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Niles PM, Nack A, Eniola F, Searing H, Morton C. "We don't really address the trauma": Patients' Perspectives on Postpartum Care Needs after Severe Maternal Morbidities. Matern Child Health J 2024:10.1007/s10995-024-03927-1. [PMID: 38864991 DOI: 10.1007/s10995-024-03927-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVES This qualitative study explored experiences of 15 women in New York City who suffered physical, emotional, and socioeconomic consequences of severe maternal morbidity (SMM). This study aimed to increase our understanding of additional burdens these mothers faced during the postpartum period. METHODS Qualitative analysis of in-depth interviews (n = 15) with women who had given birth in NYC hospitals and experienced SMM. We focused on how experiences of SMM impacted postpartum recoveries. Grounded theory methodology informed analysis of participants' one-on-one interviews. To understand the comprehensive experience of postpartum recovery after SMM, we drew on theories about social stigma, reproductive equity, and quality of care to shape constant-comparative analysis and data interpretation. FINDINGS Three themes were generated from data analysis: 'Caring for my body' defined by challenges during physical recuperation, 'caring for my emotions' which highlighted navigation of mental health recovery, and 'caring for others' defined by care work of infants and other children. Most participants identified as Black, Latinx and/or people of color, and reported the immense impacts of SMM across aspects of their lives while receiving limited access to resources and insufficient support from family and/or healthcare providers in addressing postpartum challenges. CONCLUSIONS FOR PRACTICE Findings confirm the importance of developing a comprehensive trauma-informed approaches to postpartum care as a means of addressing SMM consequences.
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Affiliation(s)
- P Mimi Niles
- Meyers College of Nursing, New York University, New York, NY, USA.
| | - Adina Nack
- California Lutheran University, Thousand Oaks, CA, USA
| | - Folake Eniola
- Research and Evaluation, NYC Department of Health and Mental Hygiene, Home Visiting Programs, New York, NY, USA
| | - Hannah Searing
- Research and Evaluation, NYC Department of Health and Mental Hygiene, Bureau of Maternal, Infant and Reproductive Health, New York, NY, USA
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Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: population based study. BMJ 2024; 385:e077190. [PMID: 38777357 PMCID: PMC11109902 DOI: 10.1136/bmj-2023-077190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour. DESIGN Population based study. SETTING All NHS hospitals in Scotland. PARTICIPANTS 567 216 women in labour at 24+0 to 42+6 weeks' gestation between 1 January 2007 and 31 December 2019, delivering vaginally or through unplanned caesarean section. MAIN OUTCOME MEASURES The primary outcome was SMM, defined as the presence of ≥1 of 21 conditions used by the US Centers for Disease Control and Prevention (CDC) as criteria for SMM, or a critical care admission, with either occurring at any point from date of delivery to 42 days post partum (described as SMM). Secondary outcomes included a composite of ≥1 of the 21 CDC conditions and critical care admission (SMM plus critical care admission), and respiratory morbidity. RESULTS Of the 567 216 women, 125 024 (22.0%) had epidural analgesia during labour. SMM occurred in 2412 women (4.3 per 1000 births, 95% confidence interval (CI) 4.1 to 4.4). Epidural analgesia was associated with a reduction in SMM (adjusted relative risk 0.65, 95% CI 0.50 to 0.85), SMM plus critical care admission (0.46, 0.29 to 0.73), and respiratory morbidity (0.42, 0.16 to 1.15), although the last of these was underpowered and had wide confidence intervals. Greater risk reductions in SMM were detected among women with a medical indication for epidural analgesia (0.50, 0.34 to 0.72) compared with those with no such indication (0.67, 0.43 to 1.03; P<0.001 for difference). More marked reductions in SMM were seen in women delivering preterm (0.53, 0.37 to 0.76) compared with those delivering at term or post term (1.09, 0.98 to 1.21; P<0.001 for difference). The observed reduced risk of SMM with epidural analgesia was increasingly noticeable as gestational age at birth decreased in the whole cohort, and in women with a medical indication for epidural analgesia. CONCLUSION Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.
