Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Antibody Titer Levels in Pregnant Individuals After Infection, Vaccination, or Both

We examined differences in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody responses in pregnant individuals with natural, vaccine-induced, or combined immunity. Participants had live or nonlive births between 2020 and 2022, were seropositive (SARS-CoV-2 spike protein, anti-S), and had available mRNA vaccination and infection information (n=260). We compared titer levels among three immunity profiles: 1) natural immunity (n=191), 2) vaccine-induced immunity (n=37), and 3) combined immunity (ie, natural and vaccine-induced immunity; n=32). We applied linear regression to compare anti-S titers between the groups, controlling for age, race and ethnicity, and time between vaccination or infection (whichever came last) and sample collection. Anti-S titers were 57.3% and 94.4% lower among those with vaccine-induced and natural immunity, respectively, compared with those with combined immunity ( P <.001, P =.005).

Training obstetrician gynaecologists in HIV PrEP (pre-exposure prophylaxis): a 2-year experience

OBJECTIVE

We aimed to evaluate the efficacy of PrEP (pre-exposure prophylaxis) training sessions for OBGYN (obstetrician gynaecologist) providers given underutilisation of PrEP among women despite a high HIV burden.

METHODS

Three separate training sessions were held for providers in the OBGYN department at an academic medical centre in New York City from 2019 to 2021. The 1-hour training sessions were conducted by HIV specialists as in-person lectures or online live lectures. Participants were surveyed after the training on metrics of PrEP awareness, knowledge and comfort with management. Two-sample t-tests were used to compare difference in proportions of binomial variables and difference in means of Likert-scored answers pretraining and post-training events.

RESULTS

63 respondents completed the surveys. There were low rates (13%) of past PrEP prescription among the respondents, while awareness of PrEP as an HIV prevention strategy was high before (95%) and after (98%) the training. After the training, there was an increase in understanding the epidemiology of HIV transmission (40% to 97%, p<0.00), familiarity with the PrEP clinical trials (18% to 97%, p<0.00), comfort in determining PrEP candidacy (mean score 2.3 to 4.1, p<0.00) and comfort prescribing PrEP (mean score 2.0 to 3.6, p<0.00). After the trainings, the majority of participants reported feeling 'comfortable' or 'very comfortable' in determining candidacy for PrEP and prescribing PrEP with follow-up.

CONCLUSION

Implementation of PrEP training courses for OBGYN providers increased knowledge and comfort in identifying and managing patients who may benefit from PrEP services. Increasing training among OBGYN providers serving women at risk for HIV infection is an effective tool to narrow gaps in PrEP access.

Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers: national cohort and co-sibling study

OBJECTIVE

To examine the associations between five major adverse pregnancy outcomes and long term risks of ischemic heart disease in mothers.

DESIGN

National cohort study.

SETTING

Sweden.

PARTICIPANTS

All 2 195 266 women with a first singleton delivery in Sweden during 1973-2015.

MAIN OUTCOME MEASURES

The main outcome measure was incidence of ischemic heart disease from delivery to 2018, identified from nationwide inpatient and outpatient diagnoses. Cox regression was used to calculate hazard ratios for ischemic heart disease associated with preterm delivery, small for gestational age, pre-eclampsia, other hypertensive disorders of pregnancy, and gestational diabetes, adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and environmental) factors.

RESULTS

During 53.6 million person years of follow-up, ischemic heart disease was diagnosed in 83 881 (3.8%) women. All five adverse pregnancy outcomes were independently associated with increased risk of ischemic heart disease. In the 10 years after delivery, adjusted hazard ratios for ischemic heart disease associated with specific adverse pregnancy outcomes were 2.09 (95% confidence interval 1.77 to 2.46) for other hypertensive disorders of pregnancy, 1.72 (1.55 to 1.90) for preterm delivery, 1.54 (1.37 to 1.72) for pre-eclampsia, 1.30 (1.09 to 1.56) for gestational diabetes, and 1.10 (1.00 to 1.21) for small for gestational age. The hazard ratios remained significantly increased even 30-46 years after delivery: 1.47 (1.30 to 1.66) for other hypertensive disorders of pregnancy, 1.40 (1.29 to 1.51) for gestational diabetes, 1.32 (1.28 to 1.36) for pre-eclampsia, 1.23 (1.19 to 1.27) for preterm delivery, and 1.16 (1.13 to 1.19) for small for gestational age. These findings were only partially (<45%) explained by shared familial (genetic or environmental) factors. Women who experienced multiple adverse pregnancy outcomes showed further increases in risk (eg, <10 years after delivery, adjusted hazard ratios associated with 1, 2, or ≥3 adverse pregnancy outcomes were 1.29 (1.19 to 1.39), 1.80 (1.59 to 2.03), and 2.26 (1.89 to 2.70), respectively)).

CONCLUSIONS

In this large national cohort, women who experienced any of five major adverse pregnancy outcomes showed an increased risk for ischemic heart disease up to 46 years after delivery. Women with adverse pregnancy outcomes should be considered for early preventive evaluation and long term risk reduction to help prevent the development of ischemic heart disease.

Impact of prenatal COVID-19 vaccination on delivery and neonatal outcomes: Results from a New York City cohort

Research suggest prenatal vaccination against coronavirus disease-19 (COVID-19) is safe. However, previous studies utilized retrospectively collected data or examined late pregnancy vaccinations. We investigated the associations of COVID-19 vaccination throughout pregnancy with delivery and neonatal outcomes. We included 1,794 mother-neonate dyads enrolled in the Generation C Study with known prenatal COVID-19 vaccination status and complete covariate and outcome data. We used multivariable quantile regressions to estimate the effect of prenatal COVID-19 vaccination on birthweight, delivery gestational age, and blood loss at delivery; and Poisson generalized linear models for Caesarean delivery (CD) and Neonatal Intensive Care Unit (NICU) admission. Using the above methods, we estimated effects of trimester of vaccine initiation on these outcomes. In our sample, 13.7% (n = 250) received at least one prenatal dose of any COVID-19 vaccine. Vaccination was not associated with birthweight (β = 12.42 g [-90.5, 114.8]), gestational age (β = 0.2 days [-1.1, 1.5]), blood loss (β = -50.6 ml [-107.0, 5.8]), the risks of CD (RR = 0.8; [0.6, 1.1]) or NICU admission (RR = 0.9 [0.5, 1.7]). Trimester of vaccine initiation was also not associated with these outcomes. Our findings suggest that there is no associated risk between prenatal COVID-19 vaccination and adverse delivery and neonatal outcomes in a cohort sample from NYC.

Late preterm antenatal corticosteroids in singleton and twin gestations: a retrospective cohort study

BACKGROUND

In 2016, the American College of Obstetricians and Gynecologists recommended antenatal corticosteroids in the late preterm period for women at risk for preterm delivery. Limited real-world evidence exists on neonatal outcomes, particularly for twin gestations, following the guideline change. The study objective is to determine the association of antenatal corticosteroids in late preterm singleton and twin pregnancies with respiratory complications and hypoglycemia in a real-world clinical setting.

METHODS

This is a retrospective cohort study comprising late preterm deliveries (4,341 mother-child pairs) within the Mount Sinai Health System, 2012-2018. The exposure of interest is antenatal corticosteroid administration of betamethasone during pregnancy between 34 0/7 and 36 6/7 weeks. Our primary outcomes are neonatal respiratory complications and hypoglycemia. Multivariable logistic regression was used to estimate the association between antenatal corticosteroid exposure and these two outcomes. We stratified the study population by singleton gestations and twins to minimize the potential confounding from different obstetric management between the two groups.

RESULTS

Among a total of 4,341 mother-child pairs (3,309 singleton and 1,032 twin mother-child pairs), 745 mothers received betamethasone, of which 40.94% (305/745) received the full course. Relative to no treatment, a full course of betamethasone was associated with reduced odds of respiratory complications (OR = 0.53, 95% CI:[0.31-0.85], p < 0.01) and increased odds of hypoglycemia (OR = 1.86, 95%CI:[1.34-2.56], p < 0.01) in singletons; however, the association with respiratory complications was not significant in twins (OR = 0.42, 95% CI:[0.11-1.23], p = 0.16), but was associated with increased odds of hypoglycemia (OR = 2.18, 95% CI:[1.12-4.10], p = 0.02). A partial course of betamethasone (relative to no treatment) was not significantly associated with any of the outcomes, other than respiratory complications in twins (OR = 0.34, 95% CI:[0.12-0.82], p = 0.02).

