Insurance coverage and discontinuity during pregnancy: Frequency and associations documented in the PROMISE cohort

Association between distance traveled and abortion consideration and completion among people with fetal myelomeningocele

BACKGROUND

Due to the small number of centers performing maternal-fetal surgery for fetal myelomeningocele, many people are required to travel significant distances for perioperative counseling at an experienced center. As part of the decision-making process for the management of myelomeningocele, some pregnant individuals are interested in, and may ultimately proceed with, termination of pregnancy. Additional travel for abortion care may compound psychological and financial burdens for pregnant individuals, given the existing barriers to accessing abortion care across the United States.

OBJECTIVE

The objective of this study was to evaluate the association between the distance traveled to a fetal care center and the consideration and completion of abortion among patients with fetal myelomeningocele.

STUDY DESIGN

We performed a retrospective cohort analysis of all singleton myelomeningocele consultations at a single fetal care center in Illinois from 2018 to 2024. The exposure was the distance traveled to the fetal care center defined as miles from the patient's zip code of residence to the fetal care center. Distance was analyzed in two ways: categorically (dichotomized based on median value) and continuously. The primary outcomes were abortion consideration, ascertained by a nurse during fetal care center intake, and abortion completion. Bivariate and multivariate log-binomial regression analyses were performed. A subgroup analysis was performed by participant state of residence. Statistical significance was considered P<.05.

RESULTS

There were 133 participants available for the abortion consideration analysis and 157 participants for the abortion completion analysis. Median distance traveled was 39 miles (IQR 15-116 miles). People traveling below the median distance were more likely to identify as Latinx, reside within Illinois, and present at an earlier gestational age when compared with those traveling above the median distance. Distance traveled was independently associated with abortion consideration, after controlling for gestational age at the time of presentation to the fetal care center (aRR 0.44, 95% CI 0.27-0.72). When treating the distance traveled as a continuous outcome, for every mile traveled the risk of considering abortion decreased by 1% (aRR 0.99, 95% CI 0.98-0.99). On subgroup analysis, this finding was persistent only among individuals living in Illinois. There was no significant relationship between the distance traveled to the fetal care center and abortion completion.

CONCLUSIONS

Increased distance traveled is associated with a lower risk of abortion consideration among individuals presenting to a fetal care center for fetal myelomeningocele consultation. These data emphasize the nuanced relationship between fetal diagnosis and abortion and the importance of providing comprehensive reproductive counseling to patients seeking consultation at a fetal care center.

Early childhood weight trajectory differences in twins, singletons, and gestational-age matched singletons

Objective

Understanding of twin growth in the United States (US) is based on outdated or predominantly non-Hispanic White samples, and the age at which twins catch up to singletons is unclear. In this study, we characterized normative weight trajectories of twins and singletons in a contemporary, diverse cohort.

Methods

Data were from the PROMISE study, an electronic health record-based cohort of pregnant people and their children in the US (2005-2021). The Jenss model was used to characterize weight trajectories from 0 to 24 months of age. Twins (n = 716) were compared to the full cohort of singletons (n = 40,075) and a matched sample with similar gestational age at birth (GA) (n = 7160).

Results

Male and female twins had lower birth weight compared to singletons and experienced a high rate of weight gain throughout infancy. Among males, twins caught up in weight to the full singleton cohort and to GA-matched singletons at approximately 12 and 6 months, respectively. Among females, twins caught up to GA-matched singletons at approximately 15 months but did not fully overcome their birth weight disadvantage to the full singleton sample by 24 months.

Conclusions

These findings highlight that the use of singleton growth charts or preterm singleton growth charts among twins may be inappropriate and suggest the need for a twin-specific growth chart. Future research is needed to understand factors that drive differences in weight trajectories between twins and singletons and to guide twin-specific guidelines.

Methods for modeling gestational weight gain: empirical application using electronic health record data from a safety net population

BACKGROUND

Understanding the risks and effects of gestational weight gain (GWG) is a prominent area of perinatal research but approaches for quantifying GWG are evolving and remain underdeveloped, especially in clinical settings for underserved demographic subgroups. To fill this gap, we demonstrated and compared six GWG metrics across pre-pregnancy BMI classifications: total GWG, trimester-specific linear rate of GWG, adherence to total and trimester-specific recommendations, area under the curve, and GWG for gestational age z-scores.

METHODS

We used clinical data on 44,801 pregnant people from community-based health care organizations with extensive longitudinal measures and substantial representation of understudied subgroups.

RESULTS

Total GWG was lower in individuals with higher pre-pregnancy BMI; yet more temporally resolved analyses revealed differences in trimester-specific weight change. Differences included common first trimester weight loss in people with pre-pregnancy class II or III obesity and substantial first trimester weight gain in people with pre-pregnancy underweight, with the greatest pre-pregnancy BMI-related variation in GWG occurring in the second trimester. These differences are reflected to varying degrees in the AUC and GWG z-score metrics.

CONCLUSIONS

Our findings inform development of GWG guidelines within BMI categories, especially in obesity subclasses and underweight, and selection, refinement, and application of GWG metrics in future research. GWG metrics differ to varying degrees across BMI categories in a population consisting of several underserved subgroups: pregnant people of color, with larger body sizes, or with lower incomes. Stronger evidence on safe levels of first trimester weight loss and obesity class-specific recommendations is needed.

Pregnancy health in a multi-state U.S. population of systemically underserved patients and their children: PROMISE cohort design and baseline characteristics

BACKGROUND

Gestational weight gain (GWG) is a routinely monitored aspect of pregnancy health, yet critical gaps remain about optimal GWG in pregnant people from socially marginalized groups, or with pre-pregnancy body mass index (BMI) in the lower or upper extremes. The PROMISE study aims to determine overall and trimester-specific GWG associated with the lowest risk of adverse birth outcomes and detrimental infant and child growth in these underrepresented subgroups. This paper presents methods used to construct the PROMISE cohort using electronic health record data from a network of community-based healthcare organizations and characterize the cohort with respect to baseline characteristics, longitudinal data availability, and GWG.

METHODS

We developed an algorithm to identify and date pregnancies based on outpatient clinical data for patients 15 years or older. The cohort included pregnancies delivered in 2005-2020 with gestational age between 20 weeks, 0 days and 42 weeks, 6 days; and with known height and adequate weight measures needed to examine GWG patterns. We linked offspring data from birth records and clinical records. We defined study variables with attention to timing relative to pregnancy and clinical data collection processes. Descriptive analyses characterize the sociodemographic, baseline, and longitudinal data characteristics of the cohort, overall and within BMI categories.

RESULTS

The cohort includes 77,599 pregnancies: 53% had incomes below the federal poverty level, 82% had public insurance, and the largest race and ethnicity groups were Hispanic (56%), non-Hispanic White (23%) and non-Hispanic Black (12%). Pre-pregnancy BMI groups included 2% underweight, 34% normal weight, 31% overweight, and 19%, 8%, and 5% Class I, II, and III obesity. Longitudinal data enable the calculation of trimester-specific GWG; e.g., a median of 2, 4, and 6 valid weight measures were available in the first, second, and third trimesters, respectively. Weekly rate of GWG was 0.00, 0.46, and 0.51 kg per week in the first, second, and third trimesters; differences in GWG between BMI groups were greatest in the second trimester.

CONCLUSIONS

The PROMISE cohort enables characterization of GWG patterns and estimation of effects on child growth in underrepresented subgroups, ultimately improving the representativeness of GWG evidence and corresponding guidelines.