Slavery, Home Ownership, and Contemporary Perinatal Outcomes in the Southeast: A Test of Mediation and Moderation.

OBJECTIVE: To estimate the effect of geographic variation in historic slavery on perinatal outcomes [chronic hypertension, hypertensive disorders of pregnancy (HDP), very preterm birth (VPTB), or very low birth weight birth (VLBW)] among Black people living in states where slavery was legal in 1860 and test mediation by Black homeownership. METHODS: We linked data from the 1860 census (the proportion of enslaved residents) to natality data on outcomes (2013-2021) using resident county. The percent of Black residents in a county who owned their home was a potential mediator. We fit log binomial models to estimate risk ratios (RRs) representing total and controlled direct effects (accounting for Black homeownership) of proportion enslaved on outcomes, accounting for potential confounding using marginal structural models. RESULTS: Among 2,443,198 included births, 8.8% (213,829) experienced HDP, 4.1% (100,549) chronic hypertension, 3.3% (81,072) VPTB, and 2.6% (62,538) VLBW. There was an increase in chronic hypertension and VPTB risk, but not HDP or VLBW, in counties with a 10% greater proportion enslaved in 1860 [adjusted RR: 1.06, 95% CI: (1.02, 1.1); 1.02 (1.00, 1.05); 1.00 (0.98, 1.02); 1.01 (1.00, 1.03)]. There was not evidence of mediation by Black homeownership. CONCLUSIONS: Historic slavery remains relevant for perinatal health.

Validation of ICD-10 Codes for Severe Maternal Morbidity at Delivery in a Public Hospital.

BACKGROUND: Severe maternal morbidity is a composite measure of serious obstetric complications that is often identified in administrative data using the International Classification of Diseases (ICD) diagnosis and procedure codes for a set of 21 indicators. Prior studies of screen-positive cases have demonstrated low predictive value for ICD codes relative to the medical record. To our knowledge, the validity of ICD-10 codes for identifying severe maternal morbidity has not been fully described. METHODS: We estimated the sensitivity, specificity, positive predictive value, and negative predictive value of ICD-10 codes for severe maternal morbidity occurring at delivery, compared with medical record abstraction (gold standard), for 1,000 deliveries that took place during 2016-2018 at a large, public hospital. RESULTS: We identified a total of 67 cases of severe maternal morbidity using the ICD-10 definition and 74 cases in the medical record. The sensitivity was 26% (95% confidence interval [CI] = 16%, 37%), the positive predictive value was 28% (95% CI = 18%, 41%), the specificity was 95% (95% CI = 93%, 96%), and the negative predictive value was 94% (95% CI = 92%, 96%). CONCLUSIONS: The validity of ICD-10 codes for severe maternal morbidity in our high-burden population was poor, suggesting considerable potential for bias.

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

OBJECTIVE: Childhood adversity is associated with poor cardiometabolic health in adulthood; little is known about how this relationship evolves through childbearing years for parous individuals. The goal was to estimate differences in cardiometabolic health indicators before, during and after childbearing years by report of childhood maltreatment in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study. METHODS: Including 743 individuals nulliparous at baseline (1985-1986) with one or more pregnancies >20 weeks during follow-up (1986-2022), we fit segmented linear regression models to estimate mean differences between individuals reporting or not reporting childhood maltreatment (physical or emotional) in waist circumference, triglycerides, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, fasting glucose, and body mass index (BMI) prior to, during, and following childbearing years using generalized estimating equations, allowing for interaction between maltreatment and time within each segment, and adjusting for total parity, parental education, and race (Black or white, self-reported). RESULTS: Individuals reporting maltreatment (19%; 141) had a greater waist circumference (post-childbearing: +2.9 cm, 95% CI (0.7, 5.0), higher triglycerides [post-childbearing: +8.1 mg/dL, 95% CI (0.7, 15.6)], and lower HDL cholesterol [post-childbearing: -2.1 mg/dL, 95% CI (-4.7, 0.5)] during all stages compared to those not reporting maltreatment. There were not meaningful differences in blood pressure, fasting glucose, or BMI. Individuals who reported maltreatment did not report faster changes over time. CONCLUSION: Differences in some aspects of cardiometabolic health between individuals reporting versus not reporting childhood maltreatment were sustained across reproductive life stages, suggesting potentially persistent impacts of childhood adversity.

