Pregnancy-Related Deaths Due to Hemorrhage: Pregnancy Mortality Surveillance System, 2012-2019.

Hemorrhage has been a leading cause of pregnancy-related death in the Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System since 1987 when reporting began. Pregnancy Mortality Surveillance System data from 2012 to 2019 were analyzed to describe pregnancy-related deaths from hemorrhage. Pregnancy-related mortality ratios were estimated for hemorrhage overall and by hemorrhage subclassifications. Specific subclassifications of hemorrhage-related deaths were analyzed by sociodemographic characteristics. Overall, there were 606 deaths due to hemorrhage. The pregnancy-related mortality ratio for hemorrhage overall was 1.94 per 100,000 live births. Ruptured ectopic pregnancy was the most frequent subclassification (22.9%) of pregnancy-related hemorrhage deaths, followed by postpartum hemorrhage (21.2%). There were no significant trends in the pregnancy-related mortality ratio, overall or among any subclassification of hemorrhage deaths, from 2012 to 2019. Reporting subclassifications of pregnancy-related hemorrhage deaths could improve the ability to focus interventions and assess progress over time.

Vital Signs: Maternity Care Experiences - United States, April 2023.

Introduction: Maternal deaths increased in the United States during 2018-2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths. Methods: CDC analyzed data from the PN View Moms survey administered during April 24-30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care. Results: Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider. Conclusions and implications for public health practice: Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.

Evaluating the public health response to a mass bat exposure-Wyoming, 2017.

Mass bat exposures (MBEs) occur when multiple people are exposed to a bat or a bat colony, often over an extended period. In August 2017, a public health investigation was started in response to an MBE that occurred during May-August 2017 at a national park research station in Wyoming. We identified 176 people who had slept primarily in two lodges (Lodges A and B) at the research station, and successfully contacted 165 (93.8%) of these individuals. Risk assessments (RAs) were administered to all 165 individuals to determine degree and type of exposures to bats (e.g., biting or scratching). Exposure status for research station guests was classified as "non-exposed," "low risk" or "high risk," and counselling was provided to guide post-exposure prophylaxis (PEP) recommendations. Prior to public health notification and intervention, 19 persons made the decision to pursue PEP. The healthcare-seeking behaviours of this group were taken to represent outcomes in the absence of public health intervention. (These persons received a RA, and their risk classification was retrospectively assigned.) Approximately 1-2 weeks after conducting the RAs, we conducted a follow-up survey to determine whether recommendations regarding PEP were ultimately followed. The proportion of individuals that unnecessarily pursued PEP was higher among the 19 individuals that sought health care prior to receiving the RA (p < 0.00001). Among those receiving the RA first, all persons classified as high risk followed public health guidance to seek PEP treatment. Despite this, upon re-interview, only 21/79 (26.6%) of guests could accurately recall their risk classification, with most people (55.7%) overestimating their risk. Study findings demonstrate that early public health interventions such as RAs can reduce unnecessary use of PEP and that messaging used during rabies counselling should be clear.

Implementing CDC's Level of Care Assessment Tool (LOCATe): A National Collaboration to Improve Maternal and Child Health.

Perinatal regionalization, or risk-appropriate care, is an approach that classifies facilities based on capabilities to ensure women and infants receive care at a facility that aligns with their risk. The CDC designed the Levels of Care Assessment Tool (LOCATe) to assist jurisdictions working in risk-appropriate care in assessing a facility's level of maternal and neonatal care aligned with the most current American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) and American Academy of Pediatrics (AAP) guidelines. LOCATe produces standardized assessments for each hospital that participates and facilitates conversations among stakeholders in risk-appropriate care. This article describes how public health departments implement and use LOCATe in their jurisdictions.

Evaluation of the Completeness, Data Quality, and Timeliness of Fetal Mortality Surveillance in Wyoming, 2006-2013.

Purpose The number of fetal deaths in the United States each year exceeds that of infant deaths. High quality fetal death certificate data are necessary for states to effectively address preventable fetal deaths. We evaluated completeness of detection of fetal deaths among Wyoming residents that occur out-of-state, quality of cause-of-death data, and timeliness of Wyoming fetal death certificate registration during 2006-2013. Description The numbers of out-of-state fetal deaths among Wyoming residents recorded by Wyoming surveillance and reported by the National Vital Statistics System were compared. Quality of cause-of-death data was assessed by calculating percentage of fetal death certificates completed in Wyoming with ill-defined, unknown, or missing cause-of-death entries. Timeliness was determined using the time between the fetal death and filing of the fetal death certificate with the Wyoming Department of Health Vital Statistics Service. Assessment Wyoming surveillance detected none of the 76 out-of-state fetal deaths among Wyoming residents reported by the National Vital Statistics System. Among 263 fetal death certificates completed in Wyoming and collected by Wyoming surveillance, 108 (41%) contained ill-defined, unknown, or missing cause-of-death entries. Median duration between the fetal death and filing with the Wyoming Vital Statistics Service was 33 days. Conclusion Wyoming fetal mortality surveillance is limited by failure to register out-of-state fetal deaths among residents, poor quality of cause-of-death data, and lack of timeliness. Strategies to improve surveillance include automating interjurisdictional sharing of fetal death data, certifier education, and electronic fetal death registration.