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Affiliation(s)
- Rachel J Kearns
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Aizhan Kyzayeva
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Lucy O E Halliday
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, University of Bristol, Bristol, UK
| | - Martin Shaw
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
- Department of Medical Physics and Bioengineering, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
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El Ayadi AM, Lyndon A, Kan P, Mujahid MS, Leonard SA, Main EK, Carmichael SL. Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017. Am J Perinatol 2024; 41:e3341-e3350. [PMID: 38057087 DOI: 10.1055/a-2223-3520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. STUDY DESIGN We analyzed California birth cohort data on all live and stillbirths ≥ 20 weeks' gestation from 1997 to 2017 (n = 10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven nonmutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. RESULTS SMM occurred in 1.16% of births and nontransfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over 3-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717 and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, U.S.-born Hispanic, and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. CONCLUSION Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities, and potential needs for intervention. KEY POINTS · By SMM subgroup, trends and racial and ethnic disparities varied yet Black individuals consistently had highest rates.. · Hemorrhage, renal, respiratory, and sepsis SMM significantly increased over time.. · Disparities increased for respiratory SMM among Black, U.S.-born Hispanic and non-U.S.-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals..
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Affiliation(s)
- Alison M El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Audrey Lyndon
- NYU Rory Meyers College of Nursing, New York, New York
| | - Peiyi Kan
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Dunlevie Maternal-Fetal Medicine Center, Stanford University School of Medicine, Stanford, California
| | - Elliott K Main
- Department of Obstetrics and Gynecology, Dunlevie Maternal-Fetal Medicine Center, Stanford University School of Medicine, Stanford, California
| | - Suzan L Carmichael
- Department of Pediatrics, Department of Obstetrics and Gynecology, Stanford University, Stanford, California
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Bose-Brill S, Gillespie SL, Venkatesh KK. Can We Implement Multispecialty Mother-Infant Dyadic Care to Systematize Interpregnancy Services After a Preterm Birth? WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:651-655. [PMID: 38155872 PMCID: PMC10754421 DOI: 10.1089/whr.2023.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Seuli Bose-Brill
- Combined Internal Medicine and Pediatrics Section, Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Shannon L. Gillespie
- The Martha S. Pitzer Center for Women, Children, and Youth, College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Kartik K. Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Phillips JM, Bodnar LM, Himes KP. Association between gestational age at delivery and indicator-specific severe maternal morbidity. J Matern Fetal Neonatal Med 2023; 36:2198633. [PMID: 37045599 DOI: 10.1080/14767058.2023.2198633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE Individuals who deliver preterm are disproportionately affected by severe maternal morbidity. Limited data suggest that indicator-specific maternal morbidity varies by gestational age at delivery. We sought to evaluate the relationship between gestational age at delivery and the incidence of severe maternal morbidity and indicator-specific severe maternal morbidity. METHODS We used a hospital administrative delivery database to identify all singleton deliveries between 16 and 42 weeks gestation from 2002 to 2018. We defined severe maternal morbidity as the presence of any International Classification of Disease diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, intensive care unit admission, and/or prolonged postpartum hospital length of stay. Indicator-specific severe maternal morbidity was based on the diagnosis and procedure codes and was characterized across gestational age epochs. We categorized gestational age into three epochs to capture extremely preterm birth (less than 28 weeks gestation), preterm birth (28-36 weeks gestation) and term birth (37 weeks gestation and above). Multivariable binomial regression was used to assess the association between categories of gestational age at delivery and severe maternal morbidity adjusting for confounders including age, race, body mass index (BMI), insurance status, and preexisting hypertension or diabetes. RESULTS Severe maternal morbidity occurred in 2.5% of all deliveries. The unadjusted incidence of severe maternal morbidity by gestational age epoch was 12% at less than 28 weeks gestation, 8.4% at 28 to 36 weeks of gestation, and 1.7% at greater than or equal to 37 weeks gestation. After controlling for potential confounders the predicted probability of severe maternal morbidity was 16% (95% CI 14,17%) at 24 weeks compared to 2.2% (95% CI 2.1,2.3%) at 38 weeks. Sepsis, acute respiratory distress syndrome, mechanical ventilation, and shock were the most common diagnostic codes in deliveries less than 28 weeks gestation. Heart failure and cardiac arrhythmias were more common in patients with severe maternal morbidity delivering at term. CONCLUSION A high proportion of severe maternal morbidity occurred in preterm patients, with the highest rates occurring at less than 28 weeks gestation. Individuals with severe maternal morbidity who deliver preterm had distinct indicators of morbidity compared to those who deliver at term.
