The contribution of preterm birth to infant mortality rates in the United States

What Do Your Neighbors Think About You? How Perceived Neighbor Attitudes Toward Latinos Influence Mental Health Among a Pregnant Latina Cohort

Latina women living in the USA experience disproportionately higher rates of psychological distress compared to their non-Latina White counterparts. Poor maternal mental health during pregnancy can contribute to intergenerational mental health disparities. Through this pathway, mothers' experiences, environments, and exposures (henceforth "exposures") during pregnancy become biologically embodied and can negatively affect the fetus and life-long developmental trajectories of her child. One of the exposures that can affect mother-offspring dyads is the neighborhood. With the goal of integrating anthropological and sociological theories to explain mental health disparities among pregnant Latina women, we explored how perceptions of neighbor attitudes may influence mental health during pregnancy. We analyzed self-reported responses from 239 pregnant Latina women in Southern California (131 foreign-born, 108 US-born) on their mental health and perceived attitudes of their neighbors using multiple linear regression models. Among foreign-born Latina women, living in neighborhoods with more favorable views of Latinos was associated with lower depression scores (pooled β =  - .70, SE = .29, p = .019) and lower pregnancy-related anxiety scores (pooled β =  - .11, SE = .05, p = .021), but greater state anxiety scores (pooled β = .09, SE = .04, p = .021). Among US-born women, there were no associations between neighbor attitudes and mental health. Overall, results suggest that social environments are correlated with mental health and that foreign-born and US-born Latinas have varied mental health experiences in the USA. Our findings highlight the importance of improving aspects of neighborhood cohesion as part of maternal-fetal care management.

Examining modification of the associations between air pollution and birth outcomes by neighborhood deprivation in a North Carolina birth cohort, 2011-2015

Background

Evidence from studies of air pollutants and birth outcomes suggests an association, but uncertainties around geographical variability and modifying factors still remain. As neighborhood-level social characteristics are associated with birth outcomes, we assess whether neighborhood deprivation level is an effect measure modifier on the association between air pollution and birth outcomes in a North Carolina birth cohort.

Methods

Using birth certificate data, all North Carolina residential singleton live births from 1 January 2011 to 31 December 2015 with gestational ages of 20-44 weeks (n = 566,799) were examined for birth defect diagnoses and preterm birth. Exposures were daily average fine particulate matter (PM2.5), daily 8-h maximum nitrogen dioxide (NO2), and daily 8-h maximum ozone (O3) modeled concentrations, and the modifier of interest was the neighborhood deprivation index (NDI). Linear binomial models were used to estimate the prevalence differences and 95% confidence intervals (CI) for the association between ambient air pollution and birth defect diagnoses. Modified Poisson regression models were used to estimate risk differences (RDs) and 95% CIs for air pollution and preterm birth. Models were stratified by the neighborhood deprivation index group (low, medium, or high) to assess potential modification by NDI.

Results

Approximately 3.1% of the study population had at least one birth defect and 8.18% were born preterm. For preterm birth, associations with PM2.5 and O3 did not follow a conclusive pattern and there was no evidence of modification by NDI. The associations between NO2 and preterm birth were generally negative across exposure windows except for a positive association with NO2 and preterm birth for high NDI [RD: 34.70 (95% CI 4.84-64.56)] for entire pregnancy exposure. There was no evidence of associations between pollutants examined and birth defects.

Conclusions

There may be differences in the association between NO2 exposure and preterm birth by NDI but we did not observe any evidence of associations for birth defects. Our results support the public health protection afforded by reductions in air pollution, even in areas of neighborhood deprivation, but future research conducted in areas with higher levels of air pollution and evaluating the potential for modification by neighborhood deprivation level would be informative.

The vaginal immunoproteome for the prediction of spontaneous preterm birth: A retrospective longitudinal study

Background

Preterm birth is the leading cause of neonatal morbidity and mortality worldwide. Most cases of preterm birth occur spontaneously and result from preterm labor with intact (spontaneous preterm labor [sPTL]) or ruptured (preterm prelabor rupture of membranes [PPROM]) membranes. The prediction of spontaneous preterm birth (sPTB) remains underpowered due to its syndromic nature and the dearth of independent analyses of the vaginal host immune response. Thus, we conducted the largest longitudinal investigation targeting vaginal immune mediators, referred to herein as the immunoproteome, in a population at high risk for sPTB.

Methods

Vaginal swabs were collected across gestation from pregnant women who ultimately underwent term birth, sPTL, or PPROM. Cytokines, chemokines, growth factors, and antimicrobial peptides in the samples were quantified via specific and sensitive immunoassays. Predictive models were constructed from immune mediator concentrations.

Results

Throughout uncomplicated gestation, the vaginal immunoproteome harbors a cytokine network with a homeostatic profile. Yet, the vaginal immunoproteome is skewed toward a pro-inflammatory state in pregnant women who ultimately experience sPTL and PPROM. Such an inflammatory profile includes increased monocyte chemoattractants, cytokines indicative of macrophage and T-cell activation, and reduced antimicrobial proteins/peptides. The vaginal immunoproteome has improved predictive value over maternal characteristics alone for identifying women at risk for early (<34 weeks) sPTB.

Conclusions

The vaginal immunoproteome undergoes homeostatic changes throughout gestation and deviations from this shift are associated with sPTB. Furthermore, the vaginal immunoproteome can be leveraged as a potential biomarker for early sPTB, a subset of sPTB associated with extremely adverse neonatal outcomes.

Funding

This research was conducted by the Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS) under contract HHSN275201300006C. ALT, KRT, and NGL were supported by the Wayne State University Perinatal Initiative in Maternal, Perinatal and Child Health.

Association of Medicaid expansion with birth outcomes: evidence from a natural experiment in Texas

BACKGROUND

Empirical evidence on the effects of Medicaid expansion is mixed and highly state-dependent. The objective of this study is to examine the association of Medicaid expansion with preterm birth and low birth weight, which are linked to a higher risk of infant mortality and chronic health conditions throughout life, providing evidence from a non-expansion state, overall and by race/ethnicity.

METHODS

We used the newborn patient records obtained from Texas Public Use Data Files from 2010 to 2019 for hospitals in Texarkana, which is located on the border of Texas and Arkansas, with all of the hospitals serving pregnancy and childbirth patients on the Texas side of the border. We employed difference-in-differences models to estimate the effect of Medicaid expansion on birth outcomes (preterm birth and low birth weight) overall and by race/ethnicity. Newborns from Arkansas (expanded Medicaid in 2014) constituted the treatment group, while those from Texas (did not adopt the expansion) were the control group. We utilized a difference-in-differences event study framework to examine the gradual impact of the Medicaid expansion on birth outcomes.

RESULTS

Medicaid expansion was associated with a 1.38-percentage-point decrease (95% confidence interval (CI), 0.09-2.67) in preterm birth overall. Event study results suggest that preterm births decreased gradually over time. Medicaid expansion was associated with a 2.04-percentage-point decrease (95% CI, 0.24-3.85) in preterm birth and a 1.75-percentage-point decrease (95% CI, 0.42-3.08) in low birth weight for White infants. However, Medicaid expansion was not associated with significant changes in birth outcomes for other race/ethnicity groups.  CONCLUSIONS: Our findings suggest that Medicaid expansion in Texas can potentially improve birth outcomes. However, bridging racial disparities in birth outcomes might require further efforts such as promoting preconception and prenatal care, especially among the Black population.

The incidence and risk factors of retinopathy of prematurity in South Korea: A nationwide cohort study

Retinopathy of prematurity (ROP) is a major treatable cause of childhood blindness. Thus, epidemiological investigations are necessary for detecting and preventing ROP. Determining risk factors for ROP are also essential to improve screening methods. Therefore, we aimed to investigate the incidence and risk factors of ROP in Korea. The National Health Insurance Service (NHIS) covers almost all Koreans. Furthermore, the National Health Screening Program for Infants and Children (NHSPIC) is a government-run, health-screening program for children aged < 6 years. We used the NHIS-Infants and Children's Health Screening cohort database to evaluate the incidence of preterm infants and ROP. The database contains data on 84,005 participants, drawn from 5% of the NHSPIC survey on participants born annually during 2008 to 2012. Sociodemographic factors and systemic diseases were assessed as potential risk factors for ROP. We identified 2615 premature infants (3.11%); 846 of them had ROP (cumulative incidence: 32.4%). Although preterm births increased annually in 2008 to 2012, the ROP incidence in preterm infants did not increase by the birth year. Twenty patients (2.4%) with ROP underwent laser photocoagulation or surgery. Extremely low birth weight was a high risk factor (odds ratio [OR] = 49.86, P < .001). Moreover, chorioamnionitis (OR = 2.77, P = .028), respiratory distress syndrome (OR = 4.09, P < .001), apnea (OR = 1.59, P = .008), anemia (OR = 2.41, P < .001), and intraventricular hemorrhage (OR = 2.34, P < .001) were found to be risk factors for ROP. In conclusion, the incidence of premature babies increased between 2008 and 2012. However, the overall incidence of ROP among premature infants remained unchanged by birth year. Our findings revealed the roles of birth weight, respiratory conditions, anemia, and intraventricular hemorrhage in ROP.

Infant, Neonatal, and Post-neonatal Mortality in Greece: A Nationwide Time-Trend Analysis

INTRODUCTION

Infant mortality is a crucial perinatal measure and is also regarded as an important public health indicator. This study aimed to comprehensively present time trends in infant, neonatal, and post-neonatal mortality in Greece.

