Health insurance coverage and experiences of intimate partner violence and postpartum abuse screening among rural US residents who gave birth 2016-2020

PURPOSE

Intimate partner violence (IPV) is elevated among rural residents and contributes to maternal morbidity and mortality. Postpartum health insurance expansion efforts could address multiple causes of maternal morbidity and mortality, including IPV. The objective of this study was to describe the relationship between perinatal health insurance, IPV, and postpartum abuse screening among rural US residents.

METHODS

Using 2016-2020 data on rural residents from the Pregnancy Risk Assessment Monitoring System, we assessed self-report of experiencing physical violence by an intimate partner and rates of abuse screening at postpartum visits. Health insurance at childbirth and postpartum was categorized as private, Medicaid, or uninsured. We also measured insurance transitions from childbirth to postpartum (continuous private, continuous Medicaid, Medicaid to private, and Medicaid to uninsured).

FINDINGS

IPV rates varied by health insurance status at childbirth, with the highest rates among Medicaid beneficiaries (7.7%), compared to those who were uninsured (1.6%) or privately insured (1.6%). When measured by insurance transitions, the highest IPV rates were reported by those with continuous Medicaid coverage (8.6%), followed by those who transitioned from Medicaid at childbirth to private insurance (5.3%) or no insurance (5.9%) postpartum. Nearly half (48.1%) of rural residents lacked postpartum abuse screening, with the highest proportion among rural residents who were uninsured at childbirth (66.1%) or postpartum (52.1%).

CONCLUSION

Rural residents who are insured by Medicaid before or after childbirth are at elevated risk for IPV. Medicaid policy efforts to improve maternal health should focus on improving detection and screening for IPV among rural residents.

Effects of Breastfeeding Peer Counseling on County-Level Breastfeeding Rates Among WIC Participants in Greater Minnesota

OBJECTIVE

U.S. breastfeeding outcomes consistently fall short of public health targets, with lower rates among rural and low-income people, as well as participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The U.S. Department of Agriculture funded a subset of local WIC agencies in Minnesota to implement Breastfeeding Peer Counseling Programs (BFPCs) aimed at improving breastfeeding rates. We examined the impact of BFPCs on breastfeeding rates among WIC participants in Greater Minnesota (outside the Minneapolis-St. Paul metropolitan area).

METHODS

We used data from the Minnesota WIC Information System for the years 2012 through 2019 to estimate the impact of peer counseling on breastfeeding duration using difference-in-differences models. Additionally, we examined results among rural counties and assessed the possibility of spillover effects by stratifying whether a county without BFPCs bordered one with BFPCs.

RESULTS

Availability of BFPCs resulted in a 3.1 to 3.4 percentage-point increase in breastfeeding rates at 3 months and a 3.2 to 3.7 percentage-point increase in breastfeeding rates at 6 months among WIC participants in Greater Minnesota. Among rural counties, results showed a statistically significant 4.1 to 5.2 percentage-point increase in breastfeeding duration rates. Both border and nonborder counties experienced positive impacts of BFPCs on breastfeeding rates, suggesting wide-ranging program spillover effects.

CONCLUSIONS

BFPCs had a significant positive impact on breastfeeding duration. Findings indicate an opportunity for improving rural breastfeeding rates through increased funding for WIC BFPCs.

Rural/urban differences in rates and predictors of intimate partner violence and abuse screening among pregnant and postpartum United States residents

OBJECTIVE

To describe rates and predictors of perinatal intimate partner violence (IPV) and rates and predictors of not being screened for abuse among rural and urban IPV victims who gave birth.

DATA SOURCES AND STUDY SETTING

This analysis utilized 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) data from 45 states and three jurisdictions.

STUDY DESIGN

This is a retrospective, cross-sectional study using multistate survey data.

DATA COLLECTION/EXTRACTION METHODS

This analysis included 201,413 survey respondents who gave birth in 2016-2020 (n = 42,193 rural and 159,220 urban respondents). We used survey-weighted multivariable logistic regression models, stratified by rural/urban residence, to estimate adjusted predicted probabilities and 95% confidence intervals (CIs) for two outcomes: (1) self-reported experiences of IPV (physical violence by a current or former intimate partner) and (2) not receiving abuse screening at health care visits before, during, or after pregnancy.