Association of short-term exposure to ground-level ozone and respiratory outpatient clinic visits in a rural location - Sublette County, Wyoming, 2008-2011.

OBJECTIVE: Short-term exposure to ground-level ozone has been linked to adverse respiratory and other health effects; previous studies typically have focused on summer ground-level ozone in urban areas. During 2008-2011, Sublette County, Wyoming (population: ~10,000 persons), experienced periods of elevated ground-level ozone concentrations during the winter. This study sought to evaluate the association of daily ground-level ozone concentrations and health clinic visits for respiratory disease in this rural county. METHODS: Clinic visits for respiratory disease were ascertained from electronic billing records of the two clinics in Sublette County for January 1, 2008-December 31, 2011. A time-stratified case-crossover design, adjusted for temperature and humidity, was used to investigate associations between ground-level ozone concentrations measured at one station and clinic visits for a respiratory health concern by using an unconstrained distributed lag of 0-3 days and single-day lags of 0 day, 1 day, 2 days, and 3 days. RESULTS: The data set included 12,742 case-days and 43,285 selected control-days. The mean ground-level ozone observed was 47 ± 8 ppb. The unconstrained distributed lag of 0-3 days was consistent with a null association (adjusted odds ratio [aOR]: 1.001; 95% confidence interval [CI]: 0.990-1.012); results for lags 0, 2, and 3 days were consistent with the null. However, the results for lag 1 were indicative of a positive association; for every 10-ppb increase in the 8-h maximum average ground-level ozone, a 3.0% increase in respiratory clinic visits the following day was observed (aOR: 1.031; 95% CI: 0.994-1.069). Season modified the adverse respiratory effects: ground-level ozone was significantly associated with respiratory clinic visits during the winter months. The patterns of results from all sensitivity analyzes were consistent with the a priori model. CONCLUSIONS: The results demonstrate an association of increasing ground-level ozone with an increase in clinic visits for adverse respiratory-related effects in the following day (lag day 1) in Sublette County; the magnitude was strongest during the winter months; this association during the winter months in a rural location warrants further investigation.

Associations between neighborhood characteristics and physical activity among youth within rural-urban commuting areas in the US.

The association among rural-urban communities, neighborhood characteristics, and youth physical activity is inconsistent in the literature. We used data from the 2007 National Survey of Children's Health, for youth aged 10-17 years (n = 45,392), to examine the association between physical activity and neighborhood characteristics, after adjusting for known confounders. We also examined the association between physical activity and neighborhood characteristics within seven levels of Rural-Urban Commuting Areas (RUCAs) that depict a continuum from isolated rural to dense urban communities. Attainment of a minimum physical activity level differed by RUCA (P = 0.0004). In adjusted, RUCA-specific models, the presence of parks was associated with attaining a minimum physical activity level in only one of the seven RUCAs (adjusted odds ratio: 3.49; 95 % confidence interval: 1.55, 7.84). This analysis identified no association between youths' minimum physical activity attainment and neighborhood characteristics in unstratified models; and, RUCA-specific models showed little heterogeneity by rural-urban community type. Although this analysis found little association between youth physical activity and neighborhood characteristics, the findings could reflect the crude categorization of the neighborhood amenities (sidewalks, parks, recreation centers) and detracting elements (litter, dilapidated housing, vandalism) and suggests that simple measurement of the presence of an amenity or detracting element is insufficient for determining potential associations with reaching minimum levels of physical activity. By exploring neighborhood characteristics and features of neighborhood amenities within the context of well-defined community types, like RUCAs, we can better understand how and why these factors contribute to different levels of youth physical activity.

Association of residential mobility with child health: an analysis of the 2007 National Survey of Children's Health.

To describe the association of residential mobility with child health. We conducted descriptive, bivariate, and multivariable analyses of data from 63,131 children, 6-17 years, from the 2007 National Survey of Children's Health. Logistic regression was used to explore the association of residential mobility with child health and measures of well-being. Analyses were carried out using SAS-callable SUDAAN to appropriately weight estimates and adjust for the complex sampling design. After adjusting for age, race/ethnicity, presence of a special health care need, family structure, parental education, poverty level, and health insurance status, children who moved ≥ 3 times were more likely to have poorer reported overall physical (AOR 1.21 [95 %CI: 1.01-1.46]) and oral health status (AOR 1.31 [95 % CI: 1.15-1.49]), and ≥ 1 moderate/severe chronic conditions (AOR 1.40 [95 % CI: 1.19-1.65]) than children who had no lifetime moves. When compared to children who had never moved, children who moved ≥ 3 times were more likely to be uninsured/have periods of no coverage (AOR 1.35; 95 % CI: 0.98-1.87) and lack a medical home (AOR 1.16, 95 % CI: 1.04-1.31). None of the outcomes were statistically significant for children who moved fewer than 3 times. Clinicians need to be aware that children who move frequently may lack stable medical homes and consistent coverage increasing their risk of poor health outcomes and aggravation of mild or underlying chronic conditions. Public health systems could provide the necessary link between parents and clinicians to ensure that continuous, coordinated care is established for children who move frequently.

