Racial and ethnic differences in preterm birth: A complex, multifactorial problem

Predicting preterm birth using electronic medical records from multiple prenatal visits

This study aimed to predict preterm birth in nulliparous women using machine learning and easily accessible variables from prenatal visits. Elastic net regularized logistic regression models were developed and evaluated using 5-fold cross-validation on data from 8,830 women in the Nulliparous Pregnancy Outcomes Study: New Mothers-to-Be (nuMoM2b) dataset at three prenatal visits: 6 0 - 13 6 , 16 0 - 21 6 , and 22 0 - 29 6 weeks of gestational age (GA). The models' performance, assessed using Area Under the Curve (AUC), sensitivity, specificity, and accuracy, consistently improved with the incorporation of data from later prenatal visits. AUC scores increased from 0.6161 in the first visit to 0.7087 in the third visit, while sensitivity and specificity also showed notable improvements. The addition of ultrasound measurements, such as cervical length and Pulsatility Index, substantially enhanced the models' predictive ability. Notably, the model achieved a sensitivity of 0.8254 and 0.9295 for predicting very preterm and extreme preterm births, respectively, at the third prenatal visit. These findings highlight the importance of ultrasound measurements and suggest that incorporating machine learning-based risk assessment and routine late-pregnancy ultrasounds into prenatal care could improve maternal and neonatal outcomes by enabling timely interventions for high-risk women.

Voting Restrictions and Increased Odds of Adverse Birth Outcomes in the US

BACKGROUND

Disparities persist in adverse birth outcomes - preterm birth and small-for-gestational age (SGA) among racialized populations. Previous studies have indicated that voting restrictions are associated with health outcomes, such as access to health insurance and teenage birth rates. This paper examines whether the association between voting restrictions and adverse birth outcomes varies according to birthing individuals' race/ethnicity.

METHODS

These analyses merged individual-level 2019-2020 Pregnancy Risk Assessment Monitoring System (PRAMS, 8th edition) data with state-level exposure information. The exposure, the Cost of Voting Index (COVI), is a 2020 state-level measure of voting restrictions, and the outcomes were preterm birth and SGA. Multilevel logistic regression, survey-weighted models adjusted for sociodemographic and geographically-based characteristics. Subanalyses examined if the association differed by race (non-Hispanic White, non-Hispanic Black, Hispanic, API, Other).

RESULTS

In the unadjusted model, a standard deviation increase in COVI was associated with increased odds of preterm birth (OR = 1.11, 95% CI = 0.98, 1.25) and SGA (OR = 1.12, 95% CI = 1.02, 1.22). The association for SGA was still significant in the fully adjusted models. Results differed by race/ethnicity with the largest effects among API (OR = 1.20, 95% CI = 0.95, 1.52) for preterm birth and OR = 1.27, 95% CI = 1.01, 1.59) for SGA respectively).

CONCLUSION

Our results suggest structural voting barriers disproportionately increase the odds of adverse birth outcomes, especially for API-birthing individuals. Increasing voting restrictions may amplify existing birth inequities.

Impact of being underweight before pregnancy on preterm birth by race/ethnicity and insurance status in California: an analysis of birth records

BACKGROUND

The US still has a high burden of preterm birth (PTB), with important disparities by race/ethnicity and poverty status. There is a large body of literature looking at the impact of pre-pregnancy obesity on PTB, but fewer studies have explored the association between underweight status on PTB, especially with a lens toward health disparities. Furthermore, little is known about how weight, specifically pre-pregnancy underweight status, and socio-economic-demographic factors such as race/ethnicity and insurance status, interact with each other to contribute to risks of PTB.

OBJECTIVES

The objective of this study was to measure the association between pre-pregnancy underweight and PTB and small for gestational age (SGA) among a large sample of births in the US. Our secondary objective was to see if underweight status and two markers of health disparities - race/ethnicity and insurance status (public vs. other) - on PTB.

STUDY DESIGN

We used data from all births in California from 2011 to 2017, which resulted in 3,070,241 singleton births with linked hospital discharge records. We ran regression models to estimate the relative risk of PTB by underweight status, by race/ethnicity, and by poverty (Medi-cal status). We then looked at the interaction between underweight status and race/ethnicity and underweight and poverty on PTB.

RESULTS

Black and Asian women were more likely to be underweight (aRR = 1.0, 95% CI: 1.01, 1.1 and aRR = 1.4, 95% CI: 1.4, 1.5, respectively), and Latina women were less likely to be underweight (aRR = 0.7, 95% CI: 0.7, 0.7). Being underweight was associated with increased odds of PTB (aRR = 1.3, 95% CI 1.3-1.3) and, after controlling for underweight, all nonwhite race/ethnic groups had increased odds of PTB compared to white women. In interaction models, the combined effect of being both underweight and Black, Indigenous and People of Color (BIPOC) statistically significantly reduced the relative risk of PTB (aRR = 0.9, 95% CI: 0.8, 0.9) and SGA (aRR = 1.0, 95% CI: 0.9, 1.0). The combined effect of being both underweight and on public insurance increased the relative risk of PTB (aRR = 1.1, 95% CI: 1.1, 1.2) but there was no additional effect of being both underweight and on public insurance on SGA (aRR = 1.0, 95% CI: 1.0, 1.0).

CONCLUSIONS

We confirm and build upon previous findings that being underweight preconception is associated with increased risk of PTB and SGA - a fact often overlooked in the focus on overweight and adverse birth outcomes. Additionally, our findings suggest that the effect of being underweight on PTB and SGA differs by race/ethnicity and by insurance status, emphasizing that other factors related to inequities in access to health care and poverty are contributing to disparities in PTB.

Greenspace Morphology and Preterm Birth: A State-Wide Study in Georgia, United States (2001-2016)

BACKGROUND

Residential greenness is linked to birth outcomes. However, the role of greenspace morphology remains poorly understood. Additionally, evidence is lacking regarding whether these relationships vary by subpopulation.

OBJECTIVE

We examined the association between preterm birth and residential greenspace morphology, including percentage, shape, connectedness, aggregation, closeness, and fragmentation.

METHODS

We analyzed 2,063,444 singleton live births between 2001 to 2016 in Georgia, USA. Thirty-meter resolution landcover data from National Land Cover Databased (2001-2016) were obtained to calculate greenspace morphology metrics for 1,953 census tracts in Georgia. A two-stage logistic regression examined associations between each greenspace morphology metric and preterm birth at individual level. Stratified analysis was conducted by maternal race, ethnicity, education, urbanicity, poverty rate, and greenspace percentage.

RESULTS

Higher greenspace percentage, aggregation, closeness, shape complexity, connectedness, and lower fragmentation were linked to a lower risk of preterm birth. After adjusting for poverty rate, associations with morphology attenuated, except for fragmentation [odds ratio (OR) = 1.014; 95% confidence interval (CI): 1.0001, 1.026] across the entire population. Strongest associations were found among black mothers and in high-poverty areas. Specifically, the odds of preterm birth in the highest quartile of greenspace percentage were 0.962 (95% CI: 0.933, 0.991) times the odds in the lowest quartile. Additionally, a lower risk of preterm birth was associated with higher greenspace aggregation (OR = 0.969; 95% CI: 0.947, 0.992), and a higher risk of preterm birth was associated with higher fragmentation (OR = 1.028; 95% CI: 1.009, 1.047), both in the black mothers group. In tracts with a high poverty rate, a lower risk of preterm birth associate with higher greenspace percentage (OR = 0.953; 95% CI: 0.910, 0.999), aggregation (OR = 0.976; 95% CI: 0.955, 0.997), and lower fragmentation (OR = 0.976; 95% CI: 0.958, 0.994). The association with greenspace morphology was most pronounced in census tracts with a medium level of greenspace percentage.

DISCUSSION

Our study complements other studies by showing the importance and protective effects of greenspace morphology. The observed effects are particularly prominent in census tracts characterized by a moderate level of greenspace percentage, high poverty rates, and among black women. Our findings suggest the need for tailored greenspace planning strategies based on varying levels of greenness in different areas. For locations with low greenness, increasing the greenspace percentage may be prioritized. In areas with a medium level of greenness, strategic enhancement of greenspace morphology is recommended. For areas with high greenness, the focus should be on improving spatial closeness of greenspace. https://doi.org/10.1289/EHP14571.

Vaginal progesterone for prevention of preterm birth in women with a history of preterm birth regardless of cervical length: an argument for use

It is well understood that preterm birth accounts for a substantial amount of poor neonatal outcomes. In 2022, preterm birth affected about 1 of every 10 infants born in the United States with complications ranging from mild respiratory distress syndrome to neonatal death. The complexity of the treatment is secondary to the fact that preterm birth is a multifactorial syndrome with intricate sociocultural factors that influence our racially disproportionate poor outcomes. One of the key risk factors for preterm birth is a history of spontaneous preterm birth. Currently, there are conflicting recommendations regarding the use of vaginal progesterone prophylactically for the prevention of recurrent preterm birth. As described in Practice Bulletin number 234 of the American College of Obstetricians and Gynecologists, the current recommendation is that patients with a singleton pregnancy and previous spontaneous preterm birth should be assessed with serial endovaginal ultrasound cervical length measurements to determine eligibility for vaginal progesterone. In contrast, the Society for Maternal-Fetal Medicine suggests the use of prophylactic vaginal progesterone with patient-centered counseling and shared decision-making. We aimed to present the rationale for the use of prophylactic vaginal progesterone in patients with singleton gestations and a history of spontaneous preterm birth.

Inpatient Skin-to-skin Care Predicts 12-Month Neurodevelopmental Outcomes in Very Preterm Infants

OBJECTIVE

To examine the relationship between inpatient skin-to-skin care rates and neurodevelopmental scores measured at 12 months in very preterm (VPT) infants.

STUDY DESIGN

From a retrospective review of medical records of 181 VPT infants (<32 weeks gestational age [GA] at birth), we derived skin-to-skin care rate, ie, total minutes of skin-to-skin care each infant received over the number of days of hospital stay. We used scores on the Capute Scales from routine follow-up assessments at 12 months to measure neurodevelopmental outcomes.

