that even though select maternal stressors may modulate lactation biology (by influencing milk composition) depending on the severity and length of exposure, exclusive and/or prolonged milk feeding may attenuate the negative in utero effects of early life stressors and promote healthy developmental trajectories. Overall, scientific evidence supports lactation to be protective against nutritive and immune stressors, but the benefits of lactation in response to psychological stressors need further investigation.

Maternal comorbidity and adverse perinatal outcomes in survivors of adolescent and young adult cancer: A cohort study

OBJECTIVE

To evaluate risks of preterm birth (PTB) and severe maternal morbidity (SMM) in female survivors of adolescent and young adult cancer and assess maternal comorbidity as a potential mechanism. To determine whether associations differ by use of assisted reproductive technology (ART).

DESIGN

Retrospective cohort.

SETTING

Commercially insured females in the USA.

SAMPLE

Females with live births from 2000-2019 within a de-identified US administrative health claims data set.

METHODS

Log-binomial regression models estimated relative risks of PTB and SMM by cancer status and tested for effect modification. Causal mediation analysis evaluated the proportions explained by maternal comorbidity.

MAIN OUTCOME MEASURES

PTB and SMM.

RESULTS

Among 46 064 cancer survivors, 2440 singleton births, 214 multiple births and 2590 linked newborns occurred after cancer diagnosis. In singleton births, the incidence of PTB was 14.8% in cancer survivors versus 12.4% in females without cancer (aRR 1.19, 95% CI 1.06-1.34); the incidence of SMM was 3.9% in cancer survivors versus 2.4% in females without cancer (aRR 1.44, 95% CI 1.13-1.83). Cancer survivors had more maternal comorbidities before and during pregnancy; 26% of the association between cancer and PTB and 30% of the association between cancer and SMM was mediated by maternal comorbidities. Tests for effect modification of cancer status on perinatal outcomes by ART were non-significant.

CONCLUSIONS

Preterm birth and SMM risks were modestly increased after cancer. Significant proportions of elevated risks may result from increased comorbidities. ART did not significantly modify the association between adolescent and young adult cancer and adverse perinatal outcomes. The prevention and treatment of comorbidities provides an opportunity to improve perinatal outcomes among cancer survivors.

Relationships among Postpartum Weight Retention, Stress, and Disinhibited Eating: A Scoping Review

Postpartum weight retention (PPWR) is a significant contributor to maternal cardiometabolic disease risk. The transition to motherhood is a stressful time period in which women report consuming food to cope, an eating behavior that is associated with PPWR. In this scoping review, we identified original research and review articles published since 2010 that examined relationships among PPWR, maternal stress, and disinhibited eating. In total, 16 articles met the inclusion criteria. Findings were inconsistent related to PPWR and stress. PPWR and disinhibited eating were not significantly correlated; however, disinhibition scores were higher during the postpartum period compared to prenatally. Stress and disinhibited eating were directly correlated in 4 studies. Our findings suggest these concepts, particularly disinhibited eating, have not been robustly examined during the postpartum period. Additionally, instruments used to measure maternal stress vary widely and should be further studied and refined.

Maternal pre-pregnancy BMI, MTHFR polymorphisms, and the risk of adverse pregnancy outcomes in pregnant women from South China: a retrospective cohort study

BACKGROUND

Increasing evidence suggests an association between maternal pre-pregnancy body mass index (pre-BMI) and adverse pregnancy outcomes. However, the effects of methylenetetrahydrofolate reductase (MTHFR) polymorphisms on these relationships require further investigation. This study aimed to investigate whether the relationship between pre-BMI and the risk of adverse pregnancy outcomes was influenced by MTHFR gene polymorphisms.

METHODS

A total of 5614 mother-fetus pairs were included in the study. The odds ratios (OR) of adverse pregnancy complications, including gestational diabetes mellitus (GDM), gestational hypertension (GHT), cesarean delivery (CS), and premature rupture of membranes (PROM), were estimated using adjusted logistic regression models and subgroup analysis.