CONCLUSIONS

Exposure to antenatal corticosteroids in singletons and twins is associated with increased odds of hypoglycemia. Among singletons, exposure to the full dosage (i.e. two doses) was associated with decreased odds of respiratory complications but this was only the case for partial dose among twins. Twin gestations were not studied by the Antenatal Late Preterm Steroids trial. Therefore, our study findings will contribute to the paucity of evidence on the benefit of antenatal corticosteroids in this group. Health systems should systematically monitor guideline implementations to improve patient outcomes.

Characteristics and Outcomes of Pregnant Women with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in New York City: A Matched Cohort Study

OBJECTIVE

The aim of this study was to examine the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and preterm birth, cesarean birth, and composite severe maternal morbidity by studying women with and without SARS-CoV-2 infection at the time of delivery hospitalization from similar residential catchment areas in New York City.

STUDY DESIGN

This was a retrospective cohort study of pregnant women with laboratory-confirmed or laboratory-denied SARS-CoV-2 on nasopharyngeal swab under universal testing policies at the time of admission who gave birth between March 13 and May 15, 2020, at two New York City medical centers. Demographic and clinical data were collected and follow-up was completed on May 30, 2020. Groups were compared for the primary outcome and preterm birth, in adjusted (for age, race/ethnicity, nulliparity, body mass index) and unadjusted analyses.

RESULTS

Among this age-matched cohort, 164 women were positive and 247 were negative for SARS-CoV-2. Of the positive group, 52.4% were asymptomatic and 1.2% had critical coronavirus disease 2019 (COVID-19). The groups did not differ by race and ethnicity, body mass index, or acute or chronic comorbidities. Women with SARS-CoV-2 were more likely to be publicly insured. Preterm birth, cesarean birth, and severe maternal morbidity did not differ between groups. Babies born to women with SARS-CoV-2 were more likely to have complications of prematurity or low birth weight (7.7 vs. 2%, p = 0.01).

CONCLUSION

Preterm and cesarean birth did not differ between women with and without SARS-CoV-2 across disease severity in adjusted and unadjusted analysis among this cohort during the pandemic peak in New York City.

Effects of severe acute respiratory syndrome coronavirus 2 infection on obstetric outcomes: Results from a prospective cohort in the Netherlands

Results of a large prospective pregnancy cohort in the Netherlands show no association of severe acute respiratory syndrome coronavirus 2 infection prior to 28 weeks of gestation with adverse obstetric outcomes.

Gestational SARS-CoV-2 infection is associated with placental expression of immune and trophoblast genes

INTRODUCTION

Maternal SARS-CoV-2 infection during pregnancy is associated with adverse pregnancy outcomes and can have effects on the placenta, even in the absence of severe disease or vertical transmission to the fetus. This study aimed to evaluate histopathologic and molecular effects in the placenta after SARS-CoV-2 infection during pregnancy.

METHODS

We performed a study of 45 pregnant participants from the Generation C prospective cohort study at the Mount Sinai Health System in New York City. We compared histologic features and the expression of 48 immune and trophoblast genes in placentas delivered from 15 SARS-CoV-2 IgG antibody positive and 30 IgG SARS-CoV-2 antibody negative mothers. Statistical analyses were performed using Fisher's exact tests, Spearman correlations and linear regression models.

RESULTS

The median gestational age at the time of SARS-CoV-2 IgG serology test was 35 weeks. Two of the IgG positive participants also had a positive RT-PCR nasal swab at delivery. 82.2% of the infants were delivered at term (≥37 weeks), and gestational age at delivery did not differ between the SARS-CoV-2 antibody positive and negative groups. No significant differences were detected between the groups in placental histopathology features. Differential expression analyses revealed decreased expression of two trophoblast genes (PSG3 and CGB3) and increased expression of three immune genes (CXCL10, TLR3 and DDX58) in placentas delivered from SARS-CoV-2 IgG positive participants.

DISCUSSION

SARS-CoV-2 infection during pregnancy is associated with gene expression changes of immune and trophoblast genes in the placenta at birth which could potentially contribute to long-term health effects in the offspring.

The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomes

BACKGROUND

Structural racism and pandemic-related stress from the COVID-19 pandemic may increase the risk of adverse birth outcomes.

OBJECTIVE

Our objective was to examine associations between neighborhood measures of structural racism and pandemic stress with 3 outcomes: SARS-CoV-2 infection, preterm birth, and delivering small-for-gestational-age newborns. Our secondary objective was to investigate the joint association of SARS-CoV-2 infection during pregnancy and neighborhood measures with preterm birth and delivering small-for-gestational-age newborns.

STUDY DESIGN

We analyzed data of 967 patients from a prospective cohort of pregnant persons in New York City, comprising 367 White (38%), 169 Black (17%), 293 Latina (30%), and 87 Asian persons (9%), 41 persons of other race or ethnicity (4%), and 10 of unknown race or ethnicity (1%). We evaluated structural racism (social/built structural disadvantage, racial-economic segregation) and pandemic-related stress (community COVID-19 mortality, community unemployment rate increase) in quartiles by zone improvement plan code. SARS-CoV-2 serologic enzyme-linked immunosorbent assay was performed on blood samples from pregnant persons. We obtained data on preterm birth and small-for-gestational-age newborns from an electronic medical record database. We used log-binomial regression with robust standard error for clustering by zone improvement plan code to estimate associations of each neighborhood measure separately with 3 outcomes: SARS-CoV-2 infection, preterm birth, and small-for-gestational-age newborns. Covariates included maternal age, parity, insurance status, and body mass index. Models with preterm birth and small-for-gestational-age newborns as the dependent variables additionally adjusted for SARS-CoV-2 infection.

RESULTS

A total of 193 (20%) persons were SARS-CoV-2-seropositive, and the overall risks of preterm birth and small-for-gestational-age newborns were 8.4% and 9.8%, respectively. Among birthing persons in neighborhoods in the highest quartile of structural disadvantage (n=190), 94% were non-White, 50% had public insurance, 41% were obese, 32% were seropositive, 11% delivered preterm, and 12% delivered a small-for-gestational-age infant. Among birthing persons in neighborhoods in the lowest quartile of structural disadvantage (n=360), 39% were non-White, 17% had public insurance, 15% were obese, 9% were seropositive, 6% delivered preterm, and 10% delivered a small-for-gestational-age infant. In adjusted analyses, structural racism measures and community unemployment were associated with both SARS-CoV-2 infection and preterm birth, but not small-for-gestational-age infants. High vs low structural disadvantage was associated with an adjusted relative risk of 2.6 for infection (95% confidence interval, 1.7-3.9) and 1.7 for preterm birth (95% confidence interval, 1.0-2.9); high vs low racial-economic segregation was associated with adjusted relative risk of 1.9 (95% confidence interval, 1.3-2.8) for infection and 2.0 (95% confidence interval, 1.3-3.2) for preterm birth; high vs low community unemployment increase was associated with adjusted relative risk of 1.7 (95% confidence interval, 1.2-1.5) for infection and 1.6 (95% confidence interval, 1.0-2.8) for preterm birth. COVID-19 mortality rate was associated with SARS-CoV-2 infection but not preterm birth or small-for-gestational-age infants. SARS-CoV-2 infection was not independently associated with birth outcomes. We found no interaction between SARS-CoV-2 infection and neighborhood measures on preterm birth or small-for-gestational-age infants.

CONCLUSION

Neighborhood measures of structural racism were associated with both SARS-CoV-2 infection and preterm birth, but these associations were independent and did not have a synergistic effect. Community unemployment rate increases were also associated with an increased risk of preterm birth independently of SARS-CoV-2 infection. Mitigating these factors might reduce the impact of the pandemic on pregnant people.

SARS-CoV-2 during pregnancy and associated outcomes: Results from an ongoing prospective cohort

BACKGROUND

The COVID-19 pandemic is an ongoing global health threat, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Questions remain about how SARS-CoV-2 impacts pregnant individuals and their children.

OBJECTIVE

To expand our understanding of the effects of SARS-CoV-2 infection during pregnancy on pregnancy outcomes, regardless of symptomatology, by using serological tests to measure IgG antibody levels.