PRINCIPAL FINDINGS

Rural residents had a higher prevalence of perinatal IPV (4.6%) than urban residents (3.2%). Rural respondents who were Medicaid beneficiaries, 18-35 years old, non-Hispanic white, Hispanic (English-speaking), or American Indian/Alaska Native had significantly higher predicted probabilities of experiencing perinatal IPV compared with their urban counterparts. Among respondents who experienced perinatal IPV, predicted probabilities of not receiving abuse screening were 21.3% for rural and 16.5% for urban residents. Predicted probabilities of not being screened for abuse were elevated for rural IPV victims who were Medicaid beneficiaries, 18-24 years old, or unmarried, compared to urban IPV victims with those same characteristics.

CONCLUSIONS

IPV is more common among rural birthing people, and rural IPV victims are at higher risk of not being screened for abuse compared with their urban peers. IPV prevention and support interventions are needed in rural communities and should focus on universal abuse screening during health care visits and targeted support for those at greatest risk of perinatal IPV.

Rural-Urban Differences in Health Care Unaffordability During the Postpartum Period

OBJECTIVE

The objective of this study was to examine health care unaffordability for rural and urban residents and by postpartum status.

METHODS

We used cross-sectional survey data on female-identifying respondents ages 18-44 (n=17,800) from the 2019 to 2021 National Health Interview Study. Outcomes of interest were 3 measures of health care unaffordability. We conducted bivariate and multivariable regression models to assess the association between health care unaffordability, rurality, and postpartum status.

RESULTS

Bivariate analyses showed postpartum people reported statistically significantly higher rates of being unable to pay medical bills and having problems medical paying bills, as compared with nonpostpartum people. Rural residents also reported statistically significantly higher rates of being unable to pay their medical bills and having problems paying medical bills as compared with urban residents. In adjusted models, the predicted probability of being unable to pay medical bills among postpartum respondents was 12.8% (CI, 10.1-15.5), which was statistically significantly higher than among nonpostpartum respondents. Similarly, postpartum respondents had statistically significantly higher predicted probabilities of reporting problems paying medical bills (18.4%, CI, 15.4-21.4) as compared with nonpostpartum respondents. The rural residency was not significantly associated with the health care unaffordability outcome measures in adjusted models.

CONCLUSIONS

Both postpartum and rural respondents reported higher rates of being unable to pay medical bills and having problems paying medical bills; however, after adjusting for covariates, only postpartum respondents reported statistically significantly higher rates of these outcomes. These results suggest that postpartum status may present challenges to health care affordability that span the urban/rural context.

Understanding categories of postpartum care use among privately insured patients in the United States: a cluster-analytic approach

The postpartum period is critical for the health and well-being of birthing people, yet little is known about the range of health care services and supports needed during this time. Maternity care patients are often targeted for clinical interventions based on "low risk" or "high risk" designations, but dichotomized measures can be imprecise and may not reflect meaningful groups for understanding needed postpartum care. Using claims data from privately insured patients with childbirths between 2016 and 2018, this study identifies categories and predictors of postpartum care utilization, including the use of maternal care and other, nonmaternal, care (eg, respiratory, digestive). We then compare identified utilization-based categories with typical high- and low-risk designations. Among 269 992 patients, 5 categories were identified: (1) low use (55% of births); (2) moderate maternal care use, low other care use (25%); (3) moderate maternal, high other (8%); (4) high maternal, moderate other (7%); and (5) high maternal, high other (5%). Utilization-based categories were better at differentiating postpartum care use and were more consistent across patient profiles, compared with high- and low-risk dichotomies. Identifying categories of postpartum care need beyond a simple risk dichotomy is warranted and can assist in maternal health services research, policymaking, and clinical practice.

Screening for and Experiences of Intimate Partner Violence in the United States Before, During, and After Pregnancy, 2016-2019

Objectives. To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States. Methods. We used 2016-2019 Pregnancy Risk Assessment Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence. Results. Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened. Conclusions. Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (Am J Public Health. 2023;113(3):297-305. https://doi.org/10.2105/10.2105/AJPH.2022.307195).

Association of Health Insurance, Geography, and Race and Ethnicity With Disparities in Receipt of Recommended Postpartum Care in the US

Importance

Little is known about the quality of postpartum care or disparities in the content of postpartum care associated with health insurance, rural or urban residency, and race and ethnicity.

Objectives

To examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity.