METHODS

The annual infant mortality rate (IMR), the neonatal mortality rate (NMR), and the post-neonatal mortality rate (PNMR) were calculated based on official national data obtained from the Hellenic Statistical Authority, spanning 67 years from 1956 to 2022. The time trends of the mortality rates were evaluated using joinpoint regression analysis, and the annual percent changes (APC) and the overall average annual percent change (AAPC) were calculated with a 95% confidence interval (95% CI).

RESULTS

The IMR exhibited accelerating declines over more than 50 years, with an APC of -1.9 (-2.8 to -1.0) from 1956 to 1968, -5.4 (-5.6 to -5.2) from 1968 to 1999, and -7.3 (-8.9 to -5.7) between 1999 and 2008. In 2008, IMR reached its all-time low of 2.7 per 1,000 live births, down 16.6-fold from its peak at 44.1 per 1,000 live births in 1957. This improving trend was reversed following the onset of the economic crisis in the country, leading to a 57% increase in IMR from 2008 to 2016, with an upward trend APC of 3.4 (1.2 to 5.5). In the recent period 2016-2022, there was an improvement with an APC of -3.7 (-6.2 to -1.1), resulting in an IMR of 3.1 per 1,000 live births in 2022. The decrease in IMR was estimated to have prevented 209,109 infant deaths in the country from 1958 to 2022. From 1956 to 2022, the IMR decreased with an AAPC of -3.9 (-4.3 to -3.4), while the PNMR saw a decline with an AAPC of -4.5 (-5.1 to -3.9) and the NMR with an AAPC of -3.2 (-3.7 to -2.6).

CONCLUSION

Greece achieved an impressive decrease in infant mortality rates, but this progress was halted and completely reversed during the economic crisis. Although there have been some recent improvements after the country's economic recovery, the rates have yet to reach pre-crisis levels.

Associations of hepatitis B and C in women aged 15-49 years with neonatal preterm birth in 66 high-income countries, 1990-2019

OBJECTIVE

To assess the associations between hepatitis B and C in women aged 15-49 years and neonatal preterm birth in high-income countries (HICs).

METHODS

This ecological study collected hepatitis B and C prevalence data in women aged 15-49 years and age-standardized incidence rates (ASIRs) of neonatal preterm birth in HICs in 1990-2019 from the Global Burden of Disease study. Estimated annual percentage changes (EAPCs) in hepatitis B and C prevalence and ASIRs of neonatal preterm birth were calculated to quantify their temporal trends. Pearson correlation tests and generalized additive mixed models were used to estimate the associations between hepatitis B and C prevalence and ASIR of neonatal preterm birth.

RESULTS

Among women aged 15-49 years in HICs, hepatitis B prevalence increased only in the Northern Mariana Islands (EAPC, 0.16 [95% confidence interval (CI), 0.05-0.27]) and the United Kingdom (EAPC, 0.08 [95% CI, 0.04-0.12]) and hepatitis C prevalence increased in more than 20% of HICs in 1990-2019, with the largest increase in Belgium (EAPC, 1.00 [95% CI, 0.65-1.35]). Nearly 80% of HICs showed an increasing trend in ASIR of neonatal preterm birth in 1990-2019, with the largest increase in Greece (EAPC, 3.91 [95% CI, 3.65-4.18]). A positive association between hepatitis C prevalence in women aged 15-49 years and ASIR of neonatal preterm birth was observed in Pearson correlation tests and generalized additive mixed models (P ≤ 0.01).

CONCLUSION

ASIR of neonatal preterm birth was associated with hepatitis C prevalence in women aged 15-49 years in HICs. Universal screening for hepatitis C virus is recommended at least once for women of reproductive age and during each pregnancy.

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

Maternal grandmothers buffer the effects of ethnic discrimination among pregnant Latina mothers

Ethnic discrimination during pregnancy is linked to maternal psychological distress, adverse birth outcomes and increased offspring morbidity and mortality. An evolutionary perspective reframes offspring health issues as a risk to maternal fitness. We argue that kin may be evolutionarily motivated to buffer psychosocial stressors for the mother during pregnancy. Previously, we found that the relationship of a pregnant woman with her own mother (fetus' maternal grandmother) had a positive association on maternal prenatal psychology, above and beyond her relationship with her fetus' father. Here, we ask if grandmothers buffer mothers' prenatal psychological distress from ethnic discrimination. Using self-report data collected from 216 pregnant Latina women living in Southern California, we found discrimination to be significantly, positively associated with depression, anxiety, and stress in linear regression models. Maternal grandmother communication attenuated the association of discrimination and all three psychological distress measures, adjusting for the mother's relationship with the father. Maternal grandmother emotional support similarly significantly moderated the relationship of discrimination with depression and anxiety. We did not observe any significant interactions for paternal grandmother relationships. Geographic proximity was not a significant stress buffer. Results suggest the important role maternal grandmothers play in perinatal mental health, and that these benefits exist uncoupled from geographic proximity.

Maternal occupational exposure to selected organic and chlorinated solvents and delivery of small-for-gestational age or preterm infants

BACKGROUND

Potential reproductive effects of organic solvent exposure during pregnancy remain unclear. We investigated the association between maternal occupational exposure during pregnancy to six chlorinated solvents, three aromatic solvents, and Stoddard solvent, and delivery of preterm infants or those born small-for-gestational age (SGA).

METHODS

In this case-control study of SGA and preterm birth (PTB) nested within the National Birth Defects Prevention Study (NBDPS) from 1997 to 2011, we analyzed data from 7504 singleton live births without major birth defects and their mothers. Self-reported information on jobs held in the periconceptional period was assessed for solvent exposure. Unconditional logistic regression was used to estimate the association between maternal occupational exposure (any, none) during early pregnancy to organic solvents and PTB and SGA. Linear regression was used to examine changes in mean birthweight potentially associated with maternal occupational solvent exposure.

RESULTS

Maternal occupational exposure to any organic solvents overall was not associated with an increased odds of PTB (adjusted odds ratio [aOR] = 0.94; 95% confidence interval [CI] 0.67-1.33) or SGA (aOR = 0.93; 95% CI 0.65-1.34). Point estimates increased modestly for higher estimated exposure versus lower, but confidence intervals were wide and not statistically significant. Maternal exposure to solvents was not associated with a statistically significant change in term birthweight among infants.

CONCLUSIONS

Occupational exposure to organic solvents at the frequency and intensity levels found in a population-based sample of pregnant workers was not associated with PTB or SGA; however, we cannot rule out any effects among pregnant workers with uncommonly high exposure to organic solvents.

Neurodevelopmental, Mental Health, and Parenting Issues in Preterm Infants

The World Health Organization in its recommendations for the care of preterm infants has drawn attention to the need to address issues related to family involvement and support, including education, counseling, discharge preparation, and peer support. A failure to address these issues may translate into poor outcomes that extend across the lifespan. In this paper, we review the often far-reaching impact of preterm birth on the health and wellbeing of the parents and highlight the ways in which psychological stress may have a negative long-term impact on the parent-child interaction, attachment, and the styles of parenting. This paper addresses the following topics: (1) neurodevelopmental outcomes in preterm infants, including cognitive, sensory, and motor difficulties, (2) long-term mental health issues in premature infants that include elevated rates of anxiety and depressive disorders, autism, and somatization, which may affect social relationships and quality of life, (3) adverse mental health outcomes for parents that include elevated rates of depression, anxiety, and symptoms of post-traumatic stress, as well as increased rates of substance abuse, and relationship strain, (4) negative impacts on the parent-infant relationship, potentially mediated by maternal sensitivity, parent child-interactions, and attachment, and (5) impact on the parenting behaviors, including patterns of overprotective parenting, and development of Vulnerable Child Syndrome. Greater awareness of these issues has led to the development of programs in neonatal mental health and developmental care with some data suggesting benefits in terms of shorter lengths of stay and decreased health care costs.

Smartphone-Based Video Antenatal Preterm Birth Education: The Preemie Prep for Parents Randomized Clinical Trial

Importance

Preterm birth is a leading cause of infant mortality and child morbidity. Preterm birth is not always unexpected, yet standard prenatal care does not offer anticipatory education to parents at risk of delivering preterm, which leaves parents unprepared to make health care choices during the pregnancy that can improve survival and decrease morbidity in case of preterm birth.

Objective

To evaluate the effect of the Preemie Prep for Parents (P3) program on maternal knowledge of preterm birth, preparation for decision-making, and anxiety.

Design, Setting, and Participants

Recruitment for this randomized clinical trial conducted at a US academic medical center took place from February 3, 2020, to April 12, 2021. A total of 120 pregnant persons with a risk factor for preterm birth were enrolled between 16 and 21 weeks' gestational age and followed up through pregnancy completion.

Intervention

Starting at 18 weeks' gestational age, P3 program participants received links delivered via text message to 51 gestational age-specific short animated videos. Control participants received links to patient education webpages from the American College of Obstetricians and Gynecologists.

Main Outcomes and Measures

At 25 weeks' gestation, scores on the Parent Prematurity Knowledge Questionnaire (scored as percent correct), Preparation for Decision Making Scale (scored 0-100), and Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety computerized adaptive test. Analysis was based on an intention to treat.