METHODS

The Generation C Study is an ongoing prospective cohort study conducted at the Mount Sinai Health System. All pregnant individuals receiving obstetrical care at the Mount Sinai Healthcare System from 20 April 2020 onwards are eligible for participation. For the current analysis, we included participants who had given birth to a liveborn singleton infant on or before 22 September 2020. For each woman, we tested the latest prenatal blood sample available to establish seropositivity using a SARS-CoV-2 serologic enzyme-linked immunosorbent assay. Additionally, RT-PCR testing was performed on a nasopharyngeal swab taken during labour. Pregnancy outcomes of interest (i.e., gestational age at delivery, preterm birth, small for gestational age, Apgar scores, maternal and neonatal intensive care unit admission, and length of neonatal hospital stay) and covariates were extracted from medical records. Excluding individuals who tested RT-PCR positive at delivery, we conducted crude and adjusted regression models to compare antibody positive with antibody negative individuals at delivery. We stratified analyses by race/ethnicity to examine potential effect modification.

RESULTS

The SARS-CoV-2 seroprevalence based on IgG measurement was 16.4% (95% confidence interval 13.7, 19.3; n=116). Twelve individuals (1.7%) were SARS-CoV-2 RT-PCR positive at delivery. Seropositive individuals were generally younger, more often Black or Hispanic, and more often had public insurance and higher pre-pregnancy BMI compared with seronegative individuals. None of the examined pregnancy outcomes differed by seropositivity, overall or stratified by race/ethnicity.

CONCLUSION

Seropositivity for SARS-CoV-2 without RT-PCR positivity at delivery (suggesting that infection occurred earlier during pregnancy) was not associated with selected adverse maternal or neonatal outcomes among live births in a cohort sample from New York City.

Improving preeclampsia risk prediction by modeling pregnancy trajectories from routinely collected electronic medical record data

Preeclampsia is a heterogeneous and complex disease associated with rising morbidity and mortality in pregnant women and newborns in the US. Early recognition of patients at risk is a pressing clinical need to reduce the risk of adverse outcomes. We assessed whether information routinely collected in electronic medical records (EMR) could enhance the prediction of preeclampsia risk beyond what is achieved in standard of care assessments. We developed a digital phenotyping algorithm to curate 108,557 pregnancies from EMRs across the Mount Sinai Health System, accurately reconstructing pregnancy journeys and normalizing these journeys across different hospital EMR systems. We then applied machine learning approaches to a training dataset (N = 60,879) to construct predictive models of preeclampsia across three major pregnancy time periods (ante-, intra-, and postpartum). The resulting models predicted preeclampsia with high accuracy across the different pregnancy periods, with areas under the receiver operating characteristic curves (AUC) of 0.92, 0.82, and 0.89 at 37 gestational weeks, intrapartum and postpartum, respectively. We observed comparable performance in two independent patient cohorts. While our machine learning approach identified known risk factors of preeclampsia (such as blood pressure, weight, and maternal age), it also identified other potential risk factors, such as complete blood count related characteristics for the antepartum period. Our model not only has utility for earlier identification of patients at risk for preeclampsia, but given the prediction accuracy exceeds what is currently achieved in clinical practice, our model provides a path for promoting personalized precision therapeutic strategies for patients at risk.

"Being able to do whatever you wanna do as a woman is important:" a qualitative exploration of contraception as a frame of reference for HIV prevention with PrEP

Background

Use of HIV PrEP (pre-exposure prophylaxis) is a strategic tool in the effort to end the HIV epidemic. 20% of new HIV infections in the US are among cis-gender women, yet they comprise only 5% of all PrEP users. Black women disproportionately bear the burden of new HIV acquisition and accounted for almost 60% of new HIV diagnoses among women in 2018. Increasing understanding and uptake of PrEP among women at risk of HIV acquisition in alignment with their reproductive values and preferences is key to increasing PrEP uptake and decreasing HIV burden in this population.

Objective

This study examines how experiences with contraception among women of color shape their perceptions and preferences regarding HIV PrEP to inform counseling that aligns with their reproductive values.

Methods

Women aged 18–45 who self-identified as Black or Latina were recruited at an academic medical center in the Bronx from June 2018 to July 2019. We enrolled 30 participants seeking family planning care (10), prenatal care (10), or care for sexually transmitted infections (10). Participants completed a brief written survey assessing their risk of HIV acquisition. Semi-structured, face-to-face interviews were then audio-recorded, transcribed, and entered into Dedoose. Grounded theory and constant comparison approaches were used to analyze the data.

Results

Twenty-one participants (70%) screened positive for HIV acquisition risk. Four had received information on PrEP from a medical provider prior to the interview. Three themes emerged from the qualitative analysis: (1) Similar to oral contraception, women conceptualized PrEP as a “daily pill” to support their reproductive health; (2) Women perceived PrEP as a tool to support autonomy and pleasure in their sexual health; (3) Like birth control, women desired multiple delivery options for HIV prophylaxis.

Conclusions

Contraception may serve as a frame of reference when counseling about PrEP among cis-women at risk of acquiring HIV. Our study suggests that this approach re-contextualizes counseling on PrEP within a sex-positive framework that prioritizes pleasure, safety, and autonomy as integral to sexual and reproductive wellness. Consideration of historically marginalized women’s experiences with contraception and reproductive values may facilitate their use of PrEP.

PrEP (pre-exposure prophylaxis) is a medicine taken daily by people at risk of getting HIV from sex or injection drug use. Although PrEP is a safe and effective medication for women, the use of PrEP remains exceedingly low among cis-gender women at risk of HIV in the US. This study examines how experiences with contraception among women of color, who disproportionately bear the burden of HIV acquisition, shape their perceptions and preferences regarding PrEP. We interviewed 30 women who self-identified as Black or Latina at an academic medical center in the Bronx. Similar to oral contraception, women in this study conceptualized PrEP as a “daily pill” to support their reproductive health. This report details how women’s experiences with contraception may serve as the foundation to re-contextualize conversations on PrEP within a sex-positive framework that prioritizes pleasure, safety, and autonomy as integral to sexual and reproductive wellness.

COVID-19 pandemic-related change in racial and ethnic disparities in exclusive breastmilk feeding during the delivery hospitalization: a differences-in-differences analysis

OBJECTIVE

Exclusive breastmilk feeding during the delivery hospitalization, a Joint Commission indicator of perinatal care quality, is associated with longer-term breastfeeding success. Marked racial and ethnic disparities in breastfeeding exclusivity and duration existed prior to COVID-19. The pandemic, accompanied by uncertainty regarding intrapartum and postpartum safety practices, may have influenced disparities in infant feeding practices. Our objective was to examine whether the first wave of the COVID-19 pandemic in New York City was associated with a change in racial and ethnic disparities in exclusive breastmilk feeding during the delivery stay.

METHODS

We conducted a cross-sectional study of electronic medical records from 14,964 births in two New York City hospitals. We conducted a difference-in-differences (DID) analysis to compare Black-white, Latina-white, and Asian-white disparities in exclusive breastmilk feeding in a pandemic cohort (April 1-July 31, 2020, n=3122 deliveries) to disparities in a pre-pandemic cohort (January 1, 2019-February 28, 2020, n=11,842). We defined exclusive breastmilk feeding as receipt of only breastmilk during delivery hospitalization, regardless of route of administration. We ascertained severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status from reverse transcription-polymerase chain reaction tests from nasopharyngeal swab at admission. For each DID model (e.g. Black-white disparity), we used covariate-adjusted log binomial regression models to estimate racial and ethnic risk differences, pandemic versus pre-pandemic cohort risk differences, and an interaction term representing the DID estimator.

RESULTS

Exclusive breastmilk feeding increased from pre-pandemic to pandemic among white (40.8% to 46.6%, p<0.001) and Asian (27.9% to 35.8%, p=0.004) women, but not Black (22.6% to 25.3%, p=0.275) or Latina (20.1% to 21.4%, p=0.515) women overall. There was an increase in the Latina-white exclusive breastmilk feeding disparity associated with the pandemic (DID estimator=6.3 fewer cases per 100 births (95% CI=-10.8, -1.9)). We found decreased breastmilk feeding specifically among SARS-CoV-2 positive Latina women (20.1% pre-pandemic vs. 9.1% pandemic p=0.013), and no change in Black-white or Asian-white disparities.

CONCLUSIONS

We observed a pandemic-related increase in the Latina-white disparity in exclusive breastmilk feeding, urging hospital policies and programs to increase equity in breastmilk feeding and perinatal care quality during and beyond this health emergency.

Women Trust Their OBGYNs to Provide Preexposure Prophylaxis: An Opportunity for HIV Prevention

Objective

The objective of this study was to understand how women perceive the role of their Obstetrician and Gynecologist (OBGYN) in screening for and providing preexposure prophylaxis (PrEP) for HIV prevention.

