Short Term Coping-Behaviors and Postpartum Health in a Population-Based Study of Women with a Live Birth, Stillbirth, or Neonatal Death

OBJECTIVE

Responding to the National Institutes of Health Working Group's call for research on the psychological impact of stillbirth, we compared coping-related behaviors by outcome of an index birth (surviving live birth or perinatal loss - stillbirth or neonatal death) and, among individuals with loss, characterized coping strategies and their association with depressive symptoms 6-36 months postpartum.

METHODS

We used data from the Stillbirth Collaborative Research Network follow-up study (2006-2008) of 285 individuals who experienced a stillbirth, 691 a livebirth, and 49 a neonatal death. We conducted a thematic analysis of coping strategies individuals recommended following their loss. We fit logistic regression models, accounting for sampling and inverse probability of follow-up weights to estimate associations between pregnancy outcomes and coping-related behaviors and, separately, coping strategies and probable depression (Edinburgh Postnatal Depression Scale > 12) for those with loss.

RESULTS

Compared to those with a surviving live birth and adjusting for pre-pregnancy drinking and smoking, history of stillbirth, and age, individuals who experienced a loss were more likely to report increased drinking or smoking in the two months postpartum (adjusted OR: 2.7, 95% CI = 1.4-5.4). Those who smoked or drank more had greater odds of probable depression at 6 to 36 months postpartum (adjusted OR 6.4, 95% CI = 2.5-16.4). Among those with loss, recommended coping strategies commonly included communication, support groups, memorializing the loss, and spirituality.

DISCUSSION

Access to a variety of evidence-based and culturally-appropriate positive coping strategies may help individuals experiencing perinatal loss avoid adverse health consequences.

Understanding the Relationship Between Gender Representation in County Government and Perinatal Outcomes to Black, White, and Hispanic Birthing People in Georgia

Objective

To characterize the association between percent of county-level elected officials who were female-presenting and perinatal outcomes in Georgia and variation by individual race, 2020-2021.

Materials and Methods

We gathered data on the gender composition of county-level elected officials for all Georgia counties (n = 159) in 2022 and calculated the percent of female elected officials (percent female, 0-100). We linked this to data from 2020 to 2021 birth certificates (n = 238,795) to identify preterm birth (PTB, <37 weeks), low birthweight (LBW, <2500 grams), hypertensive disorders of pregnancy, and cesarean delivery. We fit multilevel log binomial models with generalized estimating equations, with percent female as the primary independent variable. We adjusted for individual and county-level potential confounders and individual race/ethnicity as an effect modifier.

Results

County median percent female elected officials was 22.2% (interquartile range: 15.5). Overall, 14.6% of births were PTB and 10.1% LBW. A 15 percentage point increase in percent female elected officials was associated with lower risk of hypertensive disorders of pregnancy for white (adjusted risk ratio [RR]: 0.94, 95% confidence interval [CI]: 0.88-0.99), and possibly Hispanic (adjusted RR: 0.95, 95% CI: 0.89-1.0) and non-Hispanic other (adjusted RR: 0.94 (0.87-1.01), but not black birthing people (adjusted RR: 1.0, 95% CI: 0.95-1.05). There was not a clear pattern for PTB, birthweight, or cesarean delivery.

Conclusion

Greater female representation in county government was associated with improved maternal health for some racial/ethnic groups in Georgia.

Childhood maltreatment and trajectories of cardiometabolic health across the reproductive life span among individuals with a first birth during the Coronary Artery Risk Development in Young Adults Study

OBJECTIVE

Childhood adversity is associated with poor cardiometabolic health in adulthood; little is known about how this relationship evolves through childbearing years for parous individuals. The goal was to estimate differences in cardiometabolic health indicators before, during and after childbearing years by report of childhood maltreatment in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study.

METHODS

Including 743 individuals nulliparous at baseline (1985-1986) with one or more pregnancies >20 weeks during follow-up (1986-2022), we fit segmented linear regression models to estimate mean differences between individuals reporting or not reporting childhood maltreatment (physical or emotional) in waist circumference, triglycerides, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, fasting glucose, and body mass index (BMI) prior to, during, and following childbearing years using generalized estimating equations, allowing for interaction between maltreatment and time within each segment, and adjusting for total parity, parental education, and race (Black or white, self-reported).

RESULTS

Individuals reporting maltreatment (19%; 141) had a greater waist circumference (post-childbearing: +2.9 cm, 95% CI (0.7, 5.0), higher triglycerides [post-childbearing: +8.1 mg/dL, 95% CI (0.7, 15.6)], and lower HDL cholesterol [post-childbearing: -2.1 mg/dL, 95% CI (-4.7, 0.5)] during all stages compared to those not reporting maltreatment. There were not meaningful differences in blood pressure, fasting glucose, or BMI. Individuals who reported maltreatment did not report faster changes over time.

CONCLUSION

Differences in some aspects of cardiometabolic health between individuals reporting versus not reporting childhood maltreatment were sustained across reproductive life stages, suggesting potentially persistent impacts of childhood adversity.

Understanding the role of childhood nurture, abuse, and stability on gestational diabetes in the Coronary Artery Risk Development in Young Adults study (CARDIA)

BACKGROUND

To estimate associations between facets of the maternal childhood family environment with gestational diabetes (GDM) and to test mediation by pre-pregnancy waist circumference.

METHODS

We used data from CARDIA, a cohort of individuals aged 18-30 years at baseline (1985-86), followed over 30 years (2016). We included participants with one or more pregnancies ≥ 20 weeks after baseline, without pre-pregnancy diabetes. The primary exposure was the Childhood Family Environment Scale (assessed year 15), including the total score and abuse, nurture, and stability subscales as continuous, separate exposures. The outcome was GDM (self-reported at each visit for each pregnancy). We fit log binomial models with generalized estimating equations to calculate risk ratios (RR) and 95% confidence intervals (CI), adjusting for age at delivery, parity, race (Black or White), and parental education. We used regression models with bootstrapped CIs to test mediation and effect modification by excess abdominal adiposity at the last preconception CARDIA visit (waist circumference ≥ 88 cm).