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Affiliation(s)
- Jaclyn M Phillips
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa M Bodnar
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh Pennsylvania
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine P Himes
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh Pennsylvania
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Hassan A, Waseem H, AlDardeir N, Nasief H, Khadawardi K, Alwazzan AB, Alothmani H, Hammad Z. A Comparison of Nifedipine Versus a Combination of Nifedipine and Sildenafil Citrate in the Management of Preterm Labour. Cureus 2023; 15:e42422. [PMID: 37637555 PMCID: PMC10448571 DOI: 10.7759/cureus.42422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Background Preterm delivery is a significant contributor to neonatal and infant morbidity and mortality. Preventive methods are preferable to treatment protocols for reducing perinatal mortality and morbidity. The calcium channel blocker nifedipine has the potential to be employed as a tocolytic, whereas the phosphodiesterase inhibitor sildenafil citrate promotes smooth muscle relaxation. Objective This study aims to examine the tocolytic effect of nifedipine in combination with sildenafil citrate in managing preterm labour (PTL). Methods After approval from the ethical board, 160 patients fulfilling the selection criteria were enrolled in the study from the outpatient and emergency department of obstetrics and gynaecology, University of Lahore, Pakistan. After taking written informed consent, their demographic profile, i.e., name, age, gestational age at presentation, parity, and expected date of delivery was noted. Patients were randomly assigned in a 1:1 ratio to two study groups (Group A: sildenafil citrate + nifedipine) and (Group B: nifedipine) using a computer-generated random number table to obtain a trial sequence. In group A, each patient was given nifedipine 20 mg orally, followed by 10 mg orally every eight hours for 48 hours and vaginal administration of sildenafil citrate, 25 mg at eight-hour intervals, for 48 hours. In group B, females were given nifedipine 20 mg orally, followed by 10 mg orally every 8 hours for 48 hours. They were kept admitted for 72 hours. SPSS Statistics version 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used to enter and analyse the collected data. Mean and standard deviation was calculated for quantitative variables like age, gestational age at presentation, gestational age at delivery, and BMI. Frequency and percentage were calculated for parity and preterm delivery. Results The study involved 160 patients, with the average age in Group A being 29.60±4.9 years and in Group B being 30.96±4.98 years. In terms of gestational age at delivery, Group A had an average of 34.16±1.7 weeks, while Group B had an average of 33.5±1.8 weeks (p-value<0.05). Preterm delivery was observed in 68.5% of Group A and 41.3% of Group B, with a significant p-value of 0.001. The study also discovered that the duration of prolonged pregnancy was significantly higher in Group A compared to Group B, with averages of 14.96±10.37 days and 10.24±8.97 days, respectively (p-value=0.002). Conclusion The results of this study suggest that the combination of sildenafil citrate and nifedipine may offer a promising new approach to improving pregnancy outcomes in cases of PTL. In the present study, sildenafil citrate plus nifedipine showed a significant effect in the management of PTL and prolongation in mean gestational age at delivery.
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Affiliation(s)
- Amber Hassan
- European School of Molecular Medicine, University of Milan, Milan, ITA
- Translational Neuroscience Lab, CEINGE-Biotecnologie Avanzate, Naples, ITA
| | | | - Nashwa AlDardeir
- Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Hisham Nasief
- Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, SAU
| | | | | | - Haneen Alothmani
- Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, SAU
| | - Ziyad Hammad
- Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, SAU
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Stanhope KK, Levinson AN, Stallworth CT, Leruth S, Clevenger E, Master M, Dunlop AL, Boulet SL, Jamieson DJ, Blake S. A Qualitative Study of Perceptions, Strengths, and Opportunities in Cardiometabolic Risk Management During Pregnancy and Postpartum in a Georgia Safety-Net Hospital, 2021. Prev Chronic Dis 2022; 19:E68. [PMID: 36302381 PMCID: PMC9616128 DOI: 10.5888/pcd19.220059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder. METHODS We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management. RESULTS From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors. CONCLUSION Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.