Methods

We recruited women ages 18–45 years receiving obstetric or gynecological care at an academic medical center in the Bronx, NY. Thirty participants were enrolled: 10 seeking care for family planning, 10 seeking prenatal care, and 10 seeking care for a sexually transmitted infection. We screened participants for HIV acquisition risk using a PrEP screening tool. We conducted face-to-face, semi-structured interviews, which were audio-recorded, transcribed, and entered into Dedoose for analysis of themes using a grounded theory approach.

Results

Sixty percent of the participants were Latinx and 33% African American. Seventy percent had one or more risk factors for HIV acquisition based on the PrEP screening tool, indicating they would benefit from a PrEP discussion. Three main themes emerged from the analysis of interview data. Participants viewed OBGYNs as experts in sexual and reproductive healthcare and believed they were experts in PrEP. Participants were concerned about “PrEP stigma”, being judged by their clinicians as being sexually promiscuous if they expressed a need for PrEP. Lastly, when participants trusted their OBGYN, that trust became a facilitator for women to consider PrEP and offset stigma as a barrier to identifying patients who are candidates for PrEP.

Conclusion

Women established in care with an OBGYN are enthusiastic about having access to PrEP services incorporated into their sexual and reproductive healthcare. A universal approach to HIV prevention would avert stigma surrounding HIV care and prevention.

A comprehensive digital phenotype for postpartum hemorrhage

OBJECTIVE

We aimed to establish a comprehensive digital phenotype for postpartum hemorrhage (PPH). Current guidelines rely primarily on estimates of blood loss, which can be inaccurate and biased and ignore complementary information readily available in electronic medical records (EMR). Inaccurate and incomplete phenotyping contributes to ongoing challenges in tracking PPH outcomes, developing more accurate risk assessments, and identifying novel interventions.

MATERIALS AND METHODS

We constructed a cohort of 71 944 deliveries from the Mount Sinai Health System. Estimates of postpartum blood loss, shifts in hematocrit, administration of uterotonics, surgical interventions, and diagnostic codes were combined to identify PPH, retrospectively. Clinical features were extracted from EMRs and mapped to common data models for maximum interoperability across hospitals. Blinded chart review was done by a physician on a subset of PPH and non-PPH patients and performance was compared to alternate PPH phenotypes. PPH was defined as clinical diagnosis of postpartum hemorrhage documented in the patient's chart upon chart review.

RESULTS

We identified 6639 PPH deliveries (9% prevalence) using our phenotype-more than 3 times as many as using blood loss alone (N = 1,747), supporting the need to incorporate other diagnostic and intervention data. Chart review revealed our phenotype had 89% accuracy and an F1-score of 0.92. Alternate phenotypes were less accurate, including a common blood loss-based definition (67%) and a previously published digital phenotype (74%).

CONCLUSION

We have developed a scalable, accurate, and valid digital phenotype that may be of significant use for tracking outcomes and ongoing clinical research to deliver better preventative interventions for PPH.

Improving postpartum hemorrhage risk prediction using longitudinal electronic medical records

OBJECTIVE

Postpartum hemorrhage (PPH) remains a leading cause of preventable maternal mortality in the United States. We sought to develop a novel risk assessment tool and compare its accuracy to tools used in current practice.

MATERIALS AND METHODS

We used a PPH digital phenotype that we developed and validated previously to identify 6639 PPH deliveries from our delivery cohort (N = 70 948). Using a vast array of known and potential risk factors extracted from electronic medical records available prior to delivery, we trained a gradient boosting model in a subset of our cohort. In a held-out test sample, we compared performance of our model with 3 clinical risk-assessment tools and 1 previously published model.

RESULTS

Our 24-feature model achieved an area under the receiver-operating characteristic curve (AUROC) of 0.71 (95% confidence interval [CI], 0.69-0.72), higher than all other tools (research-based AUROC, 0.67 [95% CI, 0.66-0.69]; clinical AUROCs, 0.55 [95% CI, 0.54-0.56] to 0.61 [95% CI, 0.59-0.62]). Five features were novel, including red blood cell indices and infection markers measured upon admission. Additionally, we identified inflection points for vital signs and labs where risk rose substantially. Most notably, patients with median intrapartum systolic blood pressure above 132 mm Hg had an 11% (95% CI, 8%-13%) median increase in relative risk for PPH.

CONCLUSIONS

We developed a novel approach for predicting PPH and identified clinical feature thresholds that can guide intrapartum monitoring for PPH risk. These results suggest that our model is an excellent candidate for prospective evaluation and could ultimately reduce PPH morbidity and mortality through early detection and prevention.

Pre-term delivery and long-term risk of heart failure in women: a national cohort and co-sibling study

AIMS

Women who deliver pre-term have higher future risks of hypertension and ischaemic heart disease, but long-term risks of heart failure (HF) are unknown. We examined these risks in a large national cohort.

METHODS AND RESULTS

All 2 201 284 women with a singleton delivery in Sweden during 1973-2015 were followed up for inpatient or outpatient HF diagnoses through 2015. Cox regression was used to compute hazard ratios (HRs) for HF associated with pregnancy duration, adjusting for other maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and/or environmental) factors. In 48.2 million person-years of follow-up, 19 922 women were diagnosed with HF (median age: 60.7 years). Within 10 years after delivery, the adjusted HR was 2.96 [95% confidence interval (CI): 2.48-3.53] for HF associated with pre-term (gestational age: <37 weeks) compared with full-term (39-41 weeks) delivery. Stratified HRs were 4.27 (2.54-7.17) for extremely pre-term (22-27 weeks), 3.39 (2.57-4.48) for moderately pre-term (28-33 weeks), 2.70 (2.19-3.32) for late pre-term (34-36 weeks), and 1.70 (1.45-1.98) for early term (37-38 weeks). These HRs declined but remained elevated at 10-19 years (pre-term vs. full term: HR: 2.19; 95% CI: 1.94-2.46), 20-29 years (1.80; 1.67-1.95), and 30-43 years (1.56; 1.47-1.66) after delivery, and were not explained by shared familial factors.

CONCLUSION

Pre-term and early term delivery were associated with markedly increased future hazards for HF, which persisted after adjusting for other maternal and familial factors and remained elevated 40 years later. Pre-term and early-term delivery should be recognized as risk factors for HF across the life course.

KEY QUESTION

What are the long-term hazards for heart failure (HF) across the life course in women who deliver preterm?

KEY FINDING

Preterm and early term delivery were associated with ∼3- and 1.7-fold adjusted hazards for HF in the next 10 years vs. full-term delivery. These hazards declined but remained elevated 40 years later, and were not explained by shared familial factors.

TAKE HOME MESSAGE

Preterm and early term delivery were associated with increased future hazards for HF, which persisted for 40 years after adjusting for other maternal and familial factors. Preterm and early term delivery should be recognized as lifelong risk factors for HF.

Educational behaviors of pregnant women in the Bronx during Zika's International emerging epidemic: "First mom … and then I'd Google. And then my doctor"

Background

The objective of the study was to understand how pregnant women learned about Zika infection and to identify what sources of information were likely to influence them during their pregnancy.

Methods

We conducted 13 semi-structed interviews in English and Spanish with women receiving prenatal care who were tested for Zika virus infection. We analyzed the qualitative data using descriptive approach.

Results

Pregnant women in the Bronx learned about Zika from family, television, the internet and their doctor. Informational sources played different roles. Television, specifically Spanish language networks, was often the initial source of information. Women searched the internet for additional information about Zika. Later, they engaged in further discussions with their healthcare providers.

Conclusions

Television played an important role in providing awareness about Zika to pregnant women in the Bronx, but that information was incomplete. The internet and healthcare providers were sources of more complete information and are likely the most influential. Efforts to educate pregnant women about emerging infectious diseases will benefit from using a variety of approaches including television messages that promote public awareness followed up by reliable information via the internet and healthcare providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04170-0.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017–2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Hope versus reality: Parent expectations of genomic testing

OBJECTIVE

Genomics is increasingly used for diagnostic testing in children. This study describes the expectations of parents whose child received genomic testing and whether or not they were met.

METHODS

A diverse stratified, purposive sample of parents of 22 children in New York City was interviewed using a semi-structured guide. Genomic test results were positive, negative, or uncertain.

RESULTS

Parents expressed their expectations in narrative and numeric fashion. Parents expected that their child's test would have a direct effect on their child's diagnosis. Some believed that results would be definitive, while others recognized testing limitations. Expectations reflected parents' hope to find a diagnosis and led to disappointment when results were uninformative or did not impact clinical management.

CONCLUSION

Results suggest pre-test genetic counseling emphasize the low likelihood of actionable results; however, parents' expectations of genomics' diagnostic capabilities are strongly rooted in their need to end the diagnostic odyssey and may be difficult to manage.