Results

A total of 120 pregnant participants (mean [SD] age, 32.5 [4.9] years) were included in the study; 60 participants were randomized to each group. Participants in the P3 group scored higher than those in the control group on knowledge of long-term outcomes at 25 weeks (88.5% vs 73.2%; estimated difference, 15.3 percentage points; 95% CI, 8.3-22.5 percentage points; P < .001). Participants in the P3 group reported being significantly more prepared than did participants in the control group for neonatal resuscitation decision-making at 25 weeks (Preparation for Decision Making Scale score, 76.0 vs 52.3; difference, 23.7; 95% CI, 14.1-33.2). There was no difference between the P3 group and the control group in anxiety at 25 weeks (mean [SE] PROMIS Anxiety scores, 53.8 [1.1] vs 54.0 [1.1]; difference, -0.1; 95% CI, -3.2 to 2.9).

Conclusions and Relevance

In this randomized clinical trial, pregnant persons randomly assigned to the P3 program had more knowledge of core competencies and were more prepared to make decisions that affect maternal and infant health, without experiencing worse anxiety. Mobile antenatal preterm birth education may provide a unique benefit to parents with preterm birth risk factors.

Trial Registration

ClinicalTrials.gov Identifier: NCT04093492.

Use of personal care products during pregnancy and birth outcomes - A pilot study

Prenatal exposure to endocrine disrupting chemicals (EDCs) from personal care products may be associated with birth outcomes including preterm birth and low birth weight. There is limited research examining the role of personal care product use during pregnancy on birth outcomes. Our pilot study consisted of 164 participants in the Environmental Reproductive and Glucose Outcomes (ERGO) study (Boston, MA), with data on self-reported personal care product use at four study visits throughout pregnancy (product use in the 48 h before a study visit and hair product use in the month before a study visit). We used covariate-adjusted linear regression models to estimate differences in mean gestational age at delivery, birth length, and sex-specific birth weight-for-gestational age (BW-for-GA) Z-score based on personal care product use. Hair product use in the past month prior to certain study visits was associated with decreased mean sex-specific BW-for-GA Z-scores. Notably, hair oil use in the month prior to study visit 1 was associated with a lower mean BW-for-GA Z-score (V1: -0.71, 95% confidence interval: -1.12, -0.29) compared to non-use. Across all study visits (V1-V4), increased mean birth length was observed among nail polish users vs. non-users. In comparison, decreased mean birth length was observed among shave cream users vs. non-users. Liquid soap, shampoo, and conditioner use at certain study visits were significantly associated with higher mean birth length. Suggestive associations were observed across study visits for other products including hair gel/spray with BW-for-GA Z-score and liquid/bar soap with gestational age. Overall, use of a variety of personal care products throughout pregnancy was observed to be associated with our birth outcomes of interest, notably hair oil use during early pregnancy. These findings may help inform future interventions/clinical recommendations to reduce exposures linked to adverse pregnancy outcomes.

Association Between Antenatal Depression Symptom Trajectories and Preterm Birth

OBJECTIVE

To evaluate whether, among pregnant people referred for mental health care, improvement in antenatal depression symptoms before delivery was associated with a reduction in preterm birth.

METHODS

This retrospective cohort study included all pregnant people referred to a perinatal collaborative care program for mental health care who delivered between March 2016 and March 2021. Those referred to the collaborative care program had access to subspecialty mental health treatment, including psychiatric consultation, psychopharmacotherapy, and psychotherapy. Depression symptoms were monitored with the self-reported PHQ-9 (Patient Health Questionnarie-9) screens in a patient registry. Antenatal depression trajectories were determined by comparing the earliest prenatal PHQ-9 score after collaborative care referral with the score closest to delivery. Trajectories were categorized as improved, stable, or worsened according to whether PHQ-9 scores changed by at least 5 points. Bivariable analyses were performed. A propensity score was generated to control for confounders that were significantly different on bivariable analyses according to trajectories. This propensity score was then included in multivariable models.

RESULTS

Of the 732 pregnant people included, 523 (71.4%) had mild or more severe depressive symptoms (PHQ-9 score 5 or higher) on their initial screen. Antenatal depression symptoms improved in 256 (35.0%), remained stable in 437 (59.7%), and worsened in 39 (5.3%); the corresponding incidence of preterm birth was 12.5%, 14.0%, and 30.8%, respectively ( P =.009). Compared with those with a worsened trajectory, pregnant people who had an improved antenatal depression symptom trajectory had a significantly decreased odds of preterm birth (adjusted odds ratio 0.37, 95% CI 0.15-0.89).

CONCLUSION

Compared with worsened symptoms, an improved antenatal depression symptom trajectory is associated with decreased odds of preterm birth for pregnant people referred for mental health care. These data further underscore the public health importance of incorporating mental health care into routine obstetric care.

Neighborhood Incarceration Rates and Adverse Birth Outcomes in New York City, 2010-2014

Importance

The US has high rates of adverse birth outcomes, with substantial racial disparities augmented by stress and neighborhood disadvantage. Black people are more likely to live in neighborhoods with high rates of incarceration, which is a source of both stress and neighborhood disadvantage and, thus, may contribute to adverse birth outcomes.

Objective

To determine whether neighborhoods with high incarceration rates also have higher rates of adverse birth outcomes compared with neighborhoods with lower rates.

Design, Setting, and Participants

This cross-sectional study used publicly available data from the New York City Department of Health (2010-2014). Censored Poisson regression, with the US Census tract as the unit of analysis, was used to examine the association of neighborhood incarceration rate and birth outcomes. Multivariable models included percentage of births aggregated to the Census tract by maternal factors (age, parity, singleton vs multiple birth, insurance, and race) and neighborhood factors (poverty, education, and violent crime). Analyses were performed between May 2021 and October 2022.

Exposure

Neighborhood incarceration rate, categorized into quintiles.

Main Outcomes and Measures

The primary outcome was the incidence rate ratio (IRR) of preterm birth and low birth weight. Secondary outcomes were IRRs of very preterm birth, extremely preterm birth, and very low birth weight. Hypotheses were formulated before data collection.

Results

Among 2061 Census tracts with 562 339 births, incarceration rates varied from 0 to 4545 people incarcerated per 100 000, and high-incarceration neighborhoods had more residents of Black race (54.00% vs 1.90%), living in poverty (32.30% vs 10.00%), and without a general educational development equivalent (28.00% vs 12.00%) compared with low-incarceration neighborhoods. In fully adjusted models, high-incarceration neighborhoods had a 13% higher IRR of preterm birth (IRR, 1.13; 95% CI, 1.08-1.18), 45% higher IRR of very preterm birth (IRR, 1.45; 95% CI, 1.24-1.71), 125% higher IRR of extremely preterm birth (IRR, 2.25; 95% CI, 1.59-3.18), 10% higher IRR of low birth weight (IRR, 1.10; 95% CI, 1.05-1.16), and 52% higher IRR of very low birth weight compared with low-incarceration neighborhoods (IRR, 1.52; 95% CI, 1.28-1.81).

Conclusions and Relevance

Neighborhood incarceration rate was positively associated with adverse birth outcomes, particularly those associated with infant mortality. Black people were significantly more likely to live in high-incarceration neighborhoods, suggesting that mass incarceration may contribute to racial disparities in birth outcomes.

Analysis of an Association between Preterm Birth and Parental Educational Level in Japan Using National Data

Preterm birth rate depending on parental educational level in recent years has not been surveyed in Japan. In this study, we showed the trend in preterm birth rate depending on parental educational level from 2000 to 2020 by linking data from the Census regarding individuals' educational level and parents in birth data of the vital statistics. Four types of parental educational level, namely junior high school, high school, technical school or junior college, and university or graduate school, were compared. Slope and relative indexes of inequality for preterm birth by educational level were computed by binomial models. Data on 3,148,711 births and 381,129,294 people were used in the analysis, and data on 782,536 singleton births were used after data linkage. The preterm birth rate (%) for junior high school graduate mothers and fathers was 5.09 and 5.20 in 2020, respectively. Contrarily, the preterm birth rate (%) for parents who graduated from a university or graduate school was 4.24 for mothers and 4.39 for fathers, and the rate tended to increase as educational level decreased, irrespective of parental gender. Results of inequality indexes showed that a statistically significant inequality by parental educational level persisted from 2000 to 2020.

What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity, housing instability, and immigration in the United States

BACKGROUND

Stress during pregnancy can lead to significant adverse outcomes for maternal mental health. Early evaluation of prenatal stress can help identify treatment needs and appropriate interventions. Disparities in the social determinants of health can contribute to stress, but what constitutes stress during pregnancy within the social determinants of health framework is poorly understood.

OBJECTIVE

To scope how prenatal stress is defined and measured among pregnant people exposed to three prominent social stressors in the United States: insecurity pertaining to food, housing, and immigration.

ELIGIBILITY CRITERIA

We included all studies that focused on stress during pregnancy in the context of food insecurity, housing instability, and immigration, given their recent policy focus due to the COVID-19 pandemic and ongoing political discourse, in addition to their importance in American College of Obstetricians and Gynecologists (ACOG's) social determinants of health screening tool.

SOURCES OF EVIDENCE

We searched PubMed, Scopus, and Web of Science for articles published between January 2012 and January 2022.

CHARTING METHODS

Using a piloted charting tool, we extracted relevant study information from the selected articles and analyzed the content pertaining to stress.

RESULTS

An initial search identified 1,023 articles, of which 24 met our inclusion criteria. None of the studies defined prenatal stress, and only one used the Prenatal Distress Questionnaire, a prenatal stress-specific tool to measure it. The Perceived Stress Scale was the most common instrument used in seven studies. Fifteen studies measured over 25 alternative exposures that researchers theorized were associated with stress, and 4 of the 15 studies did not explain the association between the measure and stress.