Design, Settings, and Participants

This cross-sectional survey of patients with births from 2016 to 2019 used data from the Pregnancy Risk Assessment Monitoring System (43 states and 2 jurisdictions). A population-based sample of patients conducted by state and local health departments in partnership with the Centers for Disease Control and Prevention were surveyed about maternal experiences 2 to 6 months after childbirth (mean weighted response rate, 59.9%). Patients who attended a postpartum visit were assessed for content at that visit. Analyses were performed November 2021 to July 2022.

Exposures

Medicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups).

Main Outcomes and Measures

Receipt of 2 postpartum care components recommended by national quality standards (depression screening and contraceptive counseling), and/or other recommended components (smoking screening, abuse screening, birth spacing counseling, eating and exercise discussions) with estimated risk-adjusted predicted probabilities and percentage-point (pp) differences.

Results

Among the 138 073 patient-respondents, most (59.5%) were in the age group from 25 to 34 years old; 59 726 (weighted percentage, 40%) were insured by Medicaid; 27 721 (15%) were rural residents; 9718 (6%) were Asian, 24 735 (15%) were Black, 22 210 (15%) were Hispanic, 66 323 (60%) were White, and fewer than 1% were Indigenous (Native American/Alaska Native) individuals. Receipt of both depression screening and contraceptive counseling both significantly lower for Medicaid-insured patients (1.2 pp lower than private; 95% CI, -2.1 to -0.3), rural residents (1.3 pp lower than urban; 95% CI, -2.2 to -0.4), and people of racially minoritized groups (0.8 pp lower than White individuals; 95% CI, -1.6 to -0.1). The highest receipt of these components was among privately insured White urban residents (80%; 95% CI, 79% to 81%); the lowest was among privately insured racially minoritized rural residents (75%; 95% CI, 72% to 78%). Receipt of all other components was significantly higher for Medicaid-insured patients (6.1 pp; 95% CI, 5.2 to 7.0), rural residents (1.1 pp; 95% CI, 0.1 to 2.0), and people of racially minoritized groups (8.5 pp; 95% CI, 7.7 to 9.4). The highest receipt of these components was among Medicaid-insured racially minoritized urban residents (34%; 95% CI, 33% to 35%), the lowest was among privately insured White urban residents (19%; 95% CI, 18% to 19%).

Conclusions and Relevance

The findings of this cross-sectional survey of postpartum individuals in the US suggest that inequities in postpartum care content were extensive and compounded for patients with multiple disadvantaged identities. Examining only 1 dimension of identity may understate the extent of disparities. Future studies should consider the content of postpartum care visits.

Racial/Ethnic Disparities in Postpartum Health Insurance Coverage Among Rural and Urban U.S. Residents

Objective: Half of maternal deaths occur during the postpartum year, with data suggesting greater risks among Black, Indigenous, and people of color (BIPOC) and rural residents. Being insured after childbirth improves postpartum health-related outcomes, and recent policy efforts focus on extending postpartum Medicaid coverage from 60 days to 1 year postpartum. The purpose of this study is to describe postpartum health insurance coverage for rural and urban U.S. residents who are BIPOC compared to those who are white. Materials and Methods: Using data from the 2016-2019 Pregnancy Risk Assessment Monitoring System (n = 150,273), we describe health insurance coverage categorized as Medicaid, commercial, or uninsured at the time of childbirth and postpartum. We measured continuity of insurance coverage across these periods, focusing on postpartum Medicaid disruptions. Analyses were conducted among white and BIPOC residents from rural and urban U.S. counties. Results: Three-quarters (75.3%) of rural white people and 85.3% of urban white people were continuously insured from childbirth to postpartum, compared to 60.5% of rural BIPOC people and 65.6% of urban BIPOC people. Postpartum insurance disruptions were frequent among people with Medicaid coverage at childbirth, particularly among BIPOC individuals, compared to those with private insurance; 17.0% of rural BIPOC residents had Medicaid at birth and became uninsured postpartum compared with 3.4% of urban white people. Conclusions: Health insurance coverage at childbirth, postpartum, and across these timepoints varies by race/ethnicity and rural compared with urban residents. Policy efforts to extend postpartum Medicaid coverage may reduce inequities at the intersection of racial/ethnic identity and rural geography.

Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid

OBJECTIVE

We examined differences in rates of severe maternal morbidity and mortality (SMMM) among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography, race and ethnicity, and clinical factors.