RESULTS

Families averaged approximately 17 minutes/day of skin-to-skin care (2 days/week, 70 minutes/session), although there was substantial variability. Variation in skin-to-skin rate was positively associated with outcomes at 12 months corrected age (r = 0.25, P < .001). Skin-to-skin rate significantly predicted 6.2% unique variance in 12-month neurodevelopmental outcomes, after adjusting for GA, socioeconomic status (SES), health acuity, and visitation frequency. A 20-minute increase in skin-to-skin care per day was associated with a 10-point increase (0.67 SDs) in neurodevelopmental outcomes at 12 months. GA and infant health acuity did not moderate these relations.

CONCLUSION

VPT infants who experienced more skin-to-skin care during hospitalization demonstrated higher scores on 12-month neurodevelopmental assessments. Results provide evidence that skin-to-skin care confers extended benefits to VPT infants through the first year of life. Skin-to-skin care offers promise as a family-centered intervention designed to promote positive developmental outcomes in at-risk infants.

Digital Twin of the Female Pelvic Floor

Digital twin technology, originally developed for intricate physical systems, holds great potential in women's healthcare, particularly in the management of pelvic floor disorders. This paper delves into the development of a digital twin specifically for the female pelvic floor, which can amalgamate various data sources such as imaging, biomechanical assessments, and patient-reported outcomes to offer personalized diagnostic and therapeutic insights. Through the utilization of 3D modeling and machine learning, the digital twin may facilitate precise visualization, prediction, and individualized treatment planning. Nevertheless, it is crucial to address the ethical and practical challenges related to data privacy and ensuring fair access. As this technology progresses, it has the potential to revolutionize gynecological and obstetric care by enhancing diagnostics, customizing treatments, and increasing patient involvement.

Brain health equity and the influence of social determinants across the life cycle

Social determinants of health are social, economic and environmental factors known to influence health and development of infants, children and adults. Advancing equity in brain health relies upon interdisciplinary collaboration and recognition of the impact of social determinants on brain health through the lifespan and across generations. Critical periods of fetal, infant and early childhood development encompass intrinsic genetic and extrinsic environmental influences with complex gene-environment interactions. This review discusses the influence of social determinants on the continuum of brain health from preconception and pregnancy health, through fetal, infant and childhood neurodevelopment into adulthood. Opportunities for intervention to address the social determinants of brain health across the life cycle are highlighted.

Cancer diagnosis during pregnancy is associated with severe maternal and neonatal morbidity

BACKGROUND

Data on maternal and fetal outcomes in patients diagnosed with cancer during pregnancy are limited. Given expected increase in patients diagnosed with cancer during pregnancy, there is a growing need to evaluate clinical outcomes.

OBJECTIVE

To evaluate obstetric outcomes among women with early-stage gynecologic or breast cancer who were diagnosed during pregnancy compared to women without cancer in a population-based cohort.

STUDY DESIGN

We performed a population-based study of women aged 18 to 45 years with stage I gynecologic or stage I to III breast cancer reported to the California Cancer Registry for the years 2000 to 2012. Data were linked to the 2000 to 2012 California birth data to produce a database with cancer characteristics and obstetric outcomes. We included patients who had a delivery within the 10 months following cancer diagnosis. The primary outcome was severe maternal morbidity. Secondary outcomes included preterm birth and neonatal morbidity. Propensity scores were used to match similar controls to cases in a 2:1 ratio based on demographic attributes and medical comorbidities included in the Obstetric Comorbidity Index. Logistic regressions were used to evaluate outcomes.

RESULTS

The cohort consisted of 503 women with cancer in pregnancy (319 breast, 125 ovarian, 59 cervical) and 1006 matched controls. Cancer during pregnancy was associated with higher odds of severe maternal morbidity (6.8% vs <1.1%; odds ratio 8.03, 95% confidence interval 3.82-16.88), preterm birth between 32 and 36 weeks (32.6% vs 8.3%, odds ratio 5.38, 95% confidence interval 4.02-7.20), and neonatal morbidity (12.5% vs 6.1%; odds ratio 2.22, 95% confidence interval 1.53-3.21) compared to matched controls. In subanalysis of severe maternal morbidity indicators, hysterectomy and sepsis were significantly associated with cancer during pregnancy (4.8% vs <1.1%, P<.001; <2.2% vs 0.0%, P=.037, respectively).

CONCLUSION

Cancer during pregnancy is associated with increased risk of maternal and neonatal morbidity. These findings highlight the need for careful management and consideration of obstetric outcomes in these patients.

Social Determinants of Preterm Birth amongst Non-Hispanic Black Individuals

OBJECTIVE

 Non-Hispanic Black individuals are disproportionately affected by preterm birth (PTB), a major driver of the racial disparity in infant mortality in the United States. The objective of this study is to identify indicators of social determinants of health (SDoH) that contribute to preterm birth amongst non-Hispanic Black individuals.

STUDY DESIGN

 Population-based retrospective case-control study of U.S. birth records (2012-2016). Factors potentially associated with PTB and considered indicators of SDoH were compared between singleton live births of non-Hispanic Black individuals delivering preterm (<37 weeks of gestation) and term (≥37 weeks of gestation). Logistic regression quantified the association between SDoH and PTB such as insurance, education, and prenatal care visits and reported as odds ratios (ORs; 95% confidence interval, CI).

RESULTS

 Of 2,763,235 live births to Black individuals, 340,480 (12%) occurred <37 weeks of gestation. Factors most strongly associated with PTB (p < 0.001), presented as OR (95% CI), included no prenatal care 3.0 (95% CI: 2.9-3.1) or insufficient prenatal care 2.7 (95% CI: 2.7-2.8), smoking during pregnancy 1.4 (95% CI: 1.43-1.47), unmarried 1.18 (95% CI: 1.17-1.19), lack of high school diploma 1.1 (95% CI: 1.12-1.40), lack of father of baby listed on birth certificate 1.22 (1.21-1.23), and Black paternal race 1.10 (1.08-1.12). Receipt of WIC (women, infants, and children) during the pregnancy had a protective effect on PTB risk in Black individuals, OR 0.83 (0.83-0.84).

CONCLUSION

 Pregnancies in Black individuals who are ≥35 years old, smoke tobacco, utilize Medicaid insurance, have less than a high school education, are unmarried, have little to no prenatal care, Black paternal race, and lack of father of baby listed on birth record had increased risk of PTB. Understanding the lived experience of Black pregnant people and these selected indicators of SDoH that contribute to the risk of PTB may inform development of interventions to address the racial disparity in PTB in the United States.

KEY POINTS

· Preterm birth disproportionately affects Black individuals.. · SDoH are contributors to preterm birth.. · This study investigates social determinant influences on preterm birth among Black individuals..

Interventions to mitigate pregnancy-related mortality and morbidity in Black birthing people: a systematic review

OBJECTIVE

To conduct a systematic review of interventions to improve perinatal outcomes to mitigate pregnancy-related mortality and morbidity in Black birthing people.

DATA SOURCES

We searched 5 databases from 2000 through the final search date of April 5, 2023: Cumulative Index of Nursing and Allied Health Literature Plus with Full Text (EBSCOhost), Embase (Elsevier), PubMed, and Scopus (Elsevier) and ClinicalTrials.gov.

STUDY ELIGIBILITY CRITERIA

Only quantitative studies were eligible including observational and randomized controlled trials. All participants in selected studies must identify as Black or study results must be stratified by race that includes Black birthing people. The study must (1) measure a perinatal outcome of interest (2) occur in the United States and (3) be written in the English language. Studies were excluded if they were published prior to 2000, not published in the English language, or did not meet the criteria above.

STUDY APPRAISAL AND SYNTHESIS METHODS

A data extraction template identified intervention type and perinatal outcome. Perinatal outcomes included but were not limited to: cardiovascular disorders, mortality, or preterm delivery. Interventions included: community programs, educational enhancement, individual counseling, medical intervention, or policy. Risk of bias was assessed using the Mixed Method Appraisal Tool. Three investigators assessed studies individually and group consensus was used for a final decision.

RESULTS

From 4,302 unique studies, 41 studies met inclusion criteria. Community programs such as the Supplemental Program for Women, Infants, and Children (WIC) and Healthy Start (n=17, 41.5%) were the most common interventions studied. Individual counseling closely followed (n=15, 36.6%). Medical interventions were not among the more commonly used intervention types (n=9, 21.9%). Most articles focused on preterm delivery (n=28, 68.3%). Few articles studied cardiovascular disorders (n=4, 9.8%) or hemorrhage (n=3, 7.3%). No articles studied pregnancy-related morbidity.

CONCLUSIONS

Despite current conversations on Black maternal mortality, there is currently limited literature examining interventions addressing perinatal morbidity and mortality in Black birthing people in the United States. These interventions do not address how to mitigate perinatal outcomes of interest. Patient-centered outcomes research is warranted to better understand as well as to resolve inequities related to Black maternal health. El resumen está disponible en Español al final del artículo.

A National Study of the Associations between Hormonal Modulators in Hydraulic Fracturing Fluid Chemicals and Birth Outcomes in the United States of America: A County-Level Analysis

BACKGROUND

Risk of preterm birth (PTB) and low birth weight (LBW) due to hydraulic fracturing (HF) exposure is a growing concern. Regional studies have demonstrated links, but results are often contradictory among studies.

OBJECTIVES

This is the first US national study to our knowledge linking fracturing fluid ingredients to the human hormone pathways targeted-estrogen, testosterone, or other hormones (e.g., thyroid hormone)-to assess the effect of HF ingredients on rates of PTB and LBW.