RESULTS

Pregnant women with higher pre-BMI values were positively related to the risk of GDM, GHT, and CS. In the subgroup analysis, underweight BMI was associated with a decreased risk of CS and GDM in pregnant women with the MTHFR A1298C AA or C677T CC genotype, while overweight/obese BMI was associated with an increased risk of GDM and CS in different MTHFR variants. Moreover, pregnant women with MTHFR A1298C AC + CC or C667T CC were found to have an increased risk of GHT in the MTHFR A1298C AA or C667T CT + TT genotype. A remarkable association was observed between the obesity group with MTHFR A1298C AC + CC (OR = 6.49, CI: 2.67-15.79) and the overweight group with the C667T CC genotype (OR = 4.72, CI: 2.13-10.45).

CONCLUSIONS

MTHFR gene polymorphisms exert a modifying effect on the association between maternal pre-BMI and the risk of GHT, CS, and GDM. Pregnant women with a high pre-BMI with specific MTHFR genotypes should be considered for GHT development.

The role of the pregnancy heart team in clinical practice

Significant maternal and fetal morbidity and mortality risk has been shown to be associated with cardiovascular disease in pregnancy. Several determinants, such as the increasing number of females with corrected congenital heart disease in reproductive age, a more advanced maternal age associated with cardiovascular risk factors, and a greater prevalence of preexisting comorbidities related to cardiac disorders such as cancer and COVID-19), lead to a higher incidence of cardiac complications in pregnancy in the last few decades. However, adopting a multidisciplinary strategy may influence maternal and neonatal outcomes. This review aims at assessing the role of the Pregnancy Heart Team, which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital and other cardiac or metabolic disorders, addressing several emerging aspects in the multidisciplinary team-based approach.

Hypertensive disorders of pregnancy pre- and postaspirin guideline publication in individuals with pregestational diabetes mellitus

BACKGROUND

The US Preventive Services Taskforce published guidelines in 2014 recommending that low-dose aspirin be initiated between 12 and 28 weeks of gestation among high-risk patients for preeclampsia prophylaxis. Moreover, low-dose aspirin is recommended by some clinicians for the prevention of preterm birth.

OBJECTIVE

This study aimed to evaluate whether there is an association between the US Preventive Services Taskforce aspirin guideline hypertensive disorders of pregnancy and the rates of hypertensive disorders of pregnancy and preterm birth in individuals with pregestational diabetes mellitus.

STUDY DESIGN

This was a repeated cross-sectional analysis of individuals with pregestational diabetes mellitus and at least 1 singleton delivery at >20 weeks of gestation with records available in the National Vital Statistics System between 2010 and 2018. The primary outcome was hypertensive disorders of pregnancy, and the secondary outcome was preterm birth. Demographics and clinical characteristics among individuals in the pre-US Preventive Services Taskforce guideline cohort (2010-2013) were compared with that of individuals in the post-US Preventive Services Taskforce guideline cohort (2015-2018). Multivariable regression estimated the odds ratios and 95% confidence intervals for the association between guideline publication and the selected endpoints. Effect modification was assessed for access to prenatal care using the Kotelchuck Index (<80% vs ≥80%). Furthermore, a sensitivity analysis limited to nulliparas was performed.

RESULTS

Overall, 224,065 individuals were included. Individuals in the post-US Preventive Services Taskforce guideline cohort were more likely to be older, be obese, and have a history of preterm birth. In unadjusted and adjusted modeling, delivery in the post-US Preventive Services Taskforce guideline cohort was associated with hypertensive disorders of pregnancy (adjusted odds ratio, 1.25; 95% confidence interval, 1.22-1.28) and preterm birth (adjusted odds ratio, 1.10; 95% confidence interval, 1.08-1.12). The adjusted odds ratios for hypertensive disorders of pregnancy and preterm birth were more pronounced among those with less than adequate access to care. The findings were similar in the sensitivity analysis of only nulliparas.

CONCLUSION

Delivery after US Preventive Services Taskforce aspirin guideline publication was associated with higher rates of hypertensive disorders of pregnancy and preterm birth in a population of individuals with diabetes mellitus. It is unknown whether patient or practitioner factors, or other changes in obstetrical care, contributed to these findings.

Trend and risk Factors for Severe Peripartum Maternal morbidity - a population-based Cohort Study

OBJECTIVES

While the rates of maternal mortality in developed countries have remained low in recent years, rates of severe maternal morbidity (SMM) are still increasing in high income countries. As a result, SMM is currently used as a measure of maternity care level. The aim of this study was to investigate the prevalence and risk factors of SMM surrounding childbirth.