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Affiliation(s)
- Kaitlyn K Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, 49 Jesse Hill Dr SE, Atlanta, GA 30303.
| | | | | | - Sophie Leruth
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Emma Clevenger
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Margaret Master
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Anne L Dunlop
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Sarah Blake
- Emory University Rollins School of Public Health, Atlanta, Georgia
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Shao Y, Gu S, Zhang X. Effects of Nifedipine and Labetalol Combined with Magnesium Sulfate on Blood Pressure Control, Blood Coagulation Function, and Maternal and Infant Outcome in Patients with Pregnancy-Induced Hypertension. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:9317114. [PMID: 36277012 PMCID: PMC9584663 DOI: 10.1155/2022/9317114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/11/2022] [Accepted: 08/27/2022] [Indexed: 11/18/2022]
Abstract
Objective The purpose is to investigate the influence of nifedipine, labetalol, and magnesium sulfate on blood pressure control, blood coagulation, and maternal and infant outcome in those suffering from pregnancy-induced hypertension (PIH). Methods From January 2019 to April 2021, 100 participants with PIH in our center were randomly assigned to a control group and a research group. As a control, nifedipine combined with magnesium sulfate was administered. Nifedipine, labetalol, and magnesium sulfate were administered to the research group. The curative effect, blood pressure level, blood coagulation function, vascular endothelial function, and pregnancy comparisons were made between the two groups. Results Based on the results of the study, the effective rate totaled 92.00%, while as for the control group, it was 80.0%, which indicates that there was a statistically significant difference between the effective rates of the research group and that of the control group, and the difference was statistically significant (P < 0.05). Blood pressure and blood coagulation function did not differ significantly between the two groups before treatment, and the difference was not statistically significant (P > 0.05). After treatment, both groups experienced a significant drop in systolic and diastolic blood pressure. After treatment, a higher PT index was found in the research group than in the control group. Likewise, the Fbg, D-D, and PLT were lower compared to those in the control group, and the difference was statistically significant (P < 0.05). Neither group had significantly different vascular endothelial function before treatment, and the difference was not statistically significant (P > 0.05). After treatment, the ET-1 of the two groups decreased, and the level of NO increased. There was a lower ET-1 in the research group than in the control group as well as a higher NO level in the research group than in the control group, and the difference was statistically significant (P < 0.05). Compared with the pregnancy outcome, in comparison to the controls, the research group had a higher vaginal delivery rate. Significantly, fewer cases of fetal distress, intrauterine asphyxia, and placental abruption were reported in the research group than in the control group, and the difference was statistically significant (P < 0.05). Conclusion Nifedipine, in combination with magnesium sulfate and labetalol, is effective at treating PIH, reducing blood pressure, improving blood coagulation, preventing cardiovascular events and vascular endothelial function, and further improve the pregnancy outcome.
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Affiliation(s)
- Yuping Shao
- Department of Obstetrics and Gynecology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai 201700, China
| | - Siyi Gu
- Department of Obstetrics and Gynecology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai 201700, China
| | - Xiaoping Zhang
- Department of Obstetrics and Gynecology, Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai 201700, China
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Hahn PD, Melvin P, Graham DA, Milliren CE. A Methodology to Create Mother-Baby Dyads Using Data From the Pediatric Health Information System. Hosp Pediatr 2022; 12:884-892. [PMID: 36168855 DOI: 10.1542/hpeds.2022-006565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Linking newborn birth records with maternal delivery data is invaluable in perinatal research, though linkage is often challenging or impossible in the context of administrative data. Using data from the Pediatric Health Information System (PHIS), we describe a novel methodology to link maternal delivery data with newborn birth hospitalization records to form mother-baby dyads. METHODS We extracted singleton birth discharges and maternal delivery discharges between 2016 and 2020 from hospitals submitting large volumes of maternal delivery discharges and newborn deliveries into PHIS. Birth discharges at these PHIS hospitals included routine births and those requiring specialty care. Newborn discharges were matched to maternal discharges within hospital by date of birth, mode of delivery, and ZIP code. RESULTS We identified a matching maternal discharge for 92.1% of newborn discharges (n = 84 593/91 809). Within-hospital match rates ranged from 87.4% to 93.9%. Within the matched cohort, most newborns were normal birth weight (91.2%) and term (61.2%) or early term (27.4%). A total of 88.8% of newborns had birth stays less than 5 days and 14.2% were admitted to the NICU. CONCLUSIONS We demonstrate the feasibility of deterministically linking maternal deliveries to newborn discharges forming mother-baby dyads with a high degree of success using data from PHIS. The matched cohort may be used to study a variety of neonatal conditions that are likely to be affected by maternal demographic or clinical factors at delivery. Validation of this methodology is an important next step and area of future work.