METHODS

We constructed generalized linear regression models of the impact of HF well density and hormone targeting chemicals in HF fluids (2001-2018) on the county-level average period prevalence rates of PTB and LBW (2015-2018) with each outcome measured in separate models. Our data sources consisted of publicly available datasets, including the WellExplorer database, which uses data from FracFocus, the March of Dimes Peristats, the US Census Bureau, the US Department of Agriculture, and the Centers for Disease Control and Prevention. We conducted additional stratified analyses to address issues of confounding. We used stratification to address issues regarding outcomes in rural vs. urban communities by assessing whether our models achieved similar results in nonmetro counties, as well as farming and mining counties. We also stratified by the year of the HF data to include HF data that was closer to the time of the birth outcomes. We also added covariate adjustment to address other important factors linked to adverse birth outcomes, including the proportion of the population belonging to various racial and ethnic minority populations (each modeled as a separate variable); education (bachelor's degree and high school); use of fertilizers, herbicides, and insecticides, acres of agricultural land per square mile; poverty; insurance status; marital status; population per square mile; maternal care deserts; and drug deaths per 100,000 people.

RESULTS

We found that the density of HF wells in a county was significantly associated with both PTB and LBW rates (percentage of live births) in our fully adjusted models. We report the results from our more restrictive stratified analysis with a subset including only the 2014-2018 data, because this resulted in the most meaningful time frame for comparison. Across all models, the magnitude of effect was highest for wells with ingredients that include estrogen targeting chemicals (ETCs), testosterone targeting chemicals (TTCs) and other hormone targeting chemicals (OHTCs), and, finally, all wells grouped regardless of chemical type. For every unit increase in well density per square mile of wells that use chemicals that include an ETC, we observed a 3.789-higher PTB rate (95% CI: 1.83, 5.74) compared with counties with no ETC wells from 2014 to 2018 and likewise, we observed a 1.964-higher LBW rate (95% CI: 0.41, 3.52). Similarly, for every unit increase in well density per square mile of wells that use TTC, we observed a 3.192-higher PTB rate (95% CI: 1.62, 4.77) compared with counties with no TTC wells. Likewise, for LBW, we found a 1.619-higher LBW rate (95% CI: 0.37, 2.87). We also found that an increase in well density per square mile among wells that use chemicals that include an OHTC resulting in a 2.276-higher PTB rate (95% CI: 1.25, 3.30) compared with counties with no OHTC wells, and for LBW, we found a 1.244-higher LBW rate (95% CI: 0.43, 2.06). We also explored the role of HF well exposure in general (regardless of the chemicals used) and found that an increase in total well density (grouped regardless of hormonal targeting status of the chemicals used) resulted in a 1.228-higher PTB rate (95% CI: 0.66, 1.80) compared with counties with no wells, and for LBW, we found a 0.602-higher LBW rate (95% CI: 0.15, 1.05) compared with counties with no wells. We found similar results in our primary analysis that used all data without any exclusions and the statistical significance did not change.

DISCUSSION

Our findings reinforce previously identified regional associations between HF and PTB and LBW, but on a national scale. Our findings point to dysregulation of hormonal pathways underpinning HF exposure risk on birth outcomes, which warrants further exploration. Future research must consider the specific ingredients used in HF fluids to properly understand the differential effects of exposure. https://doi.org/10.1289/EHP12628.

Were fewer boys born in the United States during the early months of the COVID-19 pandemic? A test of the Trivers-Willard hypothesis

The Trivers-Willard hypothesis predicts that mammalian parents in poor environmental conditions will favor the offspring sex with more reliable chance of reproductive success, which in humans is females. Three months following the onset of the COVID-19 pandemic in South Africa, England, and Wales, there were significant decreases in the sex ratio at birth (SRB) (male births/total live births). We analyzed this ratio with a seasonal autoregressive moving average model, and a logistic regression, using nationwide natality data for all singleton births in the United States from 2015 to 2021 (n = 25,201,620 total births). We identified no significant change in the sex ratio in either analysis. Rather, we observed marked differences in the sex ratio by maternal characteristics of race/ethnicity, age, and education, with more vulnerable groups having lower sex ratios. These findings suggest the SRB may be an important marker of reproductive vulnerability for disadvantaged groups in the United States.

Associations between Historical Redlining and the Risk of Pregnancy Complications and Adverse Birth Outcomes in Massachusetts, 1995-2015

Objective: To assess the impact of historical redlining on the risk of pregnancy complications and adverse birth outcomes in Massachusetts (MA) from 1995 to 2015. Methods: In total, 288,787 pregnant people from the MA Birth Registry had information on parental characteristics, pregnancy factors, and redlining data at parental residences at the time of delivery. Historic redlining data were based on MA Home Owners' Loan Corporation (HOLC) security maps, with grades assigned (A "best," B "still desirable," C "definitely declining," and D "hazardous"). We used covariate-adjusted binomial regression models to examine associations between HOLC grade and each chronic condition and pregnancy/birth outcome. Results: Living in HOLC grades B through D compared with A was associated with an increased risk of entering pregnancy with chronic conditions and adverse pregnancy/birth outcomes. The strongest associations were seen with pregestational diabetes (adjusted risk ratio [RR] Grade D: 1.7, 95% confidence interval [CI]: 1.3, 2.4) and chronic hypertension (adjusted RR Grade D: 1.5, 95% CI: 1.1, 1.9). Conclusions: Historical redlining policies from the 1930s were associated with adverse pregnancy outcomes and chronic conditions; associations were strongest for chronic conditions in pregnancy.

Long-term ambient sulfur dioxide exposure during gestation and preterm birth in North Carolina, 2003-2015

BACKGROUND

Coal-fired power plants are major contributors of ambient sulfur dioxide (SO2) air pollution. Epidemiological literature suggests an adverse association between SO2 exposure during gestation and preterm birth (PTB; <37 weeks completed gestation). PTB is strongly associated with infant mortality and increased risk for later life morbidities.

OBJECTIVE

We investigated associations between SO2 and PTB in North Carolina and evaluated whether the associations were modified by race/ethnicity.

METHODS

We assembled a retrospective, administrative cohort of singleton births in North Carolina from 2003-2015. We used US EPA EQUATES data to assign long-term SO2 gestational exposures to eligible births for the entire pregnancy and by trimester. We used multivariable generalized linear regression to estimate risk differences (RD (95%CI)) per 1-ppb increase in SO2, adjusted for gestational parent education, Medicaid status, marital status, and season of conception. Multi-pollutant models were additionally adjusted for other criteria air co-pollutants (O3, PM2.5, NO2).

RESULTS

The median SO2 (24-hour average) across exposure windows was ~1.5 (IQR: 1.8) ppb. The overall baseline risk for PTB was 8,756 per 100,000 live births. When stratified by race/ethnicity, the baseline risk for PTB was 12215, 7824, and 7187 per 100,000 live births among non-Hispanic Black, non-Hispanic white, and Hispanic births, respectively. RDs per 1-ppb increase in SO2 averaged across the entire pregnancy were 317.0 (95%CI: 279.4, 354.5) and 568.2 (95%CI: 500.3, 636.1) per 100,000 live births for single- and multi-pollutant models, respectively. For the PTB multi-pollutant models, we observed similar RDs for non-Hispanic Black participants (669.6 [95%CI: 573.9, 765.2]) and non-Hispanic white participants (635.4 [95%CI: 557.2, 713.6]) with smaller RDs for Hispanic participants (336.8 [95%CI: 241.3, 432.2]).

SIGNIFICANCE

The results for our adjusted single- and multi-pollutant models showed adverse associations between SO2 and PTB, with some evidence of effect measure modification by race/ethnicity within subcategories of PTB.

Cohort profile: The Camden Study - a pregnancy cohort study of pregnancy complications and birth outcomes in Camden, New Jersey, USA

Background

Pregnancy is a unique stage of the life course characterized by trade-offs between the nutritional, immune, and metabolic needs of the mother and fetus. The Camden Study was originally initiated to examine nutritional status, growth, and birth outcomes in adolescent pregnancies and expanded to study dietary and molecular predictors of pregnancy complications and birth outcomes in young women.

Methods

From 1985-2006, 4765 pregnant participants aged 12 years and older were recruited from Camden, NJ, one of the poorest cities in the U.S. The cohort reflects a population under-represented in perinatal cohort studies (45% Hispanic, 38% non-Hispanic Black, 17% White participants; 98% using Medicaid in pregnancy). Study visits, including questionnaires, dietary assessments, and biospecimen collection, occurred in early and late pregnancy as well as at delivery. Medical records were abstracted, and a subset of mothers and infants participated in a six-week postpartum visit.

Results

Over the last five decades, the Camden Study has provided data toward the publication of numerous peer-reviewed papers. Results show that adolescent linear growth in pregnancy is associated with smaller birth size, possibly due to impaired hemodynamics. In the context of preterm birth and other perinatal outcomes, analyses of nutritional data have demonstrated the importance of micronutrients (e.g., folate, iron, zinc), as well as glucose/insulin dynamics and prenatal supplement use. More recent analyses have begun to unpack the biochemical pathways in pregnancy that may be shaped by race as an indicator for systemic racism.

Conclusions

The Camden Study data and biorepositories are well-positioned to support future research aimed at better understanding perinatal health in under-represented women and infants. Linkages to subsequent health and administrative records and the potential for recontacting participants over 18-39 years after initial participation may provide key insights into the trajectories of maternal and child health across the life course.

Neighborhood mobility and racial disparities in preterm birth: A sibling study in California

Recent work finds that upward neighborhood mobility-defined as reductions in neighborhood socioeconomic disadvantage due to moving-may improve birth outcomes. Less work, however, explores whether changes in socioeconomic context differentially impact birth outcomes by maternal race and ethnicity. In the US, mothers of minoritized racial and ethnic identity often experience worse neighborhood conditions and pregnancy outcomes than White mothers. Using a sibling-linked dataset, we examined whether neighborhood mobility corresponds with changes in preterm birth risk among Asian (N = 130,079), Black (N = 50,149), Hispanic (N = 429,938), and White (N = 233,428) mothers who delivered multiple live births in California between 2005 and 2015. We linked residential addresses at each birth to census-derived indices of neighborhood disadvantage and defined levels of neighborhood mobility as moving-induced changes in disadvantage between pregnancies. We mapped neighborhood mobility patterns and fit conditional logistic regression models estimating the odds of preterm birth in the sibling delivered after moving, controlling for the risk of preterm birth in the sibling delivered before moving, by maternal race and ethnicity. Dot density maps highlight racialized patterns of neighborhood mobility and segregation between Black and White mothers. Regression results show that Black and, in some cases, Asian and Hispanic mothers who experienced upward mobility (moves away from neighborhood disadvantage) exhibited reduced odds of preterm birth in the second delivery. Upward mobility did not reduce the odds of preterm birth among White mothers. Findings suggest that policies and programs that enable opportunities for neighborhood mobility may reduce persistent racial and ethnic disparities in adverse birth outcomes.