METHODS

A nested case-control study was performed between the years 2013-2018. SMM was defined as peripartum hospitalization involving intensive care unit (ICU). A comparison was conducted between parturient with SMM to those without, randomly matched for delivery mode and date of birth in a 1:1 ratio. Multivariable logistic regression models were used to evaluate the independent association between SMM and different maternal and pregnancy characteristics.

RESULTS

During the study period, 96,017 live births took place, of which 144 (1.5 per 1,000 live births-0.15%) involved SMM with ICU admissions. Parturient with SMM were more likely to have a history of 2 or more pregnancy losses (18.2% vs. 8.3%, p = 0.004), deliver preterm (48.9% vs. 8.8%, p < 0.001), and suffer from placenta previa (11.9% vs. 1.5%, p < 0.001), and/or placenta accreta (9.7% vs. 1.5%, p = 0.003). Several significant and independent risk factors for SMM were noted in the multivariable regression models: preterm delivery, history of ≥ 2 pregnancy losses, grand-multiparity, Jewish ethnicity, and abnormal placentation (previa or accreta).

CONCLUSIONS FOR PRACTICE

SMM rates in our cohort were lower than reported in developed countries. An independent association exists between peripartum maternal ICU admissions and several demographic and clinical risk factors, including preterm birth and abnormal placentation.

Rural-Urban Disparities in Adverse Maternal Outcomes in the United States, 2016-2019

Objectives. To describe differences in maternal admissions to the intensive care unit (ICU) and mortality in rural versus urban areas in the United States. Methods. We performed a nationwide analysis and calculated age-standardized rates and rate ratios (RRs) of maternal ICU admission and mortality per 100 000 live births between 2016 and 2019 in rural versus urban areas. Results. From 2016 to 2019, there was no significant increase in age-standardized rates of maternal ICU admissions in rural (170.6-192.3) or urban (161.7-172.4) areas, with a significantly higher rate, albeit a relatively small difference, in rural versus urban areas (2019 RR = 1.14; 95% confidence interval [CI] = 1.04, 1.20). Maternal mortality increased in both rural (66.9-81.7 deaths per 100 000 live births) and urban (38.1-42.3) areas and was nearly 2 times higher in rural areas (2019 RR = 1.93; 95% CI = 1.71, 2.17). Conclusions. Pregnant individuals in rural areas are at higher risk for ICU admission and mortality than are their urban counterparts. Significant increases in maternal mortality occurred in rural and urban areas. Public Health Implications. Public health efforts need to focus on resource-limited rural areas to mitigate geographic disparities in maternal morbidity and mortality. (Am J Public Health. 2023;113(2): 224-227.https://doi.org/10.2105/AJPH.2022.307134).

Factors associated with utilization of physical therapy services during pregnancy and after childbirth

Objective

To explore demographic and clinical factors associated with utilization of antepartum/postpartum physical therapy.

Methods

This is a secondary analysis of a cross-sectional survey of 298 women who were receiving or had received obstetric care at a medical center in southern Taiwan. Data were collected between May 2021 and May 2022 using an online questionnaire, which included demographic, medical, and obstetric details, the symptom severity questionnaires, management strategies, and experience and perception about physical therapy. Descriptive statistics, independent t-test, chi-square analysis and multivariate logistic regression model were used to analyze data.

Results

Among 298 respondents, 190 (63.8%) were pregnant and 108 (36.2%) were postpartum. Thirteen percent of pregnant participants and 27% of postpartum participants had received physical therapy during and/or after childbirth. Multivariate analyses showed that being postpartum, having an associate degree and below, and experiencing depressive symptoms were significantly associated with an increased utilization of physical therapy (postpartum: OR = 3.039, 95% CI = 1.530, 6.035; associate degree and below: OR = 2.521, 95% CI = 1.007, 6.316; depressive symptoms: OR = 3.606, 95% CI = 1.067, 12.185). The odds of utilizing physical therapy decreased with age (OR = 0.935, 95% CI = 0.874, 1.000).