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

OBJECTIVE: Responding to the National Institutes of Health Working Group's call for research on the psychological impact of stillbirth, we compared coping-related behaviors by outcome of an index birth (surviving live birth or perinatal loss - stillbirth or neonatal death) and, among individuals with loss, characterized coping strategies and their association with depressive symptoms 6-36 months postpartum. METHODS: We used data from the Stillbirth Collaborative Research Network follow-up study (2006-2008) of 285 individuals who experienced a stillbirth, 691 a livebirth, and 49 a neonatal death. We conducted a thematic analysis of coping strategies individuals recommended following their loss. We fit logistic regression models, accounting for sampling and inverse probability of follow-up weights to estimate associations between pregnancy outcomes and coping-related behaviors and, separately, coping strategies and probable depression (Edinburgh Postnatal Depression Scale > 12) for those with loss. RESULTS: Compared to those with a surviving live birth and adjusting for pre-pregnancy drinking and smoking, history of stillbirth, and age, individuals who experienced a loss were more likely to report increased drinking or smoking in the two months postpartum (adjusted OR: 2.7, 95% CI = 1.4-5.4). Those who smoked or drank more had greater odds of probable depression at 6 to 36 months postpartum (adjusted OR 6.4, 95% CI = 2.5-16.4). Among those with loss, recommended coping strategies commonly included communication, support groups, memorializing the loss, and spirituality. DISCUSSION: Access to a variety of evidence-based and culturally-appropriate positive coping strategies may help individuals experiencing perinatal loss avoid adverse health consequences.

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

OBJECTIVE: The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts. RESULTS: We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001). CONCLUSION: Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic. KEY POINTS: · Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

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

BACKGROUND: US federal and subfederal immigrant-related policy activity has increased in recent years. We hypothesize that these policies are structural determinants of health for Latinx communities, operating through access to resources, discriminatory enforcement, and stress. METHODS: We searched seven databases for quantitative studies, published as of September 2021, examining the association between the presence of federal, state, or local immigrant-related policy(ies), over time or cross-sectionally, and mental or physical health outcomes among immigrant or US-born Latinx adults. We rated studies on methodologic quality. RESULTS: Eleven studies were included. Policies included federal and state policies. Health outcomes included mental health (seven studies), self-rated health (n = 6), and physical disability (n = 1). Among immigrant, noncitizen, or Spanish-preferring Latinx adults, exclusionary policies were associated with poor self-rated health, physical disability, and poor mental health. Inclusive policies were associated with better health, although null findings were more common than among studies of exclusionary policies. Only three studies separately examined policy effects on US-born or citizen Latinx adults and these findings were often null. All studies received a weak overall study quality rating; among quality domains, studies were strongest in confounding control and weakest in outcome information bias and reporting missing data approaches. CONCLUSIONS: These results support the hypothesis that immigrant-related policies, especially exclusionary policies, are structural drivers of health for immigrant or noncitizen Latinx adults. However, evidence is scant among US-born or citizen Latinx adults. Studies of policies and physical health outcomes besides disability are lacking, as are results disaggregated by nativity and/or citizenship status.

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

INTRODUCTION: Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder. METHODS: We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management. RESULTS: From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors. CONCLUSION: Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.