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Affiliation(s)
- Phillip D Hahn
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts
| | - Patrice Melvin
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Carly E Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts
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Johnson JE, Roman L, Key KD, Meulen MV, Raffo JE, Luo Z, Margerison CE, Olomu A, Johnson-Lawrence V, White JM, Meghea C. Study protocol: The Maternal Health Multilevel Intervention for Racial Equity (Maternal Health MIRACLE) Project. Contemp Clin Trials 2022; 120:106894. [PMID: 36028193 PMCID: PMC9809987 DOI: 10.1016/j.cct.2022.106894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/09/2022] [Accepted: 08/20/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To test the effectiveness and cost-effectiveness of a multilevel intervention for population-level African American (AA) severe maternal morbidity and mortality. BACKGROUND Severe maternal morbidity and mortality in the U.S. disproportionately affect AA women. Inequities occur at many levels, including community, provider, and health system levels. DESIGN Intervention. Throughout the two intervention counties, we will expand access to enhanced prenatal care services using telehealth and flexible scheduling (community level), provide actionable maternal health-focused anti-racism training (provider level), and implement equity-focused community care maternal safety bundles (health system level). Partnership. Interventions were developed/co-developed by intervention county partners, including AA women, enhanced prenatal care staff, and health providers. For equity, 46% of project direct cost dollars go to our partners. Most study investigators are female (75%) and/or AA (38%). Partners are overwhelmingly AA women. Sample, measures, analyses. We use a quasi-experimental difference-in-differences with propensity scores approach to compare pre (2016-2019) to post (2022-2025) changes in outcomes for Medicaid-insured women in intervention counties to similar women in the other Michigan, USA, counties. The sample includes all Medicaid-insured deliveries in Michigan during these years (n ~ 540,000), with women observed during pregnancy, at birth, and up to 1 year postpartum. Measures are taken from a linked dataset that includes Medicaid claims and vital records. CONCLUSION This study is among the first to examine effects of any multilevel intervention on AA severe maternal morbidity and mortality. It features a rigorous quasi-experimental design, multilevel multi-partner county-wide interventions developed by community partners, and assessment of intervention effects using population-level data.
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Affiliation(s)
- Jennifer E Johnson
- Division of Public Health, Michigan State University College of Human Medicine, 200 East 1(st) St Room 366, Flint, MI 48502, United States of America.
| | - LeeAnne Roman
- Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University College of Human Medicine, 965 Wilson Rd, Room, Room A629B, East Lansing, MI 48823, United States of America.
| | - Kent D Key
- Division of Public Health, Michigan State University College of Human Medicine, 200 East 1(st) St Room 367, Flint, MI 48502, United States of America.
| | - Margaret Vander Meulen
- Strong Beginnings - Healthy Start, 751 Lafayette NE, Grand Rapids, MI 49503, United States of America.
| | - Jennifer E Raffo
- Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University College of Human Medicine, MSU Secchia Center, 15 Michigan St. NE, Grand Rapids, MI 49503, United States of America.