CONCLUSIONS

Our findings demonstrate a fundamental inconsistency in how prenatal stress is defined and measured in the context of social determinants of health, limiting the comparison of results across studies and the potential development of effective interventions to promote better maternal mental health.

The risk of preterm birth among women with a history of leukemia or lymphoma

OBJECTIVE

Leukemia and lymphoma are top cancers affecting children, adolescents and young adults with high five-year survival rates. Late effects of these cancers are a concern in reproductive-age patients, including pregnancy outcomes such as preterm birth. Our study aimed to evaluate whether diagnosis of leukemia or lymphoma prior to pregnancy was associated with preterm birth (<37 weeks gestation).

METHODS

We conducted a cross-sectional study using a population-based dataset from California with linked birth certificates to hospital discharge records and an Iowa-based sample that linked birth certificates to Surveillance, Epidemiology, and End Results (SEER) cancer registry data. Preterm birth was defined using birth certificates. We ascertained history of leukemia and lymphoma using discharge diagnosis data in California and SEER registry in Iowa.

RESULTS

Prevalence of preterm birth in California and Iowa was 14.6% and 12.0%, respectively, in women with a history of leukemia/lymphoma compared to 7.8% and 8.2%, respectively, in women without a cancer history. After adjusting for maternal age, race, education, smoking, and plurality, Women with history of leukemia/lymphoma were at an increased risk of having a preterm birth in California (odds ratio (OR) 1.89; 95% confidence interval (CI) 1.56-2.28) and Iowa (OR 1.61; 95% CI 1.10-2.37) compared to those with no cancer history.

CONCLUSION

In both California and Iowa, women with a history of leukemia or lymphoma were at increased risk for preterm birth. This suggests the importance of counseling with a history of leukemia/lymphoma prior to pregnancy and increased monitoring of women during pregnancy.

An evolutionary perspective on the association between grandmother-mother relationships and maternal mental health among a cohort of pregnant Latina women

Grandmothers are often critical helpers during a mother's reproductive career. Studies on the developmental origins of health and disease demonstrate how maternal psychological distress can negatively influence fetal development and birth outcomes, highlighting an area in which soon-to-be grandmothers (henceforth "grandmothers") can invest to improve both mother and offspring well-being. Here, we examine if and how a pregnant woman's mental health- specifically, depression, state-anxiety, and pregnancy-related anxiety- is influenced by her relationship with her fetus' maternal and paternal grandmother, controlling for relationship characteristics with her fetus' father. In a cohort of pregnant Latina women in Southern California (N = 216), we assessed social support, geographic proximity, and communication between the fetus' grandmothers and pregnant mother. We assessed maternal mental health with validated questionnaire-based instruments. We find that both social support from and communication with the maternal grandmother were statistically associated with less depression, while no paternal grandmother relationship characteristics were statistically significant in association with any mental health variable. These results align with the idea that maternal grandmothers are more adaptively incentivized to invest in their daughters' well-being during pregnancy than paternal grandmothers are for their daughters-in-law. Results suggest that the positive association of maternal grandmothers with mothers' mental health may not hinge on geographic proximity, but rather, potentially function through emotional support. This work represents a novel perspective describing a psychological and prenatal grandmaternal effect.

Genetics, epigenetics, and transcriptomics of preterm birth

Preterm birth contributes significantly to neonatal mortality and morbidity. Despite its global significance, there has only been limited progress in preventing preterm birth. Spontaneous preterm birth (sPTB) results from a wide variety of pathological processes. Although many non-genetic risk factors influence the timing of gestation and labor, compelling evidence supports the role of substantial genetic and epigenetic influences and their interactions with the environment contributing to sPTB. To investigate a common and complex disease such as sPTB, various approaches such as genome-wide association studies, whole-exome sequencing, transcriptomics, and integrative approaches combining these with other 'omics studies have been used. However, many of these studies were typically small or focused on a single ethnicity or geographic region with limited data, particularly in populations at high risk for sPTB, or lacked a robust replication. These studies found many genes involved in the inflammation and immunity-related pathways that may affect sPTB. Recent studies also suggest the role of epigenetic modifications of gene expression by the environmental signals as a potential contributor to the risk of sPTB. Future genetic studies of sPTB should continue to consider the contributions of both maternal and fetal genomes as well as their interaction with the environment.

Summary of neonatal and maternal transport and reimbursement policies-a 5-year update

OBJECTIVE

To examine the number of states with neonatal and maternal transport and reimbursement policies in 2019, compared with 2014.

STUDY DESIGN

We conducted a systematic review of web-based, publicly available information on neonatal and maternal transport policies for each state in 2019. Information was abstracted from rules, codes, licensure regulations, and planning and program documents, then summarized within two categories: transport and reimbursement policies.

RESULT

In 2019, 42 states had a policy for neonatal transport and 37 states had a policy for maternal transport, increasing by 8 and 7 states respectively. Further, 31 states had a reimbursement policy for neonatal transport and 11 states for maternal transport, increases of 1 state per category. Overall, the number of states with policies increased from 2014 to 2019.

CONCLUSION

The number of state neonatal and maternal transport policies increased; these policies may support provision of care at the most risk-appropriate facilities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Association between the Burden of PM2.5-Related Neonatal Preterm Birth and Socio-Demographic Index from 1990 to 2019: A Global Burden Study

BACKGROUND

Preterm birth (PTB) leads to short-term and long-term adverse effects on newborns. Exposure to fine particulate matter (PM_2.5) was positively related to PTB. However, the global annual average PM_2.5 was three times than the recommended value in 1998-2014. Socio-demographic index (SDI) is a new indicator that comprehensively reflects the overall development level of a country, partly because of "the epidemiological transition". Among other countries with higher and similar SDI levels, policy makers have the opportunity to learn from their successful experiences and avoid their mistakes by identifying whether their burdens of disease are higher or lower than the expected. However, it is unclear about the trends of the burden of PM_2.5-related preterm birth in different countries and different levels of SDI regions. Additionally, the relationship between the SDI and the burden in 1990-2019 is also unclear.

METHODS

This was a retrospective study based on the Global Burden of Disease Study 2019 (GBD2019) database from 1990 to 2019. The burden of PM_2.5-related PTB was measured by the age-standardized mortality rate (ASMR), age-standardized disability-adjusted life years rate (ASDR), mortality rate, and the disability-adjusted life years (DALYs). The annual percentage changes (APCs) and the average annual percentage changes (AAPCs) were used to reflect the trends over the past 30 years, which were calculated using a joinpoint model. The relationships between the ASMR, ASDR, and SDI were calculated using a Gaussian process regression.

FINDINGS

In 2019, the entire burden of PM_2.5-related PTB was relatively high, where the ASMR and the ASDR were 0.76 and 67.71, increasing by 7.04% and 7.12%, respectively. It mainly concentrated on early neonates, boys, and on low-middle SDI regions. The increase in the burden of PM_2.5-related PTB in low and low-middle SDI regions is slightly higher than the decrease in other SDI regions. In 2019, the burden varied greatly among different levels of SDI regions where ASMRs varied from 0.13 in high SDI regions to 1.19 in low-middle regions. The relationship between the expected value of the burden of PM_2.5-related PTB and SDI presented an inverted U-shape, and it reached the maximum when SDI is around 0.50. The burdens in four regions (South Asia, North Africa and the Middle East, western sub-Saharan Africa, and southern sub-Saharan Africa) were much higher than the mean value. Boys bore more burden that girls. The sex ratio (boys:girls) of the burden showed a dramatically increasing trend in low SDI regions and a decreasing trend in middle SDI regions and high-middle SDI regions. These differences reflect the huge inequality among regions, countries, ages, and sex in the burden of PM_2.5-related PTB.

CONCLUSION

The overall burden of PM_2.5-related PTB in 2019 was relatively high, mainly concentrated on early neonates, boys, and on low-middle SDI regions. It showed an increasing trend in low-middle and low SDI regions. The association between the burden and the SDI presented an inverted U-shape. It is very necessary to promulgate policies to prevent and control air pollution in countries with large and increasing exposure to PM_2.5 pollution because it does not need action at an individual level. Focusing on public educational interventions, public and professional policies, and improving accessibility of prenatal care are other feasible ways for low and low-middle SDI countries. Policy makers should also appropriately allocate medical resources to boys and early newborns.

Global, Regional, and National Incidence and Mortality of Neonatal Preterm Birth, 1990-2019

IMPORTANCE

Preterm birth complications are the leading cause of death in children younger than 5 years worldwide. Despite advancing knowledge of risk factors and mechanisms related to preterm labor, the preterm birth rate has risen in most industrialized countries. Moreover, the burden of neonatal preterm birth remains unclear across the world.

OBJECTIVE

To determine the trends in incidence and mortality of neonatal preterm birth at the global, regional, and national levels to quantify its burden from 1990 to 2019 using data from the 2019 Global Burden of Disease study.

DESIGN, SETTING, AND PARTICIPANTS

Annual incident cases, deaths, age-standardized incidence rates (ASIRs), and age-standardized mortality rates (ASMRs) of neonatal preterm birth between 1990 and 2019 were collected from the 2019 Global Burden of Disease study. The percentage of relative changes in incident cases and deaths as well as the estimated annual percentage changes (EAPCs) of ASIRs and ASMRs were calculated to quantify their temporal trends. Correlations of EAPC of ASIRs and ASMRs with sociodemographic index (SDI) and universal health coverage index were evaluated by Pearson correlation analyses.