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

OBJECTIVE: Postpartum preeclampsia (PE), defined as de novo PE that develops at least 48 hours following delivery, can be particularly dangerous as many patients are already discharged at that point. The goal of our study was to identify risk factors uniquely associated with the development of late postpartum preeclampsia (PPPE). STUDY DESIGN: In a retrospective cohort study of deliveries between July 1, 2016 and June 30, 2018 at a safety-net hospital in Atlanta, Georgia, we used multinomial logistic regression models to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between demographic, medical, and obstetric factors and development of PE, categorized as a three-level outcome: no PE, antepartum/intrapartum preeclampsia (APE) (diagnosed prior to or < 48 hours of delivery), and late PPPE (diagnosed ≥ 48-hour postpartum). RESULTS: Among 3,681 deliveries, women were primarily of ages 20 to 35 years (76.4%), identified as non-Hispanic Black (68.5%), and covered by public health insurance (88.6%). PE was diagnosed prior to delivery or within 48-hour postpartum in 12% (n = 477) of the study population, and 1.5% (57) developed PE greater than 48-hour postpartum. In the adjusted models, maternal age ≥ 35, race/ethnicity, nulliparity, a diagnosis of pregestational or gestational diabetes, and chronic hypertension were associated with increased odds of APE only, while maternal obesity (OR: 1.9; 95% CI: 1.0-3.5) and gestational hypertension (OR: 2.7; 95% CI: 1.5-4.8) were uniquely associated with PPPE. Multifetal gestations and cesarean delivery predicted both PPPE and APE; however, the association was stronger for PPPE. CONCLUSION: Patients with obesity, gestational hypertension, multifetal gestations, or cesarean delivery may benefit from additional follow-up in the early postpartum period to detect PPPE. KEY POINTS: · Late postpartum preeclampsia may go undetected, particularly in low-income patients.. · In a delivery cohort in Georgia, 1.5% of patients developed late postpartum preeclampsia.. · Maternal obesity and gestational hypertension were strongly associated only with late postpartum preeclampsia..

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

OBJECTIVE: Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization. STUDY DESIGN: We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). RESULTS: Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization. CONCLUSION: Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period. KEY POINTS: · Experiencing SMM was associated with three-fold excess risk of postpartum psychiatric admission.. · Experiencing SMM was not associated with an elevated risk of outpatient psychiatric care use.. · Experience SMM was not associated with outpatient psychiatric morbidity diagnoses..

Validation of Hypertensive Disorders During Pregnancy: ICD-10 Codes in a High-burden Southeastern United States Hospital.

BACKGROUND: Identification of hypertensive disorders in pregnancy research often uses hospital International Classification of Diseases v. 10 (ICD-10) codes meant for billing purposes, which may introduce misclassification error relative to medical records. We estimated the validity of ICD-10 codes for hypertensive disorders during pregnancy overall and by subdiagnosis, compared with medical record diagnosis, in a Southeastern United States high disease burden hospital. METHODS: We linked medical record data with hospital discharge records for deliveries between 1 July 2016, and 30 June 2018, in an Atlanta, Georgia, public hospital. For any hypertensive disorder (with and without unspecified codes) and each subdiagnosis (hemolysis, elevated liver enzymes, and low platelet count [HELLP] syndrome, eclampsia, preeclampsia with and without severe features, chronic hypertension, superimposed preeclampsia, and gestational hypertension), we calculated positive predictive value (PPV), negative predictive value (NPV) sensitivity, and specificity for ICD-10 codes compared with medical record diagnoses (gold standard). RESULTS: Thirty-seven percent of 3,654 eligible pregnancies had a clinical diagnosis of any hypertensive disorder during pregnancy. Overall, ICD-10 codes identified medical record diagnoses well (PPV, NPV, specificity >90%; sensitivity >80%). PPV, NPV, and specificity were high for all subindicators (>80%). Sensitivity estimates were high for superimposed preeclampsia, chronic hypertension, and gestational hypertension (>80%); moderate for eclampsia (66.7%; 95% confidence interval [CI] = 22.3%, 95.7%), HELLP (75.0%; 95% CI = 50.9%, 91.3%), and preeclampsia with severe features (58.3%; 95% CI = 52.6%, 63.8%); and low for preeclampsia without severe features (3.2%; 95% CI, 1.4%, 6.2%). CONCLUSIONS: We provide bias parameters for future US-based studies of hypertensive outcomes during pregnancy in high-burden populations using hospital ICD-10 codes.

Validation of ICD-10 Codes for Gestational and Pregestational Diabetes During Pregnancy in a Large, Public Hospital.