RESULTS

We included 1033 individuals (46% Black) with 1836 pregnancies. 130 pregnancies (7.1%) were complicated by GDM. For each 1 point increase on the abuse subscale (e.g., from "rarely or never" to "some or little of the time") there was a 30% increased risk of GDM (RR: 1.3, 95% CI: 1.0, 1.7). There was evidence of effect modification but not mediation by preconception abdominal adiposity.

CONCLUSIONS

A more adverse childhood family environment was associated with increased risk of GDM, with a stronger association among individuals with preconception waist circumference ≥ 88 cm.

Extending Driver's Licenses to Undocumented Immigrants: Comparing Perinatal Outcomes Following This Policy Shift

Research shows that restrictive immigration policies and practices are associated with poor health, but far less is known about the relationship between inclusive immigration policies and health. Using data from the United States natality files, we estimate associations between state laws granting undocumented immigrants access to driver's licenses and perinatal outcomes among 4,047,067 singleton births to Mexican and Central American immigrant birthing people (2008-2021). Fitting multivariable log binomial and linear models, we find that the implementation of a license law is associated with improvements in low birthweight and mean birthweight. Replicating these analyses among U.S.-born non-Hispanic White birthing people, we find no association between the implementation of a license law and birthweight. These findings support the hypothesis that states' extension of legal rights to immigrants improves the health of the next generation.

Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap: Seminars in Perinatology

Though stillbirth rates in the United States improved over the previous decades, inequities in stillbirth by race and ethnicity have persisted nearly unchanged since data collection began. Black and Indigenous pregnant people face a two-fold greater risk of experiencing the devastating consequences of stillbirth compared to their White counterparts. Because race is a social rather than biological construct, inequities in stillbirth rates are a downstream consequence of structural, institutional, and interpersonal racism which shape a landscape of differential access to opportunities for health. These downstream consequences can include differences in the prevalence of chronic health conditions as well as structural differences in the quality of health care or healthy neighborhood conditions, each of which likely plays a role in racial and ethnic inequities in stillbirth. Research and intervention approaches that utilize an equity lens may identify ways to close gaps in stillbirth incidence or in responding to the health and socioemotional consequences of stillbirth. A community-engaged approach that incorporates experiential wisdom will be necessary to create a full picture of the causes and consequences of inequity in stillbirth outcomes. Investigators working in tandem with community partners, utilizing a combination of qualitative, quantitative, and implementation science approaches, may more fully elucidate the underpinnings of racial and ethnic inequities in stillbirth outcomes.

Postpartum healthcare expenditures for commercially insured deliveries with and without severe maternal morbidity

BACKGROUND

Although severe maternal morbidity is associated with adverse health outcomes in the year after delivery, patterns of healthcare use beyond the 6-week postpartum period have not been well documented.

OBJECTIVE

This study aimed to estimate healthcare utilization and expenditures for deliveries with and without severe maternal morbidity in the 12 months following delivery among commercially insured patients.

STUDY DESIGN

Using data from the 2016 to 2018 IBM Marketscan Commercial Claims and Encounters Research Databases, we identified deliveries to individuals 15 to 49 years of age who were continuously enrolled in noncapitated health plans for 12 months after delivery discharge. We used multivariable generalized linear models to estimate adjusted mean 12-month medical expenditures and 95% confidence intervals for deliveries with and without severe maternal morbidity, accounting for region, health plan type, delivery method, and obstetrical comorbidities. We estimated expenditures associated with inpatient admissions, nonemergency outpatient visits, outpatient emergency department visits, and outpatient pharmaceutical claims.

RESULTS

We identified 366,282 deliveries without severe maternal morbidity and 3976 deliveries (10.7 per 1000) with severe maternal morbidity. Adjusted mean total medical expenditures for deliveries with severe maternal morbidity were 43% higher in the 12 months after discharge than deliveries without severe maternal morbidity ($5320 vs $3041; difference $2278; 95% confidence interval, $1591-$2965). Adjusted mean expenditures for readmissions and nonemergency outpatient visits during the 12-month postpartum period were 61% and 39% higher, respectively, for deliveries with severe maternal morbidity compared with deliveries without severe maternal morbidity. Among deliveries with severe maternal morbidity, adjusted mean total costs were highest for patients living in the western region ($7831; 95% confidence interval, $5518-$10,144) and those having a primary cesarean ($7647; 95% confidence interval, $6323-$8970).

CONCLUSION

Severe maternal morbidity at delivery is associated with increased healthcare use and expenditures in the year after delivery. These estimates can inform planning of severe maternal morbidity prevention efforts.

Types and timing of trauma exposure across the life course and maternal hypertension

Objective

To estimate associations between types and timing (first occurrence and time since) of trauma exposure and hypertension experienced during pregnancy in a safety-net hospital in Atlanta, Georgia.

Methods

Participants completed a 14-item trauma screener. We linked that information to data from the medical record on hypertension (inclusive of chronic hypertension, gestational hypertension, or preeclampsia). We fit logistic regression models and used the estimates to calculate risk ratios for each trauma type and each critical window (0-9 years, 10-19, and 20+). We fit unadjusted models and adjusted for age, parity, and education.

Results

We included 704 individuals with a delivery within 12 months of screening. The majority (94%, 661) reported at least one traumatic event, most commonly witnessing violence (79.4%). Overall, 18% experienced gestational hypertension, 10.8% chronic hypertension, and 11.9% preeclampsia. Among individuals who reported trauma, 31.5% screened positive for probable posttraumatic stress disorder and 30.9% for probable depression compared to 0 and 2.3% among those without reported trauma. No trauma type (violence, witnessing violence, non-interpersonal, or sexual assault) was associated with increased hypertensive risk, regardless of timing. Similarly, time between trauma and delivery (0-3 years, 3-10 years, 10+ years) was not associated with increased hypertensive risk.

Conclusions

In this sample with a high trauma and hypertension burden, trauma was not associated with elevated risk of hypertension during pregnancy, despite a high burden of PTSD and depressive symptoms among people with trauma exposure. Future research should consider how community-level exposure may modify the impact of trauma on adverse pregnancy outcomes.

Political representation and perinatal outcomes to Black, White, and Hispanic people in Georgia: a cross-sectional study

PURPOSE

Our goal was to estimate differences in perinatal outcomes by racial differences in political representation, a measure of structural racism.