PRACTICE IMPLICATIONS

Parents' hope for a resolution and effective treatment for their child is a powerful context in which genetic counseling is heard. Clinicians who provide genomic testing should continue to acknowledge parents' preconceptions. Additional research in other settings will help understand how to best address and manage parent expectations of genomic medicine.

In the Name of Prevention: Maternal Perspectives on School-Based HPV Vaccination in Rural Southern Chile

Purpose

Since the introduction of the HPV vaccine in Chile in 2014, there have been few studies exploring community perspectives on the vaccine, specifically of parents of adolescents. This study sought to identify maternal factors and family dynamics that affect HPV vaccination behavior.

Participants and Methods

Participants were recruited at an OB/GYN clinic in Linares, Chile. Participation was voluntary, and eligibility required 1) having an adolescent daughter between 9 and19 years-old and 2) demonstrating a willingness to discuss HPV-related topics. Thirty semi-structured interviews were conducted to generate qualitative data analyzed using Grounded Theory methodology.

Results

Three thematic constructs emerged from the interviews. Mothers’ motivations to vaccinate centered on disease prevention and trust in the medical system but were influenced by notions of sexual liberalism and promiscuity. Second, participants desired, but often had trouble finding, adequate information about vaccine safety and turned to the internet. Third, joint decision making in the family about vaccination led to open family discussions about sex and sexuality.

Conclusion

Chile’s school-based opt-out HPV vaccination program engenders a unique landscape of maternal decision-making, risk-benefit analysis, information-seeking, and at-home discussion. More studies are needed around the variable role of fathers in the decision-making process.

Racial/Ethnic Disparities in Very Preterm Birth and Preterm Birth Before and During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic may exacerbate existing racial/ethnic inequities in preterm birth.

OBJECTIVE

To assess whether racial/ethnic disparities in very preterm birth (VPTB) and preterm birth (PTB) increased during the first wave of the COVID-19 pandemic in New York City.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 8026 Black, Latina, and White women who gave birth during the study period. A difference-in-differences (DID) analysis of Black vs White disparities in VPTB or PTB in a pandemic cohort was compared with a prepandemic cohort by using electronic medical records obtained from 2 hospitals in New York City.

EXPOSURES

Women who delivered from March 28 to July 31, 2020, were considered the pandemic cohort, and women who delivered from March 28 to July 31, 2019, were considered the prepandemic cohort. Reverse transcription-polymerase chain reaction tests for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were performed using samples obtained via nasopharyngeal swab at the time of admission.

MAIN OUTCOMES AND MEASURES

Clinical estimates of gestational age were used to calculate VPTB (<32 weeks) and PTB (<37 weeks). Log binomial regression was performed to estimate Black vs White risk differences, pandemic cohort vs prepandemic cohort risk difference, and an interaction term representing the DID estimator. Covariate-adjusted models included age, insurance, prepregnancy body mass index, and parity.

RESULTS

Of 3834 women in the pandemic cohort, 492 (12.8%) self-identified as Black, 678 (17.7%) as Latina, 2012 (52.5%) as White, 408 (10.6%) as Asian, and 244 (6.4%) as other or unspecified race/ethnicity, with approximately half the women 25 to 34 years of age. The prepandemic cohort comprised 4192 women with similar sociodemographic characteristics. In the prepandemic cohort, VPTB risk was 4.4% (20 of 451) and PTB risk was 14.4% (65 of 451) among Black infants compared with 0.8% (17 of 2188) VPTB risk and 7.1% (156 of 2188) PTB risk among White infants. In the pandemic cohort, VPTB risk was 4.3% (21 of 491) and PTB risk was 13.2% (65 of 491) among Black infants compared with 0.5% (10 of 1994) VPTB risk and 7.0% (240 of 1994) PTB risk among White infants. The DID estimators indicated that no increase in Black vs White disparities were found (DID estimator for VPTB, 0.1 additional cases per 100 [95% CI, -2.5 to 2.8]; DID estimator for PTB, 1.1 fewer case per 100 [95% CI, -5.8 to 3.6]). The results were comparable in covariate-adjusted models when limiting the population to women who tested negative for SARS-CoV-2. No change was detected in Latina vs White PTB disparities during the pandemic.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of women who gave birth in New York City during the COVID-19 pandemic, no evidence was found for increased racial/ethnic disparities in PTB, among women who tested positive or tested negative for SARS-CoV-2.

"Is that something that should concern me?": a qualitative exploration of parent understanding of their child's genomic test results

Genetic counselors are trained to deliver complicated genomic test results to parents of pediatric patients. However, there is limited knowledge on how parents perceive this information and what they understand about the results. This research aims to qualitatively explore parents’ experiences receiving genomic test results for their children. As part of formative research for the NYCKidSeq Study, we recruited a purposive sample of parents of 22 children stratified by child race/ethnicity and test result classification (positive, uncertain, or negative) and conducted in-depth interviews using a semi-structured guide. Analysis was conducted using grounded theory’s constant comparative method across cases and themes. Parents described different elements of understanding: genetics knowledge; significance and meaning of positive, uncertain, or negative results; and implications for the health of their child and family. Parents reported challenges understanding technical details and significance of their child’s results but gladly allowed their providers to be custodians of this information. However, of the different elements of understanding described, parents cared most deeply about being able to understand implications for their child’s and family’s health. These findings suggest that a counseling approach that primarily addresses parents’ desire to understand how to best care for their child and family may be more appropriate than an information-heavy approach focused on technical details. Further research is warranted to confirm these findings in larger parent cohorts and to explore ways genetic counseling can support parents’ preferences without sacrificing important components of parent understanding and overall satisfaction with their experiences with genomic medicine.

Low molecular weight serum cell-free DNA concentration is associated with clinicopathologic indices of poor prognosis in women with uterine cancer

Background

Serum cell-free DNA (cfDNA) holds promise as a non-invasive cancer biomarker. The objective of this study was to evaluate the association of cfDNA concentration with clinicopathologic variables of poor prognosis and overall survival among women with uterine cancer compared to benign cancer-free controls.

Methods

cfDNA was extracted from the serum of 91 women with multiple uterine cancer histologies and 22 post-menopausal controls without cancer. Low molecular weight (LMW) cfDNA was separated from contaminating genomic high molecular weight cfDNA using paramagnetic bead purification and its concentration was measured using fluorometric quantification. Clinicopathologic data was abstracted from the electronic medical record. The association between serum cfDNA concentration, clinicopathologic variables, and overall survival was assessed using linear regression modelling, Cox proportional hazards modelling, and the Kaplan–Meier method.

Results

Median total serum cfDNA concentration for the cohort was 69.2 ng/mL (IQR 37.4, 132.3) and median LMW cfDNA concentration was 23.8 ng/mL (IQR 14.9, 44.4). There were no significant differences in total serum cfDNA concentration with any clinicopathologic variables. However, LMW cfDNA concentration was significantly higher in serum of women with cancer (25.8 ng/mL IQR 16.0, 49.6) compared to benign controls (15.5 ng/mL IQR 9.3, 25.8 ng/mL) (p < 0.01). It is also significantly higher among women with early stage cancer than benign controls (p < 0.01). There were also significant associations between LMW cfDNA concentration and stage of cancer (p = 0.01) and histology (p = 0.02). Patients with leiomyosarcoma and carcinosarcoma had higher cfDNA concentrations than those with endometrioid cancer. Over a median follow-up of 51.9 months, 75th percentile for overall survival for women with cancer was 24.0 months. Higher LMW cfDNA concentrations is associated with lower survival among women with cancer (p < 0.01).

Conclusions

Serum LMW cfDNA concentration is associated with overall survival in women with uterine cancer, and it is higher among women with uterine cancer compared to those of controls.

Understanding Zika virus as an STI: findings from a qualitative study of pregnant women in the Bronx

OBJECTIVES

Pregnant women in the Bronx were at risk for travel-related Zika exposure in the USA between 2016 and 2017. This qualitative study explored the experiences of 13 pregnant women to learn about their knowledge of Zika and prevention measures.

METHODS

In the summer of 2017, pregnant women at risk of travel-related Zika exposure were interviewed in either Spanish or English to learn about their experiences and transcripts were analysed using a grounded theory approach.