Conclusions

Individual factors, such as age, education level, pregnancy status, and experience of depressive symptoms, have a significant association with utilization of antepartum/postpartum physical therapy and should be considered when developing obstetric care pathways to optimize clinical and healthcare utilization outcomes.

Interactions between perceived stress and microbial-host immune components: two demographically and geographically distinct pregnancy cohorts

Higher stress during pregnancy associates with negative outcomes and elevated inflammation. The gut microbiota, reflecting environment and social interactions, alongside host immune responses have the potential to better understand perceived stress and identify when stress is excessive in pregnancy. Two U.S. cohorts of 84 pregnant individuals, composed of urban women of color and suburban white women, completed the Perceived Stress Scale-10 (PSS-10) and provided fecal and blood samples at two time points. Confirmatory Factor Analysis assessed the robustness of a two-factor PSS-10 model (Emotional Distress/ED and Self-Efficacy/SE). Gut microbiota composition was measured by 16 S rRNA amplicon sequencing and the immune system activity was assessed with a panel of 21 T-cell related cytokines and chemokines. ED levels were higher in the suburban compared to the urban cohort, but levels of SE were similar. ED and SE levels were associated with distinct taxonomical signatures and the gut microbiota data improved the prediction of SE levels compared with models based on socio-demographic characteristics alone. Integration of self-reported symptoms, microbial and immune information revealed a possible mediation effect of Bacteroides uniformis between the immune system (through CXCL11) and SE. The study identified links between distinct taxonomical and immunological signatures with perceived stress. The data are congruent with a model where gut microbiome and immune factors, both impacting and reflecting factors such as close social relationships and dietary fiber, may modulate neural plasticity resulting in increased SE during pregnancy. The predictive value of these peripheral markers merit further study.

A Qualitative Study of Perspectives of Black Women on Autonomy and Motivational Interviewing

Purpose

Motivational interviewing (MI) is an evidence-based strategy to modify health behaviors, including some risk factors for adverse birth outcomes. Black women, who have disproportionately high rates of adverse birth outcomes, have reported mixed preferences on MI. This study explored the acceptability of MI among Black women who are at high risk for adverse birth outcomes.

Methods

We conducted qualitative interviews with women with a history of preterm birth. Participants were English-language proficient and had Medicaid-insured infants. We purposively oversampled women whose infants had medical complexity. Interviews explored experiences with health care and health behaviors after birth. The interview guide was iteratively developed to obtain specific reactions to MI by including videos demonstrating MI-consistent and MI-inconsistent counseling. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes related to MI and allowed themes to emerge from the data.

Results

We interviewed 30 non-Hispanic Black women from October 2018 to July 2021. Eleven viewed the videos. Participants emphasized the importance of autonomy in decision-making and health behavior. Participants expressed a preference for MI-consistent clinical approaches, including autonomy support and building rapport, considering them respectful, nonjudgmental, and likely to support change.

Conclusions

In this sample of Black women with a history of preterm birth, participants valued an MI-consistent clinical approach. Incorporating MI into clinical care may improve the experience of health care among Black women, thus serving as one strategy to promote equity in birth outcomes.

Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events

During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.

Structural racism and adverse maternal health outcomes: A systematic review

In the United States, racial disparities in adverse maternal health outcomes remain a pressing issue, with Black women experiencing a 3-4 times higher risk of maternal mortality and a 2-3 times higher risk of severe maternal morbidity. Despite recent encouraging efforts, fundamental determinants of these alarming inequities (e.g. structural racism) remain understudied. Approaches that address these structural drivers are needed to then intervene upon root causes of adverse maternal outcomes and their disparities and to ultimately improve maternal health across the U.S. In this paper, we offer a conceptual framework for studies of structural racism and maternal health disparities and systematically synthesize the current empirical epidemiologic literature on the links between structural racism measures and adverse maternal health outcomes. For the systematic review, we searched electronic databases (Pubmed, Web of Science, and EMBASE) to identify peer-reviewed U.S. based quantitative articles published between 1990 and 2021 that assessed the link between measures of structural racism and indicators of maternal morbidity/mortality. Our search yielded 2394 studies and after removing duplicates, 1408 were included in the title and abstract screening, of which 18 were included in the full text screening. Only 6 studies met all the specified inclusion criteria for this review. Results revealed that depending on population sub-group analyzed, measures used, and covariates considered, there was evidence that structural racism may increase the risk of adverse maternal health outcomes. This review also highlighted several areas for methodological and theoretical development in this body of work. Future work should more comprehensively assess structural racism in a way that informs policy and interventions, which can ameliorate its negative consequences on racial/ethnic disparities in maternal morbidity/mortality.