METHODS

We gathered data on the racial composition of county-level elected officials for all counties in Georgia (n = 159) in 2022. We subtracted the percent of non-White elected officials from the percent of non-White residents to calculate the "representation difference," with greater positive values indicating a larger disparity. We linked this to data from 2020-2021 birth certificates (n = 238,795) on outcomes (preterm birth, <37 weeks, low birthweight birth <2500 g, birthweight, hypertensive disorders of pregnancy, cesarean delivery). We fit log binomial and linear models with generalized estimating equations, stratified by individual race/ethnicity and including individual and county covariates.

RESULTS

Median representation difference was 17.5% points (interquartile range: 17.2). A 25-percentile point increase in representation difference was associated with a greater risk of hypertensive disorders of pregnancy [White: adjusted risk ratio (RR): 1.12, 95% confidence interval (CI): (1.05, 1.2), Black: 1.06, 95% CI: (0.95, 1.17), other: 1.14, 95% CI: (1.0, 1.3), Hispanic: 1.19, 95% CI: (1.07, 1.32)] and lower mean birthweight for Black birthing people [adjusted beta -15.3, 95% CI: (-25.5, -7.4)].

CONCLUSIONS

Parity in political representation may be associated with healthier environments.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital

OBJECTIVE

The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts.

RESULTS

We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001).

CONCLUSION

Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic.

KEY POINTS

· Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

Interpretable machine learning to predict adverse perinatal outcomes: examining marginal predictive value of risk factors during pregnancy

BACKGROUND

The timely identification of nulliparas at high risk of adverse fetal and neonatal outcomes during pregnancy is crucial for initiating clinical interventions to prevent perinatal complications. Although machine learning methods have been applied to predict preterm birth and other pregnancy complications, many models do not provide explanations of their predictions, limiting the clinical use of the model.

OBJECTIVE

This study aimed to develop interpretable prediction models for a composite adverse perinatal outcome (stillbirth, neonatal death, estimated Combined Apgar score of <10, or preterm birth) at different points in time during the pregnancy and to evaluate the marginal predictive value of individual predictors in the context of a machine learning model.

STUDY DESIGN

This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be data, a prospective cohort study in which 10,038 nulliparous pregnant individuals with singleton pregnancies were enrolled. Here, interpretable prediction models were developed using L1-regularized logistic regression for adverse perinatal outcomes using data available at 3 study visits during the pregnancy (visit 1: 6 0/7 to 13 6/7 weeks of gestation; visit 2: 16 0/7 to 21 6/7 weeks of gestation; visit 3: 22 0/7 to 29 6/7 weeks of gestation). We identified the important predictors for each model using SHapley Additive exPlanations, a model-agnostic method of computing explanations of model predictions, and evaluated the marginal predictive value of each predictor using the DeLong test.

RESULTS

Our interpretable machine learning model had an area under the receiver operating characteristic curves of 0.617 (95% confidence interval, 0.595-0.639; all predictor variables at visit 1), 0.652 (95% confidence interval, 0.631-0.673; all predictor variables at visit 2), and 0.673 (95% confidence interval, 0.651-0.694; all predictor variables at visit 3). For all visits, the placental biomarker inhibin A was a valuable predictor, as including inhibin A resulted in better performance in predicting adverse perinatal outcomes (P<.001, all visits). At visit 1, endoglin was also a valuable predictor (P<.001). At visit 2, free beta human chorionic gonadotropin (P=.001) and uterine artery pulsatility index (P=.023) were also valuable predictors. At visit 3, cervical length was also a valuable predictor (P<.001).

CONCLUSION

Despite various advances in predictive modeling in obstetrics, the accurate prediction of adverse perinatal outcomes remains difficult. Interpretable machine learning can help clinicians understand how predictions are made, but barriers exist to the widespread clinical adoption of machine learning models for adverse perinatal outcomes. A better understanding of the evolution of risk factors for adverse perinatal outcomes throughout pregnancy is necessary for the development of effective interventions.

The impact of screening for social risks on OBGYN patients and providers: A systematic review of current evidence and key gaps

BACKGROUND

Increasingly, policymakers and professional organizations support screening for social assets and risks during clinical care. Scant evidence exists on how screening impacts patients, providers, or health systems.

OBJECTIVE

To systematically review published literature for evidence of the clinical utility of screening for social determinants of health in clinical obstetric and gynecologic (OBGYN) care.

SEARCH STRATEGY

We systematically searched Pubmed (March 2022, 5,302 identified) and identified additional articles using hand sorting (searching articles citing key articles (273 identified) and through bibliography review (20 identified)).

SELECTION CRITERIA

We included all articles that measured a quantitative outcome of systematic social determinants of health (SDOH) screening in an OBGYN clinical setting. Each identified citation was reviewed by two independent reviewers at both the title/abstract and full text stages.

DATA COLLECTION AND ANALYSIS

We identified 19 articles for inclusion and present the results using narrative synthesis.

MAIN RESULTS

The majority of articles reported on SDOH screening during prenatal care (16/19) and the most common SDOH was intimate partner violence (13/19 studies). Overall, patients had favorable attitudes towards SDOH screening (in 8/9 articles measuring attitudes), and referrals were common following positive screening (range 5.3%-63.6%). Only two articles presented data on the effects of SDOH screening on clinicians and none on health systems. Three articles present data on resolution of social needs, with inconsistent results.

CONCLUSIONS

Limited evidence exists on the benefits of SDOH screening in OBGYN clinical settings. Innovative studies leveraging existing data collection are needed to expand and improve SDOH screening.

A Descriptive Study of Maternal Vaccination Uptake, Attitudes, and Beliefs in Pregnancy Among Persons Delivering at an Urban Safety Net Hospital

Objective

To estimate uptake of influenza, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), and COVID-19 vaccines during pregnancy and describe vaccine attitudes and beliefs among predominantly racial and ethnic minority individuals delivering at a publicly funded hospital.