RESULTS

Most participants were Latinas living in the Bronx, median age of 29 years and median household income between $26 000 and $50 000. Participants displayed a strong understanding of Zika transmission via mosquito bites yet lacked knowledge about its sexual transmission. Interviews revealed three key themes: (1) Zika as a new disease, (2) denial as a coping mechanism and (3) the recommendation to treat Zika as an STI. Women observed Zika as a brand new disease with early messages emphasising mosquito-borne transmission. They lacked awareness of newer messaging about sexual transmission. Furthermore, if women did read about risk of sexual transmission, many stated being in denial and struggling with recommendations to prevent sexual transmission. Barriers included problems changing travel plans and rejection of condom use. Women unanimously suggested labelling Zika as an STI and adding it to existing lists of STIs for messaging and outreach in community-based and clinical prevention.

CONCLUSION

Many pregnant women were unaware that Zika virus can be sexually transmitted due to: (1) novelty of Zika, (2) denial as a coping mechanism and (3) Zika not being listed along with well-known STIs. Overcoming these barriers via community-based as well as clinical education for pregnant women in the Bronx would be helpful in 2019 and beyond when the risk of travel-related Zika exposure remains a public health threat to optimal pregnancy outcomes.

A Newborn Screening Education Best Practices Framework: Development and Adoption

Newborn screening is a process-based public health service. Newborn screening staff and families alike are essential to maintaining the timeliness of the screening process. Newborn screening education must be accurate and accessible. Past newborn screening conferences have highlighted gaps in best practice and evidence-based guidance on newborn screening education. Sharing successful strategies across programs mitigates the scarcity of resources by cutting costs and reducing the burden of work. These factors illustrate the need for an education framework to guide newborn screening education efforts. The Newborn Screening Education Best Practices Framework responds to these issues by outlining guidance for newborn screening education approaches. Experts in the fields of newborn screening, genetics, and bioethics as well as previous research on best practice guidelines have contributed to the development of this framework. The framework outlines a process for users to evaluate newborn screening education approaches as best practices. This framework reviews best practices using a two-step approach, looking at guiding questions, implementation of the newborn screening issue, and evaluation. The framework helps the user define the characteristics of the newborn screening issue, intended audience, and practical steps to implementation, and then decide whether or not it can be used as a best practice.

History of the establishment of the Preterm Birth international collaborative (PREBIC)

INTRODUCTION

The primary aim of PREBIC is to assess the underlying mechanisms and developing strategies for preterm birth (PTB) prevention.

MATERIALS AND METHODS

We used concept mapping and logic models to track goals. This paper reviews our progress over 13 years using working group activities, research developments, guest speakers, and publications.

RESULTS

Using interactions between genetics, environment, and behaviors we identified complex interactions between biological systems. PREBIC determined that epidemiology and biomarkers should be an initial focus. In 2005, we initiated presentations by young investigators, yearly satellite meetings, working groups including nutrition and inflammation, assessment of clinical trials, and accepted an invitation by the WHO to begin yearly meetings in Geneva.

DISCUSSION

PREBIC used epidemiology to identify PTB factors and complex pathways. Candidate genes are associated with the environment, behavior (stress), obesity, inflammation and insulin resistance. Epigenetic changes and production of proteins can be used as biomarkers to define risk. Subsequently, we found risk factors for PTB that were also associated with the risk of cardiovascular disease (CVD) of the mother. Tanz et al. (2017) found that a history of PTB is independently predictive of CVD later in life and suggested that a modest proportion of PTB-CVD association was accounted by CVD risk factors, many of which have been identified in this paper.

CONCLUSION

Our findings support a relationship between genes, environment, behaviors and risk of CVD in women. The next several years must assess which factors are modifiable early in life and before pregnancy to prevent PTB.

Research standardization tools: pregnancy measures in the PhenX Toolkit

Only through concerted and well-executed research endeavors can we gain the requisite knowledge to advance pregnancy care and have a positive impact on maternal and newborn health. Yet the heterogeneity inherent in individual studies limits our ability to compare and synthesize study results, thus impeding the capacity to draw meaningful conclusions that can be trusted to inform clinical care. The PhenX Toolkit (http://www.phenxtoolkit.org), supported since 2007 by the National Institutes of Health, is a web-based catalog of standardized protocols for measuring phenotypes and exposures relevant for clinical research. In 2016, a working group of pregnancy experts recommended 15 measures for the PhenX Toolkit that are highly relevant to pregnancy research. The working group followed the established PhenX consensus process to recommend protocols that are broadly validated, well established, nonproprietary, and have a relatively low burden for investigators and participants. The working group considered input from the pregnancy experts and the broader research community and included measures addressing the mode of conception, gestational age, fetal growth assessment, prenatal care, the mode of delivery, gestational diabetes, behavioral and mental health, and environmental exposure biomarkers. These pregnancy measures complement the existing measures for other established domains in the PhenX Toolkit, including reproductive health, anthropometrics, demographic characteristics, and alcohol, tobacco, and other substances. The preceding domains influence a woman's health during pregnancy. For each measure, the PhenX Toolkit includes data dictionaries and data collection worksheets that facilitate incorporation of the protocol into new or existing studies. The measures within the pregnancy domain offer a valuable resource to investigators and clinicians and are well poised to facilitate collaborative pregnancy research with the goal to improve patient care. To achieve this aim, investigators whose work includes the perinatal population are encouraged to utilize the PhenX Toolkit in the design and implementation of their studies, thus potentially reducing heterogeneity in data measures across studies. Such an effort will enhance the overall impact of individual studies, increasing the ability to draw more meaningful conclusions that can then be translated into clinical practice.

Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health

Objective

To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low‐ and middle‐income countries.

Design

Secondary analysis of a multi‐country cross‐sectional study.

Setting

29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.

Population

258 215 singleton deliveries in 286 hospitals.

Methods

We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries.

Main outcome measures

Preterm delivery.

Results

In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2–34.6%)] compared with medium (4.3%, 3.0–6.7%), and high‐HDI countries (4.8%, 4.4–5.5%).

Conclusion

Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low‐HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary.

Tweetable abstract

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Inclusion of stillbirths increases preterm birth rates estimates, especially in low‐HDI countries.

Adverse Infant Outcomes Associated with Discordant Gestational Age Estimates

BACKGROUND

Gestational age estimation by last menstrual period (LMP) vs. ultrasound (or best obstetric estimate in the US) may result in discrepant classification of preterm vs. term birth. We investigated whether such discrepancies are associated with adverse infant outcomes.

METHODS

We studied singleton livebirths in the Medical Birth Registries of Norway, Sweden and Finland and US live birth certificates from 1999 to the most recent year available. Risk ratios (RR) with 95% confidence intervals (CI) by discordant and concordant gestational age estimation for infant, neonatal and post-neonatal mortality, Apgar score <4 and <7 at 5 min, and neonatal intensive care unit (NICU) admission were estimated using generalised linear models, adjusting for maternal age, education, parity, year of birth, and infant sex. Results were presented stratified by country.

RESULTS

Compared to infants born at term by both methods, infants born preterm by ultrasound/best obstetric estimate but term by LMP had higher infant mortality risks (range of adjusted RRs 3.9 to 7.2) and modestly higher risks were obtained among infants born preterm by LMP but term by ultrasound/best obstetric estimate (range of adjusted RRs 1.6 to 1.9). Risk estimates for the other outcomes showed the same pattern. These findings were consistent across all four countries.

CONCLUSIONS

Infants classified as preterm by ultrasound/best estimate, but term by LMP have consistently higher risks of adverse outcomes than those classified as preterm by LMP but term by ultrasound/best estimate. Compared with ultrasound/best estimate, use of LMP overestimates the proportion of births that are preterm.

Variations in very preterm birth rates in 30 high-income countries: are valid international comparisons possible using routine data?

OBJECTIVE

Concerns about differences in registration practices across countries have limited the use of routine data for international very preterm birth (VPT) rate comparisons.

DESIGN

Population-based study.

SETTING

Twenty-seven European countries, the United States, Canada and Japan in 2010.

POPULATION

A total of 9 376 252 singleton births.

METHOD

We requested aggregated gestational age data on live births, stillbirths and terminations of pregnancy (TOP) before 32 weeks of gestation, and information on registration practices for these births. We compared VPT rates and assessed the impact of births at 22-23 weeks of gestation, and different criteria for inclusion of stillbirths and TOP on country rates and rankings.

MAIN OUTCOME MEASURES

Singleton very preterm birth rate, defined as singleton stillbirths and live births before 32 completed weeks of gestation per 1000 total births, excluding TOP if identifiable in the data source.