Maternal peripheral blood telomere length and preterm birth in African American women: a pilot study

PURPOSE

This study aimed to explore the association between preterm birth and telomere length of maternal peripheral blood in African American women.

METHODS

78 African American women were recruited for this study between 2018 and 2023 from 2 prenatal clinics in central and east Texas. Participants provided blood samples and completed clinic questionnaires, with clinical data collected from their post-delivery medical records. Telomere length was measured using monochrome multiplex quantitative real-time polymerase chain reaction. Linear regression and multinomial logistic regression were used to analyze the association between telomere length and gestational length. Kruskal-Wallis's test and Fisher's exact test were used to compare preterm birth, early-term birth and full-term birth by telomere length, social-demographic characteristics, stress and discrimination.

RESULTS

The rates of preterm birth was higher in pregnant women with shorter telomeres. After adjusting for confounders, for every 10-units increase in the relative telomere-to-single-copy gene (T/S) ratio, gestational days increased by 1.090 days (90% CI 0.182, 1.997), and for every 10-units decrease in the T/S ratio, the odds of preterm birth was 2.664 (90% CI 1.064, 6.673) times greater than the odds of full-term birth. No statistically significant associations were observed between stress, discrimination, and either preterm birth or telomere length.

CONCLUSIONS

Maternal peripheral blood telomere shortening is associated with preterm birth, providing support to further explore the clinical utility of maternal telomere testing for prediction and early intervention of preterm birth and the study of biological mechanisms of spontaneous preterm birth.

SMFM Consult Series #70: Management of short cervix in individuals without a history of spontaneous preterm birth

Most deliveries before 34 weeks of gestation occur in individuals with no previous history of preterm birth. Midtrimester cervical length assessment using transvaginal ultrasound is one of the best clinical predictors of spontaneous preterm birth. This Consult provides guidance for the diagnosis and management of a short cervix in an individual without a history of preterm birth. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that all cervical length measurements used to guide therapeutic recommendations be performed using a transvaginal approach and in accordance with standardized procedures as described by organizations such as the Perinatal Quality Foundation or the Fetal Medicine Foundation (GRADE 1C); (2) we recommend using a midtrimester cervical length of ≤25 mm to diagnose a short cervix in individuals with a singleton gestation and no previous history of spontaneous preterm birth (GRADE 1C); (3) we recommend that asymptomatic individuals with a singleton gestation and a transvaginal cervical length of ≤20 mm diagnosed before 24 weeks of gestation be prescribed vaginal progesterone to reduce the risk of preterm birth (GRADE 1A); (4) we recommend that treatment with vaginal progesterone be considered at a cervical length of 21 to 25 mm based on shared decision-making (GRADE 1B); (5) we recommend that 17-alpha hydroxyprogesterone caproate, including compounded formulations, not be prescribed for the treatment of a short cervix (GRADE 1B); (6) in individuals without a history of preterm birth who have a sonographic short cervix (10-25 mm), we recommend against cerclage placement in the absence of cervical dilation (GRADE 1B); (7) we recommend that cervical pessary not be placed for the prevention of preterm birth in individuals with a singleton gestation and a short cervix (GRADE 1B); and (8) we recommend against routine use of progesterone, pessary, or cerclage for the treatment of cervical shortening in twin gestations outside the context of a clinical trial (GRADE 1B).

Associations between Individual- and Structural-Level Racism and Gestational Age at Birth in the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be

The purpose of this study was to investigate the associations between multilevel racism and gestational age at birth among nulliparous women. We conducted a secondary analysis of data of the nuMoM2b Study (2010-2013) to examine the associations between individual- and structural-level experiences of racism and discrimination and gestational age at birth among nulliparous women (n = 9148) at eight sites across the U.S. Measures included the individual Experiences of Discrimination (EOD) scale and the Index of Concentration at the Extremes (ICE) to measure structural racism. After adjustment, we observed a significant individual and structural racism interaction on gestational length (p = 0.012). In subgroup analyses, we found that among those with high EOD scores, women who were from households concentrated in the more privileged group had significantly longer gestations (β = 1.27, 95% CI: 0.48, 2.06). Women who reported higher EOD scores and more economic privilege had longer gestations, demonstrating the moderating effect of ICE as a measure of structural racism. In conclusion, ICE may represent a modifiable factor in the prevention of adverse birth outcomes in nulliparas.

Association between endometrial thickness and birthweight of singletons from vitrified-warmed cycles: a retrospective cohort study

RESEARCH QUESTION

What is the association between endometrial thickness (EMT) and the birthweight of singleton infants born from frozen-thawed embryo transfer cycles?

DESIGN

This retrospective cohort study was conducted from January 2016 to December 2019. Participants were categorized into a natural cycle (NC, n = 8132) group and hormone replacement therapy (HRT, n = 4975) group. Only singleton deliveries were included. The primary outcomes were measures of birthweight and relevant indexes. Multivariable logistic regression and multivariable-adjusted linear regression models that incorporated restricted cubic splines were used.

RESULTS

In the HRT group, the risk of delivering a small for gestational age (SGA) infant was increased in women with an EMT <8.0 mm (adjusted odds ratio [aOR] 1.85, 95% confidence interval [CI] 1.17-2.91) compared with women with an EMT of 8.0 to <12.0 mm, and increased with an EMT ≥12.0 mm (aOR 1.85, 95% CI 1.03-3.33). An inverted U-shaped relationship was found between EMT and birthweight in women with HRT. No significant differences were shown in birthweight z-score, or being SGA or large for gestational age, in singletons among the three EMT groups in the natural cycles.

CONCLUSIONS

A thinner endometrium seen in women undergoing HRT cycles was associated with a lower birthweight z-score, as well as a higher risk of SGA. However, no significant association was observed between EMT and birthweight z-score or SGA in the NC group. It is noteworthy that a thicker endometrium was not associated with a higher birthweight in frozen-thawed embryo transfer (FET) cycles. Women with a thin endometrium who achieve pregnancy require specialized attention, particularly if they are undergoing FET with HRT cycles.

Caregiver and Provider Perceptions of Health Disparities in the Neonatal Intensive Care Unit: A Qualitative Study

OBJECTIVE

1) To describe the experience of caregivers and their perceptions of disparate care in the neonatal intensive care unit (NICU) and 2) explore interprofessional NICU provider perspectives on potential biases and perceptions of disparate care.

METHODS

This qualitative study was conducted in 1 southeastern level IV NICU. Semistructured interviews assessed caregiver and provider perspectives on NICU care. Purposive sampling ensured ≥50% of caregivers self-identified as racial and/or ethnic minorities. Interviews were recorded, transcribed verbatim, and audio verified. A coding scheme was developed, raw data were systematically coded, and emerging themes were identified using thematic analyses.

RESULTS

Twenty-three caregivers and 14 providers were interviewed, including 5 neonatologists, 6 nurses, and 3 residents. Caregivers were predominantly English-speaking (85%); 96% were mothers with a mean age of 32 years. Neonates were predominantly racial and ethnic minorities (62%). Providers were predominantly White (71%) and female (71%). Five themes emerged 1) ineffective, biased communication between caregivers, providers, and health care team may contribute to disparities; 2) language barriers and lack of interpreter access play a significant role in perceived negative care; 3) lack of caregiver involvement and role in decision-making may negatively influence NICU outcomes, especially for those not able to be present at the bedside; and 4) multiple biases may affect neonatal health disparities.

CONCLUSIONS

Our study highlights the importance of considering both provider and racial and/or ethnic minority caregiver perceptions disparities in NICU care delivery. It adds to the literature as one of the few qualitative studies comparing perceptions of disparate NICU care among both caregivers and providers.

"MAMA's is like a second mom:" Client and Staff Experiences in a Comprehensive Social Risk Care Management Program Within a Perinatal Medical Home

INTRODUCTION

Addressing persistent racial inequities in preterm birth requires innovative health care approaches. The Los Angeles County Maternity Assessment and Management Access Service Synergy Neighborhood program (MAMA's) is a perinatal medical home program designed to alleviate the impacts of chronic stress by addressing social determinants of health. It reduced odds of preterm birth rates in Black participants, yet it is unclear which program components most contributed to this reduction. This study seeks to understand the experiences of staff and clients within the MAMA's program to identify what factors decrease stress, how the program addresses racism and the challenges and opportunities of optimizing health during the COVID-19 pandemic.

METHODS

21 staff and 34 clients completed semi-structured interviews from November 2020-December 2021. Separate interview guides for staff and clients explored experiences within the program, experiences during the COVID-19 pandemic, and how racism affects clients. Interviews were recorded and transcribed. Analysis used a phenomenologic framework. Coding was performed using grounded theory to identify themes.

RESULTS

Analysis revealed six key themes: Stressors clients face, barriers for undocumented, Latina, and Spanish-speaking clients, exceptional care, emotional support, naming and responding to racism and discrimination, and impacts of COVID-19 pandemic.

DISCUSSION

Staff and clients work together to address social needs in order to address chronic stress and racism in their lives, especially during the COVID-19 pandemic. Interviews revealed relationship building is a cornerstone of the program's success and plays a significant role in alleviating chronic stress in this population.

Assessing the Role of Asthma on the Relationship between Neurodevelopmental Disabilities and Adverse Birth Outcomes

BACKGROUND

Investigating asthma as an effect modifier between adverse birth outcomes and neurodevelopmental disabilities (NDDs) across different races is crucial for tailored interventions and understanding variable susceptibility among diverse populations.