METHODS

We used maternal discharge records from childbirth hospitalizations in the Health care Cost and Utilization Project's National Inpatient Sample from 2007 to 2015. We calculated predicted probabilities using weighted multivariable logistic regressions to estimate adjusted rates of SMMM, examining differences in rates by payer, rurality, race and ethnicity, and clinical factors. To assess the presence and extent of additive risk by payer, with other risk factors, on rates of SMMM, we estimated the proportion of the combined effect that was due to the interaction.

RESULTS

In this analysis of 6,357,796 hospitalizations for childbirth, 2,932,234 were Medicaid funded and 3,425,562 were privately insured. Controlling for sociodemographic and clinical factors, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Medicaid-funded births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. Thirty-two percent (Bonferroni-adjusted 95% confidence interval, 19%-45%) of SMMM cases among patients with chronic heart disease were due to payer interaction, and 19% (Bonferroni-adjusted 95% confidence interval, 17%-22%) among those with cesarean birth were due to the interaction.

CONCLUSIONS

Heightened rates of SMMM among Medicaid-funded births indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.

Association Between Medicaid Expansion And Closure Of Hospital-Based Obstetric Services

Access to obstetric services has declined steadily during the past decade, driven by the closure of hospital-based obstetric units and of entire hospitals. A fundamental challenge to maintaining obstetric services is that they are frequently unprofitable for hospitals to operate, threatening hospital viability. Medicaid expansion has emerged as a possible remedy for obstetric service closure because it reduces uncompensated care and improves hospital finances. Using national hospital data from the period 2010-18, we assessed the relationship between Medicaid expansion and obstetric service closure in rural and urban communities. We found that expansion led to a large reduction in hospital closures; however, this effect was concentrated among hospitals that did not have obstetric units. Considering closure of obstetric units, we found that rural obstetric units were less likely to close immediately after expansion, but this effect faded within two years. Overall, our findings suggest that Medicaid expansion had little effect on the closure of obstetric services. Policies supporting access to obstetric care may need to directly address the financial challenges specific to this service line.

Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018

IMPORTANCE

Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.

OBJECTIVE

To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.

EXPOSURE

Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.

MAIN OUTCOMES AND MEASURES

Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.

RESULTS

The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.

CONCLUSIONS AND RELEVANCE

In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.

Prescription opioid use during pregnancy and risk for preterm birth or term low birthweight

OBJECTIVE

Examine the relationship between prescription opioid analgesic use during pregnancy and preterm birth or term low birthweight.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed data from the National Birth Defects Prevention Study, a US multisite, population-based study, for births from 1997 to 2011. We defined exposure as self-reported prescription opioid use between one month before conception and the end of pregnancy, and we dichotomized opioid use duration by ≤7 days and >7 days.

MAIN OUTCOME MEASURES

We examined the association between opioid use and preterm birth (defined as gestational age <37 weeks) and term low birthweight (defined as <2500 g at gestational age ≥37 weeks).

RESULTS

Among 10,491 singleton mother/infant pairs, 470 (4.5 percent) reported opioid use. Among women reporting opioid use, 236 (50 percent) used opioids for > 7 days; codeine (170, 36 percent) and hydrocodone (163, 35 percent) were the most commonly reported opioids. Opioid use was associated with slightly increased risk for preterm birth [adjusted odds ratio, 1.4; 95 percent confidence interval, 1.0, 1.9], particularly with hydrocodone [1.6; 1.0, 2.6], meperidine [2.5; 1.2, 5.2], or morphine [3.0; 1.5, 6.1] use for any duration; however, opioid use was not significantly associated with term low birthweight.

CONCLUSIONS

Preterm birth occurred more frequently among infants of women reporting prescription opioid use during pregnancy. However, we could not determine if these risks relate to the drug or to indications for use. Patients who use opioids during pregnancy should be counseled by their practitioners about this and other potential risks associated with opioid use in pregnancy.

Local Capacity for Emergency Births in Rural Hospitals Without Obstetrics Services

BACKGROUND

Rural hospitals are closing obstetric units, and limited information is available about local emergency obstetric preparedness and capacity in rural communities where hospitals do not routinely provide this care.

OBJECTIVE

To describe emergency obstetric capacity at rural US hospitals that do not routinely offer childbirth services.

METHODS

Data from the 2018 American Hospital Association Annual Survey were used to identify a random sample of rural hospitals that did not offer obstetric services. A survey was developed based on World Health Organization criteria for obstetric emergencies. With data collected from 69 rural hospital emergency departments (48% response rate), we analyzed local capacity to support childbirth.