Methods

We collected survey and electronic medical record data for English-speaking postpartum individuals who delivered a live-born infant from July 7, 2022, through August 21, 2022, and agreed to participate in our study. The 58-item survey included questions about general vaccine attitudes and beliefs as well as vaccine-specific questions. We calculated rates of influenza, Tdap, and COVID-19 vaccinations and compared distributions of survey responses by number (no vaccines, one vaccine, or two or three of the recommended vaccines) and type of vaccines received during pregnancy.

Results

Of the 231 eligible individuals, 125 (54.1%) agreed to participate. Rates of influenza, Tdap, and COVID-19 vaccination were 18.4%, 48.0%, and 5.6% respectively. A total of 61 (48.8%) did not receive any recommended vaccines during pregnancy, 40 (32.0%) received one vaccine, and 24 (19.0%) received two or three vaccines. Approximately 66.1% of the no vaccine group, 81.6% of the one vaccine group, and 87.5% of the two or three vaccine group strongly agreed or agreed that they trusted the vaccine information provided by their obstetrician or midwife. While most (>69.2%) agreed that the vaccine-preventable diseases were dangerous for pregnant women, only 24.0%, 29.3%, and 40.3% agreed that they were worried about getting influenza, whooping cough, or COVID-19, respectively, while pregnant.

Discussion

Vaccine uptake in our population was low and may be due, in part, to low perceived susceptibility to vaccine-preventable diseases. Obstetricians and midwives were trusted sources of vaccine information, suggesting that enhanced communication strategies could be critical for addressing maternal vaccine hesitancy, particularly in communities of color justifiably affected by medical mistrust.

Impact of the COVID-19 Pandemic on Obstetric Interventions at a Public Hospital

INTRODUCTION

In response to the COVID-19 pandemic, health systems quickly implemented changes in care delivery with a goal of balancing patient-focused obstetric care with the need to protect pregnant persons and health care providers from infection. Yet, there is no consensus within the scientific community on the impact these measures have on obstetric outcomes in vulnerable populations. We aimed to assess the impact of the COVID-19 pandemic on rates of obstetric procedures and severe maternal morbidity (SMM) among births at an urban safety net institution.

METHODS

We used an interrupted time series design to calculate risk ratios (RRs) and 95% confidence intervals (CIs) comparing monthly rates of labor induction, cesarean births (overall and among nulliparous, term, singleton, vertex births), operative vaginal births, and SMM among births occurring at a public hospital before (March 1, 2016, to February 29, 2020) and during (March 1, 2020, to May 31, 2021) the COVID-19 pandemic.

RESULTS

There were 10,714 and 2,736 births in the prepandemic and postpandemic periods, respectively. Overall, the rates of obstetric interventions and SMM were constant over the two time periods. There were no significant differences in rates of labor induction (42% during prepandemic period vs. 45% during pandemic period; RR, 1.12; 95% CI, 0.93-1.34), operative vaginal births (5% vs. 6%; RR, 1.24; 95% CI, 0.88-1.76), cesarean births (28% vs. 33%; RR, 1.10; 95% CI, 0.94-1.28), or nulliparous, term, singleton, vertex cesarean births (24% vs. 31%; RR, 1.27; 95% CI, 0.92-1.74). Rates of SMM (7% vs. 8%; RR, 1.19; 95% CI, 0.86-1.65) were also unchanged.

CONCLUSIONS

Our findings indicate that the rapid implementation of measures to reduce viral transmission in the labor and delivery setting did not materially affect routine clinical management or rates of serious maternal complications.

Social Determinants of Health Needs and Perinatal Risk in Socially Vulnerable Pregnant Patients

OBJECTIVES

To understand perinatal risks associated with social needs in pregnancy Methods. Multivariable log-binomial regression analyses adjusting for age, parity, and insurance were used to evaluate the relationship between any social need (e.g., housing, transportation, food, and intimate partner violence) and adverse perinatal outcomes (stillbirth, prematurity, maternal morbidity) in a cohort of English and Spanish-speaking patients who obtained prenatal care and birthed at our institution during a one-year period.

RESULTS

Of 2,435 patients, 1,608 (66%) completed social needs screening at least once during prenatal care. The cohort was predominantly non-Hispanic Black (1,294, 80%) and publicly insured (1,395, 87%). Having one or more social need was associated with three-fold increased risk of stillbirth (aRR 3.35, 95%CI 1.31,8.6) and 14% reduction in postpartum care attendance (aRR 0.86, 95%CI 0.78-0.95) and was highest in individuals reporting transportation needs.

CONCLUSIONS

Social needs during pregnancy were associated with increased risk of stillbirth.

Postpartum Psychiatric Outcomes following Severe Maternal Morbidity in an Urban Safety-Net Hospital

OBJECTIVE

 Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization.

STUDY DESIGN

 We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS

 Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization.

CONCLUSION

 Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period.

KEY POINTS

· Experiencing SMM was associated with three-fold excess risk of postpartum psychiatric admission.. · Experiencing SMM was not associated with an elevated risk of outpatient psychiatric care use.. · Experience SMM was not associated with outpatient psychiatric morbidity diagnoses..

A Qualitative Study of Perceptions, Strengths, and Opportunities in Cardiometabolic Risk Management During Pregnancy and Postpartum in a Georgia Safety-Net Hospital, 2021

INTRODUCTION

Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder.

METHODS

We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management.

RESULTS

From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors.

CONCLUSION

Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.

Neighborhood deprivation and severe maternal morbidity in a medicaid-Insured population in Georgia

BACKGROUND

Despite growing acceptance of the role of context in shaping perinatal risk, data on how neighborhood factors may identify high-risk obstetric patients is limited. In this study, we evaluated the effect of neighborhood deprivation and neighborhood racial composition on severe maternal morbidity (SMM) among persons delivered in a large public health system in Atlanta, Georgia.

METHODS

We conducted a population cohort study using electronic medical record data on all deliveries at Grady Memorial Hospital during 2011-2020. Using residential zip codes, we calculated neighborhood deprivation index based on data from the US Census. We used log-binomial regression with generalized estimating equations to estimate crude and adjusted relative risks (aRR) and 95% confidence intervals (CI) for the association between tertile of neighborhood deprivation and SMM, adjusting for demographic, clinical, and neighborhood-level (racial composition, food desert, and transit access) covariates.