RESULTS

Rates varied from 5.7 to 15.7 per 1000 total births and 4.0 to 11.9 per 1000 live births. Country registration practices were related to percentage of births at 22-23 weeks of gestation (between 1% and 23% of very preterm births) and stillbirths (between 6% and 40% of very preterm births). After excluding births at 22-23 weeks, rate variations remained high and with a few exceptions, country rankings were unchanged.

CONCLUSIONS

International comparisons of very preterm birth rates using routine data should exclude births at 22-23 weeks of gestation and terminations of pregnancy. The persistent large rate variations after these exclusions warrant continued surveillance of VPT rates at 24 weeks and over in high-income countries.

TWEETABLE ABSTRACT

International comparisons of VPT rates should exclude births at 22-23 weeks of gestation and terminations of pregnancy.

Temporal Trends in Late Preterm and Early Term Birth Rates in 6 High-Income Countries in North America and Europe and Association With Clinician-Initiated Obstetric Interventions

IMPORTANCE

Clinicians have been urged to delay the use of obstetric interventions (eg, labor induction, cesarean delivery) until 39 weeks or later in the absence of maternal or fetal indications for intervention.

OBJECTIVE

To describe recent trends in late preterm and early term birth rates in 6 high-income countries and assess association with use of clinician-initiated obstetric interventions.

DESIGN

Retrospective analysis of singleton live births from 2006 to the latest available year (ranging from 2010 to 2015) in Canada, Denmark, Finland, Norway, Sweden, and the United States.

EXPOSURES

Use of clinician-initiated obstetric intervention (either labor induction or prelabor cesarean delivery) during delivery.

MAIN OUTCOMES AND MEASURES

Annual country-specific late preterm (34-36 weeks) and early term (37-38 weeks) birth rates.

RESULTS

The study population included 2,415,432 Canadian births in 2006-2014 (4.8% late preterm; 25.3% early term); 305,947 Danish births in 2006-2010 (3.6% late preterm; 18.8% early term); 571,937 Finnish births in 2006-2015 (3.3% late preterm; 16.8% early term); 468,954 Norwegian births in 2006-2013 (3.8% late preterm; 17.2% early term); 737,754 Swedish births in 2006-2012 (3.6% late preterm; 18.7% early term); and 25,788,558 US births in 2006-2014 (6.0% late preterm; 26.9% early term). Late preterm birth rates decreased in Norway (3.9% to 3.5%) and the United States (6.8% to 5.7%). Early term birth rates decreased in Norway (17.6% to 16.8%), Sweden (19.4% to 18.5%), and the United States (30.2% to 24.4%). In the United States, early term birth rates decreased from 33.0% in 2006 to 21.1% in 2014 among births with clinician-initiated obstetric intervention, and from 29.7% in 2006 to 27.1% in 2014 among births without clinician-initiated obstetric intervention. Rates of clinician-initiated obstetric intervention increased among late preterm births in Canada (28.0% to 37.9%), Denmark (22.2% to 25.0%), and Finland (25.1% to 38.5%), and among early term births in Denmark (38.4% to 43.8%) and Finland (29.8% to 40.1%).

CONCLUSIONS AND RELEVANCE

Between 2006 and 2014, late preterm and early term birth rates decreased in the United States, and an association was observed between early term birth rates and decreasing clinician-initiated obstetric interventions. Late preterm births also decreased in Norway, and early term births decreased in Norway and Sweden. Clinician-initiated obstetric interventions increased in some countries but no association was found with rates of late preterm or early term birth.

Maternal Whole Blood Gene Expression at 18 and 28 Weeks of Gestation Associated with Spontaneous Preterm Birth in Asymptomatic Women

The heterogeneity of spontaneous preterm birth (SPTB) requires an interdisciplinary approach to determine potential predictive risk factors of early delivery. The aim of this study was to investigate maternal whole blood gene expression profiles associated with spontaneous preterm birth (SPTB, <37 weeks) in asymptomatic pregnant women. The study population was a matched subgroup of women (51 SPTBs, 114 term delivery controls) who participated in the All Our Babies community based cohort in Calgary (n = 1878). Maternal blood at 17–23 (sampling time point 1, T₁) and 27–33 weeks of gestation (T₂) were collected. Total RNA was extracted and microarray was performed on 326 samples (165 women). Univariate analyses determined significant clinical factors and differential gene expression associated with SPTB. Thirteen genes were validated using qRT-PCR. Three multivariate logistic models were constructed to identify gene expression at T₁ (Model A), T₂ (Model B), and gene expression fold change from T₁ to T₂ (Model C) associated with SPTB. All models were adjusted for clinical factors. Model C can predict SPTB with 65% sensitivity and 88% specificity in asymptomatic women after adjusting for history of abortion and anaemia (occurring before T₂). Clinical data enhanced the sensitivity of the Models to predict SPTB. In conclusion, clinical factors and whole blood gene expression are associated with SPTB in asymptomatic women. An effective screening tool for SPTB during pregnancy would enable targeted preventive approaches and personalised antenatal care.

Prenatal Education of Parents About Newborn Screening and Residual Dried Blood Spots: A Randomized Clinical Trial

IMPORTANCE

Research clearly indicates that current approaches to newborn blood spot screening (NBS) education are ineffective. Incorporating NBS education into prenatal care is broadly supported by lay and professional opinion.

OBJECTIVE

To determine the efficacy and effect of prenatal education about newborn screening and use of residual dried blood spots (DBS) in research on parental knowledge, attitudes, and behaviors.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial of prenatal educational interventions, with outcomes measured by survey at 2 to 4 weeks postpartum. Participants were recruited from obstetric clinics in Salt Lake City, Utah; San Francisco, California; and the Bronx, New York. Eligible women were English- or Spanish-speaking adults and did not have a high-risk pregnancy. A total of 901 women were enrolled. Participants who completed the follow-up survey included 212 women in the usual care group (70% retention), 231 in the NBS group (77% retention), and 221 women in the NBS + DBS group (75% retention). Those who completed the survey were similar across the 3 groups with respect to age, ethnicity, race, education, marital status, income, obstetric history, and language.

INTERVENTIONS

Participants were randomized into 1 of 3 groups: usual care (n = 305), those viewing an NBS movie and brochure (n = 300), and those viewing both the NBS and DBS movies and brochures (n = 296).

MAIN OUTCOMES AND MEASURES

Two to four weeks postpartum, women completed a 91-item survey by telephone, addressing knowledge, attitudes, and behavior with respect to opting out of NBS or DBS for their child.

RESULTS

A total of 901 women (mean age, 31 years) were randomized and 664 completed the follow-up survey. The total correct responses on the knowledge instrument in regard to NBS were 69% in the usual care group, 79% in the NBS group, and 75% in the NBS + DBS group, a significant between-group difference (P < .05). Although all groups showed strong support for NBS, the percentage of women who were "very supportive" was highest in the NBS group (94%), followed by the NBS + DBS group (86%) and was lowest in the usual care group (73%) (P < .001). The interventions were not associated with decisions to decline newborn screening or withdraw residual DBS. Nine women stated that they had declined NBS (all the usual care group; P < .001). With respect to DBS, 5 participants indicated that they contacted the health department to have their child's sample withdrawn after testing: 3 in the NBS + DBS group and 2 in the usual care group (P = .25).

CONCLUSIONS AND RELEVANCE

Educational interventions can be implemented in the prenatal clinic, using multimedia tools and electronic platforms. Prenatal education is effective in increasing postnatal knowledge and support for these programs. These results are relevant to other contexts in which residual clinical specimens and data are used for research purposes.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02676245.

Chromosomal microarray in prenatal diagnosis: case studies and clinical challenges

Chromosomal microarray analysis (CMA) is a diagnostic tool used in the evaluation of pediatric patients with congenital anomalies or developmental and intellectual disability. In both the pediatric and prenatal patient population, CMA has been shown to have a higher detection rate of chromosomal abnormalities than conventional karyotype alone. Currently, the diagnostic yield of prenatal CMA is highest when applied to the evaluation of a fetus with multiple ultrasound anomalies. Challenges arise when CMA yields isolated findings not associated with a phenotype on ultrasound or variants of uncertain significance, which warrants evaluation of the risks, benefits, limitations and optimal incorporation of CMA into prenatal care. The clinical cases presented here will be used to illustrate these issues.