Dense phenotyping from electronic health records enables machine learning-based prediction of preterm birth

BACKGROUND

Identifying pregnancies at risk for preterm birth, one of the leading causes of worldwide infant mortality, has the potential to improve prenatal care. However, we lack broadly applicable methods to accurately predict preterm birth risk. The dense longitudinal information present in electronic health records (EHRs) is enabling scalable and cost-efficient risk modeling of many diseases, but EHR resources have been largely untapped in the study of pregnancy.

METHODS

Here, we apply machine learning to diverse data from EHRs with 35,282 deliveries to predict singleton preterm birth.

RESULTS

We find that machine learning models based on billing codes alone can predict preterm birth risk at various gestational ages (e.g., ROC-AUC = 0.75, PR-AUC = 0.40 at 28 weeks of gestation) and outperform comparable models trained using known risk factors (e.g., ROC-AUC = 0.65, PR-AUC = 0.25 at 28 weeks). Examining the patterns learned by the model reveals it stratifies deliveries into interpretable groups, including high-risk preterm birth subtypes enriched for distinct comorbidities. Our machine learning approach also predicts preterm birth subtypes (spontaneous vs. indicated), mode of delivery, and recurrent preterm birth. Finally, we demonstrate the portability of our approach by showing that the prediction models maintain their accuracy on a large, independent cohort (5978 deliveries) from a different healthcare system.

CONCLUSIONS

By leveraging rich phenotypic and genetic features derived from EHRs, we suggest that machine learning algorithms have great potential to improve medical care during pregnancy. However, further work is needed before these models can be applied in clinical settings.

Vitamin D-Related Risk Factors for Maternal Morbidity during Pregnancy: A Systematic Review

Vitamin D has well-defined classical functions related to metabolism and bone health but also has non-classical effects that may influence pregnancy. Maternal morbidity remains a significant health care concern worldwide, despite efforts to improve maternal health. Nutritional deficiencies of vitamin D during pregnancy are related to adverse pregnancy outcomes, but the evidence base is difficult to navigate. The primary purpose of this review is to map the evidence on the effects of deficiencies of vitamin D on pregnancy outcome and the dosage used in such studies. A systematic search was performed for studies on vitamin D status during pregnancy and maternal outcomes. A total of 50 studies came from PubMed, 15 studies came from Cochrane, and 150 studies came from Embase, for a total of 215 articles. After screening, 34 were identified as candidate studies for inclusion. Finally, 28 articles met the inclusion criteria, which originated from 15 countries. The studies included 14 original research studies and 13 review studies conducted between 2012 and 2021. This review was finally limited to the 14 original studies. This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, and the quality and strength of the evidence was evaluated using the Navigation Guide Systematic Review Methodology (SING). We found evidence that supports the idea that supplementary vitamin D for pregnant women is important for reducing the risk of gestational diabetes, hypertension, preeclampsia, early labor, and other complications. The data retrieved from this review are consistent with the hypothesis that adequate vitamin D levels might contribute to a healthy pregnancy.

Double, Triple, and Quadruple Jeopardy: Entering Pregnancy With Two or More Multimorbid Diagnoses and Increased Risk of Severe Maternal Morbidity and Postpartum Readmission

INTRODUCTION

Multimorbidity, the presence of two or more chronic disease diagnoses, is associated with an increased risk of mortality and high health care costs in the general population and older adults. However, little evidence is available about the prevalence and impact of multimorbidity in obstetric populations. The goal of this analysis was to estimate the association between multimorbidity and severe maternal morbidity (SMM) and 90-day postpartum readmission in an obstetric cohort in Atlanta, Georgia.