EXPOSURES

Infants born alive before 37 completed weeks of gestation between 1990 and 2019.

MAIN OUTCOMES AND MEASURES

Incident cases, deaths, ASIRs, and ASMRs of neonatal preterm birth.

RESULTS

Globally, the incident cases of neonatal preterm birth decreased by 5.26% from 16.06 million in 1990 to 15.22 million in 2019, and the deaths decreased by 47.71% from 1.27 million in 1990 to 0.66 million in 2019. The overall ASIR (EAPC = -0.19 [95% CI, -0.27 to -0.11]) and ASMR (EAPC = -2.09 [95% CI, -1.99 to -2.20]) decreased in this period. The ASIR of neonatal preterm birth increased by a mean of 0.25% (95% CI, 0.13%-0.38%) in high-SDI regions from 1990 to 2019. The ASMR of neonatal preterm birth increased by a mean of 2.09% (95% CI, 1.99%-2.20%) in Southern Sub-Saharan Africa in this period. A positive correlation was observed between EAPC of ASIR and SDI or universal health coverage index in 2019, while a negative correlation was observed between EAPC in ASMR and SDI or universal health coverage index in 2019 at national levels.

CONCLUSIONS AND RELEVANCE

Preterm birth remains a crucial issue in children worldwide, with an increasing trend in ASIR in high-SDI regions and in ASMR in Southern Sub-Saharan Africa between 1990 to 2019. Efforts to reduce both the incidence and mortality of preterm births are essential.

Early life host-microbe interactions in skin

Our skin is the interface through which we mediate lifelong interactions with our surrounding environment. Initial development of the skin's epidermis, adnexal structures, and barrier function is necessary for normal cutaneous microbial colonization, immune development, and prevention of disease. Early life microbial exposures can have unique and long-lasting impacts on skin health. The identity of neonatal skin microbes and the context in which they are first encountered, i.e., through a compromised skin barrier or in conjunction with cutaneous inflammation, can have additional short- and long-term health consequences. Here, we discuss key attributes of infant skin and endogenous and exogenous factors that shape its relationship to the early life cutaneous microbiome, with a focus on their clinical implications.

Mortality in the neonatal intensive care unit: improving the accuracy of death reporting

OBJECTIVE

Death certificates commonly contain errors, which hinders understanding of infant mortality. We, therefore, undertook a quality improvement (QI) initiative to improve death reporting in our neonatal intensive care unit (NICU).

STUDY DESIGN

After our baseline assessment (January 1, 2015 to June 30, 2017), we implemented our QI initiatives using Plan, Do, Study, Act (PDSA) tests of change. We prospectively reviewed death certificates (July 1, 2017 to December 31, 2019) to evaluate the impact of our interventions.

RESULTS

The overall proportion of incorrect death certificates significantly decreased from 71 to 22% with special cause variation noted after the second PDSA cycle. The most common errors involved inaccurate or incomplete reporting of prematurity and errors in the sequence of events.

CONCLUSION

Through a series of PDSA cycles focused on formal provider education and ongoing review, we significantly reduced inaccurate death reporting. These interventions are generalizable across NICUs and important to improve public health reporting accuracy.

Integration of health systems science and women's healthcare

Health systems science addresses the complex interactions in healthcare delivery. At its core, health systems science describes the intricate details required to provide high-quality care to individual patients by assisting them in navigating the multifaceted and often complicated US healthcare delivery system. With advances in technology, informatics, and communication, the modern physician is required to have a strong working knowledge of health systems science to provide effective, low-cost, high-quality care to patients. Medical educators are poised to introduce health systems science concepts alongside the basic science and clinical science courses already being taught in medical school. Because of the common overlap of women's healthcare subject matter with health systems science topics, such as interprofessional collaboration, ethics, advocacy, and quality improvement, women's health medical educators are at the forefront of incorporating health systems science into the current medical school educational model. Here, the authors have described the concept of health systems science and discussed both why and how it should be integrated into the undergraduate medical education curriculum. Medical educators must develop physicians of the future who can not only provide excellent patient care but also actively participate in the advancement and improvement of the healthcare delivery system.

Mid-trimester uterine electromyography in patients with a short cervix

BACKGROUND

Preterm birth is the largest single cause of infant death in the United States. A cervical length of <2.5 cm, measured in the mid-trimester, has been shown to identify individuals at increased risk. Uterine electromyography is an emerging technology for noninvasively assessing uterine bioelectrical activity. With its ability to characterize nuanced differences in myometrial signals, uterine electromyography assessments during the mid-trimester may provide insight into the mechanisms of cervical shortening.

OBJECTIVE

This study aimed to characterize uterine bioelectrical activity in pregnant individuals with short cervices in the mid-trimester compared with that of pregnant individuals of the same gestational age with normal cervical lengths.

STUDY DESIGN

This is a prospective cohort study of subjects with singleton, nonanomalous pregnancies between 16 weeks and 0 days and 22 weeks and 6 days of gestational age. Subjects with normal cervical length (≥3.0 cm) were compared with subjects with short cervical length (<2.5 cm). The short-cervical-length cohort was further stratified by history of preterm birth. Multichannel uterine electromyography recordings were obtained for ∼60 minutes using proprietary, directional electromyography sensors on the abdomen. Uterine electromyography signals were observed and classified in groups as spikes, short bursts, and bursts. Primary outcomes were relative expression of spike, short-burst, and burst uterine electromyography signals. Subgroup analyses assessed each signal percentage by cervical length, history of preterm birth, and gestational age at delivery. Differences in percentage of uterine electromyography signals according to cervical length were analyzed using nonparametric tests of significance.

RESULTS

Of the 28 included subjects, 10 had normal and 18 had short cervical length. There were 9 subjects with short cervical length and a history of preterm birth. Spikes were the most commonly recorded signals and were higher in the normal-cervical-length cohort (96.3% [interquartile range, 93.1%-100.0%]) than the short-cervical-length cohort (75.2% [interquartile range, 66.7%-92.0%], P=.001). In contrast, median percentages of short-bursts and bursts were significantly higher in subjects with a short cervical length (17.3% [interquartile range, 13.6%-23.9%] vs 2.5% for normal cervical length [interquartile range, 0%-5.5%], P=.001 and 6.6% [interquartile range, 0%-13.4%] vs 0% for normal cervical length [interquartile range, 0%-2.8%], P=.014, respectively). Within subgroup analyses, cervical length was inversely proportional to percentage of observed short-bursts (P=.013) and bursts (P=.014). Subjects with short cervical length and history of preterm birth had higher burst percentages (12.8% [interquartile range, 9.0%-15.7%]) than those with short cervical length and no history of preterm birth (3.3% [interquartile range, 0%-5.0%], P=.003).

CONCLUSION

Short-burst and burst uterine electromyography signals are observed more frequently in mid-trimester patients with short cervical lengths. This relationship provides insight into abnormal myometrial activation in the mid-trimester and offers a plausible biophysiological link to cervical shortening.

Study protocol to quantify the genetic architecture of sonographic cervical length and its relationship to spontaneous preterm birth

INTRODUCTION

A short cervix (cervical length <25 mm) in the midtrimester (18-24 weeks) of pregnancy is a powerful predictor of spontaneous preterm delivery. Although the biological mechanisms of cervical change during pregnancy have been the subject of extensive investigation, little is known about whether genes influence the length of the cervix, or the extent to which genetic factors contribute to premature cervical shortening. Defining the genetic architecture of cervical length is foundational to understanding the aetiology of a short cervix and its contribution to an increased risk of spontaneous preterm delivery.

METHODS/ANALYSIS

The proposed study is designed to characterise the genetic architecture of cervical length and its genetic relationship to gestational age at delivery in a large cohort of Black/African American women, who are at an increased risk of developing a short cervix and delivering preterm. Repeated measurements of cervical length will be modelled as a longitudinal growth curve, with parameters estimating the initial length of the cervix at the beginning of pregnancy, and its rate of change over time. Genome-wide complex trait analysis methods will be used to estimate the heritability of cervical length growth parameters and their bivariate genetic correlation with gestational age at delivery. Polygenic risk profiling will assess maternal genetic risk for developing a short cervix and subsequently delivering preterm and evaluate the role of cervical length in mediating the relationship between maternal genetic variation and gestational age at delivery.

ETHICS/DISSEMINATION

The proposed analyses will be conducted using deidentified data from participants in an IRB-approved study of longitudinal cervical length who provided blood samples and written informed consent for their use in future genetic research. These analyses are preregistered with the Center for Open Science using the AsPredicted format and the results and genomic summary statistics will be published in a peer-reviewed journal.

Competing Effects on the Average Age of Infant Death

In recent decades, the relationship between the average length of life for those who die in the first year of life-the life table quantity a10-and the level of infant mortality, on which its calculation is often based, has broken down. The very low levels of infant mortality in the developed world correspond to a range of a10 quantities. We illustrate the competing effect of falling mortality and reduction in preterm births on a10 through two populations with very different levels of premature birth-infants born to non-Hispanic White mothers and infants born to non-Hispanic Black mothers in the United States-using linked birth and infant death cohort data. Through simulation, we further demonstrate that falling mortality reduces a10, while a reduction in premature births increases it. We use these observations to motivate the formulation of a new approximation formula for a10 in low-mortality contexts, which aims to incorporate differences in preterm birth through a proxy measure-the ratio of infant to under-five mortality. Models are built and tested using data from the Human Mortality Database. Model results and validation show that the newly proposed model outperforms existing alternatives.