METHODS

Data were collected through the National Survey of Children's Health. This cross-sectional study included 131,774 children aged 0 to 17 years. Study exposures comprised adverse birth outcomes including preterm birth and low birth weight. Weighted prevalence estimates and odds ratios with 95% confidence intervals (CIs) among children with and without adverse birth outcomes were calculated for NDDs including attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, seizure, and several others including behavior problems. Adjusted odds ratios were stratified by asthma status and separate interactions were assessed for each outcome.

RESULTS

Of 131,774 participants, 10,227 were born low birth weight (9.12%; 95% CI: 8.77% to 9.49%), 14,058 were born preterm (11.35%; 95% CI: 10.94% to 11.76%), and 16,166 participants had asthma (11.97%; 95% CI: 11.58% to 12.37%). There were 68,100 males (51.11%), 63,674 females (48.89%), 102,061 non-Hispanic Whites (NHW) (66.92%), 8,672 non-Hispanic Blacks (NHB) (13.97%), and 21,041 participants (19.11%) categorized as other. NHB children with adverse birth outcomes had higher prevalence of several NDDs compared to NHW children.

CONCLUSIONS

Asthma was not shown to be an effect modifier of the association between adverse birth outcomes and NDDs. Nevertheless, these results suggest that NDDs are more prevalent within US children with adverse birth outcomes, with higher rates among NHB compared to NHW children. These findings support screening for NDDs in pediatric health care settings among patients with adverse birth outcomes, particularly among those from ethnic minority backgrounds.

Increased mortality in infants with abnormal T-cell receptor excision circles

BACKGROUND

T-Cell Receptor Excision Circles based newborn screening (TREC-NBS) allows for early detection of T-cell lymphopenia in infants with primary immunodeficiency disorders (PIDD). The utility of abnormal TREC-NBS in infants without PIDD is not well studied. We sought to evaluate the association of abnormal TREC-NBS with mortality.

METHODS

365,207 TREC-NBS from October 2011 to December 2014 were reviewed. 467 newborns had abnormal screens and did not meet the criteria for a PIDD diagnosis. Cases were matched to controls (1:3) based on gestational age, birth weight, neonatal intensive care unit status (NICU), and race. Data were obtained through NBS, birth and death certificates records from the Michigan Department of Health and Human Services (MDHHS) databases.

RESULTS

Infants with abnormal TREC-NBS had higher mortality even when PIDD was ruled-out. Transient abnormal TREC-NBS was not associated with higher mortality, but unresolved or late abnormal TREC-NBS was associated with higher mortality. Infants with late abnormal TREC-NBS had severe prematurity, lower birth weight, lower Apgar scores, and higher percentage of congenital anomalies.

CONCLUSION

Infants with abnormal TREC-NBS may be at a higher risk of morbidity and mortality and should be carefully followed, especially if discharged home before a repeat screen can be completed.

IMPACT

This study explores the risk factors and mortality for newborns with secondary T-cell lymphopenia captured on T-Cell Receptor Excision Circles based newborn screening (TREC-NBS). Abnormal TREC-NBS allows for prompt life-saving interventions for primary immunological conditions such as Severe Combined Immunodeficiency (SCID), but can also be associated with non-immunologic conditions. Unresolved and late abnormal TREC-NBS is associated with higher mortality even without primary immunodeficiency, likely detected in infants with more severe prematurity, lower birth weight, and congenital anomalies. TREC-NBS positive infants with secondary T-cell lymphopenia require special attention and close monitoring.

Characterizing the utilization of doula support services among birthing people of color in the United States: a scoping review

BACKGROUND

Birthing people of color experience disproportionately higher rates of infant and maternal mortality during pregnancy and birth compared to their white counterparts. The utilization of doula support services may lead to improvements in the birthing experiences of birthing people of color. Yet, the research in this area is sparse. Thus, the purpose of this review is to characterize the research on doula utilization among birthing people of color, identify gaps in the field, and provide recommendations for future research.

METHODS

Utilizing PRISMA guidelines, we conducted a scoping review, searching PubMed, PsycINFO, CINAHL, and Google Scholar for peer-reviewed articles published between January 1, 2016, to July 3, 2022.

RESULTS

Twenty-five articles met inclusion criteria. We identified the three themes characterizing included studies: (1) how doulas support (HDS) their clients, (2) doula support outcomes (DSO), and (3) considerations for implementing doula support services (CIDS). Despite doulas being described as agents of empowerment, and providing social support, education, and advocacy, birthing people of color reported low utilization of doula support services and findings regarding their effectiveness in improving birthing outcomes were mixed.

CONCLUSIONS

While some studies suggest that doulas may offer important services to birthing people of color, doulas are largely under-utilized, with many birthing people reporting low knowledge of their potential roles during the pre- and post-partum periods. Moreover, few studies were designed to assess intervention effects, limiting our ability to draw firm conclusions. Birthing people of color are at elevated risk for maternal mortality. As such, interventions are needed to support this population and improve outcomes. Our review suggests that, while doulas have the potential to make important contributions to the birthing support team, they are underutilized, and intervention studies are needed to enable estimates of their true effectiveness.

Racial and ethnic differences in the risk of recurrent preterm or small for gestational age births in the United States: a systematic review and stratified analysis

BACKGROUND

The risk of recurrent adverse birth outcomes has been reported worldwide, but there are limited estimates of these risks by social subgroups such as race and ethnicity in the United States. We assessed racial and ethnic disparities in the risk of recurrent adverse birth outcomes, including preterm birth, low birthweight, fetal growth restriction, small for gestational age, stillbirth, and neonatal mortality in the U.S.

METHODS

We searched MEDLINE, CINAHL Complete, Web of Science, and Scopus from the date of inception to April 5, 2022. We identified 3,540 articles for a title and abstract review, of which 80 were selected for full-text review. Studies were included if they focused on the recurrence of any of the six outcomes listed in the objectives. Study quality was assessed using the NIH Study Quality Assessment Tool. Heterogeneity across studies was too large for meta-analysis, but race and ethnicity-stratified estimates and tests for homogeneity results were reported.

RESULTS

Six studies on recurrent preterm birth and small for gestational age were included. Pooled comparisons showed a higher risk of recurrent preterm birth and small for gestational age for all women. Stratified race comparisons showed a higher but heterogeneous risk of recurrence of preterm birth across Black and White women. Relative risks of recurrent preterm birth ranged from 2.02 [1.94, 2.11] to 2.86 [2.40, 3.39] for Black women and from 3.23 [3.07, 3.39] to 3.92 [3.35, 4.59] for White women. The evidence was weak for race and ethnicity stratification for Hispanic and Asian women for both outcomes.

CONCLUSIONS

Disparities exist in the recurrence of preterm birth, and race/ethnicity-concordant comparisons suggest race is an effect modifier for recurrent preterm birth for Black and White women. Due to the small number of studies, no conclusions could be made for small for gestational age or Hispanic and Asian groups. The results pose new research areas to better understand race-based differences in recurrent adverse birth outcomes.

Academic performance in moderately and late preterm children in the United States: are they catching up?

OBJECTIVE

To determine whether preterm birth of 32-36 6/7 weeks gestation affected school performance from kindergarten through fifth grade.

STUDY DESIGN

We assessed 14350 term infants and 1195 32-36 6/7 weeks gestation infants followed in the Early Childhood Longitudinal Study Kindergarten 2011 cohort for classroom performance in kindergarten-fifth grade. Multivariable regression was performed for comparisons, and data were weighted to be representative of the US population.

RESULTS

Children born 35-36 6/7 weeks gestation had no significant difference in their academic scores or performance, while 32-34 6/7 weeks' children had lower academic scores and teacher performance scores when compared to term children. Children born between 32 and 36 6/7 weeks gestation had higher odds of individualized education plan needs and had learning disability diagnoses compared to term children.

CONCLUSIONS

Children born between 32 and 34 6/7 weeks gestation have poor school performance compared to term children. Children born between 32 and 36 6/7 weeks gestation are at risk for learning disabilities and likely benefit from continued support and services to improve achievement throughout school.

The Diverging Trend in Exposure to Environmental Tobacco Smoke Among US Children

OBJECTIVE

Environmental tobacco smoke exposure (ETSE) was race/ethnicity-specific, but how the race/ethnicity-specific ETSE has changed over time, diverging or converging, remains unclear. We examined ETSE trends by race/ethnicity in US children aged 3-11 years.

METHODS

We analyzed the data of 9678 children who participated in the biennial National Health and Nutrition Examination Surveys, 1999-2018. ETSE was defined as serum cotinine ≥ 0.05 ng/ml, with ≥ 1 ng/ml as heavy exposure. For trend description, adjusted biennial prevalence ratios (abiPR: the ratio associated with a 2-year increase in time) were estimated by race/ethnicity. The prevalence ratios between races/ethnicities were used to quantify ethnoracial differences in different survey periods. Analyses were performed in 2021.

RESULTS

The overall ETSE prevalence was cut by almost half, from 61.59% (95% confidence interval = 56.55%, 66.62%) in the 1999-2004 survey to 37.61% (33.90%, 41.31%) in 2013-2018, exceeding the national 2020 health target (47.0%). However, the decrease occurred unequally between races/ethnicities. Heavy ETSE declined significantly in white [abiPR = 0.80 (0.74, 0.86)] and Hispanic children [0.83 (0.74, 0.93)], but insignificantly in black children [0.97 (0.92, 1.03)]. Consequently, the adjusted prevalence ratio between black children and white children increased from 0.82 (0.47, 1.44) in 1999-2004 to 2.73 (1.51, 4.92) in 2013-2018 for heavy ETSE. Hispanic children remained at the lowest risk throughout the study period.

CONCLUSION

Overall ETSE prevalence was cut by half between 1999 and 2018. However, due to uneven declines, the gaps between black children and others have expanded in heavy ETSE. Special vigilance is needed in preventive medicine practice with black children.