RESULTS

Among 25,257 deliveries, 6.2% (1566) experienced SMM. Approximately 24.0%, 32.0%, and 44.0% of women lived in the lowest, middle, and highest tertile of neighborhood deprivation, respectively and 64.9% lived in a neighborhood with majority non-Hispanic Black residents. After adjustment, there was no association between neighborhood deprivation and SMM (aRR: 1.0 (0.8, 1.1)) or residence in a majority Black neighborhood and SMM (aRR:1.0 (0.9, 1.2)).

CONCLUSION

In this safety-net hospital, residence in a high deprivation or majority Black neighborhood did not predict SMM at or following delivery. Individual-level social determinants may better explain variation in risk, particularly in high-burden populations.

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

INTRODUCTION

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Identification of Distinct Risk Factors for Antepartum and Postpartum Preeclampsia in a High-Risk Safety-Net Hospital

OBJECTIVE

 Postpartum preeclampsia (PE), defined as de novo PE that develops at least 48 hours following delivery, can be particularly dangerous as many patients are already discharged at that point. The goal of our study was to identify risk factors uniquely associated with the development of late postpartum preeclampsia (PPPE).

STUDY DESIGN

 In a retrospective cohort study of deliveries between July 1, 2016 and June 30, 2018 at a safety-net hospital in Atlanta, Georgia, we used multinomial logistic regression models to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between demographic, medical, and obstetric factors and development of PE, categorized as a three-level outcome: no PE, antepartum/intrapartum preeclampsia (APE) (diagnosed prior to or < 48 hours of delivery), and late PPPE (diagnosed ≥ 48-hour postpartum).

RESULTS

 Among 3,681 deliveries, women were primarily of ages 20 to 35 years (76.4%), identified as non-Hispanic Black (68.5%), and covered by public health insurance (88.6%). PE was diagnosed prior to delivery or within 48-hour postpartum in 12% (n = 477) of the study population, and 1.5% (57) developed PE greater than 48-hour postpartum. In the adjusted models, maternal age ≥ 35, race/ethnicity, nulliparity, a diagnosis of pregestational or gestational diabetes, and chronic hypertension were associated with increased odds of APE only, while maternal obesity (OR: 1.9; 95% CI: 1.0-3.5) and gestational hypertension (OR: 2.7; 95% CI: 1.5-4.8) were uniquely associated with PPPE. Multifetal gestations and cesarean delivery predicted both PPPE and APE; however, the association was stronger for PPPE.

CONCLUSION

 Patients with obesity, gestational hypertension, multifetal gestations, or cesarean delivery may benefit from additional follow-up in the early postpartum period to detect PPPE.

KEY POINTS

· Late postpartum preeclampsia may go undetected, particularly in low-income patients.. · In a delivery cohort in Georgia, 1.5% of patients developed late postpartum preeclampsia.. · Maternal obesity and gestational hypertension were strongly associated only with late postpartum preeclampsia..

Immigrant-Related Policies and the Health Outcomes of Latinx Adults in the United States: A Systematic Review

BACKGROUND

US federal and subfederal immigrant-related policy activity has increased in recent years. We hypothesize that these policies are structural determinants of health for Latinx communities, operating through access to resources, discriminatory enforcement, and stress.

METHODS

We searched seven databases for quantitative studies, published as of September 2021, examining the association between the presence of federal, state, or local immigrant-related policy(ies), over time or cross-sectionally, and mental or physical health outcomes among immigrant or US-born Latinx adults. We rated studies on methodologic quality.

RESULTS

Eleven studies were included. Policies included federal and state policies. Health outcomes included mental health (seven studies), self-rated health (n = 6), and physical disability (n = 1). Among immigrant, noncitizen, or Spanish-preferring Latinx adults, exclusionary policies were associated with poor self-rated health, physical disability, and poor mental health. Inclusive policies were associated with better health, although null findings were more common than among studies of exclusionary policies. Only three studies separately examined policy effects on US-born or citizen Latinx adults and these findings were often null. All studies received a weak overall study quality rating; among quality domains, studies were strongest in confounding control and weakest in outcome information bias and reporting missing data approaches.

CONCLUSIONS

These results support the hypothesis that immigrant-related policies, especially exclusionary policies, are structural drivers of health for immigrant or noncitizen Latinx adults. However, evidence is scant among US-born or citizen Latinx adults. Studies of policies and physical health outcomes besides disability are lacking, as are results disaggregated by nativity and/or citizenship status.

Epidemiology beyond its limits

In 1995, journalist Gary Taubes published an article in Science titled "Epidemiology faces its limits," which questioned the utility of nonrandomized epidemiologic research and has since been cited more than 1000 times. He highlighted numerous examples of research topics he viewed as having questionable merit. Studies have since accumulated for these associations. We systematically evaluated current evidence of 53 example associations discussed in the article. Approximately one-quarter of those presented as doubtful are now widely viewed as causal based on current evaluations of the public health consensus. They include associations between alcohol consumption and breast cancer, residential radon exposure and lung cancer, and the use of tanning devices and melanoma. This history should inform current debates about the reproducibility of epidemiologic research results.

Risk of recurrent severe maternal morbidity in an urban safety net health system

BACKGROUND

Rates of severe maternal morbidity (SMM) are steadily increasing in the US and are highest among women who are Black, publicly insured, or deliver at a safety net hospital. There is limited information on the risk of SMM recurrence in subsequent births, particularly among socially vulnerable women.

OBJECTIVE

To estimate the risk of SMM recurrence among a singleton births in a large, public hospital system.

STUDY DESIGN

We conducted a population-based cohort study using electronic medical record data on deliveries occurring at an urban public hospital between 2011 and 2020. We included all women with two singleton deliveries at ≥20 weeks gestation (live or stillborn) during the study period and assessed SMM recorded at delivery or within 42 days postpartum. We used generalized linear models to estimate adjusted risk ratios (aRR), adjusted risk differences (aRD) and 95% confidence intervals (CI) for SMM at the subsequent birth, controlling for age, parity, self-reported race/ethnicity, insurance type, chronic hypertension and diabetes, and obesity at the index delivery.