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, B627 West Fee Hall, 909 Wilson Road, East Lansing, MI 48823, United States of America.
| | - Claire E Margerison
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, 909 Wilson Rd. Rm 601B, East Lansing, MI 48823, United States of America.
| | - Adesuwa Olomu
- Department of Medicine, Michigan State University College of Human Medicine, B323 Clinical Center, East Lansing, MI 48824, United States of America.
| | - Vicki Johnson-Lawrence
- Department of Family Medicine, Michigan State University College of Human Medicine, B106 Clinical Center, 788 Service Road, East Lansing, MI 48824., United States of America.
| | - Jonne McCoy White
- Division of Public Health, Michigan State University College of Human Medicine, 200 East 1(st) St Room 371, Flint, MI 48502, United States of America.
| | - Cristian Meghea
- Department of Obstetrics, Gynecology, and Reproductive Biology, Michigan State University College of Human Medicine, 965 Wilson Rd, Room A627, East Lansing, MI 48823, USA.
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Snowden JM, Lyndon A, Kan P, El Ayadi A, Main E, Carmichael SL. Severe Maternal Morbidity: A Comparison of Definitions and Data Sources. Am J Epidemiol 2021; 190:1890-1897. [PMID: 33755046 DOI: 10.1093/aje/kwab077] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 11/14/2022] Open
Abstract
Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957-965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007-2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ < 0.41 for 13 of 21 two-way comparisons). Low concordance was particularly driven by the presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research on validity of SMM definitions, using more fine-grained data sources, is needed.
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12
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Wall-Wieler E, Butwick AJ, Gibbs RS, Lyell DJ, Girsen AI, El-Sayed YY, Carmichael SL. Maternal Health after Stillbirth: Postpartum Hospital Readmission in California. Am J Perinatol 2021; 38:e137-e145. [PMID: 32365389 PMCID: PMC7609589 DOI: 10.1055/s-0040-1708803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to assess whether the risk of postpartum readmission within 6 weeks of giving birth differs for women who had stillbirths compared with live births. STUDY DESIGN Using data from the Office of Statewide Health Planning and Development in California, we performed a population-based cohort study of 7,398,640 births between 1999 and 2011. We identified diagnoses and procedures associated with the first postpartum hospital readmission that occurred within 6 weeks after giving birth. We used log-binomial models to estimate relative risk (RR) of postpartum readmission for women who had stillbirth compared with live birth deliveries, adjusting for maternal demographic, prepregnancy, pregnancy, and delivery characteristics. RESULTS The rate of postpartum readmission was higher among women who had stillbirths compared with women who had live births (206 and 96 per 10,000 births, respectively). After adjusting for maternal demographic and medical characteristics, the risk of postpartum readmission for women who had stillbirths was nearly 1.5 times greater (adjusted RR = 1.47, 95% confidence interval: 1.35-1.60) compared with live births. Among women with stillbirths, the most common indications at readmission were uterine infection or pelvic inflammatory disease, psychiatric conditions, hypertensive disorder, and urinary tract infection. CONCLUSION Based on our findings, women who have stillbirths are at higher risk of postpartum readmissions within 6 weeks of giving birth than women who have live births. Women who have stillbirths may benefit from additional monitoring and counseling after hospital discharge for potential postpartum medical and psychiatric complications. KEY POINTS · Women who have stillbirths are at nearly 1.5 times greater risk of postpartum readmission than women who have live births.. · Uterine infections and pelvic inflammatory disease, and psychiatric conditions are the most common reasons for readmission among women who had a stillbirth.. · Women who have stillbirths may benefit from additional monitoring and counseling after hospital discharge for potential postpartum medical and psychiatric complications..