Computational Approaches for Predicting Preterm Birth and Newborn Outcomes

Preterm birth (PTB) and its associated morbidities are a leading cause of infant mortality and morbidity. Accurate predictive models and a better biological understanding of PTB-associated morbidities are critical in reducing their adverse effects. Increasing availability of multimodal high-dimensional data sets with concurrent advances in artificial intelligence (AI) have created a rich opportunity to gain novel insights into PTB, a clinically complex and multifactorial disease. Here, the authors review the use of AI to analyze 3 modes of data: electronic health records, biological omics, and social determinants of health metrics.

State paid family leave policies and breastfeeding duration: cross-sectional analysis of 2021 national immunization survey-child

BACKGROUND

Paid parental leave policies may promote breastfeeding, which can have short- and long-term health benefits for both members of the birthing person-infant dyad. In the United States, where 56% of the workforce qualifies for unpaid federal medical leave, certain states have recently enacted paid parental and family leave policies. We aimed to assess the extent to which living in states with versus without paid family leave was associated with feeding regimens that included breastfeeding.

METHODS

In this cross-sectional analysis of the 2021 National Immunization Survey-Child, we assessed feeding outcomes: (1) exclusively breastfed (only fed breastmilk-never infant formula-both before and after six months of age), (2) late mixed breastfeeding (formula after six months), (3) early mixed breastfeeding (breastfed, formula before six months), and (4) never breastfed. We conducted Pearson χ2 to compare social-demographic characteristics and multivariable nominal regression to assess extent to paid family leave was associated with breastfeeding regimens, compared with never breastfeeding.

RESULTS

Of the 35,995 respondents, 5,806 (25% of weighted respondents) were from states with paid family leave policies. Compared with never breastfeeding, all feeding that incorporated breastfeeding-exclusive breastfeeding, late mixed feeding (breastfed, formula introduced after six months), and early mixed feeding (breastfed, formula introduced before six months)-were more prevalent in states with paid family leave policies. The adjusted prevalence ratio (aPR) and differences in adjusted prevalence compared with never breastfeeding in states with versus without paid family leave policies were: aPR 1.41 (95% CI 1.15, 1.73), 5.36% difference for exclusive breastfeeding; aPR 1.25 (95% CI 1.01, 1.53), 3.19% difference for late mixed feeding, aPR 1.32 (95% CI 1.32, 1.97), 5.42% difference for early mixed feeding.

CONCLUSION

States with paid family leave policies have higher rates of any breastfeeding and of exclusive breastfeeding than states without such policies. Because all feeding types that incorporate breastfeeding were higher in states with paid family leave policies, expansion of paid family leave may improve breastfeeding rates.

Changes in Lipid Profiles with the Progression of Pregnancy in Black Women

Background/Objectives: Lipid metabolism plays an important role in maternal health and fetal development. There is a gap in the knowledge of how lipid metabolism changes during pregnancy for Black women who are at a higher risk of adverse outcomes. We hypothesized that the comprehensive lipidome profiles would show variation across pregnancy indicative of requirements during gestation and fetal development. Methods: Black women were recruited at prenatal clinics. Plasma samples were collected at 8-18 weeks (T1), 22-29 weeks (T2), and 30-36 weeks (T3) of pregnancy. Samples from 64 women who had term births (≥37 weeks gestation) were subjected to "shotgun" Orbitrap mass spectrometry. Mixed-effects models were used to quantify systematic changes and dimensionality reduction models were used to visualize patterns and identify reliable lipid signatures. Results: Total lipids and major lipid classes showed significant increases with the progression of pregnancy. Phospholipids and glycerolipids exhibited a gradual increase from T1 to T2 to T3, while sphingolipids and total sterol lipids displayed a more pronounced increase from T2 to T3. Acylcarnitines, hydroxy acylcarnitines, and Lyso phospholipid levels significantly decreased from T1 to T3. A deviation was that non-esterified fatty acids decreased from T1 to T2 and increased again from T2 to T3, suggestive of a potential role for these lipids during the later stages of pregnancy. The fatty acids showing this trend included key fatty acids-non-esterified Linoleic acid, Arachidonic acid, Alpha-linolenic acid, Eicosapentaenoic acid, Docosapentaenoic acid, and Docosahexaenoic acid. Conclusions: Mapping lipid patterns and identifying lipid signatures would help develop intervention strategies to reduce perinatal health disparities among pregnant Black women.

A Scoping Review of Preterm Birth Risk Factors

Preterm birth is a major cause of neonatal morbidity and mortality, but its etiology and risk factors are poorly understood. We undertook a scoping review to illustrate the breadth of risk factors for preterm birth that have been reported in the literature. We conducted a search in the PubMed database for articles published in the previous 5 years. We determined eligibility for this scoping review by screening titles and abstracts, followed by full-text review. We extracted odds ratios and other measures of association for each identified risk factor in the articles. A total of 2,509 unique articles were identified from the search, of which 314 were eligible for inclusion in our final analyses. We summarized risk factors and their relative impacts in the following categories: Activity, Psychological, Medical History, Toxicology, Genetics, and Vaginal Microbiome. Many risk factors for preterm birth have been reported. It is challenging to synthesize findings given the multitude of isolated risk factors that have been studied, inconsistent definitions of risk factors and outcomes, and use of different covariates in analyses. Novel methods of analyzing large datasets may promote a more comprehensive understanding of the etiology of preterm birth and ability to predict the outcome. KEY POINTS: · Preterm birth is difficult to predict.. · Preterm birth has many diverse risk factors.. · Holistic approaches may yield new insights..

Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study

OBJECTIVE

Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explored expert opinion on their etiology, potential solutions, and the ability of health equity dashboards to meaningfully capture NICU disparities.

STUDY DESIGN

We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis.

RESULT

We identified three sources of disparity: interpersonal bias, care process and institutional barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited, because clinical metrics do not account for many of the aforementioned sources of disparities.

CONCLUSION

Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women

OBJECTIVE

Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women.

STUDY DESIGN

Cross-sectional data (n = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors.

RESULTS

Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (β0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (β -1.26, 95%CI: -2.08, -0.44), multifetal gestation (β -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (β -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia.

CONCLUSION

Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors.

KEY POINTS

· We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors..

Population-Level Study on Fetal Deaths and Preterm Births during SARS-CoV-2 Pandemic in the State of Michigan

OBJECTIVE

The aim of the study is to explore the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on preterm birth at different gestational ages and fetal death in the state of Michigan.

STUDY DESIGN

Data on live births and fetal deaths in the state of Michigan from March to November in the years 2017 through 2020 were obtained from Michigan Department of Health and Human Services (MDHHS). Preterm birth rate, fetal death rate (per 1,000 live births) overall and stratified by race and maternal comorbidities during the period of pandemic (March-November 2020) were compared with the same period (March-November) in the prepandemic years (2017-2019).

RESULTS

Of 328,879 live births and 1,470 fetal deaths during the study period, 77,983 live births and 242 fetal deaths were reported in 2020. Compared with prepandemic years, fetal death rate per 1,000 live births was significantly lower in 2020 (3.1 vs. 4.7 [2017], 5.2 [2018], 4.4 [2019], p-value <0.001). The adjusted risk for fetal death in 2020 was decreased (odds ratio [OR] = 0.64 [95% confidence interval (CI): 0.56-0.74], p <0.0001), compared with prepandemic years. Fetal death was significantly associated with African-American race, pregnancy hypertension and prepregnancy diabetes. No significant difference in the proportion of preterm births (<37 weeks' gestation) was noted between pandemic and prepandemic years (9.9 vs. 10.0%, p = 0.50). There was no significant difference in the risk of preterm birth across gestational age strata (<28, 28-316/7, 32-366/7, 37-416/7, and >42 weeks) between pandemic and prepandemic years on multinomial analysis. Significant associations with preterm birth across all years included African American race, lower level of maternal education, pregnancy-induced hypertension, chronic hypertension, prepregnancy diabetes, congenital anomalies, previous preterm birth, and prolonged rupture of membranes >12 hours.

CONCLUSION

Fetal death rate was significantly lower whereas preterm births remained unchanged during pandemic in comparison with prepandemic years in the state of Michigan.

KEY POINTS

· A decrease in fetal death rate was noted during SARS CoV-2 pandemic in the State of Michigan.. · Overall state-wide rates of preterm birth did not change in 2020, compared to previous years.. · Significant risk factors associated with preterm birth and fetal deaths did not differ between prepandemic and pandemic years..

Role of IL-6, IL-10 and TNFα Gene Variants in Preterm Birth

Background: The association of gene variants for interleukin 6 (IL-6) (rs1800796), interleukin 10 (IL-10) (rs1800896) and tumor necrosis factorα (TNFα (rs1800629) with the occurrence of spontaneous preterm birth (PTB) was investigated to determine whether these genetic variants are a risk factor. Methods: A total of 199 blood samples from pregnant women who had given birth prematurely and 200 control blood samples were analyzed to determine single nucleotide polymorphisms (SNPs) of genes for IL-6 (rs1800796), IL-10 (rs1800896) and TNFα (rs1800629). The control samples were samples from pregnant women with term delivery. The isolation of DNA was performed on mini-spin columns according to the manufacturer's protocol. The quality and purity of the isolated DNA were tested using a Qubit 3 fluorometer. Genotyping was performed with an ABI PRISM 7500 SDS using TaqMan SNP genotyping assays. The genotypes obtained were analyzed using the 7500 Software v2.3 package. Results: Carriers of the A/A genotype for the rs1800629 SNP of the TNFα gene have a 4.81 times greater chance of late-onset PTB compared to carriers of the G/G and A/G genotypes in the recessive inheritance model. The presence of the G/G genotype in the recessive inheritance model compared with the G/A and A/A genotypes for the rs1800896 SNP of the IL-10 gene represents a potentially protective factor, with mothers in the term-birth group having an almost 2-fold lower odds of PTB in general and an almost 10-fold lower odds of early PTB. On the other hand, carriers of the A/G genotype of rs1800896 have a 1.54-fold higher chance of preterm birth in general and a 1.6-fold higher chance of late preterm birth in the superdominant inheritance model compared to the A/A and G/G genotypes in the group of mothers with PTB. In this study, no association was found between PTB and the rs1800796 SNP of the IL-6 gene. Conclusions: rs1800629 in mothers was associated with PTB. rs1800896 shows a potentially protective effect for the occurrence of PTB in this study. No association was found between PTB and rs1800796.

