Factors Associated with Receiving No Maternal or Neonatal Interventions among Periviable Deliveries.

OBJECTIVE: The aim of this study was to quantify the influence of maternal sociodemographic, medical, and pregnancy characteristics on not receiving maternal and neonatal interventions with deliveries occurring at 22 to 23 weeks of gestation. STUDY DESIGN: This was a case-control study of U.S. live births at 220/6 to 236/7 weeks of gestation using vital statistics birth records from 2012 to 2016. We analyzed births that received no interventions for periviable delivery. Births were defined as having no interventions if they did not receive maternal (cesarean delivery, maternal hospital transfer, or antenatal corticosteroid administration) or neonatal interventions (neonatal intensive care unit admission, surfactant administration, antibiotic administration, or assisted ventilation). Logistic regression estimated the influence of maternal and pregnancy factors on the receipt of no interventions when delivery occurred at 22 to 23 weeks. RESULTS: Of 19,844,580 U.S. live births in 2012-2016, 24,379 (0.12%) occurred at 22 to 23 weeks; 54.3% of 22-week deliveries and 15.7% of 23-week deliveries received no interventions. Non-Hispanic Black maternal race was associated with no maternal interventions at 22 and 23 weeks. Private insurance, singleton pregnancy, and small for gestational age were associated with receiving no neonatal interventions at 22 and 23 weeks of gestation. CONCLUSIONS: Withholding or refusing maternal and neonatal interventions occurs frequently at the threshold of viability. Our data highlight various sociodemographic, pregnancy, and medical factors associated with decisions to not offer or receive maternal or neonatal interventions when birth occurs at the threshold of viability. The data elucidate observed practices and may assist in the development of further research. KEY POINTS: · Non-Hispanic Black race was associated with receiving no maternal interventions.. · Indicators of high socioeconomic status were associated with no neonatal inventions.. · Patient-level factors influence the receipt of no interventions for periviable birth..

Influence of periconception smoking behavior on birth defect risk.

BACKGROUND: Smoking is one of the most important modifiable risk factors for adverse maternal and neonatal outcomes. Smoking during pregnancy has been associated with fetal growth restriction, adverse pregnancy outcomes, and chronic adult diseases. Existing research has evaluated the risk of smoking on congenital defects. However, no studies have evaluated how periconception smoking affects birth defects. OBJECTIVE: The purpose of this study was to assess the association of maternal smoking and the timing of periconception exposure with congenital birth defects. STUDY DESIGN: This study was a population-based retrospective cohort of live births in Ohio from 2006-2015 with the use of data from birth certificates. Rates of cardiovascular, musculoskeletal, gastrointestinal, and neural tube birth defects were compared between a referent group of women who did not smoke and a group of women who smoked (1) during the preconception period of 3 months before conception only and not in the first trimester and (2) in the preconception period plus throughout the first trimester of pregnancy. Multivariate logistic regression was used to quantify the relationship between periconception smoking and the rate of birth defects after adjustment for maternal race, age, pregestational diabetes mellitus, and socioeconomic factors. RESULTS: Of the 1,436,036 live births in the study period, 75% of mothers did not smoke during the preconception period or during pregnancy. There were 334,156 women (23.3%) who smoked during pregnancy; 6.0% of the population smoked preconception only, and 17.3% of the population smoked both during the preconception period and through the first trimester. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis. Smoking that was limited to preconception only was not associated with any other individual birth defects. However, smoking through the first trimester was associated with a statistically significant increased risk of several defects that included gastroschisis and limb reduction and a composite outcome of any defect, even after adjustment for coexisting factors. CONCLUSION: Smoking during the period of fetal organogenesis (during the first trimester of pregnancy) is associated with increased risk of some birth defects. In this study, we provide novel data that smoking during the few months before conception, even with cessation in the first trimester, may also pose a risk for fetal malformation such as gastroschisis. These findings highlight the importance of preconception women's public health education efforts and warrant further investigation.

Association Between State Paid Family and Medical Leave and Breastfeeding, Depression, and Postpartum Visits.