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Affiliation(s)
- Elizabeth Wall-Wieler
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alexander J. Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald S. Gibbs
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Deirdre J. Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Anna I. Girsen
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Yasser Y. El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
| | - Suzan L. Carmichael
- Department of Pediatrics and Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California
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13
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Garg B, Hersh A, Caughey AB, Pilliod RA. Severe maternal morbidity and Black-white differences in Washington State. J Matern Fetal Neonatal Med 2021; 35:5949-5956. [PMID: 33775201 DOI: 10.1080/14767058.2021.1903423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Rates of severe maternal morbidity (SMM) are significantly higher among Black women and some data suggests further worsening of these rates among hospitals with the highest proportion of Black deliveries. In this study, we sought to examine whether Black women have higher SMM in Washington State and whether this varied by hospital. METHODS We conducted a retrospective cohort study using linked birth-hospital discharge data from Washington State. We compared Non-Hispanic Black women with Non-Hispanic white women and excluded observations with missing hospital information. SMM was defined using an already published algorithm. We ranked hospitals into low-, medium- and high Black-serving hospitals by using proportions of deliveries to Black women among all deliveries. Multivariable logistic regression models were used to examine the association of Black women with SMM adjusted for demographics, co-morbidities and clustering within hospital. RESULTS In the cohort of 407,808 women, 4556 (1.12%) had SMM. High Black-serving hospitals had the highest rate of SMM (1.94%) as compared to medium Black-serving hospitals (1.16%) and low Black-serving hospitals (1.06%) (p < .01). Odds of SMM was higher in Black women (OR = 1.58, 95% CI: 1.39-1.78) and remained elevated after adjusting for demographics and the level of Black-serving hospital (aOR= 1.29, 95% CI: 1.11-1.49). CONCLUSION We found that the risk of SMM was higher among Black women. Hospital level performance and health outcomes stratified by maternal race and ethnicity in hospitals and hospital systems should be addressed to further reduce disparities and optimize outcomes.
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Affiliation(s)
- Bharti Garg
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Alyssa Hersh
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Rachel A Pilliod
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
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14
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Korst LM, Gregory KD, Nicholas LA, Saeb S, Reynen DJ, Troyan JL, Greene N, Fridman M. A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance. Matern Health Neonatol Perinatol 2021; 7:3. [PMID: 33407937 PMCID: PMC7789633 DOI: 10.1186/s40748-020-00123-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors. Objective To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM. Search methods Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.” Selection criteria Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded. Data collection and analysis Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed. Main results Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty). Conclusions The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest. Supplementary Information The online version contains supplementary material available at 10.1186/s40748-020-00123-1.
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Affiliation(s)
- Lisa M Korst
- Childbirth Research Associates, LLC, North Hollywood, CA, USA.
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA.,Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Community Health Sciences, Fielding School of Public Health at UCLA, Los Angeles, CA, USA
| | - Lisa A Nicholas
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Samia Saeb
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA
| | - David J Reynen
- Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, CA, USA
| | - Jennifer L Troyan
- Maternal, Child and Adolescent Health Division, California Department of Public Health, Sacramento, CA, USA
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA, USA
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15
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Liu C, Wall-Wieler E, Urquia M, Carmichael SL, Stephansson O. Severe maternal morbidity among migrants with insecure residency status in Sweden 2000-2014: a population-based cohort study. J Migr Health 2020; 1-2:100006. [PMID: 34405161 PMCID: PMC8352011 DOI: 10.1016/j.jmh.2020.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Migrants with insecure residency status (i.e., undocumented migrants and asylum-seekers, who are denied or waiting for authorized residency) often experience social and psychosocial adversities and limited access to health care. Nonetheless, they have not been profiled on the risk of severe maternal morbidity (SMM), a sentinel measure of maternal health and maternity care. METHODS A cohort study on all births recorded in the Swedish Medical Birth Register from 2000-2014 (N = 1,570,472). Lacking a maternal personal identification number was used as an indicator for insecure residency status (1.3% of all births). We used Poisson regression models to estimate risk ratios of SMM in migrant women with insecure residency status compared to the Swedish-born or migrant women with long-term residency, adjusting for the calendar year of birth, maternal age, and parity. RESULTS Overall SMM rate among migrant women with insecure residency status was 21.5/1000 and 14.7/1000 among Swedish-born women. Compared to Swedish-born, migrants with insecure residency status had 50% higher risk of overall SMM (adjusted risk ratio (aRR)=1.54 [1.37-1.74]) and over 80% higher risk of SMM excluding transfusion-only cases (aRR=1.88 [1.37-2.57]). When compared to migrant women with long-term residency, migrant women with insecure residency also had a higher risk of SMM (overall SMM aRR=1.42 [1.26,1.61]; SMM excluding transfusion only cases aRR=1.43 [1.04,1.97]), suggesting that insecure residency conferred additional risks of SMM beyond migration. CONCLUSION Migrant women with insecure residency status had increased risk of severe maternal morbidity.