RESULTS

Between 2011 and 2020, there were 26,994 singleton deliveries to 21,638 women. Among 4,368 women with two singleton births at ≥20 weeks gestation, 4.8% (n=211) had SMM at the index birth, and 5.7% (n=250) had SMM at the subsequent birth. SMM at the index birth was associated with an over 3-fold increased risk of SMM in a subsequent pregnancy (aRR 3.65, 95% CI: 2.65-5.03) and an excess risk of 12.9 per 100 deliveries (aRD 12.9, 95% CI: 7.7-18.1).

CONCLUSIONS

The results of our study suggest that women who experienced SMM in a prior birth are at increased risk for SMM recurrence and may warrant additional monitoring in subsequent pregnancies.

Delivery outcomes after induction of labor among women with hypertensive disorders of pregnancy

OBJECTIVE

Induction of labor is known to be safe and highly effective in low-risk women. However, only limited research considers the relative success rates of induction of labor among women with one or more obstetric comorbidities. Our objective was to determine if the risk of cesarean delivery after induction of labor (IOL) is increased in women with a spectrum of hypertensive disorders of pregnancy compared to women with normotensive pregnancies.

STUDY DESIGN

We analyzed data from 1842 women undergoing IOL occurring at Grady Memorial Hospital in Atlanta, Georgia 2016-2018. We used multivariable log binomial models to estimate unadjusted and adjusted risk ratios (aRR) describing the association between hypertensive disorder diagnosis (preeclampsia with or without severe features, gestational hypertension, and chronic hypertension) and cesarean delivery, adjusting for demographics, pre-pregnancy conditions, and gestational age at delivery.

RESULTS

Overall, 44% (n = 808) of women in our study were diagnosed with any hypertensive disorder. Among women with hypertensive disorders, 74% had a successful vaginal delivery after IOL as compared to 82% of women without a hypertensive disorder. In the fully adjusted model, women with preeclampsia with severe features (aRR: 1.6, 95% CI: (1.3, 2.0)) and chronic hypertension had the largest risk for cesarean delivery (aRR 1.3, 95% CI: 0.9, 1.7)) compared with women with a normotensive pregnancy.

CONCLUSION

Our study suggests that while patients with certain hypertensive diagnoses may be at increased risk for cesarean delivery following IOL, most patients with hypertensive disorders were still able to undergo a successful vaginal delivery following IOL.

Perceptions of stress and resilience among Latina women enrolled in prenatal care in Metro Atlanta through an ecosocial lens

Stress across the life course is highly prevalent, particularly among immigrant and racial/ethnic minority women who face adversities associated with structural and interpersonal racism. Understanding how women perceive and describe stress and resilience can provide cultural context to inform interventions to improve health among pregnant women facing adversity. The goal of this project was to examine how external stressors and coping strategies prior to and during pregnancy are reflected in Latina women's narratives about their lives through an Ecosocial framework. This mixed methods research study explores pregnant Latina women's psychosocial well-being before and during pregnancy based on Ecosocial theory. We conducted 111 surveys with Latina women receiving prenatal care in Atlanta, Georgia in 2017-2018. We conducted 24 in-depth interviews, chosen purposively from survey respondents, collecting narratives of stress and resilience over the course of pregnancy. We purposively sampled equal numbers of women who did and did not report an ongoing stressor in the survey. The survey and interview guide were focused on domains of stress, psychosocial being, coping and resilience. The majority of survey participants spoke Spanish (86%) and were born in Mexico (42%) or Guatemala (27%). Less than half (37%) reported ongoing stress, most commonly from a loved one's illness or work-related problem. The majority of women felt they should control emotional responses to external stressors during pregnancy to protect their baby's health. Women described motherhood and previous challenges as sources of maturity and improved coping. Familial financial and emotional support were perceived as critical to women's successful coping.

Demographic and Clinical Predictors of Postpartum Blood Pressure Screening Attendance

Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly dangerous, as it can go undiagnosed and cause complications. The American College of Obstetricians and Gynecologists recommends women with HDP undergo blood pressure (BP) screening 7-10 days after delivery to detect postpartum hypertension. This study aimed to describe predictors of postpartum BP screening attendance among a high-risk safety-net population in Atlanta, Georgia. Materials and Methods: We conducted a population-based cohort study of pregnant women who delivered at a large public hospital in Atlanta between July 1, 2016, and June 30, 2018. We manually abstracted demographic and clinical data from electronic medical records and used multivariable log binomial regression to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) for associations with BP screening attendance. Results: Of 1260 women diagnosed with HDP, 13.7% attended a BP screening visit within 10 days of delivery. Women with preeclampsia with severe features were more likely to attend a BP visit than women with gestational hypertension (aRR 2.10, 95% CI 1.35-3.27). Rates of BP screening attendance were lower for women with inadequate (aRR 0.42, 95% CI 0.26-0.67) and intermediate (aRR 0.40, 95% CI 0.21-0.74) prenatal care utilization relative to women with adequate utilization. Conclusions: Among a high-risk safety-net population with HDP, most women did not attend a BP screening visit within 10 days of delivery. Addressing this gap requires further research and creative solutions to address barriers at the individual, provider, and system levels.

The relationship between the neighborhood built and social environment and hypertensive disorders of pregnancy: A scoping review

BACKGROUND

Theory and limited empirical research suggest that the neighborhood environment influences maternal health outcomes. The goal of this scoping review is to summarize extant research considering the impact of the built and social environment of resident neighborhood on hypertensive disorders of pregnancy (HDP) globally.

METHODS

We performed a systematic search of the literature using four databases, PubMed, Web of Science, CINAHL, and Embase on July 15, 2020. We excluded articles not in English, that did not consider one or more HDP as a primary or secondary outcome, and that did not include an element of the neighborhood built or social environment as an exposure. We applied a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to evaluate quality of included studies.

RESULTS

Our search identified 11,385 unique abstracts for screening. Following exclusions, we included 64 articles in the final review. The majority of articles measured an element of the built environment (70.3% (44)), most commonly traffic-related air pollution (42.2% (27)). A third of articles (31.3% (20)) considered an element of the neighborhood social environment, most commonly neighborhood deprivation (10.9% (7)). Global quality ratings were mostly moderate (29.7% (19)) or weak (68.8% (44)), primarily due to inattention to neighborhood-level confounding.