Assisted Reproductive Technology Surveillance - United States, 2018

Problem/Condition

Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple births because multiple embryos might be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2018 and compares birth outcomes that occurred in 2018 (resulting from ART procedures performed in 2017 and 2018) with outcomes for all infants born in the United States in 2018.

Period Covered

2018.

Description of System

In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102–493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from the 50 U.S. states, the District of Columbia, and Puerto Rico.

Results

In 2018, a total of 203,119 ART procedures (range: 196 in Alaska to 26,028 in California) were performed in 456 U.S. fertility clinics and reported to CDC. These procedures resulted in 73,831 live-birth deliveries (range: 76 in Puerto Rico and Wyoming to 9,666 in California) and 81,478 infants born (range: 84 in Wyoming to 10,620 in California). Nationally, among women aged 15–44 years, the rate of ART procedures performed was 3,135 per 1 million women. ART use exceeded 1.5 times the national rate in seven states (Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island) and the District of Columbia. ART use rates exceeded the national rate in an additional seven states (California, Delaware, Hawaii, New Hampshire, Utah, Vermont, and Virginia).

Nationally, among all ART transfer procedures, the average number of embryos transferred was similar across age groups (1.3 among women aged <35 years, 1.3 among women aged 35–37 years, and 1.4 among women aged >37 years). The national single-embryo transfer (SET) rate among all embryo-transfer procedures was 74.1% among women aged <35 years (range: 28.2% in Puerto Rico to 89.5% in Delaware), 72.8% among women aged 35–37 years (range: 30.6% in Puerto Rico to 93.7% in Delaware), and 66.4% among women aged >37 years (range: 27.1% in Puerto Rico to 85.3% in Delaware).

In 2018, ART contributed to 2.0% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.1% in Massachusetts) from procedures performed in 2017 and 2018. Approximately 78.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 12.5% of all multiple births, including 12.5% of all twin births and 13.3% of all triplets and higher-order births. ART-conceived twins accounted for approximately 97.1% (15,532 of 16,001) of all ART-conceived multiple births. The percentage of multiple births was higher among infants conceived with ART (21.4%) than among all infants born in the total birth population (3.3%). Approximately 20.7% (15,532 of 74,926) of ART-conceived infants were twins, and 0.6% (469 of 74,926) were triplets and higher-order multiples.

Nationally, infants conceived with ART contributed to 4.2% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 18.3% were low birthweight compared with 8.3% among all infants. ART-conceived infants contributed to 5.1% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (26.1%) than among all infants born in the total birth population (10.0%).

The percentage of low birthweight among singletons was 8.3% among ART-conceived infants and 6.6% among all infants born. The percentage of preterm births among ART-conceived singleton infants was 14.9% compared with 8.3% among all singleton infants. The percentages of small for gestational age infants was 7.3% among ART-conceived infants compared with 9.4% among all infants.

Interpretation

Although singleton infants accounted for the majority of ART-conceived infants, multiple births from ART varied substantially among states and nationally, contributing to >12% of all twins, triplets, and higher-order multiple infants born in the United States. Because multiple births are associated with higher rates of prematurity than singleton births, the contribution of ART to poor birth outcomes continues to be noteworthy. Although SET rates increased among all age groups, variations in SET rates among states and territories remained, which might reflect variations in embryo-transfer practices among fertility clinics and might in part account for variations in multiple birth rates among states and territories.

Public Health Action

Reducing the number of embryos transferred and increasing use of SET, when clinically appropriate, can help reduce multiple births and related adverse health consequences for both mothers and infants. Whereas risks to mothers from multiple-birth pregnancy include higher rates of caesarean delivery, gestational hypertension, and gestational diabetes, infants from multiple births are at increased risk for numerous adverse sequelae such as preterm birth, birth defects, and developmental disabilities. Long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes on a population basis.

Maternal plasma lipids are involved in the pathogenesis of preterm birth

BACKGROUND

Preterm birth is defined by the onset of labor at a gestational age shorter than 37 weeks, and it can lead to premature birth and impose a threat to newborns' health. The Puerto Rico PROTECT cohort is a well-characterized prospective birth cohort that was designed to investigate environmental and social contributors to preterm birth in Puerto Rico, where preterm birth rates have been elevated in recent decades. To elucidate possible relationships between metabolites and preterm birth in this cohort, we conducted a nested case-control study to conduct untargeted metabolomic characterization of maternal plasma of 31 women who experienced preterm birth and 69 controls who underwent full-term labor at 24-28 gestational weeks.

RESULTS

A total of 333 metabolites were identified and annotated with liquid chromatography/mass spectrometry. Subsequent weighted gene correlation network analysis shows that the fatty acid and carene-enriched module has a significant positive association (P = 8e-04, FDR = 0.006) with preterm birth. After controlling for potential clinical confounders, a total of 38 metabolites demonstrated significant changes uniquely associated with preterm birth, where 17 of them were preterm biomarkers. Among 7 machine-learning classifiers, the application of random forest achieved a highly accurate and specific prediction (AUC = 0.92) for preterm birth in testing data, demonstrating their strong potential as biomarkers for preterm births. The 17 preterm biomarkers are involved in cell signaling, lipid metabolism, and lipid peroxidation functions. Additional modeling using only the 19 spontaneous preterm births (sPTB) and controls identifies 16 sPTB markers, with an AUC of 0.89 in testing data. Half of the sPTB overlap with those markers for preterm births. Further causality analysis infers that suberic acid upregulates several fatty acids to promote preterm birth.

CONCLUSIONS

Altogether, this study demonstrates the involvement of lipids, particularly fatty acids, in the pathogenesis of preterm birth.

Population birth outcomes in 2020 and experiences of expectant mothers during the COVID-19 pandemic: A 'born in Wales' mixed methods study using routine data

BACKGROUND

Pregnancy can be a stressful time and the COVID-19 pandemic has affected all aspects of life. This study aims to investigate the pandemic impact on pregnancy experience, rates of primary childhood immunisations and the differences in birth outcomes in during 2020 to those of previous years.

METHODS

Self-reported pregnancy experience: 215 expectant mothers (aged 16+) in Wales completed an online survey about their experiences of pregnancy during the pandemic. The qualitative survey data was analysed using codebook thematic analysis. Population-level birth outcomes in Wales: Stillbirths, prematurity, birth weight and Caesarean section births before (2016-2019) and during (2020) the pandemic were compared using anonymised individual-level, population-scale routine data held in the Secure Anonymised Information Linkage (SAIL) Databank. Uptake of the first three scheduled primary childhood immunisations were compared between 2019 and 2020.

FINDINGS

The pandemic had a negative impact on the mental health of 71% of survey respondents, who reported anxiety, stress and loneliness; this was associated with attending scans without their partner, giving birth alone, and minimal contact with midwives. There was no significant difference in annual outcomes including gestation and birth weight, stillbirths, and Caesarean sections for infants born in 2020 compared to 2016-2019. There was an increase in late term births (≥42 weeks gestation) during the first lockdown (OR: 1.28, p = 0.019) and a decrease in moderate to late preterm births (32-36 weeks gestation) during the second lockdown (OR: 0.74, p = 0.001). Fewer babies were born in 2020 (N = 29,031) compared to 2016-2019 (average N = 32,582). All babies received their immunisations in 2020, but there were minor delays in the timings of immunisations. Those due at 8-weeks were 8% less likely to be on time (within 28-days) and at 16-weeks, they were 19% less likely to be on time.

INTERPRETATION

Whilst the pandemic had a negative impact on mothers' experiences of pregnancy. Population-level data suggests that this did not translate to adverse birth outcomes for babies born during the pandemic.

Effect of preterm birth on early neonatal, late neonatal, and postneonatal mortality in India

Despite India having a high burden of infant deaths and preterm birth, there is a clear lack of studies documenting association between preterm birth and infant mortality in India. Additionally, existing studies have failed to account for unobserved heterogeneity while linking preterm birth with infant mortality. Hence, the present study examines association of preterm birth with early neonatal death (ENND), late neonatal death (LNND), and postneonatal death (PNND) in India. We used the reproductive calendar canvassed in the cross-sectional National Family Health Survey 2015-16 (NFHS-4) to identify preterm births. We used multivariable logistic regression to examine the associations for all births, most-, second most-, and third most- recent births occurred in five years preceding NFHS-4. We use mother fixed-effect logistic regression to confirm the associations among all recent births. Among all births, preterm births were 4.2, 3.8, and 1.7 times as likely as full-term births to die during early neonatal, late neonatal, and postneonatal periods respectively. Among most recent births, preterm births were 4.4, 4.0, and 2.0 times as likely as full-term births to die during early neonatal, late neonatal, and postneonatal periods respectively. Preterm births were also associated with risk of only ENND, LNND, and PNND among the second most recent births. Preterm births were associated with risk of only ENND and LNND among the third most recent births. Preterm births were also associated with ENND, LNND, and PNND in the mother fixed-effects regressions. This study establishes associations of preterm birth with ENND, LNND, and PNND in India using over 0.2 million births that occurred in 5 years preceding one of the largest population-based representative household surveys conducted in any part of the world. Our findings call for programmatic and policy interventions to address the considerable burden of preterm birth in the country.