Implementing competency based admissions at the Albert Einstein College of Medicine

The Albert Einstein College of Medicine (Einstein) was founded in 1955 during an era of limited access to medical school for women, racial minorities, and many religious and ethnic groups. Located in the Bronx, NY, Einstein seeks to educate physicians in an environment of state-of-the-art scientific inquiry while simultaneously fulfilling a deep commitment to serve its community by providing the highest quality clinical care. A founding principle of Einstein, the basis upon which Professor Einstein agreed to allow the use of his name, was that admission to the student body would be based entirely on merit. To accomplish this, Einstein has long used a 'holistic' approach to the evaluation of its applicants, actively seeking a diverse student body. More recently, in order to improve its ability to identify students with the potential to be outstanding physicians, who will both advance medical knowledge and serve the pressing health needs of a diverse community, the Committee on Admissions reexamined and restructured the requirements for admission. These have now been categorized as four 'Admissions Competencies' that an applicant must demonstrate. They include: 1) cocurricular activities and relevant experiences; 2) communication skills; 3) personal and professional development; and 4) knowledge. The purpose of this article is to describe the process that resulted in the introduction and implementation of this competency based approach to the admission process.

Cumulative psychosocial stress, coping resources, and preterm birth

Preterm birth constitutes a significant international public health issue, with implications for child and family well-being. High levels of psychosocial stress and negative affect before and during pregnancy are contributing factors to shortened gestation and preterm birth. We developed a cumulative psychosocial stress variable and examined its association with early delivery controlling for known preterm birth risk factors and confounding environmental variables. We further examined this association among subgroups of women with different levels of coping resources. Utilizing the All Our Babies (AOB) study, an ongoing prospective pregnancy cohort study in Alberta, Canada (n = 3,021), multinomial logistic regression was adopted to examine the independent effect of cumulative psychosocial stress and preterm birth subgroups compared to term births. Stratified analyses according to categories of perceived social support and optimism were undertaken to examine differential effects among subgroups of women. Cumulative psychosocial stress was a statistically significant risk factor for late preterm birth (OR = 1.73; 95 % CI = 1.07, 2.81), but not for early preterm birth (OR = 2.44; 95 % CI = 0.95, 6.32), controlling for income, history of preterm birth, pregnancy complications, reproductive history, and smoking in pregnancy. Stratified analyses showed that cumulative psychosocial stress was a significant risk factor for preterm birth at <37 weeks gestation for women with low levels of social support (OR = 2.09; 95 % CI = 1.07, 4.07) or optimism (OR = 1.87; 95 % CI = 1.04, 3.37). Our analyses suggest that early vulnerability combined with current anxiety symptoms in pregnancy confers risk for preterm birth. Coping resources may mitigate the effect of cumulative psychosocial stress on the risk for early delivery.

Disclosing Genetic Information to Family Members About Inherited Cardiac Arrhythmias: An Obligation or a Choice?

Inherited cardiac arrhythmias such as long QT syndrome and Brugada syndrome, present clinical as well as ethical, legal, and social challenges. Many individuals who carry a deleterious mutation are largely asymptomatic and therefore may not be diagnosed until after the occurrence of a personal or family member's cardiac event. The familial nature of inherited genetic information raises numerous ethical, legal, and social issues regarding the sharing of genetic information, particularly when an individual found to carry a deleterious mutation refuses to disclose his or her results to at-risk family members who could benefit from life-saving treatments. This qualitative study sought to understand the experiences with genetic testing for individuals (n = 50) with a personal or family history of cardiac events or sudden death. Unstructured in-person focus groups or interviews were conducted for each participant in the study. The recordings of these interviews were transcribed verbatim and subsequently analyzed and coded. Participants' comments regarding sharing of genetic information centered around four main themes: (1) motivation to disclose; (2) extent of disclosure; (3) effect of disclosure on family dynamics; and (4) reasons for not sharing genetic information. The majority of individuals believed that affected individuals are obligated to disclose genetic information to family members. In the era of personalized medicine, the disclosure of genetic information provides individuals the opportunities to learn about the genetics, disease characteristics, and treatment options in order to reduce morbidity and mortality in themselves and their family members. Further research is necessary to identify and explore the barriers to sharing genetic information with at-risk family members.

Translating advances in cardiogenetics into effective clinical practice

In this article we describe a qualitative research study in which we explored individuals' subjective experiences of both genetic testing and cardiogenetic disorders. Using a grounded theory approach, we coded and analyzed interview and focus group transcripts from 50 participants. We found that just under half of the participants who received their diagnosis during the study reported difficulty understanding information about both the purpose of genetic testing and their cardiac disease. A high level of anxiety about genetic testing and cardiac symptoms exacerbated individuals' cognitive confusion. Participants reported both positive and negative interactions with the medical community, depending on health care professionals' knowledge of cardiogenetic disorders. Overall, participants expressed a range of attitudes--positive, negative, and ambivalent--toward genetic testing. We conclude with a discussion of the barriers to achieving effective clinical care for genetic conditions and offer suggestions for improving collaborative decision making between physicians and patients.

Psychological stress associated with cardiogenetic conditions

AIM

Genetic testing now makes it possible to identify specific mutations that may lead to life-threatening cardiac arrhythmias. This article presents data from a qualitative research study that explored the subjective experiences of individuals and families with cardiogenetic conditions. We focus on describing patients' experiences of psychological stresses associated with having a cardiogenetic condition, illustrating the importance of integrating psychological and medical care. This integration of care is particularly important as personalized genomic medicine continues to evolve and the implications of genetic testing have a profound effect on individuals and families.

METHODS

The researchers interviewed 50 participants from 32 families. The research team used a systematic, grounded theory procedure to code and analyze interview and focus group transcripts, incorporating multiple coders at several stages of the data analysis process.

RESULTS

Three major themes emerged: a bereavement trajectory associated with sudden death in the absence of prior symptoms; high anxiety about transmitting a genetic mutation; and resilience reflected in positive lifestyle changes and participation in support groups.

CONCLUSION

This article identifies patient perspectives on personalized genomic medicine in cardiogenetics that can improve clinical care, including: specialized bereavement counseling; improving education about cardiogenetic conditions for medical professionals; parent guidelines for discussing cardiogenetic conditions with their children; information about support groups; and the routine inclusion of clinical psychologists in interdisciplinary treatment teams. Given recent advances in technology and decreasing costs, whole-genome sequencing is likely to become common practice in the near future. Therefore, these recommendations are likely to be relevant for other genetic conditions, as well as the entire field of personalized genomic medicine.

What parents want to know about the storage and use of residual newborn bloodspots

Many state newborn screening programs retain residual newborn screening bloodspots for a variety of purposes including quality assurance, biomedical research, and forensic applications. This project was designed to determine the information that prospective parents want to know about this practice. Eleven focus groups were conducted in four states. Pregnant women and their partners and parents of young children (N = 128) were recruited from the general public. Focus group participants viewed two educational movies on newborn screening and DBS retention and use. Transcripts were analyzed with qualitative methods and the results were synthesized to identify key information items. We identified 14 categories of information from the focus groups that were synthesized into seven items prospective parents want to know about residual DBS. The items included details about storage, potential uses, risks and burdens, safeguards, anonymity, return of results, and parental choice. For those state programs that retain residual dried bloodspots, inclusion of the seven things parents want to know about residual dried bloodspots in educational materials may improve parental understanding, trust, and acceptance of the retention and use of stored bloodspots.

Implementation of an electronic genomic and family health history tool in primary prenatal care

"The Pregnancy and Health Profile," (PHP) is a free genetic risk assessment software tool for primary prenatal providers that collects patient-entered family (FHH), personal, and obstetrical health history, performs risk assessment, and presents the provider with clinical decision support during the prenatal encounter. The tool is freely available for download at www.hughesriskapps.net. We evaluated the implementation of PHP in four geographically diverse clinical sites. Retrospective chart reviews were conducted for patients seen prior to the study period and for patients who used the PHP to collect data on documentation of FHH, discussion of cystic fibrosis (CF) and hemoglobinopathy (HB) carrier screening, and CF and HB interventions (tests, referrals). Five hundred pre-implementation phase and 618 implementation phase charts were reviewed. Documentation of a 3-generation FHH or pedigree improved at three sites; patient race/ethnicity at three sites, father of the baby (FOB) race/ethnicity at all sites, and ancestry for the patient and FOB at three sites (P < 0.001-0001). CF counseling improved for implementation phase patients at one site (8% vs. 48%, P < 0.0001) and CF screening/referrals at two (2% vs. 14%, P < 0.0001; 6% vs. 14%; P = 0.05). Counseling and intervention rates did not increase for HB. This preliminary study suggests that the PHP can improve documentation of FHH, race, and ancestry, as well as the compliance with current CF counseling and intervention guidelines in some prenatal clinics. Future evaluation of the PHP should include testing in a larger number of clinical environments, assessment of additional performance measures, and evaluation of the system's overall clinical utility.