CONCLUSION

Critical gaps remain in understanding how the resident neighborhood may impact HDP. Future research should focus on designing high-quality studies incorporating elements of both the built and social environment to holistically understand how context may impact maternal health.

A scoping review of recommendations in the English language on conducting research with trauma-exposed populations since publication of the Belmont report; thematic review of existing recommendations on research with trauma-exposed populations

OBJECTIVE

To identify recommendations for conducting public health research with trauma-exposed populations.

METHODS

Researchers searched Embase, PubMed, Scopus, Web of Science, Open Grey, and Google Scholar for recommendations. Trauma that causes psychological impact was our exposure of interest and we excluded clinical articles on treating physical trauma. We reviewed titles and abstracts of 8,070 articles and full text of 300 articles. We analyzed recommendations with thematic analysis, generated questions from the existing pool of recommendations, and then summarized select gaps.

RESULTS

We abstracted recommendations from 145 articles in five categories: community benefit, participant benefit, safety, researcher well-being, and recommendations for conduct of trauma research.

CONCLUSIONS

Gold standards to guide the conduct of trauma-informed public health research do not yet exist. The literature suggests participation in trauma research is not inherently harmful, and current recommendations concern using research to benefit communities and participants, protecting participants and researchers from harm, and improving professional practice. As public health researchers increasingly analyze trauma as a determinant of health, gold standards for the conduct of trauma-informed public health research would be appropriate and timely.

Spatial Variation in Very Preterm Birth to Hispanic Women Across the United States: The Role of Intensified Immigration Enforcement

Introduction

Limited existing research suggests that immigration climate and enforcement practices represent a social determinant of health for immigrants, their families, and communities. However, national research on the impact of specific policies is limited. The goal of this article is to estimate the effect of county-level participation in a 287(g) immigration enforcement agreement on very preterm birth (VPTB, <32 weeks' gestation) rates between 2005-2016 among US-born and foreign-born Hispanic women across the United States.

Methods

We fit spatial Bayesian models to estimate the effect of local participation in a 287(g) program on county VPTB rates, accounting for variation by maternal nativity, county ethnic density, and controlling for individual specific Hispanic background and nativity and county-level confounders.

Results

While there was no global effect of county participation in a 287(g) program on county VPTB rates, rates were slightly increased in some counties, primarily in the Southeast (Virginia, North Carolina, South Carolina).

Future Directions

Future research should consider the mechanisms through which immigration policies and enforcement may impact health of both immigrants and wider communities.

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta

BACKGROUND

Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta.

DESIGN

We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma.

RESULTS

Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)).

CONCLUSIONS

Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Variation in the Content of Postpartum Visits by Maternal Race/Ethnicity, Preconception, and Pregnancy-Related Cardiovascular Disease Risk, PRAMS, 2016-2017

OBJECTIVES

Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content.

METHODS

We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status.

RESULTS

Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0).

CONCLUSIONS

Health systems should consider novel strategies to improve and standardize the content of postpartum visits.

Federal, State, and Local Immigrant-Related Policies and Child Health Outcomes: a Systematic Review

The passage of US immigrant-related policies at the federal, state, and local level is on the rise. These policies may affect child health through several mechanisms. We performed a systematic review of English-language, peer-reviewed, quantitative studies examining US immigrant-related policies and the mental and physical health of youth in immigrant families. We searched PubMed and five social science databases for studies published between 1986 and 2019. Two independent reviewers screened the studies and appraised study quality. Of the final 17 studies, ten studies examined birth outcomes and seven studies examined other outcomes in childhood and adolescence (e.g., self-rated health). Generally, exclusionary policies were associated with worse health outcomes and inclusive policies were associated with better health outcomes. Several studies did not observe an association, but only one study found an association of the opposite direction. In that study, similar trends in different policy environments and across foreign-born and US-born women suggest alternative causes for the observed association. Overall, we find that exclusionary policies are, at best, neutral, but likely harmful towards child wellbeing, while inclusive policies can be beneficial.

Association Between Recommended Preconception Health Behaviors and Screenings and Improvements in Cardiometabolic Outcomes of Pregnancy

INTRODUCTION

Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are associated with increased risk of maternal and infant illness and long-term elevated cardiometabolic risk. Little information exists on the prevention of either disorder before pregnancy. Our goal was to describe the association between preconception indicators and risk of gestational diabetes and hypertensive disorders of pregnancy.

METHODS

We used logistic regression to analyze cross-sectional data from the 2016-2017 Pregnancy Risk Assessment Monitoring System (N = 68,493) to quantify the association between 14 preconception health indicators (across domains of health care, nutrition and physical activity, tobacco and alcohol, chronic conditions, mental health, and emotional and social support) and, separately, GDM and HDP. We accounted for sampling weights and controlled for maternal age, race/ethnicity, prepregnancy insurance, prepregnancy body mass index, and report of a check-up in the year before pregnancy.

RESULTS

Prepregnancy obesity was the strongest predictor of both HDP (adjusted odds ratio [aOR], 3.1; 95% CI, 2.8-3.5) and GDM (aOR, 3.1; 95% CI, 2.7-3.5). Individual behaviors (eg, exercise, attending a check-up) were not associated with either HDP or GDM. A diagnosis of diabetes before pregnancy predicted HDP (aOR, 2.3; 95% CI, 1.7-3.0).

CONCLUSION

Prepregnancy chronic disease and obesity predicted pregnancy complications (ie, GDM and HDP). Given the challenges in reversing these conditions in the year before pregnancy, efforts to improve preconception health may be best directed broadly to expand access to primary care for all women.

Hypertensive Disorders of Pregnancy, Cesarean Delivery, and Severe Maternal Morbidity in an Urban Safety-Net Population

Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016-2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.

Sociodemographic Predictors of SARS-CoV-2 Infection in Obstetric Patients, Georgia, USA

We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.

Adverse childhood experiences and lifetime adverse maternal outcomes (gestational diabetes and hypertensive disorders of pregnancy) in the Hispanic Community Health Study/Study of Latinos

PURPOSE

Childhood adversity is associated with increased risk of adult disease, including type II diabetes and hypertension. However, little is known about potential associations between childhood adversity and adverse pregnancy outcomes. The goal of this study was to examine the relationship between adverse childhood experiences (ACEs) and ever experiencing gestational diabetes mellitus (GDM) or a hypertensive disorder of pregnancy (HDP) in a cohort of Hispanic or Latina women.