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Affiliation(s)
- Can Liu
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Elizabeth Wall-Wieler
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Marcelo Urquia
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
- Division of Maternal- Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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Scott KA, Chambers BD, Baer RJ, Ryckman KK, McLemore MR, Jelliffe-Pawlowski LL. Preterm birth and nativity among Black women with gestational diabetes in California, 2013-2017: a population-based retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:593. [PMID: 33023524 PMCID: PMC7541301 DOI: 10.1186/s12884-020-03290-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/27/2020] [Indexed: 02/08/2023] Open
Abstract
Background Despite the disproportionate prevalence of gestational diabetes (GDM) and preterm birth (PTB) and their associated adverse perinatal outcomes among Black women, little is known about PTB among Black women with GDM. Specifically, the relationship between PTB by subtype (defined as indicated PTB and spontaneous PT labor) and severity, GDM, and nativity has not been well characterized. Here we examine the risk of PTB by severity (early < 34 weeks, late 34 to 36 weeks) and early term birth (37 to 38 weeks) by nativity among Black women with GDM in California. Methods This retrospective cohort study used linked birth certificate and hospital discharge data for 8609 of the 100,691 self-identifying non-Hispanic Black women with GDM who had a singleton live birth between 20 and 44 weeks gestation in California in 2013–2017. Adjusted odds ratios (aOR) and 95% confidence intervals (CIs) were examine risks for PTB, by severity and subtype, and early term birth using multivariate regression modeling. Results Approximately, 83.9% of Black women with GDM were US-born and 16.1% were foreign-born. The overall prevalence of early PTB, late PTB, and early term birth was 3.8, 9.5, and 29.9%, respectively. Excluding history of prior PTB, preeclampsia was the greatest overall risk factor for early PTB (cOR = 6.7, 95%, CI 5.3 to 8.3), late PTB (cOR = 4.3, 95%, CI 3.8 to 5.0), and early term birth (cOR = 1.8, 95%, CI 1.6 to 2.0). There was no significant difference in the prevalence of PTB by subtypes and nativity (p = 0.5963). Overall, 14.2% of US- compared to 8.9% of foreign-born women had a PTB (early PTB: aOR = 0.56, 95%, CI 0.38 to 0.82; late PTB: aOR = 0.57, 95%, CI 0.45 to 0.73; early term birth: aOR = 0.67, 95%, CI 0.58 to 0.77). Conclusions Foreign-born status remained protective of PTB, irrespective of severity and subtype. Preeclampsia, PTB, and GDM share pathophysiologic mechanisms suggesting a need to better understand differences in perinatal stress, chronic disease, and vascular dysfunction based on nativity in future epidemiologic studies and health services research.
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Affiliation(s)
- Karen A Scott
- Department of Obstetrics, Gynecology & Reproductive Sciences, School of Medicine, University of California San Francisco, 2356 Sutter Street, J-140, San Francisco, CA, 94143, USA.
| | - Brittany D Chambers
- California Preterm Birth Initiative, University of California San Francisco, 3333 California Street, Suite 285, San Francisco, CA, 94118, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, 560 16th Street, Second Floor, San Francisco, CA, 94158, USA
| | - Rebecca J Baer
- Department of Obstetrics, Gynecology & Reproductive Sciences, School of Medicine, University of California San Francisco, 2356 Sutter Street, J-140, San Francisco, CA, 94143, USA.,California Preterm Birth Initiative, University of California San Francisco, 3333 California Street, Suite 285, San Francisco, CA, 94118, USA.,Department of Pediatrics, University of California San Diego, 9500 Gilman Drive, Building 3, La Jolla, CA, 92161, USA
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa College of Public Health, 145 N. Riverside Drive, Office S435 CPHB, Iowa City, IA, 52242, USA
| | - Monica R McLemore
- Family Health Care Nursing Department, School of Nursing, University of California, 2 Koret Way, N431H, San Francisco, San Francisco, CA, 94143, USA
| | - Laura L Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California San Francisco, 3333 California Street, Suite 285, San Francisco, CA, 94118, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, 560 16th Street, Second Floor, San Francisco, CA, 94158, USA
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