RESULTS

Most responding hospitals (65%) were located 30 or more miles away from a hospital with obstetric services. Some reported having emergency room births in the past year (28%), an unanticipated adverse birth outcome (32%), and/or a delay in urgent transport for a pregnant patient (22%). More than 90% of responding hospitals had capacity for blood transfusion, intravenous antibiotics or anticonvulsants, and basic neonatal resuscitation. However, less than one-fifth had capacity to perform surgery (16%), remove retained products of delivery (17%), or had a policy for emergency cesarean (18%). Almost all respondents (80%) reported the need for additional training or resources to handle emergency obstetric situations.

CONCLUSION

Many rural hospitals do not have basic capacity to provide emergency obstetric services. Programs and policies to improve this may focus on surgical care, clinician and staff training, transportation, and coordination with nearby hospitals that provide obstetric services.

Characteristics of US Rural Hospitals by Obstetric Service Availability, 2017

Objectives. To describe characteristics of rural hospitals in the United States by whether they provide labor and delivery (obstetric) care for pregnant patients.Methods. We used the 2017 American Hospital Association Annual Survey to identify rural hospitals and describe their characteristics based on the lack or provision of obstetric services.Results. Among the 2019 rural hospitals in the United States, 51% (n = 1032) of rural hospitals did not provide obstetric care. These hospitals were more often located in rural noncore counties (counties with no town of more than 10 000 residents). Rural hospitals without obstetrics also had lower average daily censuses, were more likely to be government owned or for profit compared with nonprofit ownership, and were more likely to not have an emergency department compared with hospitals providing obstetric care (P for all comparisons < .001).Conclusions. Rural US hospitals that do not provide obstetric care are located in more sparsely populated rural locations and are smaller than hospitals providing obstetric care.Public Health Implications. Understanding the characteristics of rural hospitals by lack or provision of obstetric services is important to clinical and policy efforts to ensure safe maternity care for rural residents.

Changes in Hospital-Based Obstetric Services in Rural US Counties, 2014-2018

This study describes hospital-based obstetric service losses in rural US counties between 2014 and 2018 overall and by county population and urban adjacency.

Policies, practices and barriers to implementing tuberculosis preventive treatment-35 countries, 2017

BACKGROUND: Tuberculosis preventive treatment (TPT) reduces the development of tuberculosis (TB) disease and mortality in people living with human immunodeficiency virus (HIV) infection. Despite this known effectiveness, global uptake of TPT has been slow. We aimed to assess current status of TPT implementation in countries supported by the US President's Emergency Plan for AIDS Relief (PEPFAR).METHODS: We surveyed TB-HIV program staff at US Centers for Disease Control and Prevention (CDC) country offices in 42 PEPFAR-supported countries about current TPT policies, practices, and barriers to implementation. Surveys completed from July to December 2017 were analyzed.RESULTS: Of 42 eligible PEPFAR-supported countries, staff from 35 (83%) CDC country offices completed the survey. TPT was included in national guidelines in 33 (94%) countries, but only 21 (60%) reported nationwide programmatic TPT implementation. HIV programs led TPT implementation in 20/32 (63%) countries, but TB programs led drug procurement in 18/32 (56%) countries. Stock outs were frequent, as 21/28 (75%) countries reported at least one isoniazid stock out in the previous year.CONCLUSION: Despite widespread inclusion of TPT in guidelines, programmatic TPT implementation lags. Successful scale-up of TPT requires uninterrupted drug supply chains facilitated by improved leadership and coordination between HIV and TB programs.

Discussing Appropriate Medication Use and Multivitamin Intake with a Healthcare Provider: An Examination of Two Elements of Preconception Care Among Latinas

BACKGROUND

Counseling for appropriate medication use and folic acid consumption are elements of preconception care critical for improving pregnancy outcomes. Hispanic women receive less preconception care than women of other race/ethnic groups. The objective of this analysis is to describe differences in these two elements of preconception care among Hispanic subsegments.

MATERIALS AND METHODS

Porter Novelli's 2013 Estilos survey was sent to 2,609 U.S. Hispanic adults of the Offerwise QueOpinas Panel. Surveys were completed by 1,000 individuals (calculated response rate 42%), and results were weighted to the 2012 U.S. Census Hispanic proportions for sex, age, income, household size, education, region, country of origin, and acculturation. Responses were analyzed with weighted descriptive statistics, linear regression, and Rao-Scott chi-square tests.