A multivariate analysis of risk factors for the air-trapping asthmatic phenotype as measured by quantitative CT analysis.

BACKGROUND: Patients with severe asthma have increased physiologically measured air trapping; however, a study using CT measures of air trapping has not been performed. This study was designed to address two hypotheses: (1) air trapping measured by multidetector CT (MDCT) quantitative methodology would be a predictor of a more severe asthma phenotype; and (2) historical, clinical, allergic, or inflammatory risk factors could be identified via multivariate analysis. METHODS: MDCT scanning of a subset of Severe Asthma Research Program subjects was performed at functional residual capacity. Air trapping was defined as >or= 9.66% of the lung tissue < - 850 Hounsfield units (HU). Subjects classified as having air trapping were then compared to subjects without air trapping on clinical and demographic factors using both univariate and multivariate statistical analyses. RESULTS: Subjects with air trapping were significantly more likely to have a history of asthma-related hospitalizations, ICU visits, and/or mechanical ventilation. Duration of asthma (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.08 to 1.87), history of pneumonia (OR, 8.55; 95% CI, 2.07 to 35.26), high levels of airway neutrophils (OR, 8.67; 95% CI, 2.05 to 36.57), airflow obstruction (FEV(1)/FVC) [OR, 1.61; 95% CI, 1.21 to 2.14], and atopy (OR, 11.54; 95% CI, 1.97 to 67.70) were identified as independent risk factors associated with the air-trapping phenotype. CONCLUSIONS: Quantitative CT-determined air trapping in asthmatic subjects identifies a group of individuals at high risk for severe disease. Several independent risk factors for the presence of this phenotype were identified: perhaps most interestingly, history of pneumonia, neutrophilic inflammation, and atopy.

Exhaled nitric oxide identifies the persistent eosinophilic phenotype in severe refractory asthma.

BACKGROUND: The fractional concentration of exhaled nitric oxide (FENO) is increased in asthma, correlates with eosinophilic inflammation, and decreases after steroid therapy. OBJECTIVE: We sought to examine whether persistent eosinophilia would be accompanied by an increased FENO level despite steroid therapy in patients with severe refractory asthma (SRA) as manifestations of steroid resistance. METHODS: Subjects with SRA, subjects with mild-moderate asthma, and healthy control subjects had FENO measured, followed by endobronchial biopsy and bronchoalveolar lavage. Tissue and bronchoalveolar lavage inflammatory cells were assessed for all subjects, and eosinophil status (EOS+/EOS-) was determined for subjects with SRA. RESULTS: Twenty-four subjects with SRA, 15 subjects with moderate-mild asthma, and 17 healthy control subjects were studied. Subjects with EOS+ SRA had significantly higher median FENO levels compared with levels in subjects with EOS- SRA (P = .0084) and all other groups. In subjects with SRA, FENO levels correlated with tissue eosinophils (r(s) = 0.54, P = .007), lymphocytes (r(s) = 0.40, P = .003), and mast cells (r(s) = 0.44, P = .05). FENO levels of greater than 72.9 ppb were associated with a sensitivity of 0.56 and a specificity of 1.0 for EOS+ status in subjects with SRA. CONCLUSION: FENO measurement identified the subgroup of subjects with SRA with persistent eosinophilia despite steroid therapy. Further studies are needed on the use of FENO to monitor response to therapy over time in subjects with SRA.

Distinguishing severe asthma phenotypes: role of age at onset and eosinophilic inflammation.

BACKGROUND: Asthma is a heterogeneous process, yet little is understood regarding phenotypes. OBJECTIVE: To determine whether phenotypic differences exist between early-onset, severe asthma as compared with late-onset disease and whether the presence or absence of eosinophilia influences the phenotypes. METHODS: Cross-sectional analysis of integrated clinical, physiologic, and pathologic data collected from 80 subjects with severe asthma. Subjects were divided into those with asthma onset before age 12 years (n = 50) versus after age 12 (n = 30) and by the presence or absence of lung eosinophils. RESULTS: Subjects with early-onset, severe asthma had significantly more allergen sensitivity (skin test positivity, 98% vs 76%, P <.007) and more allergic symptoms (P values all