BACKGROUND: The use of billing codes (ICD-10) to identify and track cases of gestational and pregestational diabetes during pregnancy is common in clinical quality improvement, research, and surveillance. However, specific diagnoses may be misclassified using ICD-10 codes, potentially biasing estimates. The goal of this study is to provide estimates of validation parameters (sensitivity, specificity, positive predictive value, and negative predictive value) for pregestational and gestational diabetes diagnosis using ICD-10 diagnosis codes compared with medical record abstraction at a large public hospital in Atlanta, Georgia. METHODS: This study includes 3,654 deliveries to Emory physicians at Grady Memorial Hospital in Atlanta, Georgia, between 2016 and 2018. We linked information abstracted from the medical record to ICD-10 diagnosis codes for gestational and pregestational diabetes during the delivery hospitalization. Using the medical record as the gold standard, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for each. RESULTS: For both pregestational and gestational diabetes, ICD-10 codes had a high-negative predictive value (>99%, Table 3) and specificity (>99%). For pregestational diabetes, the sensitivity was 85.9% (95% CI = 78.8, 93.0) and positive predictive value 90.8% (95% CI = 85, 97). For gestational diabetes, the sensitivity was 95% (95% CI = 92, 98) and positive predictive value 86% (95% CI = 81, 90). CONCLUSIONS: In a large public hospital, ICD-10 codes accurately identified cases of pregestational and gestational diabetes with low numbers of false positives.

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta.

BACKGROUND: Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta. DESIGN: We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma. RESULTS: Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)). CONCLUSIONS: Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

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

INTRODUCTION: Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are associated with increased risk of maternal and infant illness and long-term elevated cardiometabolic risk. Little information exists on the prevention of either disorder before pregnancy. Our goal was to describe the association between preconception indicators and risk of gestational diabetes and hypertensive disorders of pregnancy. METHODS: We used logistic regression to analyze cross-sectional data from the 2016-2017 Pregnancy Risk Assessment Monitoring System (N = 68,493) to quantify the association between 14 preconception health indicators (across domains of health care, nutrition and physical activity, tobacco and alcohol, chronic conditions, mental health, and emotional and social support) and, separately, GDM and HDP. We accounted for sampling weights and controlled for maternal age, race/ethnicity, prepregnancy insurance, prepregnancy body mass index, and report of a check-up in the year before pregnancy. RESULTS: Prepregnancy obesity was the strongest predictor of both HDP (adjusted odds ratio [aOR], 3.1; 95% CI, 2.8-3.5) and GDM (aOR, 3.1; 95% CI, 2.7-3.5). Individual behaviors (eg, exercise, attending a check-up) were not associated with either HDP or GDM. A diagnosis of diabetes before pregnancy predicted HDP (aOR, 2.3; 95% CI, 1.7-3.0). CONCLUSION: Prepregnancy chronic disease and obesity predicted pregnancy complications (ie, GDM and HDP). Given the challenges in reversing these conditions in the year before pregnancy, efforts to improve preconception health may be best directed broadly to expand access to primary care for all women.

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

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

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

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

Stressful Life Events Among New Mothers in Georgia: Variation by Race, Ethnicity and Nativity.

INTRODUCTION: Prior research has identified psychosocial stress as a risk factor for adverse maternal and infant outcomes for non-Hispanic Black and White women. However, whether psychosocial stress differs in its profile and association with preterm birth across diverse racial-ethnic-nativity groups in the Southeast remains unexamined. Both foreign-born and Hispanic women represent important proportions of new mothers in many Southeastern states. The objective of this paper is to describe the prevalence of categories of prenatal life events among Georgia mothers, the variation across race, ethnicity and nativity, and the association of prenatal stress with prevalence of preterm birth. METHODS: We calculated racial-ethnic-nativity specific prevalence of stress categories (emotional/traumatic, financial, or partner-related) with data from the 2012 to 2015 Georgia PRAMS. Maternal race, ethnicity, and nativity were reported on birth certificates. We used logistic regression to examine the association of different categories of stress with preterm birth. We conducted a bias analysis to estimate the potential impact of recall bias on observed associations. RESULTS: The sample was 20.2% foreign born overall, 15.5% non-Hispanic White, 45.7% non-Hispanic Black, 32.3% Hispanic, and 6.5% non-Hispanic other. The prevalence of specific stressors varied by race-ethnicity-nativity. Women who experienced financial stress had a slightly elevated prevalence of preterm birth (prevalence ratio: 1.32 (0.97-1.79)). DISCUSSION: Prenatal and preconception stress were common among women who gave birth between 2012 and 2015 in Georgia and may have implications for preterm and postpartum maternal mental health.