RESULTS

Of the 499 female respondents, 248 had a child under the age of 18 years and were asked about healthcare provider discussions concerning medication use before or during their last pregnancy. Timing of discussions varied by maternal age, marital status, income, youngest child's country of birth, and acculturation. Discussions before pregnancy were reported by 47% of the female respondents; high acculturated women more often reported never having such discussions. Among female respondents, 320 were of reproductive age, and 27% of those reported daily multivitamin use. Multivitamin use varied by pregnancy intention and youngest child's country of birth, but did not vary significantly by acculturation.

CONCLUSIONS

Differences in discussions concerning medication use in pregnancy and multivitamin use exist among Hispanic subsegments based on pregnancy intention, marital status, income, youngest child's country of birth, and level of acculturation.

Association between antibiotic use among pregnant women with urinary tract infections in the first trimester and birth defects, National Birth Defects Prevention Study 1997 to 2011

BACKGROUND

Previous studies noted associations between birth defects and some antibiotics (e.g., nitrofurantoin, sulfonamides) but not others (e.g., penicillins). It is unclear if previous findings were due to antibiotic use, infections, or chance. To control for potential confounding by indication, we examined associations between antibiotic use and birth defects, among women reporting urinary tract infections (UTIs).

METHODS

The National Birth Defects Prevention Study is a multi-site, population-based case-control study. Case infants/fetuses have any of over 30 major birth defects and controls are live-born infants without major birth defects. We analyzed pregnancies from 1997 to 2011 to estimate the association between maternally reported periconceptional (month before conception through the third month of pregnancy) use of nitrofurantoin, trimethoprim-sulfamethoxazole, or cephalosporins and specific birth defects, among women with periconceptional UTIs. Women with periconceptional UTIs who reported penicillin use served as the comparator.

RESULTS

Periconceptional UTIs were reported by 7.8% (2029/26,068) of case and 6.7% (686/10,198) of control mothers. Most (68.2% of case, 66.6% of control mothers) also reported antibiotic use. Among 608 case and 231 control mothers reporting at least one periconceptional UTI and certain antibiotic use, compared with penicillin, nitrofurantoin use was associated with oral clefts in the offspring (adjusted odds ratio, 1.97 [95% confidence interval, 1.10-3.53]), trimethoprim-sulfamethoxazole use with esophageal atresia (5.31 [1.39-20.24]) and diaphragmatic hernia (5.09 [1.20-21.69]), and cephalosporin use with anorectal atresia/stenosis (5.01 [1.34-18.76]).

CONCLUSION

Periconceptional exposure to some antibiotics might increase the risk for certain birth defects. However, because individual birth defects are rare, absolute risks should drive treatment decisions.Birth Defects Research (Part A) 106:940-949, 2016.© 2016 Wiley Periodicals, Inc.

Risk comparison for prenatal use of analgesics and selected birth defects, National Birth Defects Prevention Study 1997-2011

PURPOSE

To compare the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or opioids to the use of acetaminophen without NSAIDs or opioids with respect to associations with birth defects.

METHODS

We used data from the National Birth Defects Prevention Study (1997-2011). Exposure was self-reported maternal analgesic use from the month before through the third month of pregnancy (periconceptional). Adjusted odds ratios (aORs) were calculated to examine associations with 16 birth defects.

RESULTS

Compared to acetaminophen, mothers reporting NSAIDs were significantly more likely to have offspring with gastroschisis, hypospadias, cleft palate, cleft lip with cleft palate, cleft lip without cleft palate, anencephaly, spina bifida, hypoplastic left heart syndrome, pulmonary valve stenosis, and tetralogy of Fallot (aOR range, 1.2-1.6). Opioids were associated with tetralogy of Fallot, perimembranous ventricular septal defect, and ventricular septal defect with atrial septal defect (aOR range, 1.8-2.3), whereas use of both opioids and NSAIDs was associated with gastroschisis, cleft palate, spina bifida, hypoplastic left heart syndrome, and pulmonary valve stenosis (aOR range, 2.0-2.9).

CONCLUSIONS

Compared to periconceptional use of acetaminophen, selected birth defects occurred more frequently among infants of women using NSAIDs and/or opioids. However, we could not definitely determine whether these risks relate to the drugs or to indications for treatment.