Cross-State Differences in the Processes Generating Black-White Disparities in Neonatal Mortality

The U.S. Black neonatal mortality rate is more than twice the White rate. This dramatic disparity can be decomposed into two components: (1) disparities due to differences in the distribution of birth weights, and (2) disparities due to differences in birth weight-specific mortality. I utilize this distinction to explore how the social context into which infants are born contributes to gaps in mortality between Black and White neonates. I analyze variation in Black-White differences in neonatal mortality across 33 states using 1995-2010 data. For each state, I calculate the contribution of differences in birth weight distribution versus differences in birth weight-specific mortality to the total disparity in mortality between White and Black neonates. Disparities are largely a product of different birth weight distributions between Black and White newborns (mirroring the pattern for the United States as a whole). However, in at least nine states, differences in birth weight-specific mortality make a notable contribution. This pattern is observed even among those from advantaged sociodemographic backgrounds and is driven by differences in mortality among very low birth weight neonates. This calls attention to inequality in medical care at birth as an importantcontributor to racial disparities in neonatal mortality.

Epidemiologic View and Spatial Analysis of the Mortality of Children under 5 Years of Age in Isfahan Province in 2011-2016

Background

Children's mortality rate reflects the health level of the community. Therefore, accurate mapping of child mortality is one of the most important ways to reduce this rate. The purpose of this study was to investigate the mortality rate of children under 5 in Isfahan province in 2011-2016.

Methods

In this analytical cross-sectional study, all mortalities of children under 5 of Isfahan province related to Child Death Care System Program during 2011-2016 were studied. Mortality rate of children was calculated. Relationship between variables [demographic characteristics, place of death (urban/rural), and underlying cause of death] and child mortality was analyzed using Chi-square test. Mortality rate in the cities of Isfahan province was plotted on a geographical map.

Results

Whole number of mortalities of children under 5 was 5247 cases. Most of the mortalities (60.1%) were occurred in neonatal. Mortality rate was higher in boys than girls (12.6 vs. 11.1 per 1000 live births) (P < 0.001); "mortality rate in non-Iranians who live in Iran was more than that of Iranians (21.4 vs. 11.5 per 1000 live birth) (P < 0.001) and rural areas more than urban areas (15.2 vs. 11.4 per thousand live births) (P < 0.001)." Certain conditions originating in the perinatal period were reported as the greatest causes of death (45.9%). Congenital malformations (27.4%) and external causes of morbidity and mortality (6.7%) were the second and third causes of death. Fereidun Shahr had the highest U5MR and Khansar had the lowest U5MR.

Conclusions

Considering the major contribution of neonatal to the death of children under 5 and also the most important causes of death, interventions such as preventing early delivery, genetic counseling in high-risk couples, and parent training for accident prevention can play an effective role in reducing child mortality.

Living in a block group with a higher eviction rate is associated with increased odds of preterm delivery

BACKGROUND

Housing instability is associated with adverse pregnancy outcomes. Recent studies indicate that eviction, which may affect a larger segment of the population than other forms of housing instability, is also associated with adverse pregnancy outcomes. However, these studies evaluate eviction across large areas, such as counties, so it remains unclear whether these patterns extend to individual-level pregnancy outcomes.

METHODS

We used data on a cohort of all singleton live births at a single Chicago hospital between March 2008 and March 2018 to investigate the associations between block-group eviction rates and individual adverse pregnancy outcomes. Eviction data were obtained from the Eviction Lab at Princeton University. Generalised estimating equations were used to estimate associations and account for correlations among individuals living in the same block groups.

RESULTS

Individuals living in block groups in the highest quartile for eviction filing rate were 1.17 times as likely to deliver preterm (95% CI: 1.08 to 1.27) and 1.13 times as likely to deliver a small for gestational age infant (95% CI: 1.03 to 1.25) as compared with individuals living in block groups in the lowest quartile. Further, tests for linear trend indicated that for each quartile increase in eviction filing rate, there was a corresponding increase in odds of adverse outcomes (p<0.05). Results were strongest in magnitude for those with low neighbourhood and individual socioeconomic status, who are most likely to be renters and affected by local eviction policies.

CONCLUSION

Our results suggest that individuals living in block groups with higher eviction rates are more likely to deliver preterm. Future research should explore associations of individual experience with eviction on adverse pregnancy outcomes and examine whether policies to improve tenant protections also impact pregnancy outcomes.

Safety and efficacy of colistin and fluoroquinolone in neonatal persistent late-onset sepsis

Growing resistance of microorganisms to antibiotics for the treatment of late-onset sepsis (LOS) in premature infants has led physicians to use antibiotics that are not well studied in neonatal populations. We aimed to determine the efficacy and safety of colistin and fluoroquinolone for the treatment of persistent LOS. We retrospectively reviewed infants with gram-negative LOS, who received either colistin or fluoroquinolone therapy, to determine if there was a significant difference in kidney and liver function tests and electrolyte levels before, during, and at the end of the treatment. Infants who received colistin and fluoroquinolone had 17 and 34 positive cultures with gram-negative organisms, respectively. Multi-drug resistant organisms were more common in infants who received colistin than in those who received fluoroquinolone. Microbiological clearance was found to be higher in infants treated with fluoroquinolone than in those treated with colistin. In both the groups, the median levels of kidney and liver function tests and electrolytes showed a significant increase during the treatment. The prescription of colistin and fluoroquinolones should be reserved for cases with no other safe and effective alternatives.

Maternal Adverse Childhood Experiences, Paternal Involvement, and Infant Health

OBJECTIVES

To assess the interplay between maternal exposure to adverse childhood experiences (ACEs) and father's acknowledgment of paternity (AOP; a proxy for paternal involvement) in the risk of low birth weight (<2500 grams) and preterm birth (<37 weeks) among offspring.

STUDY DESIGN

Data come from the 2018 North Dakota and South Dakota Pregnancy Risk Assessment Monitoring System (n = 1896). Logistic regression models were used to assess low birth weight and preterm birth outcomes. Moderation analyses are conducted to assess the interaction between maternal ACEs and father's AOP.

RESULTS

Moderation analyses demonstrated a positive interaction between an accumulating number of maternal ACEs and being unmarried without AOP for low birth weight and preterm birth. Upon comparing newborns of unmarried women without AOP, those whose mothers were exposed to 4 or more ACEs had a 3.74 times greater probability of low birth weight (0.050 vs 0.187) and a 1.74 times greater probability of preterm birth (0.085 vs 0.148) than those whose mothers reported no ACE exposure.

CONCLUSIONS

Exposure to accumulating ACEs substantially increases the risk of deleterious infant health outcomes, but only for newborns of unmarried women without AOP. Future research should assess the efficacy of interventions that can mitigate the impact of maternal ACEs in the absence of father's AOP.

Risk Factors of Preterm Birth in Nepal: A Hospital-Based Matched Case-Control Study

Background: Preterm birth is a significant cause of neonatal death globally. Nepal is in the 20th position in the world, with the highest rate of preterm deliveries. The risk factors of preterm birth have not been fully identified and established in Nepal. The study aims to identify risk factors of preterm birth among women who underwent delivery in a tertiary maternal hospital in Nepal.

Methods: This study employed a hospital-based matched case-control study design. The case included women who delivered before 37 weeks of gestation, and women who delivered between 37 and 42 weeks of gestation served as controls. The ratio of the case to control was 1:2, and matching was done for the type of delivery. The first author collected the data in the Paropakar Maternity and Women's Hospital between December 2015 and January 2016. Face-to-face interviews were conducted using a structured questionnaire. Backward conditional logistic regression was performed to identify the independent risk factors of preterm birth.

Results: Antihelminthic treatment during pregnancy was found to be protective for preterm birth. Women performing intensive physical work during their pregnancy and women exposed to indoor air pollution were more likely to have a preterm birth than women not performing intensive physical work and women not exposed to indoor pollution, respectively.

Conclusions: Women who had not consumed antihelminthic drugs per protocol, those exposed to indoor air pollution, and those who performed intensive work during pregnancy were at higher risk for preterm birth. Maternal health programs can encourage women to consume antihelminthic drugs, take proper rest during pregnancy, and prevent indoor pollution exposure.

Influence of Gestational Weight Gain on the Risk of Preterm Birth for Underweight Women Living in Food Deserts

OBJECTIVE

Preterm birth (PTB) and food insecurity are two of the most significant public health crises in the United States. Effects of being underweight among populations with low food security are not well understood. We assess whether the protective effect of gestational weight gain (GWG) for women with low prepregnancy body mass index (BMI) differs by accessibility to sources of healthy food.

STUDY DESIGN

Population-based retrospective cohort study using Ohio birth records analyzing all live births, 2006 to 2015. Analyses were stratified by maternal BMI (underweight, normal, overweight, and obese), Institute of Medicine (IOM) recommended GWG (under vs. met), and whether the U.S. Department of Agriculture (USDA) classified the residential census tract for each birth as a food desert. Food access data were retrieved from the USDA's 2018 Food Access Research Atlas. Covariates were selected using least absolute shrinkage and selection operator regression. Logistic regression models estimated the risk ratio (RR) of PTB for each group based on under or exceeded recommended GWG (reference = met), adjusting for coexisting risk factors.

RESULTS

Analysis was performed on 1,124,299 births. PTB risk was highest for underweight women below GWG recommendations (no food desert: 21.3%, RR = 2.15, 95% confidence interval [CI]: 1.81-2.57; food desert: 21.0%, RR = 1.46, 95% CI: 0.96-2.21). Underweight women living in food deserts who exceeded GWG recommendations had lower PTB risk than those who met GWG recommendations (13.5 vs. 14.3%, RR = 0.85, 95% CI: 0.51-1.41). Factors other than GWG significantly associated with PTB included in the adjusted analysis include maternal age and race, education, marital status, interpregnancy interval, and presence of prepregnancy diabetes or hypertension.