METHODS

We analyzed data from 2319 women from the Hispanic Community Health Study/Study of Latinos who had ever given birth to a liveborn infant. We fit separate logistic regression models accounting for sample weights to examine the association between ACEs and risk of GDM and HDP adjusting for Hispanic/Latino background, age at immigration to the United States, and education.

RESULTS

Women who reported four or more ACEs did not show increased odds of GDM or HDP compared with those who reported three or fewer (GDM adjusted odds ratio: 0.8 [0.5, 1.3]; HDP adjusted OR: 1.0 [0.7, 1.5]).

CONCLUSIONS

Unlike previous research with majority non-Hispanic White cohorts, there was no association between ACEs and GDM or HDP. Future research should explore if this relationship varies by race/ethnicity in multiethnic cohorts.

Feasibility of a Multicomponent Program to Promote Physical Activity and Nutrition in Georgia Low-Income Early Care and Education Settings

BACKGROUND

This article describes the process and intermediate outcomes from a program implemented in 65 Early Care and Education (ECE) centers serving low-income families throughout Georgia during the 2014-2017 school years.

METHODS

The HealthMPowers' Empowering Healthy Choices in Schools, Homes, and Communities ECE program was based on the organization's previously successful elementary school program and aligns with current early childhood nutrition and physical activity recommendations. Participating centers worked with HealthMPowers for up to 3 years. A team from each center led changes by conducting annual self-assessments, creating and implementing improvement plans, and implementing nutrition and physical activity programs using educational resources and environmental cues. A monitoring and evaluation plan provided ongoing feedback to HealthMPowers and centers. Family and staff surveys provided insights into behaviors of children, families, and staff. Process measures included specific benchmarks (e.g., center leadership team formation, improvement plan implementation). Annual self-assessment results served as intermediate outcome measures.

RESULTS

As of 2017, 65 centers had enrolled in the program. All centers formed a health team and completed the baseline self-assessment and most implemented an improvement plan (88%). At the 1-year follow-up self-assessment, centers reported improvements from baseline including never offering food incentives for good behavior (75%-86%), conducting taste testing at least once a month (61%-79%), and rarely/never serving sugar-sweetened beverages (93%-96%).

CONCLUSIONS

Initial process measures from a multicomponent health promotion program in ECE were promising. An integrated continuous improvement approach to working with child care settings is feasible and likely effective.

Effect of Cardiorespiratory Fitness on Academic Achievement is Stronger in High-SES Elementary Schools Compared to Low

BACKGROUND

Academic achievement is influenced by factors at the student, school, and community levels. We estimated the effect of cardiorespiratory fitness performance on academic performance at the school level in Georgia elementary schools and examined effect modification by sociodemographic factors.

METHODS

This study is a repeat cross-sectional analysis of Georgia elementary schools between 2011 and 2014 (approximately 1138 schools per year). Multivariable beta regression estimated the effect of the proportion of 4th and 5th graders meeting cardiorespiratory fitness standards on the proportion of 5th graders passing standardized tests for Reading, English and Language Arts, Mathematics, Science, and Social Studies and considered potential interaction by school-level socioeconomic status (SES), racial composition, and urbanity.

RESULTS

There was a 0.15 higher estimated odds (OR: 1.15 (1.09, 1.22)) of passing the mathematics standardized test for every 10-percentage-point increase in school-level cardiorespiratory fitness among high-SES schools and 0.04 higher odds (OR: 1.04 (1.02, 1.05)) for low-SES schools. This pattern was similar for other academic subjects. No effect modification by racial composition or urbanity was observed for any academic subject.

CONCLUSIONS

Promoting physical fitness may be effective in improving academic performance among high-SES schools, but additional strategies may be needed among lower-SES schools.

Using a monitoring and evaluation framework to improve study efficiency and quality during a prospective cohort study in infants receiving rotavirus vaccination in El Alto, Bolivia: the Infant Nutrition, Inflammation, and Diarrheal Illness (NIDI) study

BACKGROUND

Implementing rigorous epidemiologic studies in low-resource settings involves challenges in participant recruitment and follow-up (e.g., mobile populations, distrust), biological sample collection (e.g., cold-chain, laboratory equipment scarcity) and data collection (e.g., literacy, staff training, and infrastructure). This article describes the use of a monitoring and evaluation (M&E) framework to improve study efficiency and quality during participant engagement, and biological sample and data collection in a longitudinal cohort study of Bolivian infants.

METHODS

The study occurred between 2013 and 2015 in El Alto, Bolivia, a high-altitude, urban, low-resource community. The study's M&E framework included indicators for participant engagement (e.g., recruitment, retention, safety), biological sample (e.g., stool and blood), and data (e.g., anthropometry, questionnaires) collection and quality. Monitoring indicators were measured regularly throughout the study and used for course correction, communication, and staff retraining.

RESULTS

Participant engagement indicators suggested that enrollment objectives were met (461 infants), but 15% loss-to-follow-up resulted in only 364 infants completing the study. Over the course of the study, there were four study-related adverse events (minor swelling and bruising related to a blood draw) and five severe adverse events (infant deaths) not related to study participation. Biological sample indicators demonstrated two blood samples collected from 95% (333 of 350 required) infants and stool collected for 61% of reported infant diarrhea episodes. Anthropometry data quality indicators were extremely high (median SDs for weight-for-length, length-for-age and weight-for-age z-scores 1.01, 0.98, and 1.03, respectively), likely due to extensive training, standardization, and monitoring efforts.

CONCLUSIONS

Conducting human subjects research studies in low-resource settings often presents unique logistical difficulties, and collecting high-quality data is often a challenge. Investing in comprehensive M&E is important to improve participant recruitment, retention and safety, and sample and data quality. The M&E framework from this study can be applied to other longitudinal studies.

Measurement of obesity prevention in childcare settings: A systematic review of current instruments

OBJECTIVE

The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children.

METHODS

Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity.

RESULTS

One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools.

CONCLUSION

Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.