STUDY DESIGN

We conducted a retrospective cohort study of livebirths and stillbirths at Grady Memorial Hospital, from October 2015 to April 2021. To determine preexisting chronic conditions, we linked information on births to inpatient diagnoses within the prior year. Multimorbidity was defined as the presence of two or more chronic disease diagnoses at birth or within the prior year. We conducted multivariable log binomial regression to estimate risk ratios and 95% confidence intervals for the crude and adjusted (for age, race/ethnicity, parity, and insurance) association between multimorbidity (two or more chronic conditions vs. zero or one) and SMM (at or within 42 days after birth) or 90-day postpartum readmission for any reason.

RESULTS

Of 14,225 included births, 10.1% were to patients with multimorbidity. Overall, SMM complicated 7.5% of births, and the 90-day readmission rate was 2.4%. Both SMM and readmission were more common among women with multimorbidity (SMM, 18.6% among women with multimorbidity compared with 6.3% without; 90-day readmission, 5.4% compared with 2.1%). Adjusting for potential confounders, multimorbidity was associated with increased risk of SMM (adjusted risk ratio, 2.9; 95% confidence interval, 2.5-3.0) and readmission (adjusted risk ratio, 2.2; 95% confidence interval, 1.7-2.9).

CONCLUSIONS

Individuals entering pregnancy with two or more chronic diseases were at an increased risk of SMM and postpartum readmission compared with individuals with one or zero chronic disease diagnoses.

Trends in Hypertensive Disorders of Pregnancy in the United States From 1989 to 2020

Hypertensive disorders of pregnancy affect up to 8% of pregnancies, but updated national trends are lacking. We performed a repeated cross-sectional analysis of individuals with singleton pregnancies who delivered at greater than 20 weeks of gestation, with data in the U.S. National Vital Statistics System from 1989 to 2020. Temporal trends in hypertensive disorders of pregnancy, chronic hypertension, and eclampsia were characterized using joinpoint regression. Overall, 122,329,914 deliveries were included. Hypertensive disorders of pregnancy increased from 2.79% in 1989 to 8.22% in 2020, representing an average annual percentage change (AAPC) of 3.6% (95% CI 3.0-4.1%). Chronic hypertension increased (AAPC 4.1%, 95% CI 3.3-4.9%), whereas eclampsia decreased (AAPC -2.5%, 95% CI -4.0% to -1.0%). Hypertensive disorders of pregnancy are associated with significant morbidity and mortality; the rising incidence is concerning.

Evaluation of the feasibility of the FAST-M maternal sepsis intervention in Pakistan: a protocol

BACKGROUND

Maternal sepsis is a life-threatening condition, defined by organ dysfunction caused by infection during pregnancy, childbirth, and the postpartum period. It is estimated to account for between one-tenth and half (4.7% to 13.7%) of all maternal deaths globally. An international stakeholder group, including the World Health Organization, developed a maternal sepsis management bundle called "FAST-M" for resource-limited settings through a synthesis of evidence and international consensus. The FAST-M treatment bundle consists of five components: Fluids, Antibiotics, Source identification and control, assessment of the need to Transport or Transfer to a higher level of care and ongoing Monitoring (of the mother and neonate). This study aims to adapt the FAST-M intervention and evaluate its feasibility in Pakistan.

METHODS

The proposed study is a mixed method, with a before and after design. The study will be conducted in two phases at the Liaquat University of Medical and Health Sciences, Hyderabad. In the first phase (formative assessment), we will adapt the bundle care tools for the local context and assess in what circumstances different components of the intervention are likely to be effective, by conducting interviews and a focus group discussion. Qualitative data will be analyzed considering a framework method approach using NVivo version 10 (QSR International, Pty Ltd.) software. The qualitative results will guide the adaptation of FAST-M intervention in local context. In the second phase, we will evaluate the feasibility of the FAST-M intervention. Quantitative analyses will be done to assess numerous outcomes: process, organizational, clinical, structural, and adverse events with quantitative comparisons made before and after implementation of the bundle. Qualitative analysis will be done to evaluate the outcomes of intervention by conducting FGDs with HCPs involved during the implementation process. This will provide an understanding and validation of quantitative findings.

DISCUSSION

The utilization of care bundles can facilitate recognition and timely management of maternal sepsis. There is a need to adapt, integrate, and optimize a bundled care approach in low-resource settings in Pakistan to minimize the burden of maternal morbidities and mortalities due to sepsis.