CONCLUSION

Underweight women who do not meet GWG recommendations are at high risk for PTB. Increasing pregnancy weight gain to a level that exceeds IOM recommendations was not associated with a reduction in PTB risk for underweight women who reside in food deserts compared with women who met GWG recommendations.

KEY POINTS

· Women with low prepregnancy BMI are at high risk of PTB.. · Food insecurity increases the risk of PTB for underweight women.. · Excessive GWG for underweight women in food deserts does not reduce PTB risk..

Mass Incarceration and Children's Health: A State-Level Analysis of Adverse Birth Outcomes and Infant, Child, and Teen Mortality

Children's health indicators such as mortality and adverse birth outcomes are poorer in the United States than in comparable nations. These measures also show racial inequities within the United States, with Black children experiencing the highest levels. Mass incarceration may partially explain these findings. High incarceration rates can disrupt community functioning, influencing behavior and health. The purpose of the current study was to conduct a macro (state)-level analysis examining whether yearly state incarceration rates predict health outcomes including infant, child, and teen mortality as well as preterm birth and low birth weight. It was hypothesized that prior year incarceration rates would show positive relationships with all outcomes and that relationships would be stronger for Black than for white children. Yearly state-level panel data were gathered from 1990 to 2017. Weighted least squares regression used states' prior year incarceration rates to predict child health outcomes, using controls for overall state effects and year-to-year effects. Time-varying covariates such as state unemployment rate were also included to address the possibility of spurious relationships. Results indicated that as hypothesized, incarceration rates positively predicted infant mortality, child mortality (for Black children only), preterm births, and low-weight births. Relationships tended to be stronger for Black than for white children.

Home Visiting for NICU Graduates: Impacts of Following Baby Back Home

BACKGROUND AND OBJECTIVES

The Following Baby Back Home (FBBH) home visiting program supports families of high-risk low birth weight preterm infants after discharge from a hospital NICU. This study compares the health care use, immunization, and infant mortality rate of low birth weight preterm infants enrolled in FBBH with similar infants not in the program.

METHODS

From January 2013 to December 2017, 498 children enrolled in FBBH were identified in Arkansas vital statistics records and the Arkansas All-Payer Claims Database. Infants in FBBH were matched with children in a control group on the basis of demographics and medical conditions of the infant. Generalized linear mixed models with double propensity-score adjustment were used to estimate program effects.

RESULTS

In the first year after discharge and compared with a propensity-score matched cohort of control infants, those enrolled in FBBH were significantly more likely to have higher numbers of medical appointments and more compliant immunization history. The odds of dying in the first year of life for control infants was 4.4 times (95% confidence interval: 1.2-20.7) higher than those managed in the program.

CONCLUSIONS

A goal of the FBBH home visiting program is to work with parents to educate and support them as they care for their medically fragile infants. We conclude that education and support was instrumental in the infant health care use and outcome differences we observed during the first year of life.

The Unrecognized Mortality Burden of Genetic Disorders in Infancy

Objectives. To determine how deaths of infants with genetic diagnoses are described in national mortality statistics. Methods. We present a retrospective cohort study of mortality data, obtained from the National Death Index (NDI), and clinical data for 517 infants born from 2011 to 2017 who died before 1 year of age in the United States. Results. Although 115 of 517 deceased infants (22%) had a confirmed diagnosis of a genetic disorder, only 61 of 115 deaths (53%) were attributed to International Classification of Diseases, 10th Revision codes representing congenital anomalies or genetic disorders (Q00-Q99) as the underlying cause of death because of inconsistencies in death reporting. Infants with genetic diagnoses whose underlying causes of death were coded as Q00-Q99 were more likely to have chromosomal disorders than monogenic conditions (43/61 [70%] vs 18/61 [30%]; P < .001), which reflects the need for improved accounting for monogenic disorders in mortality statistics. Conclusions. Genetic disorders, although a leading cause of infant mortality, are not accurately captured by vital statistics. Public Health Implications. Expanded access to genetic testing and further clarity in death reporting are needed to describe properly the contribution of genetic disorders to infant mortality.

Preterm birth and PM2.5 in Puerto Rico: evidence from the PROTECT birth cohort

BACKGROUND

Preterm birth (PTB, birth before 37 weeks of gestation) has been associated with adverse health outcomes across the lifespan. Evidence on the association between PTB and prenatal exposure to air pollutants is inconsistent, and is especially lacking for ethnic/racial minority populations.

METHODS

We obtained data on maternal characteristics and behaviors and PTB and other birth outcomes for women participating in the Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) cohort, who lived in municipalities located along the North Coast of Puerto Rico. We assessed pre-natal PM_2.5 exposures for each infant based on the nearest US Environmental Protection Agency monitor. We estimated prenatal phthalate exposures as the geometric mean of urinary measurements obtained during pregnancy. We then examined the association between PM_2.5 and PTB using modified Poisson regression and assessed modification of the association by phthalate exposure levels and sociodemographic factors such as maternal age and infant gender.

RESULTS

Among 1092 singleton births, 9.1% of infants were born preterm and 92.9% of mothers had at least a high school education. Mothers had a mean (standard deviation) age of 26.9 (5.5) years and a median (range) of 2.0 (1.0-8.0) pregnancies. Nearly all women were Hispanic white, black, or mixed race. Median (range) prenatal PM_2.5 concentrations were 6.0 (3.1-19.8) μ g/m³. Median (interquartile range) prenatal phthalate levels were 14.9 (8.9-26.0) and 14.5 (8.4-26.0), respectively, for di-n-butyl phthalate (DBP) and di-isobutyl phthalate (DiBP). An interquartile range increase in PM_2.5 was associated with a 1.2% (95% CI 0.4, 2.1%) higher risk of PTB. There was little difference in PTB risk in strata of infant sex, mother's age, family income, history of adverse birth outcome, parity, and pre-pregnancy body mass index. Pregnancy urinary phthalate metabolite levels did not modify the PM_2.5-PTB association.

CONCLUSION

Among ethnic minority women in Puerto Rico, prenatal PM_2.5 exposure is associated with a small but significant increase in risk of PTB.

PretermConnect: Leveraging mobile technology to mitigate social disadvantage in the NICU and beyond

Preterm birth (PTB) - delivery prior to 37-weeks gestation - disproportionately affects low-income and minority populations and leads to substantial infant morbidity and mortality. The time following a PTB represents an optimal window for targeted interventions that encourage mothers to prioritize their own health and that of their babies. Healthcare teams can leverage digital strategies to address maternal and infant needs in this postpartum period, both in the neonatal intensive care unit and beyond. We therefore developed PretermConnect, a mobile app designed to educate, engage, and empower women at risk for PTB. This article describes the participant-centered design approach of PretermConnect, with preliminary findings from focus groups and co-design sessions in different community settings and suggested future directions for mobile technologies in population health. Apps such as PretermConnect can mitigate social disadvantage by serving as remote monitoring tools, providing social support, preventing recurrent PTB and lowering infant mortality rates.

Vaginal Microbiome Composition in Early Pregnancy and Risk of Spontaneous Preterm and Early Term Birth Among African American Women

Objective

To evaluate the association between the early pregnancy vaginal microbiome and spontaneous preterm birth (sPTB) and early term birth (sETB) among African American women.

Methods

Vaginal samples collected in early pregnancy (8-14 weeks' gestation) from 436 women enrolled in the Emory University African American Vaginal, Oral, and Gut Microbiome in Pregnancy Study underwent 16S rRNA gene sequencing of the V3-V4 region, taxonomic classification, and community state type (CST) assignment. We compared vaginal CST and abundance of taxa for women whose pregnancy ended in sPTB (N = 44) or sETB (N= 84) to those who delivered full term (N = 231).

Results

Nearly half of the women had a vaginal microbiome classified as CST IV (Diverse CST), while one-third had CST III (L. iners dominated) and just 16% had CST I, II, or V (non-iners Lactobacillus dominated). Compared to vaginal CST I, II, or V (non-iners Lactobacillus dominated), both CST III (L. iners dominated) and CST IV (Diverse) were associated with sPTB with an adjusted odds ratio (95% confidence interval) of 4.1 (1.1, infinity) and 7.7 (2.2, infinity), respectively, in multivariate logistic regression. In contrast, no vaginal CST was associated with sETB. The linear decomposition model (LDM) based on amplicon sequence variant (ASV) relative abundance found a significant overall effect of the vaginal microbiome on sPTB (p=0.034) but not sETB (p=0.320), whereas the LDM based on presence/absence of ASV found no overall effect on sPTB (p=0.328) but a significant effect on sETB (p=0.030). In testing for ASV-specific effects, the LDM found that no ASV was significantly associated with sPTB considering either relative abundance or presence/absence data after controlling for multiple comparisons (FDR 10%), although in marginal analysis the relative abundance of Gardnerella vaginalis (p=0.011), non-iners Lactobacillus (p=0.016), and Mobiluncus curtisii (p=0.035) and the presence of Atopobium vaginae (p=0.049), BVAB2 (p=0.024), Dialister microaerophilis (p=0.011), and Prevotella amnii (p=0.044) were associated with sPTB. The LDM identified the higher abundance of 7 ASVs and the presence of 13 ASVs, all commonly residents of the gut, as associated with sETB at FDR < 10%.

Conclusions

In this cohort of African American women, an early pregnancy vaginal CST III or IV was associated with an increased risk of sPTB but not sETB. The relative abundance and presence of distinct taxa within the early pregnancy vaginal microbiome was associated with either sPTB or sETB.