Increasing Preterm Delivery and Small for Gestational Age Trends in South Carolina during the COVID-19 Pandemic

Preterm delivery (PTD) complications are a major cause of childhood morbidity and mortality. We aimed to assess trends in PTD and small for gestational age (SGA) and whether trends varied between race-ethnic groups in South Carolina (SC). We utilized 2015-2021 SC vital records linked to hospitalization and emergency department records. PTD was defined as clinically estimated gestation less than (<) 37 weeks (wks.) with subgroup analyses of PTD < 34 wks. and < 28 wks. SGA was defined as infants weighing below the 10th percentile for gestational age. This retrospective study included 338,532 (243,010 before the COVID-19 pandemic and 95,522 during the pandemic) live singleton births of gestational age ≥ 20 wks. born to 260,276 mothers in SC. Generalized estimating equations and a change-point during the first quarter of 2020 helped to assess trends. In unadjusted analyses, pre-pandemic PTD showed an increasing trend that continued during the pandemic (relative risk (RR) = 1.04, 95% CI: 1.02-1.06). PTD < 34 wks. rose during the pandemic (RR = 1.07, 95% CI: 1.02-1.12) with a significant change in the slope. Trends in SGA varied by race and ethnicity, increasing only in Hispanics (RR = 1.02, 95% CI: 1.00-1.04) before the pandemic. Our study reveals an increasing prevalence of PTD and a rise in PTD < 34 wks. during the pandemic, as well as an increasing prevalence of SGA in Hispanics during the study period.

Inpatient Skin-to-Skin Care Predicts 12-month Neurodevelopmental Outcomes in Very Preterm Infants

Objective

Limited research links hospital-based experiences of skin-to-skin (STS) care to longer-term neurodevelopmental outcomes in preterm children. The present study examined relations between inpatient STS and neurodevelopmental scores measured at 12 months in a sample of very preterm (VPT) infants.

Study Design and Methods

From a retrospective study review of medical records of 181 VPT infants (<32 weeks gestational age (GA)) we derived the STS rate, i.e., the total minutes of STS each infant received/day of hospital stay. We used scores on the Capute Scales from routine follow-up care at 12 months as the measure of neurodevelopmental outcome (n=181).

Results

Families averaged approximately 17 minutes/day of STS care (2 days/week, 70 minutes/session), although there was substantial variability. Variation in STS rate was positively associated with outcomes at 12 months corrected age ( r = 0.25, p < .001). STS rate significantly predicted 6.2% unique variance in 12-month neurodevelopmental outcomes, after controlling for GA, socioeconomic status (SES), health acuity, and visitation frequency. A 20-minute increase in STS per day was associated with a 10-point increase (.67 SDs) in neurodevelopmental outcomes at 12 months. SES, GA, and infant health acuity did not moderate these relations.

Conclusion

VPT infants who experienced more STS during hospitalization demonstrated higher scores on 12-month assessments of neurodevelopment. Results provide evidence that STS care may confer extended neuroprotection on VPT infants through the first year of life.

An evaluation of the quality, suitability and impact on equity of clinical practice guidelines relevant to preterm birth for use in Aotearoa New Zealand

BACKGROUND

Preterm birth is a leading cause of perinatal morbidity and mortality and a defining event for pregnant people, infants, and whānau (extended families). Recommendations have been made for a national preterm birth prevention initiative focusing on equity in Aotearoa New Zealand, including the development of a national best practice guide. An understanding of the number and quality of guidelines, and consideration of their suitability and impact on equity is required.

METHODS

Guidelines were identified through a systematic literature search, search of professional bodies websites, and invitation to regional health services in Aotearoa New Zealand. Obstetric and midwifery clinical directors were invited to report on guideline use. Identified guidelines were appraised by a 23-member trans-disciplinary Review Panel; quantitatively using the AGREE-II instrument and qualitatively using modified ADAPTE questions. The quality of guidelines available but not in use was compared against those in current use, and by health services by level of maternity and neonatal care. Major themes affecting implementation and impact on equity were identified using Braun and Clarke methodology.

RESULTS

A total of 235 guidelines were included for appraisal. Guidelines available but not in use by regional health services scored higher in quality than guidelines in current use (median domain score Rigour and Development 47.5 versus 18.8, p < 0.001, median domain score Overall Assessment 62.5 versus 44.4, p < 0.001). Guidelines in use by regional health services with tertiary maternity and neonatal services had higher median AGREE II scores in several domains, than those with secondary level services (median domain score Overall Assessment 50.0 versus 37.5, p < 0.001). Groups identified by the Review Panel as experiencing the greatest constraints and limitations to guideline implementation were rural, provincial, low socioeconomic, Māori, and Pacific populations. Identified themes to improve equity included a targeted approach to groups experiencing the least advantage; a culturally considered approach; nationally consistent guidance; and improved funding to support implementation of guideline recommendations.

CONCLUSIONS

We have systematically identified and assessed guidelines on preterm birth. High-quality guidelines will inform a national best practice guide for use in Taonga Tuku Iho, a knowledge translation project for equity in preterm birth care and outcomes in Aotearoa.

Prenatal and Postnatal Disparities in Very-Preterm Infants in a Study of Infections between 2018-2023 in Southeastern US

BACKGROUND

The birthrate of Black preterm (BPT) infants is 65% higher than White preterm (WPT) infants with a BPT mortality that is 2.3 times higher. The incidence of culture-positive late-onset sepsis is as high as 41% in very-preterm infants. The main purpose of this study was to examine thermal gradients and the heart rate in relation to the onset of infection. This report presents disparities in very-preterm infection incidence, bacteria, and mortality data amongst BPT and WPT infants.

METHODS

367 preterms born at <32 weeks gestational age (GA) between 2019-2023 in five neonatal intensive care units (NICUs) were enrolled to study the onset of infections and dispositions; REDCap data were analyzed for descriptive statistics.

RESULTS

The 362 infants for analyses included 227 BPTs (63.7%) and 107 WPTs (29.6%), with 28 infants of other races/ethnicities (Hispanic, Asian, and other), 50.6% female, mean GA of 27.66 weeks, and 985.24 g birthweight. BPT infants averaged 968.56 g at birth (SD 257.50), and 27.68 (SD 2.07) weeks GA, compared to WPT infants with a mean birthweight of 1006.25 g (SD 257.77, p = 0.2313) and 27.67 (SD 2.00, p = 0.982) weeks GA. Of the 426 episodes of suspected infections evaluated across all the enrolled infants, the incidence of early-onset sepsis (EOS) was 1.9%, with BPT infants having 2.50 times higher odds of EOS than WPT infants (p = 0.4130, OR (odds ratio) = 2.50, p_or = 0.408). The overall incidence of late-onset sepsis (LOS) was 10.8%, with LOS in 11.9% of BPT infants versus 9.3% (p = 0.489, OR = 1.21, p_or = 0.637) of WPT infants. BPT infants made up 69.2% of the 39 infants with Gram-positive infections vs. 25.6% for WPT infants; 16 infants had Gram-negative culture-positive infections, with 81.2% being BPT infants versus 18.8% being WPT infants. Of the 27 urinary tract infections, 78% were in BPTs. The necrotizing enterocolitis incidence was 6.9%; the incidence in BPT infants was 7.5% vs. 6.5% in WPT infants. The overall mortality was 8.3%, with BPTs at 8.4% vs. WPT infants at 9.3%, (p = 0.6715).

CONCLUSIONS

BPTs had a higher rate of positive cultures, double the Gram-negative infections, a much higher rate of urinary tract infections, and a higher rate of mortality than their WPT counterparts. This study emphasizes the higher risk of morbidity and mortality for BPTs.

Prevalence of Preterm Birth and Perinatal Outcomes in a Tertiary Hospital in Malaysia

Background Preterm birth (PTB) is defined as neonates that are born alive >22 weeks of gestation and <37 weeks of gestation. Because of the immaturity of different organ systems, 14.84 million newborns worldwide are born prematurely, which is the largest contributing factor to mortality and morbidity. Although studies have been conducted in this field, the magnitude of PTB is a major issue in most developing countries including Malaysia. Objective To assess the prevalence of PTB and the perinatal outcome among women delivered in a tertiary university hospital in Malaysia.  Methods This was a cross-sectional study evaluating all singleton live births weighing>500g and delivered at >22+1 weeks of gestation between January 2015 and December 2019 in Universiti Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia. Data were collected from the hospital's recorded birth registry. The primary outcome was the PTB rate. Data were entered and analysed using Statistical Product and Service Solutions (SPSS) (version 28.0; IBM SPSS Statistics for Windows, Armonk, NY). Results A total of 26,022 singleton live births were reported for the period 2015-2019. PTB rates showed a sharp 6% decrease from 2015 to 2016, after which the trend was inconsistent until 2019. The risk of preterm babies being admitted to the neonatal intensive care unit (NICU) or the ward compared to the risk of neonatal mortality increases for babies of identified sex, delivered via caesarean, and with a birth weight between 2 and 3 kgs. Babies born at a gestational age between 22+1 and 33+6 have a higher risk of neonatal mortality compared to late preterm babies. Conclusions The PTB incidence trend was inconsistent from 2015 to 2019 in a tertiary university hospital in Malaysia, with a far higher prevalence compared to national data. The high NICU admission and mortality rates among preterm infants mean urgent strategies and policies are needed to improve perinatal outcomes.