OBJECTIVE: To evaluate the association of state paid family and medical leave policies with the likelihood of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit. METHODS: This was a cross-sectional study that used 2016-2019 data from PRAMS (Pregnancy Risk Assessment Monitoring System) for 43 states and Washington, DC. We describe the association of state paid family and medical leave generosity with rates of breastfeeding, postpartum depression symptoms, and attendance of the postpartum visit. Logistic and Poisson regression models tested the significance of state paid family and medical leave coverage generosity after controlling for individual respondent sociodemographic characteristics, with sensitivity analyses for respondents with deliveries covered by Medicaid insurance. RESULTS: Of the 143,131 respondents, representative of an estimated 7,426,725 population, 26.2% lived in eight states and DC with the most generous paid family and medical leave, 20.5% lived in nine states with some paid family and medical leave, and 53.3% lived in 26 states with little or no paid family and medical leave. Overall, 54.8% reported breastfeeding at 6 months or at time of the survey, ranging from 59.5% in the most generous paid family and medical leave states to 51.0% in states with the least paid family and medical leave coverage. Postpartum depression symptoms varied from 11.7% in the most generous states to 13.3% in the least generous states (both P <.001). State differences in postpartum visit attendance rates (90.9% overall) did not differ significantly. After adjusting for respondent characteristics, compared with states with the least paid family and medical leave, breastfeeding was 9% more likely (adjusted incidence rate ratio [aIRR] 1.09, 95% CI, 1.07-1.11) in states with the strongest paid family and medical leave coverage and 32% more likely (aIRR 1.32, 95% CI, 1.25-1.39) in analyses limited to respondents with deliveries covered by Medicaid insurance. A more generous state paid family and medical leave policy was significantly associated with a lower likelihood of postpartum depression symptoms compared with states with the least paid family and medical leave (adjusted odds ratio 0.85, 95% CI, 0.76-0.94) and a modest but significant increase in postpartum visit attendance (aIRR 1.03, 95% CI, 1.01-1.04) among respondents with deliveries covered by Medicaid insurance. CONCLUSION: Respondents from states with strong paid family and medical leave had a greater likelihood of breastfeeding and had lower odds of postpartum depression symptoms, with stronger associations among respondents with deliveries covered by Medicaid insurance. Despite major potential health benefits of paid family and medical leave, the United States remains one of the few countries without federally mandated paid parental leave.

How many US obstetrical trials reach publication? A cross-sectional analysis of ClinicalTrials.gov and PubMed from 2007 to 2019.

BACKGROUND: Obstetrical clinical trials are the foundation of evidence-based medicine during pregnancy. As more obstetrical trials are conducted, understanding the publication characteristics of these trials is of utmost importance to advance obstetrical health. OBJECTIVE: This study aimed to characterize the frequency of publication and trial characteristics associated with publication among obstetrical clinical trials in the United States. We additionally sought to examine time from trial completion to publication. STUDY DESIGN: This was a cross-sectional analysis of completed obstetrical trials with an intervention design and at least 1 site in the United States registered to ClinicalTrials.gov from 2007 to 2019. Trial characteristics were cross-referenced with PubMed to determine publication status up to 2021 using the National Clinical Trial identification number. Bivariable analyses were conducted to determine trial characteristics associated with publication. Multivariable logistic regression models controlling for prespecified covariates were generated to estimate the relationship between funding, primary purpose, and therapeutic foci with publication. Additional exploratory analyses of other trial characteristics were conducted. Time to publication was analyzed using Kaplan-Meier curves and Cox regression models. RESULTS: Of the 1879 obstetrical trials with registered completion, a total of 575 (30.6%) had at least 1 site in the United States, were completed before October 1, 2019, and were included in this analysis. Between October 2007 and October 2019, fewer than two-thirds (N=348, 60.5%) of trials reached publication. Annual rates of publication ranged from 46.4% in 2018 to 70.0% in 2007. No difference was observed in publication by funding, primary purpose, or therapeutic foci (all P>.05). Trials with characteristics indicating high trial quality-including randomized allocation scheme, ≥50 participants enrolled, ≥2 sites, and presence of a data safety monitoring committee-had increased odds of publication compared with those without such characteristics (all P<.05). For example, studies with randomized allocation of intervention had 2-fold greater odds of publication than nonrandomized studies (adjusted odds ratio, 2.09; 95% confidence interval, 1.30-3.37). Studies with ≥150 participants had nearly 8-fold odds of publication (adjusted odds ratio, 7.90; 95% confidence interval, 3.78-17.49) relative to studies with <50 participants. Temporal analysis demonstrated variability in time to publication among obstetrical trials, with a median time of 20.1 months after trial completion, and with most trials that reached publication having been published by 40 months. No difference was observed in time to publication by funding, primary purpose, or therapeutic foci (all P>.05). CONCLUSION: Publication of obstetrical trials remains suboptimal, with significant differences observed between trials with indicators of high quality and those without. Most trials that reach publication are published within 2 years of registered completion on ClinicalTrials.gov.