The Association Between Adequate Prenatal Care and Severe Maternal Morbidity Among Teenage Pregnancies: A Population-Based Cohort Study

Background

The aim of this study was to examine whether inadequate prenatal care affect the risk of severe maternal morbidity in teenage pregnancies.

Methods

We included 23,202 delivery cases among adolescent mothers aged between 13 and 19 years old with ≥ 37 weeks' gestational age. Data were derived from the National Health Insurance Service National Delivery Cohort in Korea between 2003 and 2018. We used a generalized estimating equation model while adjusting for numerous covariates to determine the adjusted relative risk (RR) associated with severe maternal morbidity. The main outcome measures were severe maternal morbidity and the Kessner Adequacy of Prenatal Care Index.

Results

Severe maternal morbidity occurred in 723 (3.1%) of the 23,202 investigated delivery cases. The risk of severe maternal morbidity was 1.8-fold higher among adolescent mothers who had received inadequate prenatal care (RR, 1.81, 95% confidence interval [CI], 1.39–2.37) and 1.6-fold higher among those who had received intermediate prenatal care (RR, 1.59, 95% CI, 1.33–1.87) compared to those with adequate prenatal care. Synergistic effects of inadequate prenatal care and maternal comorbidities affected severe maternal morbidity.

Conclusion

This study confirmed that inadequate prenatal care is associated with increased risk of severe maternal morbidity among pregnant teenagers. Notably, maternal comorbidity and inadequate prenatal care produced synergistic effects on severe maternal morbidity. Public health policy makers should focus on the development and implementation of programs to ensure that adequate prenatal care and financial/healthcare support is provided to teenage mothers during their pregnancies.

Squatting, pelvic morphology and a reconsideration of childbirth difficulties

 

Childbirth is commonly viewed as difficult in human females, encompassed by the 'Obstetrical Dilemma' (OD) described by early palaeoanthropologists as an evolved trade-off between a narrow pelvis necessitated by bipedalism and a large-brained fetal head. The OD has been challenged on several grounds. We add to these challenges by suggesting humans likely squatted regularly during routine tasks prior to the advent of farming societies and use of seats. We suggest that habitual squatting, together with taller stature and better nutrition of ancestral hunter-gatherers compared with later Neolithic and industrial counterparts, obviated an OD. Instead, difficulties with parturition may have arisen much later in our history, accompanying permanent settlements, poorer nutrition, greater infectious disease loads and negligible squatting in daily life. We discuss bioarchaeological and contemporary data that support these viewpoints, suggest ways in which this hypothesis might be tested further and consider its implications for obstetrical practice.

Lay Summary

Human childbirth is viewed as universally difficult. Evidence from physical therapies/engineering and studies of living and ancestral humans illustrates habitual squatting widens the pelvis and could improve childbirth outcomes. Obstetrical difficulties emerged late in prehistory accompanying settled agriculture, poorer nutrition and less squatting. Specific physical exercises could improve obstetrical practice.

Injustices in Black Maternal Health: A Call for Different Research Questions, Orientations, and Methodologies

For decades, Black mothers have been most likely to suffer the worst outcomes of pregnancy, including death. Even though traditional individual level risk factors do not explain racial inequities in maternal morbidity, most studies identify Black race as a predictor, instead of the ways in which our society is structured around racism that makes Black mothers vulnerable to adverse health outcomes. As an example, the U.S is exceptional in incarcerating its residents, and Black men are six times and Black women are three times more likely than their white counterparts to be incarcerated. Relatedly, violent death caused by homicides disproportionately impacts Black communities, such that is the leading cause of death for males and females aged 10–34 years. Estimates suggest that more than 50% of urban residents know more than 10 murder victims, and approximately 200 people are affected by each neighborhood murder. Recent research has begun to shed light on the impacts of stressful neighborhood social conditions on risk of the adverse birth outcomes among Black mothers however, few studies have quantified the impact of macro-social neighborhood factors like violent death exposures and mass incarceration on Black maternal health. Future research that leverages relevant theoretical frameworks, is co-created and co-led with affected communities, and focuses on relevant neighborhood level traumas is warranted if we are to address the longstanding racial inequities in maternal health.