Environmental Justice Index and adverse pregnancy outcomes

BACKGROUND

The Environmental Justice Index is a tool released by the Centers for Disease Control and Prevention that quantifies and ranks the environmental burden and social vulnerability of each census tract. Racial and ethnic disparities in adverse pregnancy outcomes are well established. The relative contributions of individual (person-level) and environmental (neighborhood-level) risk factors to disease prevalence remain poorly understood.

OBJECTIVE

This study aimed to determine whether the Environmental Justice Index is associated with adverse pregnancy outcomes after adjustment for individual clinical and sociodemographic risk factors.

STUDY DESIGN

This was a retrospective cross-sectional study of all patients who delivered a singleton newborn at ≥23 weeks of gestation between January 2019 and February 2022 at 7 hospitals within a large academic health system in New York. Patients were excluded if their home address was not available, if the address could not be geocoded to a census tract, or if the census tract did not have corresponding Environmental Justice Index data. Patients were also excluded if they had preexisting diabetes or hypertension. For patients who had multiple pregnancies during the study period, only the first pregnancy was included for analysis. Clinical and demographic data were obtained from the electronic medical record. Environmental Justice Index score, the primary independent variable, ranges from 0 to 1. Higher Environmental Justice Index scores indicate communities with increased cumulative environmental burden and increased social vulnerability. The primary outcome was adverse pregnancy outcome, defined as the presence of ≥1 of any of the following conditions: hypertensive disorders of pregnancy, gestational diabetes, preterm birth, fetal growth restriction, low birthweight, small for gestational age newborn, placental abruption, and stillbirth. Multivariable logistic regression was performed to investigate the relationship between Environmental Justice Index score and adverse pregnancy outcome, adjusting for potential confounding variables, including body mass index group, race and ethnicity group, advanced maternal age, nulliparity, public health insurance, and English as the preferred language.

RESULTS

A total of 65,273 pregnancies were included for analysis. Overall, adverse pregnancy outcomes occurred in 37.6% of pregnancies (n=24,545); hypertensive disorders of pregnancy (13.4%) and gestational diabetes (12.2%) were the most common adverse pregnancy outcome conditions. On unadjusted analysis, the strongest associations between Environmental Justice Index score and individual adverse pregnancy outcome conditions were observed for stillbirth (odds ratio, 1.079; 95% confidence interval, 1.025-1.135) and hypertensive disorders of pregnancy (odds ratio, 1.052; 95% confidence interval, 1.042-1.061). On multivariable logistic regression, every 0.1 increase in Environmental Justice Index score was associated with 1.4% higher odds of adverse pregnancy outcome (adjusted odds ratio, 1.014; 95% confidence interval, 1.007-1.021). The strongest associations with adverse pregnancy outcomes were observed with well-established clinical and social risk factors, including class 3 obesity (adjusted odds ratio, 1.710; 95% confidence interval, 1.580-1.849; reference: body mass index <25 kg/m2) and certain race and ethnicity groups (reference: non-Hispanic White), particularly Asian and Pacific Islander (adjusted odds ratio, 1.817; 95% confidence interval, 1.729-1.910), and non-Hispanic Black (adjusted odds ratio, 1.668; 95% confidence interval, 1.581-1.760) people.

CONCLUSION

Environmental Justice Index score is positively associated with adverse pregnancy outcomes, and most strongly associated with stillbirth and hypertensive disorders of pregnancy. Geospatial analysis with Environmental Justice Index may help to improve our understanding of health inequities by identifying neighborhood characteristics that increase the risk of pregnancy complications.

Application of the Adverse Childhood Experiences Framework to the NICU

BACKGROUND

Infants and families requiring neonatal intensive care unit (NICU) care often experience significant stress and trauma during the earliest period of the infant's life, leading to increased risks for poorer infant and family outcomes. There is a need for frameworks to guide clinical care and research that account for the complex interactions of generational stress, pain, toxic stress, parental separation, and lifelong health and developmental outcomes for infants and families.

PURPOSE

Apply the Adverse Childhood Experiences (ACEs) framework in the context of the NICU as a usable structure to guide clinical practice and research focused on infant neurodevelopment outcomes and parental attachment.

METHODS

An overview of ACEs is provided along with a detailed discussion of risk at each level of the ACEs pyramid in the context of the NICU. Supportive and protective factors to help mitigate the risk of the ACEs in the NICU are detailed.

RESULTS

NICU hospitalization may be considered the first ACE, or potentially an additional ACE, resulting in an increased risk for poorer health outcomes. The promotion of safe, stable, and nurturing relationships and implementation of trauma-informed care and individualized developmental care potentially counter the negative impacts of stress in the NICU.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Nurses can help balance the negative and positive stimulation of the NICU through activities such as facilitated tucking, skin-to-skin care, mother's milk, and active participation of parents in infant care. Future research can consider using the ACEs framework to explain cumulative risk for adverse health and well-being in the context of NICU care.

Resuscitation, survival and morbidity of extremely preterm infants in California 2011-2019

OBJECTIVE

To describe changes over time in resuscitation, survival, and morbidity of extremely preterm infants in California.

STUDY DESIGN

This population-based, retrospective cohort study includes infants born ≤28 weeks. Linked birth certificates and hospital discharge records were used to evaluate active resuscitation, survival, and morbidity across two epochs (2011-2014, 2015-2019).

RESULTS

Of liveborn infants, 0.6% were born ≤28 weeks. Active resuscitation increased from 16.9% of 22-week infants to 98.1% of 25-week infants and increased over time in 22-, 23-, and 25-week infants (p-value ≤ 0.01). Among resuscitated infants, survival to discharge increased from 33.2% at 22 weeks to 96.1% at 28 weeks. Survival without major morbidity improved over time for 28-week infants (p-value < 0.01).

CONCLUSION

Among infants ≤28 weeks, resuscitation and survival increased with gestational age and morbidity decreased. Over time, active resuscitation of periviable infants and morbidity-free survival of 28-week infants increased. These trends may inform counseling around extremely preterm birth.

Perinatal health outcomes of women from Gypsy, Roma and Traveller communities: A systematic review

BACKGROUND

GRT communities are disadvantaged minority groups in Europe and experience some of the poorest health outcomes, including maternal and child health. This systematic review aimed to assess the maternal, perinatal and infant health outcomes of women from GRT communities and the factors associated with the reported outcomes.

METHODS

Database searches were conducted from inception to June 2023 in 4 bibliographic databases supplemented with an additional Google Scholar search. Studies with quantitative data on maternal outcomes published in English were considered. A narrative synthesis was performed, and data were presented in text, figures and tables.

FINDINGS

Forty-five studies from 13 European countries were included. Outcome factors related to mothers showing low healthcare engagement, high fertility rates and shorter gestation periods among GRT women. Child wantedness was also noted to influence pregnancy completeness, which included abortion and miscarriage. More negative infant outcomes were seen in GRT infants than non-GRT infants; this included higher preterm births, lower birth weight, higher rates of intrauterine growth restriction and infant mortality. Risk factors of poorer maternal outcomes were early reproduction, education, smoking, alcohol consumption, deprivation, poor nutrition and perinatal care.

CONCLUSION

This review provides evidence that GRT women and children experience more negative outcomes than general populations. It also highlights the gaps in ethnicity and health inequalities more broadly. The significant importance of this research is the need for increased focus on reducing health inequalities, especially among the GRT community.

Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies

BACKGROUND

While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown.

OBJECTIVE

To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies.

METHODS

This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering.

RESULTS

Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability.

CONCLUSION

Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.

Language outcomes at 18-24 months of preterm infants from US Spanish- and English-speaking homes

AIM

To evaluate the association of Spanish compared to English primary household language on preterm (PT) infants' language outcomes in the United States and to examine associations with socio-economic factors.

METHODS

This was a retrospective cohort of PT infants born <32 weeks gestation from Spanish-speaking (n = 95) and English-speaking homes (n = 1030) born 2005-2019. Language (primary outcome) and cognitive and motor skills (secondary outcomes) were measured using the BSID-III at 18-24 months corrected age. Group differences were evaluated using bivariate comparisons and logistic regression analyses.

RESULTS

Mothers reporting Spanish-speaking homes had higher rates of public insurance and lower educational achievement. Group newborn characteristics were similar. Preterm infants from Spanish-speaking homes had significantly lower BSID-III language composite, cognitive composite, receptive and expressive scores compared to infants from English-speaking homes. Logistic regression modelling identified independent negative effects of Spanish-speaking household OR 3.26 (CI 1.89-5.62) and public insurance OR 2.31 (CI 1.71-3.12) with a protective benefit derived from breast milk OR 0.68 (CI 0.50-0.92) when adjusting for medical morbidities, socio-economic factors and gestational age.

CONCLUSION

Public health policies and interventions in the United States should target language and cognitive outcomes of PT infants from Spanish-speaking homes.

Impact of COVID-19 on Perinatal Outcomes and Birth Locations in a Large US Metropolitan Area

This was a population-based study to determine the impact of COVID-19 on birth outcomes in the Chicago metropolitan area, comparing pre-pandemic (April-September 2019) versus pandemic (April-September 2020) births. Multivariable regression models that adjusted for demographic and neighborhood characteristics were used to estimate the marginal effects of COVID-19 on intrauterine fetal demise (IUFD)/stillbirth, preterm birth, birth hospital designation, and maternal and infant hospital length of stay (LOS). There were no differences in IUFD/stillbirths or preterm births between eras. Commercially insured preterm and term infants were 4.8 percentage points (2.3, 7.4) and 3.4 percentage points (2.5, 4.2) more likely to be born in an academic medical center during the pandemic, while Medicaid-insured preterm and term infants were 3.6 percentage points less likely (-6.5, -0.7) and 1.8 percentage points less likely (-2.8, -0.9) to be born in an academic medical center compared to the pre-pandemic era. Infant LOS decreased from 2.4 to 2.2 days (-0.35, -0.20), maternal LOS for indicated PTBs decreased from 5.6 to 5.0 days (-0.94, -0.19), and term births decreased from 2.5 to 2.3 days (-0.21, -0.17). The pandemic had a significant effect on the location of births that may have exacerbated health inequities that continue into childhood.