Why women choose to to seek facility-level obstetrical care in rural Guatemala: A qualitative study.

OBJECTIVE: The majority of indigenous Guatemalan women give birth at home with traditional birth attendants (TBAs), and maternal mortality rates are high (Ministerio de Salud, 2017). Our objective was to better understand decision-making around whether to remain in the home or to seek facility-level care for obstetric complications. METHODS: This study was a qualitative analysis using semi-structured interviews in a Maya population in the Western Highlands of Guatemala who received prenatal care between April 2017 and December 2018. We used qualitative interviews with women who were identified as medically high-risk and needing facility-level care, offered assistance with acquiring such care, and yet declined this option. Women interviewed were connected to a primary care organization called Maya Health Alliance, through care with TBAs involved in a program utilizing a smartphone-based decision support application to identify maternal and neonatal complications of pregnancy. Interviews were analyzed using Dedoose (www.dedoose.com). Deductive and inductive analysis was performed. RESULTS: Barriers to care included a disagreement between the respondent and TBA about indications for facility care, fear of hospital care, concerns about the quality of hospital care, logistical obstacles, and lack of control; and they were more often described by respondents who had previous healthcare experiences. Therapeutic misalignment occurred more with conditions perceived to be less severe. Participants described a balancing of fears and apprehensions against concerns of low quality and disrespectful maternity care, and in the setting of emergent conditions, disregarded barriers that were often described as inhibiting non-urgent obstetric care. CONCLUSIONS: The decision to engage in medical care in this population of Maya women involves a weighing of the perception of seriousness of the medical complication against fears of facility level care and concerns of a poor quality of care.

Early diagnosis and treatment challenges of endodermal sinus tumors: A case report.

BACKGROUND: Ovarian endodermal sinus tumors (ESTs) are rapidly growing and highly malignant tumors that respond well to chemotherapy. They can be difficult to diagnose and delayed diagnosis can worsen prognosis. CASE: We present the case of a 20-year-old woman with an EST initially misdiagnosed as a tubo-ovarian abscess who then experienced rapid progression within weeks of initial presentation and was subsequently found to have unresectable advanced stage disease. CONCLUSION: ESTs are extremely aggressive and require prompt referral and early treatment with chemotherapy. Presenting symptoms of pain and a mass can lead to a broad range of differential diagnoses. In such patients, early consideration of tumor markers is warranted. This case report reviews the key aspects for prompt diagnosis and rapid treatment of these tumors, which significantly impacts the prognosis.

The Influence of Culture on Teamwork and Communication in a Simulation-Based Resuscitation Training at a Community Hospital in Honduras.

STATEMENT: Communication and teamwork are important aspects of medicine and have been a recent focus of resuscitation. Culture can influence communication and teamwork, and these effects have not been studied in low-resource settings. Using a case study and the TEAM scale, we evaluated how culture influences teamwork and communication during resuscitation simulations, in addition to examining other challenges of simulation research in low-resource settings. We observed lower scores in leadership and communication skills than have been seen in other studies using the TEAM scale, which led us to evaluate the possible role of culture in influencing these skills. The high power distance and collectivism in Latin America can make communication difficult, especially during debriefing. Furthermore, in a male-biased medical hierarchy, female nurses may be less likely to voice concerns. Ultimately, this commentary provides advice for taking the influences of culture into account when planning future simulation training in low-resource settings.