Maternal Use of Opioids During Pregnancy and Congenital Malformations: A Systematic Review

CONTEXT

Opioid use and abuse have increased dramatically in recent years, particularly among women.

OBJECTIVES

We conducted a systematic review to evaluate the association between prenatal opioid use and congenital malformations.

DATA SOURCES

We searched Medline and Embase for studies published from 1946 to 2016 and reviewed reference lists to identify additional relevant studies.

STUDY SELECTION

We included studies that were full-text journal articles and reported the results of original epidemiologic research on prenatal opioid exposure and congenital malformations. We assessed study eligibility in multiple phases using a standardized, duplicate review process.

DATA EXTRACTION

Data on study characteristics, opioid exposure, timing of exposure during pregnancy, congenital malformations (collectively or as individual subtypes), length of follow-up, and main findings were extracted from eligible studies.

RESULTS

Of the 68 studies that met our inclusion criteria, 46 had an unexposed comparison group; of those, 30 performed statistical tests to measure associations between maternal opioid use during pregnancy and congenital malformations. Seventeen of these (10 of 12 case-control and 7 of 18 cohort studies) documented statistically significant positive associations. Among the case-control studies, associations with oral clefts and ventricular septal defects/atrial septal defects were the most frequently reported specific malformations. Among the cohort studies, clubfoot was the most frequently reported specific malformation.

LIMITATIONS

Variabilities in study design, poor study quality, and weaknesses with outcome and exposure measurement.

CONCLUSIONS

Uncertainty remains regarding the teratogenicity of opioids; a careful assessment of risks and benefits is warranted when considering opioid treatment for women of reproductive age.

Assessment of YouTube videos as a source of information on medication use in pregnancy

BACKGROUND

When making decisions about medication use in pregnancy, women consult many information sources, including the Internet. The aim of this study was to assess the content of publicly accessible YouTube videos that discuss medication use in pregnancy.

METHODS

Using 2023 distinct combinations of search terms related to medications and pregnancy, we extracted metadata from YouTube videos using a YouTube video Application Programming Interface. Relevant videos were defined as those with a medication search term and a pregnancy-related search term in either the video title or description. We viewed relevant videos and abstracted content from each video into a database. We documented whether videos implied each medication to be "safe" or "unsafe" in pregnancy and compared that assessment with the medication's Teratogen Information System (TERIS) rating.

RESULTS

After viewing 651 videos, 314 videos with information about medication use in pregnancy were available for the final analyses. The majority of videos were from law firms (67%), television segments (10%), or physicians (8%). Selective serotonin reuptake inhibitors (SSRIs) were the most common medication class named (225 videos, 72%), and 88% of videos about SSRIs indicated that they were unsafe for use in pregnancy. However, the TERIS ratings for medication products in this class range from "unlikely" to "minimal" teratogenic risk.

CONCLUSION

For the majority of medications, current YouTube video content does not adequately reflect what is known about the safety of their use in pregnancy and should be interpreted cautiously. However, YouTube could serve as a platform for communicating evidence-based medication safety information.

Hypothyroidism after cancer and the ability to meet reproductive goals among a cohort of young adult female cancer survivors

OBJECTIVE

To determine whether developing hypothyroidism after cancer treatment is associated with a decreased probability of women being able to meet their reproductive goals.

DESIGN

A population-based cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 1,282 cancer survivors, of whom 904 met the inclusion criteria for the analysis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Three outcomes that may indicate reduced fertility, which include failure to achieve desired family size, childlessness, and not achieving pregnancy after at least 6 months of regular unprotected intercourse.

RESULT(S)

We used data from the Furthering Understanding of Cancer Health and Survivorship in Adult (FUCHSIA) Women's Study to examine the association between being diagnosed with hypothyroidism after cancer and meeting reproductive goals. After adjusting for age and other potential confounders, women reporting hypothyroidism after cancer treatment were twice as likely to fail to achieve their desired family size (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI], 1.09, 3.33) and be childless (aOR 2.13; 95% CI, 1.25, 3.65). They were also more likely to report having unprotected intercourse for at least 6 months without conceiving (aOR 1.37; 95% CI, 0.66, 2.83).

CONCLUSION(S)

Although cancer treatments themselves are gonadotoxic, it is important to consider other medical conditions such as hypothyroidism that occur after cancer treatment when counseling patients on the risks for impaired fertility or a shortened reproductive window.