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

BACKGROUND: Implementing rigorous epidemiologic studies in low-resource settings involves challenges in participant recruitment and follow-up (e.g., mobile populations, distrust), biological sample collection (e.g., cold-chain, laboratory equipment scarcity) and data collection (e.g., literacy, staff training, and infrastructure). This article describes the use of a monitoring and evaluation (M&E) framework to improve study efficiency and quality during participant engagement, and biological sample and data collection in a longitudinal cohort study of Bolivian infants. METHODS: The study occurred between 2013 and 2015 in El Alto, Bolivia, a high-altitude, urban, low-resource community. The study's M&E framework included indicators for participant engagement (e.g., recruitment, retention, safety), biological sample (e.g., stool and blood), and data (e.g., anthropometry, questionnaires) collection and quality. Monitoring indicators were measured regularly throughout the study and used for course correction, communication, and staff retraining. RESULTS: Participant engagement indicators suggested that enrollment objectives were met (461 infants), but 15% loss-to-follow-up resulted in only 364 infants completing the study. Over the course of the study, there were four study-related adverse events (minor swelling and bruising related to a blood draw) and five severe adverse events (infant deaths) not related to study participation. Biological sample indicators demonstrated two blood samples collected from 95% (333 of 350 required) infants and stool collected for 61% of reported infant diarrhea episodes. Anthropometry data quality indicators were extremely high (median SDs for weight-for-length, length-for-age and weight-for-age z-scores 1.01, 0.98, and 1.03, respectively), likely due to extensive training, standardization, and monitoring efforts. CONCLUSIONS: Conducting human subjects research studies in low-resource settings often presents unique logistical difficulties, and collecting high-quality data is often a challenge. Investing in comprehensive M&E is important to improve participant recruitment, retention and safety, and sample and data quality. The M&E framework from this study can be applied to other longitudinal studies.

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

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

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

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

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

BACKGROUND: Although severe maternal morbidity is associated with adverse health outcomes in the year after delivery, patterns of healthcare use beyond the 6-week postpartum period have not been well documented. OBJECTIVE: This study aimed to estimate healthcare utilization and expenditures for deliveries with and without severe maternal morbidity in the 12 months following delivery among commercially insured patients. STUDY DESIGN: Using data from the 2016 to 2018 IBM Marketscan Commercial Claims and Encounters Research Databases, we identified deliveries to individuals 15 to 49 years of age who were continuously enrolled in noncapitated health plans for 12 months after delivery discharge. We used multivariable generalized linear models to estimate adjusted mean 12-month medical expenditures and 95% confidence intervals for deliveries with and without severe maternal morbidity, accounting for region, health plan type, delivery method, and obstetrical comorbidities. We estimated expenditures associated with inpatient admissions, nonemergency outpatient visits, outpatient emergency department visits, and outpatient pharmaceutical claims. RESULTS: We identified 366,282 deliveries without severe maternal morbidity and 3976 deliveries (10.7 per 1000) with severe maternal morbidity. Adjusted mean total medical expenditures for deliveries with severe maternal morbidity were 43% higher in the 12 months after discharge than deliveries without severe maternal morbidity ($5320 vs $3041; difference $2278; 95% confidence interval, $1591-$2965). Adjusted mean expenditures for readmissions and nonemergency outpatient visits during the 12-month postpartum period were 61% and 39% higher, respectively, for deliveries with severe maternal morbidity compared with deliveries without severe maternal morbidity. Among deliveries with severe maternal morbidity, adjusted mean total costs were highest for patients living in the western region ($7831; 95% confidence interval, $5518-$10,144) and those having a primary cesarean ($7647; 95% confidence interval, $6323-$8970). CONCLUSION: Severe maternal morbidity at delivery is associated with increased healthcare use and expenditures in the year after delivery. These estimates can inform planning of severe maternal morbidity prevention efforts.